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Questions of the Week between January
and March, 2007 |
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March 24, 2007
Q
Our grandfather is very depressed. Are there any negatives to his taking
antidepressants?
A
There are several medical contraindications that you should explore, and you may
also find this helpful: "SSRI treatment may lead to apathy in depressed elderly.
Among depressed elderly patients, use of a selective serotonin reuptake
inhibitor (SSRI) may lead to apathy, despite improvements in depressive
symptoms.
These findings support research reported over the past decade that the use of
SSRIs may associate with the emergence of apathy. Using an apathy subscale the
researchers had developed based on the Geriatric Depression and the Hamilton
Rating Scales, they determined that 153 SSRI users were apathetic at admission
and 128 remained apathetic at discharge, while 214 patients who received other
antidepressants were apathetic at admission and 157 remained apathetic at
discharge.
While SSRI use was not a predictor of apathy at admission, it was at discharge.
The SSRI user group showed more patients with apathy than the non-SSRI user
group.
In both SSRI users and non-SSRI users, all apathy scores were lower at discharge
than at admission to the day hospital. Therefore, both SSRIs and non-SSRIs
appeared to be somewhat effective in treating the apathy of depression.
Patients and caregivers should be informed to be more aware of this potential
adverse effect when using SSRIs. Careful monitoring for apathy, and
consideration of switching antidepressant class in patients presenting with
apathy, should be undertaken in all patients receiving an SSRI."
Ann Gen Psych 2007;6:7.
March 17, 2007
Q
My daughter's baby is a very tiny baby (low birth weight). Are you aware of any
studies about psychological risks in such cases?
A
"Birth weight may be associated with the risk of depression in adulthood.
Prenatal care may be important for the development of good mental health, as
well as good physical health. Physicians should be aware that lower birth weight
may be a risk factor for depression later in life in women.
Among adult women, current symptoms of depression were strongly inversely
associated with birth weight. This association persisted after adjustment for
potential confounding factors.
Among adult men, there was no association between depression and birth weight.
When more stringent criteria were used to define depression, however, there
appeared to be a positive association between birth weight and greater symptoms
of depression in men.
The association between an indicator of poor fetal growth and future depressive
symptoms is not explained by maternal symptoms of depression or anxiety during
pregnancy. Further research in studies with detailed and repeated measurements
of markers for these different hormonal pathways is required to determine the
underlying mechanisms."
Am J Epidemiol 2007;165:575-582.
March 12, 2007
Q
What about managing pain in depressed people or depressions impact upon pain?
A
"Pain, through its interference with normal
activities, impedes recovery from depression in older adults. Patients with
higher levels of pain severity and work activity interference had blunted
improvements in depressive symptoms.
Pain interference had a greater effect on depressive symptoms than did pain
severity. Pain interference fully accounted for the moderating effects of pain
severity on changes in symptoms of depression over time in patients with major
depression.
The mere experience of pain may contribute to greater distress and depressive
symptoms both directly and indirectly via its impact on physical and
psychosocial functioning.
Dealing with severe pain may be distracting and hinder, both physically and
psychologically, the patient's ability to concentrate on a treatment regimen or
successfully engage in treatment visits."
J Am Geriatr Soc 2007;55:202-211.
March 5, 2007
Q
Any more recent data on depression and heart failure or cardiovascular disease?
A
"Clinical depression significantly raises the risk of death or CV
hospitalization in patients with heart failure independently of the syndrome's
severity. Being depressed isn't simply a marker for more severe disease.
"Depression is common in this patient population, and it carries its own
independent risk, even in these patients with significantly compromised hearts."
People who are depressed may be less active than others, more likely to smoke,
and less likely to comply with prescribed therapies. Depression has been
associated with increased sympathetic activity and platelet activation, reduced
heart-rate variability, and endothelial dysfunction.
Remarkably, the use of antidepressant medications elevated risk. Taking an
antidepressant may be a marker for chronic, recurrent, or treatment-resistant
depression."
Sherwood A, Blumenthal JA, Trivedi R, et al. Relationship of depression to death
or hospitalization in patients with heart failure. Arch Intern Med 2007;
167:367-373.
