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Questions of the Week between January
and March, 2006 |
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March 27, 2006
Q "Do
they still believe that things like schizophrenia are
biological or do you learn them?"
A For
example: A recent study: "suggest an association between schizophrenia and
a large range of autoimmune diseases.
"Individuals with schizophrenia and their relatives tend to have either higher
or lower than expected prevalences of autoimmune disorders, especially
rheumatoid arthritis, celiac disease, autoimmune thyroid diseases, and type 1
diabetes.
Subjects with one or more autoimmune diseases had a 45% increased risk of
schizophrenia, and schizophrenia patients had a higher prevalence of nine
autoimmune disorders compared with the controls. The parents of schizophrenic
patients had a higher prevalence of 12 autoimmune diseases compared with the
parents of the controls.
Thyrotoxicosis, celiac disease, acquired hemolytic anemia, interstitial
cystitis, and Sjogren's syndrome occurred more often in schizophrenic patients
and their parents compared with the controls and their parents, the researchers
report."
Am J Psychiatry 2006;163:521-528.
March 20, 2006
Q "My
sister's teenager took her own life. She is very depressed,
and we are extremely worried about her."
A
You need to seek professional
consultation: "In addition to prolonged anxiety and
depression, parents who have a child who dies at home may be
at increased risk of suicide...looking after the caregiver,
both before, during, and in the aftermath of the death is an
integral part of comprehensive care" for parents whose
children suffered a prolonged illness."
BMJ 2006;332:620-621,647-648.
March 13, 2006
Q "Do
antidepressants cause heart attacks?"
A
Not that anyone can demonstrate at this time. This may be
helpful: "Patients with coronary artery disease (CAD) may be
at increased risk of death while using antidepressant
drugs..but..people with heart disease should definitely not
stop taking their antidepressants, because we do not know if
antidepressants were causing this (increased risk) or if it
was due to some other characteristics of folks who are on
antidepressants.
Antidepressants were
being used by 19.4% of subjects. Two thirds of the antidepressants were
selective serotonin reuptake inhibitors (SSRIs).
During a mean of 3 years of follow-up, 21.4% of those taking antidepressants
died, compared with 12.5% of those not on antidepressants. After adjusting for
demographics, left ventricular ejection fraction, Beck Depression Inventory
score, and comorbidities, antidepressant use remained an independent risk factor
for mortality (hazard ratio 1.62, p = 0.029).
...have to be clear about the fact that because this was not a
placebo-controlled trial, it's possible that patients taking antidepressants had
other factors (that could account for the increased risk)...the...finding could
be an epiphenomenon...For example, people on antidepressants may be sicker or
more depressed, she explained, which in turn could lead to suppression of the
immune system or an increase in cardiovascular risk factors such as
hypertension, physical inactivity or alcohol or tobacco abuse.
Past Questions of the Week are available through the educational resources of the website. If you would like to submit your own question for consideration as a public Question of the Week, please contact the practice.
March 6, 2006
Q "We
are having our first baby, and my husband insists that there
are risks to my continuing to work in my high stress
environment. True?"
A
Congratulations. Stress
effects many aspects of health. "Maternal stress in the
first few weeks of pregnancy, based on elevated cortisol
levels, is associated with an increased risk of
miscarriage...Maternal stress is often considered a risk
factor for miscarriage, yet physiologic data supporting this
association is lacking...
Previous studies looking at this topic may have failed to
identify a link because they focused on clinical pregnancy,
which occurs at least 6 weeks after the last menstrual
period. By contrast, most miscarriages occur earlier in
pregnancy, usually within 3 weeks of conception.
In the current study reported, maternal urinary cortisol
levels were determined during the first 3 weeks of 22
pregnancies. Thirteen of the pregnancies eventually
miscarried with a mean time from ovulation to fetal loss of
16 days.
Women with cortisol levels above their usual baseline value
were 2.7-times more likely to experience a miscarriage than
women without increased cortisol levels.
There is an association between increased maternal cortisol
and higher risk of miscarriage within the first 3 weeks of
conception, together with the failure of previous research
to find such an association later during gestation, suggests
that pregnancy may be particularly sensitive to maternal
stress during the placentation period."
Proc Natl Acad Sci USA 2006
February 27, 2006
Q "My
father is a graduate engineer with some early signs of
Alzheimer's Disease. Won't his intelligence work in his
favor?"
