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QUESTION OF THE WEEK |
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March 31, 2008
Q "My
teenager has that typical sleep pattern of going to be late and then sleeping
either until the following afternoon or sometimes only for a few hours. I
know that he does not need the sleep of a small child, but I think he needs more
than he is getting."
A
"A new study suggests that insomnia among
adolescents in the United States is chronic and common, with a prevalence that
is as high as or higher than that of other (disorders), including major
depression, generalized anxiety, conduct disorders, and substance abuse.
The investigators also found the impact of insomnia on adolescents compared with
their nonsleep-deprived counterparts was profound.
Kids' chronic insomnia was much more likely to have all types of negative
sequelae and had more physical and psychological health problems, difficulties
with interpersonal relationships, and more problems with daily activities.
...chronic nonrestorative sleep posed the greatest risk for poor outcomes at
1-year follow-up. This was followed by chronic difficulty initiating sleep...
chronic insomnia may be the underlying cause, rather than the consequence, of
health, psychological, or behavioral problems in adolescents.
Previous recent research by his group has shown that chronic sleep deprivation
is common among youth, with 25% of individuals reporting they get 6 or fewer
hours of sleep per night. In contrast, research from sleep studies indicates
that adolescents, just like children, need 9 or more hours of sleep per night.
During adolescence children's circadian rhythms change, causing them to stay up
later and sleep later. While the majority of youth go to bed later once they hit
adolescence, the demands of daily life do not allow them to sleep later.
...primary care physicians and parents should also screen adolescents for
potential sleep disturbances and encourage them to practice proper sleep
hygiene. In cases of chronic insomnia, cognitive behavioral therapy, which has
been shown to be effective in adults, may also help young patients.
J Adolesc Health. 2008;42:294-302. Abstract
March 24, 2008
Q "Do
people differ in their tendency to develop PTSD after trauma?"
A
Yes, among other factors: "A new study reports that the development of adult
posttraumatic stress disorder (PTSD) can involve a significant interaction
between childhood abuse and variants of FKBP5, a gene that regulates
glucocorticoid activity.
In the face of...trauma exposure, people develop a disorder that involves not
being able to turn down their fear response. On average, up to about 70% of the
US population is exposed to at least 1 traumatic event in their lifetime
FKBP5 was a good candidate for PTSD association because of its involvement in
the human stress response. Normal FKBP5 expression is induced by glucocorticoids.
It is part of a negative feedback loop, preventing activation of additional
glucocorticoid receptors (GRs) and turning them back down. When FKBP5 is
overexpressed, the receptors are more resistant to glucocorticoid binding. At
least 2 FKBP5 SNPs have been associated with peritraumatic dissociation in
children after medical trauma.
Results support a developmental effect on the consequences of FKBP5 expression
for GR sensitivity. The study indicates that information about FKBP5
polymorphisms and childhood abuse can predict the severity of adult PTSD
symptoms."
JAMA. 2008;299(11):12911305.
March 17, 2008
Q "Is
there a direct relationship between things like cholesterol and depression?"
A
Not direct in the sense that high cholesterol invariably leads to depression,
but "Metabolic syndrome may be a "predisposing factor for the development of
depression. Non-depressed subjects at baseline with metabolic syndrome were
twice as likely as subjects without metabolic syndrome to have symptoms of
depression at follow-up 7 years later.
The increasing incidence of metabolic syndrome suggests that the incidence of
depression may rise accordingly. Effective prevention and treatment of the
metabolic syndrome may, in turn, reduce the incidence of depression." J
Clin Psychiatry 2008;69:178-182.
March 10, 2008
Q "Do
anorexics eventually wind up starving to death...is that how they die?"
A
"A study of 9 case reports of anorexic patients who died by suicide found that
death was a result of using highly lethal methods rather than the result of
compromised health.the Journal of Affective Disorders.
...findings support the hypothesis which suggests that anorexic individuals may
become accustomed to pain during the course of their illness and die by using
methods that are highly lethal.
Anorexia nervosa is associated with 1 of the highest premature death rates of
all mental disorders, and suicide is a leading cause of death among individuals
(mainly women) who are anorexic, the group writes.
This high rate of death by suicide might be the result of weak suicide attempts
combined with fragile medical health. Alternatively, suicidal anorexic patients
might use highly lethal methods with low rescue potential, which would kill even
healthy individuals.
The study results show that anorexic individuals who attempt suicide have a
strong wish to die and engage in an act of self-injury with a very high
likelihood of death.
