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Atlanta Medical Psychology
The clinical practice of Dr. David B. Adams is located in The Medical Quarters in the northside of Atlanta at the junction of Scottish Rite, Northside and Saint Joseph's Hospitals. Dr. Adams consults to occupational medicine, surgeons, nurse case managers, insurers and employers regarding the psychological impact of work-related injury and the role of psychological factors in short- and long-term disability. 

Q "With the media covering the mother's recent murder of her children, I wondered what some of the current thinking on depression after giving birth?"

A Treatment with 17ß-estradiol can rapidly reduce severe postpartum depression in estrogen-deficient women, according to Finnish researchers.

In spite of multiple contacts with health providers, women with postpartum depression often remain unrecognized and untreated.

Within the first week of the 8-week treatment period, depressive symptoms diminished significantly and serum estradiol concentrations increased. By the end of the second week, depression rating scores were compatible with clinical recovery in 19 of the patients studied.

By correcting the hormonal balance with physiologic...estrogen, a quick effect on mood improvement may be reached in a group of young mothers vulnerable to depression.

J Clin Psychiatry 2001;62:332-336.

Q "Do they ever use hypnosis rather than epidurals to reduce the pain of childbirth?"

A: Self-hypnosis during childbirth may ease some of the pain of labor, lower the risk of medical complications and reduce the need for surgery, study results suggest.

Hypnotherapy has been shown to reduce pain and the need for anesthesia, as well as ease anxiety and fear during childbirth, Dr. Paul G. Schauble and colleagues note in the Journal of Family Practice for May. The use of hypnosis during pregnancy to prepare women for delivery may be key since it gives them a sense of control, they say.

To investigate, the researchers, who are at the University of Florida in Gainesville, assigned 42 pregnant teenagers to receive either counseling or four sessions of instruction in self-hypnosis for childbirth. Teens in the hypnosis group learned deep relaxation and imagery techniques to help them cope with pain. They also received suggestions to help them respond to possible complications and boost their confidence in their ability to manage anxiety.

According to the report, only 1 of 22 patients in the hypnosis group remained in the hospital longer than 2 days after delivery, compared with 8 of 20 patients who did not learn self-hypnosis. None of the patients in the hypnosis group needed surgical intervention, compared with 60% of those in the non-hypnosis group.

In addition, fewer patients in the hypnosis group experienced complications such as high blood pressure or vacuum-assisted delivery, opted for medical anesthesia or oxytocin, or required medication after delivery.

"This study provides empirical data demonstrating that the use of hypnosis in preparing pregnant women for labor and delivery reduces the risk of complications, decreases the need for medical intervention...and promotes safer, more comfortable delivery for mother and child. We anticipate this will lead to a reduction in the costs involved in childbirth."

J Fam Pract 2001;50:441-443.

Q "Of those with depression, how many seek care...or do they try to ignore it?"

A  Less than 20% of the millions of American adults who have experienced clinical depression or anxiety have ever been treated for the disorders. In total, 93% of undiagnosed people in  a recent study "do not associate their symptoms with a mental health disorder," despite the fact that 44% of people in this group say that their symptoms cause them "significant emotional pain and restricted functioning," in daily life, the researchers noted. Close to half (44%) of those who would not seek diagnosis or therapy believe they can treat themselves. Among this group, remedies include prayer (41%), rest (38%), exercise (37%), sleep (31%), or emotional support from family and friends (31%). Receiving a diagnosis of depression or anxiety is shameful to many Americans, according to the researchers. Forty-two percent of people with a formal diagnosis of depression or generalized anxiety disorder report being embarrassed by their symptoms compared with 17% of those who have never been diagnosed. Only 45% of those who have been diagnosed with the disorders expect their treatment will provide even initial symptom relief.

Q "Was there not something about a "notch gene" that causes schizophrenia?"

A Previous evidence linking the NOTCH4 gene with schizophrenia was not replicated in other populations, according to two reports in the June issue of Nature Genetics.

Linkage disequilibrium mapping was used in an earlier study to identify a putative link between NOTCH4 and schizophrenia in 80 British parent-offspring trios. NOTCH4 belongs to a family of genes involved in determining cell fate.

No new study found any evidence for an association between NOTCH4 and schizophrenia. In fact, each putative schizophrenia-associated allele had a somewhat lower frequency among schizophrenics than among controls.

There is not a general risk conferred by these markers to all schizophrenics of the magnitude originally found.

Nat Genet 2001;28:126-129

Q "Depression is chemical is it not? So it really does not matter what happens in life...you either get depressed or you don't, right?"