A
No one knows for certain, but you may find this helpful: "The
rate of cognitive decline seen with Alzheimer's disease (AD)
is directly related to the educational level of the affected
individual.
Executive speed and
memory were the primary cognitive domains affected by education level, the
report indicates.
Further analysis showed that the link between education and cognitive decline
was independent of age, mental function at diagnosis, or other factors known to
have an impact on cognition, such as depression and vascular disease.
Previous studies have provided evidence that high levels of education stave off
AD. The cognitive reserve hypothesis has been put forth as a possible
explanation for the effect of education on AD.
This theory, they explain, holds that highly educated individuals have more
cognitive reserve so that the onset of overt AD symptoms is delayed. However,
once the disease becomes apparent, more damage has accumulated than in less
educated brains, so the subsequent decline in cognitive function is more rapid."
J Neurol Neurosurg Psychiatry 2006;77:308-316.
February 20, 2006
Q "I
have read some grim things about the Paxil I take?"
A
"The US Food and Drug Administration (FDA) has warned
healthcare professionals that exposure to paroxetine (Paxil)
during the first trimester of pregnancy may increase the
risk for congenital malformations, particularly
cardiovascular defects.
In a separate study, data from a US insurance claims
database revealed that use of paroxetine rather than other
antidepressants during the first trimester of pregnancy was
linked to a 1.8-fold increased risk for congenital
malformations and a 1.5-fold increased risk for cardiac
malformations.
Cardiac defects occurred in approximately 1.5% of paroxetine-exposed
infants compared with 1% of infants exposed to other
antidepressants. In most cases, the malformations consisted
of atrial or ventricular septal defects.
The FDA is currently awaiting the final results of these
studies and accruing additional data to better characterize
the risk of congenital malformations associated with
paroxetine use during pregnancy.
In the interim, the pregnancy category for paroxetine has
been changed from C to D. Patients receiving paroxetine
therapy who become pregnant or are currently in their first
trimester of pregnancy should be alerted to the potential
risk to the fetus; discontinuation of paroxetine or use of
an alternative antidepressant should be considered.
The FDA notes that the data in these studies were limited to
first-trimester paroxetine exposures, and information is not
currently available to determine whether this or any other
risk extends to later periods of pregnancy.
Paroxetine HCl tablets and oral solution (Paxil, made by
GlaxoSmithKline) are indicated for the treatment of major
depressive disorder (MDD), obsessive-compulsive disorder (OCD),
panic disorder (PD), social anxiety disorder, generalized
anxiety disorder, and posttraumatic stress disorder.
Paroxetine HCl tablets are also available in generic
formulations.
The tablet formulation of paroxetine HCl controlled-release
(Paxil CR, made by GlaxoSmithKline) is indicated for the
treatment of MDD, PD, social anxiety disorder, and
premenstrual dysphoric disorder.
Paroxetine mesylate (Pexeva tablets, made by Synthon
Pharmaceuticals, Ltd) is indicated for the treatment of MDD,
OCD, and PD."
February 13, 2006
Q "Well,
then does depression cause heart attacks?"
A
"There appears to
be an association between depression and an increased risk
of sudden cardiac death, independent of established coronary
heart disease risk factors...The association of depression
with coronary heart disease-related mortality has been
widely recognized...This finding may partly reflect an
association between depression and sudden death, in part
because the imbalance between sympathetic and
parasympathetic tone is altered in depressed subjects."
The odds of cardiac arrest were higher among clinically depressed subjects (,
and the increased risk persisted in multivariate analysis controlling for
confounders.
Compared with patients without clinical depression, the risk of cardiac
arrest was increased in patients with less severe depression as well as those
with severe depression.
Poor adherence to treatment and unhealthy lifestyle habits may also explain
the association."
Arch Intern Med 2006;166:195-200.
February 6, 2006
Q "So,
if you treat depression, do diabetics improve?"
A
Please read the following: "Even though many patients
with diabetes are also depressed, which may complicate their
efforts at managing their diabetes, better treatment of
their depression seems to have no effect on how they deal
with their diabetes. Diabetics are roughly twice as likely
as the general population to have depression. Those with
both disorders tend to have worse glycemic control, more
severe symptoms and complications due to diabetes, and to
use health care resources at a higher rate.
Overall, the
researchers detected no differences in diabetes self-management between the
intervention and the usual care groups during the 12-year period.
However, the researchers say the findings do not imply that "depression care is
not useful for improving diabetes self-management or outcomes."