These findings support Dr. Joiner's theory of suicidal behavior that suggests
that individuals with anorexia may habituate to the experience of pain as a
result of their illness (such as starvation pain and frequent chest pain) and
die by using extreme suicide methods."
J Affect Disord. 2008;107:231-236.
March 3, 2008
Q "Antidepressants cure obsessive
compulsive patients, right?"
A Modest improvement: "Selective serotonin-reuptake inhibitor (SSRI)
antidepressants were almost twice as likely as placebo to confer modest
improvement in symptoms of obsessive-compulsive disorder (OCD) among patients
who responded to treatment in 17 short-term studies published from 1989 to 2004.
The 5 SSRIs that were examined citalopram (Celexa, Forest Pharmaceuticals),
fluoxetine (Prozac, Eli Lilly), fluvoxamine (Luvox, Solvay Pharmaceuticals),
paroxetine (Paxil, GlaxoSmithKline), and sertraline (Zoloft, Pfizer) appeared
to be equally effective, although individual drugs had different adverse
effects, most commonly nausea, headache, and insomnia.
This systematic review provides evidence that SSRIs are moderately effective, at
least in the short term, in adults with OCD of varying duration. However,
treatment decisions need to take into account the potential adverse effects with
SSRIs, and in some patients, alternative treatments such as cognitive behavioral
therapy may need to be considered, they note.
The necessary duration of SSRI treatment in OCD and the long-term outcomes
remain to be determined.
The investigators determined that if 10% of OCD patients might be expected to
recover without treatment (a very conservative estimate), then 12 patients would
need to be treated with SSRIs to achieve improvement for 1 additional patient.
Assuming that 20% of patients might recover without treatment (a conservative
estimate), then 6 patients would need to be treated for 1 to improve.
Adverse effects most commonly nausea, headache, and insomnia were
significantly worse with an SSRI than with placebo. Other commonly reported
adverse effects included dyspepsia, diarrhea, constipation, anxiety, fatigue,
sedation, somnolence, asthenia, and forgetfulness.
The effect of SSRIs in achieving improvement of OCD symptoms is modest, and the
clinical utility of these interventions should be weighed against the adverse
effects, particularly those that impact on quality of life, such as sexual
adverse effects," the group summarizes."
February 25, 2008
Q "My
mother is increasingly arthritic, and we also believe that she is depressed.
Is this a common overlap?"
A
"While patients with rheumatoid arthritis (RA),
especially those whose activities are more restricted due to their RA, may have
depressive symptoms, few depressed patients discuss their condition with their
rheumatologists. Depression is common among patients with RA, with a prevalence
of 15-20%, and patients with RA are twice as likely as members of the general
population to experience depression."
Rheumatologists could ask RA patients if they are experiencing depressive
symptoms during visits or their office staff could conduct a brief screening for
depression using an instrument like the Patient Health Questionnaire before the
patient's visit, and the rheumatologist could discuss the results with patients
if needed.
There is often a stigma attached to depression which prevents individuals from
discussing how they feel with family, friends, or physicians, but if individuals
do not talk about it, it prevents them from getting treatment that may help
them."
Arthritis Rheum 2008;59:186-191
February 18, 2008
Q "Are
there any benefits to limited exercise in chronic pain patients?"
A
"Physical conditioning in chronic pain patients can
have immediate and long-term benefits.
A frequent comorbid condition of chronic pain is profound physical
deconditioning, which results from inactivity. People with chronic pain don't
want to exercise the main reason is that they are in so much pain.
Decreases in pain, depression, and anxiety following treatment in a pain
rehabilitation program have been well documented.
On average, patients received 5 hours of conditioning per week, in addition to
routine daily activities. Results demonstrated significant short- and long-term
benefits of exercise. Patients showed a statistically significant reduction in
exercise-induced cardiac acceleration from admission to 3 weeks. The brief
exercise protocol also produced significant immediate antidepressant and
anxiolytic effects. The research suggests that relatively modest exercise leads
to improved mood and physical capacity, which has further implications for
mortality risk. The review also suggests that brief exercise is a safe,
cost-free, nonpharmacologic strategy for immediately reducing depression and
anxiety."
American Academy of Pain Medicine 24th Annual Meeting.
February 11, 2008
Q "We
have a child with school phobia which he expresses with a combination of
headaches but mostly stomach aches. Read any research on this?"