A This overview may be helpful to you. "Our concept of the etiology of depression has changed from very simplistic models to complex ones. It is becoming increasingly evident that depression is a heterogeneous, systemic illness, involving an array of different neurotransmitters, neurohormones, and neuronal pathways. The notion that depression is the result of a simple hereditary process or traumatic life event that ultimately leads to a single neurotransmitter deficiency is simply unsubstantiated by the evidence.

It is now assumed that depression may result from a complex interaction between genetic predisposition to the illness and early untoward life events such as child abuse or neglect. Such interactions undoubtedly induce significant changes in the CNS. Specifically, these interactions result in hyperactive CRF and NE systems, which are the main moderators of the stress response. The CRF and NE systems exert wide influences on multiple regions of the CNS, as well as the periphery, via the HPA axis and the autonomic nervous system. These neurobiological perturbations may persist into adulthood, leading to a hypersensitive stress response system, which overreacts to all forms of stress in adults, including mild stress or daily life events. It is hypothesized that this hypersensitive stress response system underlies, in part, the neurobiological vulnerability to depression and anxiety. After exposure to repetitive or chronic stress, genetically vulnerable individuals likely develop mood and/or anxiety disorders. The current limitations of this theory are that many depressed patients apparently lack 1 of the above-mentioned risk factors (ie, genetic predisposition or early trauma).

There are many neurobiological substrates for depression that we have not reviewed. Research has provided evidence about the potential role of substance P, a neuropeptide, in the pathogenesis of depression. Moreover, there is some evidence supporting a role of dopamine circuit dysfunction in depression.Interestingly, nomifensine, a selective dopamine reuptake inhibitor, was an effective antidepressant, but was removed from the market because of an unacceptably high rate of hemolytic anemia in a small number of patients. Also, several studies have documented that increased cholinergic activity might be associated with depressed mood; however, the role of acetylcholine in the development of depression remains obscure. Because neurotransmitters ultimately produce their effects via alterations in intracellular mechanisms, such as second messengers and neurotropic elements (factors and gene expression), these factors have received more attention in the last decade.

The new findings in the neurobiology of depression have led to a better understanding of the action of antidepressants, which have been found to return the alterations of the CRF system back to normal. Also, there has been an active search for newer agents to target the newly discovered neurotransmitters. Novel agents, such as CRF receptor and NK-1 antagonists, are still experimental, but they hold promise for a better antidepressant treatment, especially for refractory patients, and they have a more tolerable side-effect profile compared with that for the currently available agents.

The new discoveries regarding the "stress-diathesis model" of depression have stimulated renewed interest in the paramount role of child abuse and other early untoward life events in the pathogenesis of depression. Because multiple studies have shown the long-term deleterious effects of early trauma on vulnerability to depression, and because child abuse is tragically a common societal problem (at least 1 million cases verified each year in the US), identification of and intervention for such vulnerable individuals is an important goal."

May 20, 2001

Q "I am nervous almost all the time...have been for as long as I can remember. I am wondering if this is common and what can be done."

A There is a condition called generalized anxiety disorder. Patients with generalized anxiety disorder experience worry or anxiety and a number of physical and psychologic symptoms. The disorder is frequently difficult to diagnose because of the variety of presentations and the common occurrence of comorbid medical or psychological conditions. 

The lifetime prevalence is approximately 4 to 6 percent in the general population and is more common in women than in men. It is often chronic, and patients with this disorder are more likely to be seen by family physicians than by psychologists. 

Treatment consists of pharmacotherapy and various forms of psychotherapy. The benzodiazepines (Valium, Ativan, etc) are used for short-term treatment, but because of the frequently chronic nature of generalized anxiety disorder, they may need to be continued for months to years. Buspirone (BuSpar) and antidepressants (e.g. Paxil, etc) are also used for the pharmacologic management of patients with generalized anxiety disorder. Patients must receive an appropriate pharmacologic trial with dosage titrated to optimal levels as judged by the control of symptoms and the tolerance of side effects. Psychiatric consultation should be considered for patients who do not respond to an appropriate trial of pharmacotherapy. (Am Fam Physician 2000;62:1591-600,1602.)

Q:  "Is PMS really a disorder or is it my wife's excuse for being bitchy?"

A: Whether premenstrual dysphoric disorder (PMDD) is a real disease or diagnostic label for normal phenomena has been a subject of hot debate. Two new studies using strict criteria to determine the prevalence of PMDD suggest two things: It is real, and it is significantly disruptive in some women's lives.

PMDD is a severe form of PMS, and patients typically have symptoms suggestive of depression, anxiety, or other psychiatric conditions. The condition affects almost all menstrual cycles and complicates normal daily functioning in patients.

The two studies -- one of younger women and one of older -- appear to indicate that the conventional prevalence estimates of 3-5% are roughly correct. 