February 26, 2007
Q
My son is severely asthmatic and is having a difficult time coping. Any
thoughts?
A
Please do a search of psychological.com. You will
find numerous references to asthmatics and their adjustment difficulties.
Restrictive and obstructive lung dysfunction is associated with an increased
risk of mental health problems. Specifically, obstructive lung function was
associated with significantly lower overall well-being after adjustment for
differences in demographic characteristics. Significant associations were
observed between restrictive lung function and lower overall well-being, general
health, vitality, and self-control, and with higher depression subscale scores.
The mechanism underlying the association between lung function and mental health
problems is unclear. Lung function may lead to a decreased sense of well-being
as a result of physical limitations associated with physical disease. Even
patients who do not have limitations on functioning may experience subjective
distress over poor physical health, and this may lead to increased depression
and worry.
Am J Epidemiol 2007;165:383-388.
February 19, 2007
Q
You once said that people with personality disorders do not think of themselves
as crazy, but they drive others crazy. How true. So they do not
suffer at all?
A
They suffer not only emotionally, but physically "Research indicates that
children exposed in utero to cocaine exhibit behavior problems up to at least 7
years of age.
After controlling for time-varying covariates (including ongoing caregiver use
of legal and illegal substances), demographic factors, family violence, and
caregiver psychological distress, there was found an association between high
prenatal cocaine exposure and the trajectory of internalizing, externalizing,
and total behavior problems.
Prenatal and postnatal exposure to tobacco and alcohol were also significantly
associated with total behavior problem trajectories through age 7 years.
Caregiver depression and physical or sexual abuse were independently associated
with all behavior problems."
Pediatrics 2007;119:e348-e359
February 12, 2007
Q
Can you not just talk someone out of being a hypochondriac?
A
Hypochondriasis is a (one of the) somatoform disorders. You cannot talk
someone out of their belief that they are physically ill.
"Cognitive
behavior therapy and Paxil are both effective short-term treatments for patients
with hypochondriasis. In a Dutch study, pooled analysis indicated that the
treatment response of patients who received cognitive behavior therapy (p =
0.001) or paroxetine (p = 0.03) was significantly better than those assigned to
placebo.
The analysis showed that 45% of the patients in the cognitive behavior therapy
group responded, compared with 30% of those in the paroxetine group and 14% of
those in the placebo group.
"After these treatments, subjects appeared to be less frequently and intensively
preoccupied with their fears of having a serious disease and also had less
associated depressive, anxious, and psychoneurotic symptoms."
The researchers suggest that further research investigate the durability of
these responses to get a better picture of the effectiveness of the treatments,
the researchers add."
Am J Psychiatry 2007;164:91-99.
February 5, 2007
Q
Can depression disable a person from working?
A
It can impact the quality of work. A "study assessed
the relationship between depression severity and job performance among employed
primary care patients. At baseline and each follow-up, the depression group had
significantly greater deficits in managing mental-interpersonal, time, and
output tasks, as measured by the Work The rheumatoid arthritis group's deficits
in managing physical job demands surpassed those of either the depression or
comparison groups. Improvements in job performance were predicted by symptom
severity. However, the job performance of even the "clinically improved" subset
of depressed patients remained consistently worse than the control groups.
Multiple dimensions of job performance are impaired by depression. This impact
persisted after symptoms have improved."
January 29, 2007
Q
For anxiety disorders, which is more effective behavioral therapies or cognitive
behavioral therapies?
A
Current evidence suggests that for treatment of generalized anxiety disorder
(GAD), cognitive behavioral therapy (CBT) is effective. Still, the evidence
supporting CBT over other psychotherapy was weak.
CBT facilitates the identification of irrational, anxiety-provoking thoughts,
and challenges these negative automatic thoughts and dysfunctional underlying
beliefs through collaborative 'hypothesis-testing', using...diary-keeping and
validity-testing of beliefs between sessions, and skills training within
sessions.