A
"A review of 6 small trials of cognitive behavioral therapy (CBT) vs other
interventions for recurrent abdominal pain suggests that most children are
likely to improve with reassurance and time, but CBT might be warranted for
children with severe or continuing problems. Evidence for the effectiveness of
CBT is relatively weak, since the studies were small and had methodological
flaws.
The most important finding here is that there seems to be some evidence of
benefit of psychosocial interventions in reducing the pain of school-age
children with recurrent abdominal pain.
Recurrent abdominal pain is very common in children, and between 4% and 25% of
school-age children complain of pain that is severe enough to interfere with
daily activities, the group writes. The abdominal pain is often accompanied by
headaches, limb pain, pallor, and vomiting.
In most cases, no organic causes can be identified, and the etiology of the pain
remains unclear. Child temperament along with anxiety in parents is a strong
predictor of this problem. Food allergies and a low-fiber diet have been
suggested as possible causes, and some authors recommend dietary manipulations.
A variety of drugs, including sedatives, have occasionally been used. But most
clinicians continue to view this as a psychogenic problem, and many children
receive psychological interventions. In recurrent abdominal pain cases, there is
evidence that the pain is real although the main organic cause is still not
clear, it seems that there is an important mental component."
Most of the body's serotonin is in the nerves of the bowels, not the brain, so
problems with this system could be a factor in recurrent abdominal pain of the
"abdominal-migraine" type."
Cochrane Database Syst Rev. 2008;(1):CD003014.
February 4, 2008
Q "What about those who do not want to
take medication but have obsessive-compulsive disorder? Are there
alternatives?"
A
"Breast cancer patients who were randomized to a
program of psychological intervention had significantly better health a year
later than those who did not follow such a program.
Patients who participated in the program showed fewer and less severe symptoms,
and functioned better than those who didn't take part.
Women participating in the program improved their physical functioning by 7%,
compared with only 1% in the control group. They also reported a 29% decrease in
disease symptoms and signs and adverse treatment effects, compared with only 14%
in the control group.
In addition, the researchers found a significant association between exercise
and the dose of taxanes tolerated. The actual dosage differences were
substantial. Women who exercised frequently received a significantly higher
proportion of taxanes compared with women who exercised less or not at all. Post
hoc analysis showed that the women tolerating the higher doses were exercising 4
times a week or more.
The relaxation had huge positive effects and it is an easy technique to master.
More frequent use of progressive muscle relaxation was associated with a lower
level of emotional distress. More frequent use of dietary strategies was
associated with greater positive change in patients' food habits. Multiple
strategies using conceptualization to understand daily stressors, relaxation,
communicating needs to medical providers, and increasing physical activity
(exercise) were all associated with a reduction in symptoms, signs, and
cancer-treatment toxicities. Finally, of the patients receiving taxane-based
chemotherapies, those increasing their activity level the most received a
significantly higher relative dose intensity than women exercising less (or not
at all)."
J Consult Clin Psychol. 2007; 75:927-938.
January 28, 2008
Q
"What about those who do not want to take medication but have
obsessive-compulsive disorder? Are there alternatives?"
A
"In a small study of 10 patients with
obsessive-compulsive disorder (OCD), just 4 weeks of intensive cognitive
behavioral therapy resulted in significant changes in activity in certain
regions of the brain.
In addition to having significant declines in bilateral thalamic activity, the
patients had significant increases in right dorsal anterior cingulate cortex
activity that correlated with improvement in OCD symptoms.
This study tells us more about how cognitive behavioral therapy works for OCD
and shows that both robust clinical improvements and changes in brain activity
occur after only 4 weeks of intensive treatment.
Clinical response to OCD symptoms usually requires up to 12 weeks of treatment
with serotonin-reuptake inhibitors (SRIs) or standard weekly outpatient
cognitive behavioral therapy, little is known about the brain's response to
cognitive behavioral therapy in OCD.
Brief, intensive, daily cognitive behavioral therapy (specifically, exposure and
response-prevention therapy) has been shown to be effective in 60% to 80% of OCD
patients in as little as 4 weeks, with a symptom improvement of 50% to 80%.
After 4 weeks of treatment, the patients showed robust improvements in OCD
symptoms, depression, anxiety, and overall functioning, and they had significant
changes in regional cerebral glucose metabolism. Nine of the 10 patients met
criteria for treatment response.