One study of 513 women aged 36-44 showed that 33 (or 6.4%) met criteria for the disorder listed in the APA's Diagnostic and Statistical Manual. 

PMDD was associated with lower education, a history of major depression, current cigarette smoking, and working outside the home.

Because the study only looked at older premenstrual women, the prevalence may have been slightly higher than what actually exists. In addition, subjects in the study were followed for only a month.

Preliminary findings from another study of PMDD among females aged 13-55 showed a lower prevalence. Of 430 subjects studied, just seven -- or less than 2% -- met criteria for a diagnosis of PMDD, according to the survey sponsored by the National Institute of Mental Health.

Of the 423 women in the sample who did not meet criteria for a diagnosis, 73% said they were less productive and efficient at home, 68% said their symptoms interfered with their ability to get things done at home, and 64% said their symptoms interfered with relationships at home.

Smaller but still significant percentages of women not meeting criteria for a diagnosis of PMDD said their symptoms interfered with social activities, ability to do their work, or with relationships at work.

By distinguishing true PMDD from chronic depression and anxiety, physicians can tailor therapy to their patients. Specifically, they should try a course of antidepressants for the 14-day period prior to menses, for two or three cycles.

May 6, 2001

Q "My husband quit smoking with ease. I am having a terrible time. My best friend and her husband showed the same pattern. Do women have a more difficult time quitting?"

A A number of medical and social factors combine to make it more difficult for women to quit smoking than men.

In the May issue of CNS Drugs, data show that the "benefit from nicotine replacement is not as great in women as it is for men."

Medications that are not nicotine replacement therapies, such as clonidine, bupropion and mecamylamine, may produce comparable smoking cessation rates between women and men, he notes.

Among the other factors that make it harder for women to stop smoking is fear of gaining weight and antismoking medication restrictions during pregnancy. In addition, the effects of antismoking drugs and smoking withdrawal can have a negative impact during menses.

Women are less likely to receive social support that fosters smoking cessation and are more susceptible to the influence of smoking-associated environmental cues, such as smoking with friends or being in a specific mood.

Particularly, women need to learn coping strategies to deal with socially conditioned cues that are barriers to quitting. Although one may handle the nicotine withdrawal reasonably well with gums and patches, something still needs to be done for all the condition cues that make quitting smoking difficult. Since these are probably more important for women than men, women are at a disadvantage.

CNS Drugs 2001;15:391-411.

Q "My daughter is bulimic, and my son has been diagnosed with borderline personality disorder. He has been doing very well in DBT; would this work for my daughter?"

A Dialectical behavior therapy, a form of therapy originally developed to treat parasuicidal behavior in patients with borderline personality disorder, also seems to help bulimics break out of the binge/purge cycle. Although not effective in all bulimic patients, it significantly reduces binge/purge episodes, according to a report in the April issue of the American Journal of Psychiatry.

Dialectical behavior therapy, or DBT, says that binge eating is a way of dealing with unbearable feelings. It teaches new ways to control and manage emotions, replacing dangerous behaviors with much healthier options. It's a way of distracting oneself, it's a behavior that regulates [mood]. According to this therapy, an inability to self-soothe is at the core of bulimia.

People who display parasuicidal behavior hurt themselves to feel better, and there seems to be a direct analogy between those behaviors and binge eating. Bulimics are using food to avoid painful emotional states.

In fact, many bulimics report entering a detached, trancelike state while binging and purging. 

In DBT, patients are not told that their feelings are wrong, but rather that they need to find a more positive way to manage them. They learn mindfulness -- stepping back and being conscious of the moment without judging it as good or bad -- and other emotion-regulating skills, so that their feelings have less influence on their behavior.

They also learn distress tolerance -- coping with situations as they are -- and methods of self-soothing and distraction, and they practice these skills until they replace the automatic binge/purge response.

After 20 weeks, 28.6% of women in the DBT group had stopped binging and purging completely, while 35.7% reported significant reductions (88%) in the frequency of binge/purse episodes. Five patients continued to fulfill criteria for bulimia nervosa.

Bulimics do not have skills for dealing with their emotions. Food is used to create walls because they don't have a way to let what is going on outside while remaining calm inside.

The first important skill to learn is stepping back from whatever is so overwhelming and just looking at it without engaging in compulsive behaviors to avoid it.

Q "My wife's sex drive has really decreased since she has been taking anti-depressants. I have never heard of this side effect."

A  As many as half of patients taking SSRIs have resultant sexual dysfunction. A report in the March Journal of Clinical Psychiatry indicates that sustained-release bupropion (Wellbutrin SR) may be an effective antidote.

You can interfere with sexual function by interfering with serotonin tone. With SSRIs you make the system more active. Bupropion works in the dopamine system, which is linked to desire.