They suggest that "integrated diabetes and depression care management, including
specific support for diabetes medication adherence and self-care activities, as
well as systematic depression care, can help patients achieve better
psychological and diabetes outcomes."
Ann Fam Med 2006;4:46-53.
January 30, 2006
Q
"Is there a relationship between
diabetes and depression?"
A Read the following: "Low brain
serotonergic neurotransmission may account for mood disorders in children with
type 1 diabetes. Research in experimental animals suggests that type 1 diabetes
could diminish the functional activity of the serotonergic system. Children with
diabetes had significantly lower FFT than did normal children, and there was a
decrease in the FFT-to-neutral amino acids ratio in the children with type 1
diabetes.
The decrease of FFT in plasma with a concomitant decrease of the FFT-to-neutral
amino acids ratio suggests a decrease in the transport of the precursor amino
acids of the brain related to a decrease in its availability at the blood brain
barrier level that in turn may induce a decrease in the serotonin synthesis
rate, similar to that observed in the brain of diabetic rats.
The increase of the ASF slope in children with type 1 diabetes suggests that the
response of the auditory cortex to sound intensity stimulus may be regulated by
the serotonergic tone and that decreased serotonergic neurotransmission may
provoke a different behavior of sensory cortices.
They say their
findings may have clinical relevance, "because brain serotonin is known to play
an important role in the pathophysiology of various neuropsychiatric disorders
that are commonly present in patients with type 1 diabetes like anxiety and
depression."
Diabetes Care 2006;29:73-77.
January 23, 2006
Q "Do
people with seizures get more depressed than those who don't?"
A
A history of major depression and a past suicide attempt
increase the risk for unprovoked seizure and epilepsy. There
appears to be an underlying susceptibility to epilepsy and
major depression and suicidal behavior, which exists even
for idiopathic/cryptogenic epilepsy where environmental
causes are presumed absent. This decreases the likelihood
that our finding is explained by shared environmental risk
factors. Ann Neurol 2006;59:35-41.
January 16, 2006
Q "Do
rich folk get well quicker from depression or anxiety?"
A
Please review this: "Older adult residents of
low-income neighborhoods are less likely to respond to
antidepressant treatments and more likely to be suicidal
than those living in higher income neighborhoods...The
researchers assessed the relationship between the
socioeconomic status of subjects, determined by census data
on median annual household income in their residential area,
educational attainment, and treatment response.
The median times to response were 9.1, 7.0, and 7.4 weeks
among patients living in low-, middle-, and high-income
areas, respectively. Middle-income residents were
significantly more likely to respond to antidepressant
treatment than low-income residents ...Compared to the
low-income group, those in the middle- and high-income
groups were significantly less likely to report suicidal
ideation...it does suggest that the social worlds in which
people live influence the effectiveness of antidepressant
treatments even in the context of clinical trials in which
all participants receive the same high quality care...we
would find similar social inequalities in response to
treatment for many chronic diseases, for example, diabetes,
arthritis, and asthma."
Arch Gen Psychiatry 2006;63:50-56.
January 9, 2006
Q "My
husband needs to be on antidepressants, but I hear about
these law suits because someone killed themselves because
they were taking the medication."
A
Please review this: "Starting
treatment with a newer antidepressant does not increase the
risk of suicide attempts, according to results of a 10-year
population-based study. In fact, there appears to be a sharp
decline in risk during the first month of treatment, and a
gradual decline over the next 6 months.
Moreover, the risk associated with newer antidepressants
appears to be far lower than that observed when older
antidepressants are prescribed.
In March 2004, the US Food and Drug Administration issued a
public health advisory advising closer monitoring of
suicidality in patients treated with 10 newer
antidepressants (bupropion, citalopram, fluoxetine,
fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline,
escitalopram and venlafaxine).
Even though results of a meta-analysis suggest a higher risk
of suicidal behavior in adolescents starting treatment with
newer antidepressants, there are no data to support
higher risk among adults receiving the same treatment.
The highest risk of serious suicide attempt was observed in
the month before starting treatment, which fell by more than
one half in the month after starting medications and
declined progressively after that.
They also found that the risk of serious suicide attempt was
76 per 100,000 among those using drugs included in the FDA
warning, compared with 129 per 100,000 in those using other
drugs, primarily tricyclic antidepressants and trazodone...warnings
regarding suicide precipitated by antidepressants may do
more to discourage effective treatment than to improve the
quality of follow-up care." Am J Psychiatry
2006;163:41-47.
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