The OCD patients had significant changes in brain activity after just 4 weeks of
intensive cognitive behavioral therapy, much faster than previously seen with
SRI treatment or standard weekly cognitive behavioral therapy. This brief
intervention resulted in a unique pattern of changes in normalized regional
glucose metabolism."
A reduction in thalamic activity may be a final common pathway for improvement
of OCD symptoms in response to a variety of treatment modalities. Response to
intensive cognitive behavioral therapy may require activation of the dorsal
anterior cingulate cortex, a region involved in the reappraisal and suppression
of negative emotions."
Mol Psychiatry. Published online January 8, 2008.
January 21, 2008
Q "Our son is in Afghanistan, but
he is in communications, not combat. He seems extremely agitated, and we
wondered if he could have some disorder arise even though not in combat."
A "US soldiers who are deployed overseas and face combat have a
3-fold increased risk of developing posttraumatic stress disorder (PTSD)
compared with their nondeployed colleagues, a new study shows.
There is a 3-fold adjusted increase in risk of new-onset self-reported symptoms
of posttraumatic stress disorder among those who were deployed and who also
report combat exposures compared with nondeployed cohort members.
The findings define the importance of posttraumatic stress disorder in this
population and emphasize that specific combat exposures, rather than the
deployment itself, significantly affect the onset of symptoms of posttraumatic
stress disorder after deployment.
Mental health issues among soldiers are on the minds of many Americans as
fighting continues in Iraq and Afghanistan. The unpredictability and intensity
of urban combat, constant risk of roadside bombs, multiple and prolonged tours,
and complex problems of differentiating enemies from allies can leave many
troops with high stress levels and possible lasting health consequences.
New-onset self-reported symptoms of PTSD were proportionately higher among
women, younger soldiers, those who had less education, those who had never
married, and in smokers and problem drinkers.
PTSD among soldiers is not a new phenomenon. It has been reported in as many as
30% of Vietnam veterans and in more than 10% of military personnel after
returning from the 1991 Gulf war."
BMJ. Published online January 15, 2008. Abstract
January 14, 2008
Q "What
sort of things can you use biofeedback for? ....just headaches?"
A
In older women with urge urinary incontinence (UI), biofeedback therapy improves
not only symptoms of incontinence but also psychological outcomes, especially in
patients with a history of depression.
Psychological factors are relevant outcome measures for UI, and these data
suggest that focusing on UI frequency alone may have underestimated
biofeedback's efficacy and additional therapeutic benefits.
For the group as a whole, biofeedback significantly improved incontinence
frequency by 45%. It also improved psychological burden by 15.8 points, or
22.4%, on the Urge Impact Scale, the team reports in the December issue of the
Journal of the American Geriatric Society.
Improvements in UI frequency were similar for both subgroups, but improvement in
psychological outcomes was roughly twice as great in women with a history of
depression, particularly on the perception of control subscale. Psychological
improvement was not related to baseline depressive symptoms.
J Am Geriatr Soc 2007;55:2010-2015.
January 7, 2008
Q
"I told my wife she should discontinue her (mood stabilizing agent for bipolar
disorder) since we have learned she is pregnant."
A
She should be discussing this with her OB-Gyn and
mental health provider. Please read this: "In a prospective observational study
of 89 pregnant women with bipolar disorder, 71% had at least 1 mood episode
recurrence during pregnancy. Compared with the women who continued taking mood
stabilizers, those who stopped this treatment had a 2-fold higher risk for mood
relapse, a 4-fold shorter time to relapse, and a 5-fold greater amount of time
spent ill during pregnancy.
The findings challenge the evidently common practice of abruptly stopping
maintenance treatment for psychiatric disorders during pregnancy, given the high
morbidity associated with discontinuation of mood stabilizing treatment and its
uncertain impact on fetal development, a more balanced consideration of risks
and benefits in the clinical management of pregnant women with bipolar disorder
is recommended.
Women with bipolar disorder who become pregnant encounter several obstacles to
care, including "extraordinary knowledge gaps" about the course of the illness
during pregnancy, predictors of recurrence, and reproductive safety data for
mood stabilizers, the group writes.
During pregnancy, 70.8% of the women in this study experienced at least 1
episode of bipolar disorder. Compared with the women who continued taking a mood
stabilizer, those who discontinued this treatment had a 2-fold greater risk for
recurrence and a more than 4-fold shorter time to a new episode of bipolar
disorder."
Am J Psychiatry. 2007; 164:1817-1824, 1771-1773.
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