Bupropion tends to be a well-tolerated medication. Sometimes it makes patients a bit jittery, sometimes gives them headaches, but it does treat sexual dysfunction well under the dose at which one sees an increased incidence of seizure.

April 16, 2001

Q "I gather that most people treat insomnia with drugs. Is there any form of psychotherapy that works for my problems with sleep?"

A Cognitive-behavioral therapy (CBT) focusing on changing specific thoughts, behaviors, and assumptions can help transform that nighttime tossing and turning into a time of rest and relaxation, say researchers reporting in the April 11 edition of JAMA.

The treatment is widely used in the treatment of depression and anxiety disorders, employs a combination of education and practice exercises -- not unlike homework assignments -- to alter "dysfunctional thoughts, beliefs, and assumptions.

Results showed that patients receiving the CBT program had an average 54% reduction in the amount of time they spent awake after having fallen asleep. Patients in the muscle relaxation program had only a 16% reduction, while the sham treatment group had only a 12% reduction.

Edinger explains that when CBT is applied to insomnia, it seeks to reverse the underlying beliefs, assumptions, and habits that contribute to a pattern of sleeplessness. For example, people with insomnia are liable to have fallen into a pattern of using their time on the pillow to watch television, read, or plot and plan anxiously for the next day. Over time, the pattern becomes a habit, and lying in bed gradually becomes associated with wakefulness rather than sleep.

With CBT, participants are trained not to think and worry while lying in bed, not to read or watch television in bed, and never to lie in bed for long periods. They are told to avoid daytime napping and to establish a standard rising time. Time-in-bed restrictions are designed to reinforce the stimulus control by helping patients to learn to use the bed only for sex and sleeping.

April 9, 2001

Q "I have heard of "runner's high" and that some people become depressed when they stop running regularly. Is there any know relationship between running and depression?"

A It was recently written that "A simple program of regular aerobic exercise can substantially improve depression scores in patients with moderate to severe major depression, despite prior failures with pharmacologic therapy.

Overall, exercise training caused a clinically significant drop in depression scores during the 10 days. Of the twelve patients in the study, six demonstrated "substantial" improvements — including five of the patients with refractory depression — two demonstrated slight improvements and four remained unchanged.

"Aerobic exercise may certainly be used as complementary therapy in severely depressed patients who receive antidepressants and do not have contraindications for exercise. Since there is no evidence about the long-term effects of exercise [and] compliance and outcomes when stopping training, aerobic exercise should not be used as first-line therapy for depression until confirmatory studies have been concluded."

Br J Sports Med 2001;35:114-117.

Q "My teenager has been depressed and talking about life is not worth living. I know teenagers do this, but I am also concerned. Yet, I feel that if I bring up my concerns about suicide, my mentioning it might increase the chance that he would do it. What do you do with such a situation?"

A "According to a new study, doctors need to start asking teens about their mental health status because all evidence indicates that they won't volunteer the information on their own. Psychological problems may be as much as seven times more common among teens than their medical files indicate, according to a study in a recent issue of the journal Family Practice.

This gap is dangerous because teen mental health problems -- if left untreated -- may result in academic problems and even suicide. The good news, though, is that mental health problems in children and adolescents -- from eating disorders and depression to stress and attempted suicide -- are very often treatable.

Another red flag raised by the new study: Teens with mental health problems -- including those who attempt suicide -- are indistinguishable from their nonemotionally disturbed peers in terms of how often they visit the doctor. This finding contradicts earlier work that suggested depressed teens have more contact with healthcare professionals than other youths.

Overall, just 4% consulted their doctor about mental health problems, and just 3% of all case notes had information about emotional well-being, the researchers report. One percent of the adolescents had attempted suicide, and one in five had done so on more than one occasion.

"It could be argued that adolescents are not bringing their mental health concerns to the attention of their [general practitioner]. Alternatively, it is possible that [general practitioners] do not pick up and respond to ... comments and nonverbal cues from adolescents," write researchers from the departments of child and adolescent psychiatry and general practice at the University of Glasgow, Scotland.

Their solution? Ask teens to fill out questionnaires assessing their mental health before they meet with their doctor, as they may find it easier to disclose emotional problems in this manner.

"Because the risk of school failure and suicide is quite high in depressed children and adolescents, prompt referral or close collaboration with a mental health professional is often necessary," Son and Kirchner conclude in the Nov. 15, 2000, issue of the American Family Physician.

At the root of the resistance, she says, is that people don't like to admit that they need help coping with emotional issues. They feel they should be tough enough to take care of it on their own.

That's why it's important to let teenagers know that it's OK -- that emotional problems are normal -- and that they should not be afraid to discuss their concerns with their doctor. With parents, some are attuned to mental well-being and others aren't."