When compared with treatment as usual, CBT was more effective in reducing
anxiety. CBT also decreased symptoms of worry and depression, and improved
social functioning and quality of life. Only when treatment sessions exceeded
eight, did CBT reduce worry, depression, and fear, compared with supportive
therapy. The one trial of psychodynamic therapy indicated better response to CBT.
January 22, 2007
Q
Women make more suicidal attempts, right, and men are more successful at
completing the suicidal act?
A
"Clinical predictors of suicidal acts after major depression differ between men
and women. Studies have shown that men have higher suicide rates, while women
are at higher risk for suicide attempts.
For men cigarette smoking and family history of suicidal acts emerged as the
most robust predictors of future suicidal acts, but early separation from
family, borderline personality disorder, and past drug abuse were no longer
predictive.
For women, previous attempts, suicidal ideation, and smoking had independent
effects on the risk for suicidal acts. The presence of multiple suicide
attempts, borderline personality disorder, greater subjective depression, fewer
perceived reasons for living, and hostility were no longer significant."
Am J Psychiatry 2007;164:134-141.
January 15, 2007
Q I
read that Iraq war vets who have PTSD have a higher physical pain threshold. Is
that accurate?
A
You may want to read a recent article "Military
veterans with posttraumatic stress disorder (PTSD) show reduced pain sensitivity
compared with healthy controls, and altered pain processing may be responsible,
according to findings from a functional imaging study.
Previous studies have yielded conflicting results regarding pain perception in
PTSD patients, with some showing increased sensitivity and others showing the
opposite.
12 male veterans with PTSD and 12 matched veterans without PTSD who underwent
functional MRI. During imaging, fixed and variable temperatures were applied to
the subjects' hands and they were asked to rate the pain experienced.
When exposed to the same temperatures, PTSD patients rated them as being less
painful than did controls. Similarly, the temperatures that elicited the same
subjective pain rating were higher in PTSD than in controls.
During fixed-temperature testing, PTSD patients displayed increased activation
in the left hippocampus and decreased activation in the right amygdala and the
bilateral ventrolateral prefrontal cortex. During variable temperature testing,
heightened activation in the right putamen and bilateral insula were noted along
with decreased activation in the right amygdala and right precentral gyrus.
All of these brain regions are associated with cognitive and affective pain
processing.
The neural pattern with decreased activity in the right amygdala and the
bilateral ventrolateral prefrontal cortex may reflect altered pain regulation
mechanisms in patients with PTSD."
January 1, 2007
Q
Have you head of sleep eating disorder (or something like that) where a person
wakes up and eats at night. What is used to treat that?
A
You may want to read a recent article (J
Clin Psychiatry 2006;67:1729-1734 "Topiramate
is safe and effective in the treatment of sleep-related eating disorder (SRED).
SRED is a behavioral disorder combining the repetitive nocturnal awakenings of a
sleep disorder with the driven, compulsive eating of a daytime eating disorder.
Sleep-related eating disorder is characterized by partial or full awakenings
from sleep with compulsive eating, usually of high-calorie foods."
Overall, 30 patients were prescribed topiramate. Of these, 25 had at least one
post-baseline follow-up appointment. The mean age of these 25 patients was 44
years, and 76% were female. The mean age at onset of SRED was 25.2 years. Before
starting topiramate, all patients experienced nocturnal eating on a nightly
basis, and most had multiple episodes of eating per night. The mean dose of
topiramate was 135 mg over a mean of 11.6 months.
68% of 25 patients were considered responders, 7 (28%) of 25 were unchanged, and
1 (4%) of 25 was worse," Dr. Winkelman writes. "Twenty-eight percent (7/25) of
patients lost greater than 10% of body weight.
Twenty-one patients (84%) reported adverse events. The most common adverse
events were paresthesias (20%), excessive daytime sleepiness (16%), and sexual
dysfunction (12%). There were no serious adverse events. Forty-one percent (7 of
17 patients) of responders discontinued topiramate after a mean of 12.4 months.
Topiramate was found to be of substantial benefit in patients with SRED in this
open-label case series, though adverse events limited its tolerability."
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