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Clinical
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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. |
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| PAST QUESTIONS OF THE WEEK |
June 27, 2005
Q "I
have heard that stress can reduce a woman's ability to have
a baby. Does it have no impact upon a man's ability?"
A A
recent article finds that "Infertility-related stress in men as well as women
may have an effect on treatment success...male stress does play a role in
treatment failure, albeit a weaker one than that observed for women...The effect
was not due to an additive effect of the male partner's distress on a woman's
distress level...
Both male and female fertility problem stress scores were associated with
treatment outcome with a greater effect for women. Women reporting more marital
distress required a median of three treatment cycles to conceive, compared with
a median of two for the less-distressed women. More-distressed women were also
less likely to become pregnant in a given cycle.
The researchers also found that fertility problem stress in the personal and
marital domain was more strongly associated with treatment outcome than stress
arising in the social domain...."
Fertil Steril 2005;83:1745-1752.
June 20, 2005
Q "Is
there a relationship between asthma and like emotional
symptoms ...depression for example?"
A
"Adult asthmatics often experience depressive symptoms, which are associated
with poor health outcomes...Psychological disorders, including depression, are
common in adults with asthma..."Although depression is treatable, its impact on
longitudinal asthma outcomes is not clear."
Adult asthmatics recently hospitalized for asthma had a prevalence of depressive
symptoms of 18%. After controlling for age, sex, race/ethnicity, education, and
smoking, an association was observed between depressive symptoms and greater
severity-of-asthma scores (mean score increment, 2.6 points).
Depression was also associated with poorer asthma-specific quality of life
...poorer physical health status...more frequent emergency department visits and
more additional hospitalizations.
"In a subsequent analysis controlling for the preventive care measures
associated with depressive symptoms...depressive symptoms were more strongly
associated with the risk of hospitalization..." Ann Allergy Asthma Immunol
2005;94:566-574."
June 13, 2005
Q "My
wife's asthma attacks look just like a panic attack. Are
they related or even the same?"
A
They are not the same, but there may be a close relationship
in which one triggers the other, and psychological
evaluation of those with asthma may, at some point, be
recommended:
"Active asthma
predicts subsequent panic disorder, and the presence of panic disorder predicts
subsequent asthma activity. In longitudinal analyses, asthma was associated with
a 4.5-fold increase in the risk of subsequent panic disorder, and the presence
of panic disorder was associated with a 6.3-fold increase in the risk of
subsequent asthma activity.
Similar but less marked associations were also seen between asthma and the
subsequent development of any panic, the researchers note, but any panic did not
predict subsequent asthma.
More research is needed to improve diagnostic precision and to evaluate
anti-panic treatments in patients with the asthma-panic comorbidity."
Am J Respir Crit Care Med 2005;171:1224-1230.
June 6, 2005
Q "I
guess this is just an academic question, but if people get
depressed after having a baby, do they get more depressed if
they have twins or triplets? Just wondering?"
A
Apparently, the incidence of post-partum depression is, indeed, greater for
those patients who have had fertility treatment to increase the chances of
having multiple births.
"Having
twins or triplets following assisted reproductive therapy (ART) makes it
difficult for mothers to meet their basic material needs, lowers their quality
of life, and increases the risk of depression.
The investigators found that each additional multiple birth child increased the
odds of having difficulty meeting basic material needs by a factor of 4.74. The
risks of lower quality of life as measured..and increased sense of social
stigma..."These qualitative data suggested that a multiple birth exposes women
to unwanted public speculations and intrusive questions about their fertility
status and their children's conception status...Moreover, the likelihood of
depression as measured by the Centers for Epidemiological Study-Depression Scale
was increased with each additional child (odds ratio 1.71).
"The identification of these risks may be helpful in counseling those seeking
fertility treatment...as patients may underestimate the difficulties involved in
raising multiple birth children, or may understand the risks associated with
triplets but be naive with respect to twins."
Fertil Steril 2005;83:1422-1428.
May 29, 2005
Q "My
husband and I are in our 80s. He has been quite depressed
lately but will not consider seeing a doctor, fearing that
they would prescribe antidepressants. I read about all
those people committing suicide because of the
anti-depressants and am hesitant for him to go as well."
A
There are many causes for depressive symptoms,
and some of them relate to other health care concerns. He should see his primary
care physician. Regarding the risk of suicide, there was a recent "study of 200
elderly patients admitted to a psychiatric hospital in Israel found that
antidepressants, including selective serotonin reuptake inhibitors (SSRIs), cut
the risk of suicide attempts by about 50%.
The result appears to be the reverse of the increased risk associated with use
of the same drugs in children and adolescents. Because of that risk, SSRIs for
children were banned in the UK, and suicide risk warnings are now required in
the US.
In a 10-year retrospective, case-control study presented today at the 158th
annual meeting of the American Psychiatric Association, Dr. Yoram Barak,
professor of geriatric psychiatry, at the Medical School of Tel-Aviv University,
said treatment with benzodiazepines in addition to antidepressants reduced risk
of attempted suicides by another 10%.
Based on a review of prescriptions, the group that had not attempted suicide
were much more likely to be prescribed antidepressants. Among the
antidepressants, the most frequently prescribed were SSRIs. If you are elderly
and depressed, and take an antidepressant, you have half the risk of attempting
suicide. The suicide group received much less antidepressants and much less
SSRIs, and therefore they had twice the risk of suicide.
The reason why
children may be at higher risk for suicide when given antidepressants, could be
that they may not necessarily have major depression as their primary diagnosis.
Adolescents with depressive symptoms may be experiencing a traumatic reaction to
a loss, rather than major depression.
In the elderly, he said, 74% of cases of death by suicide are associated with
depression."
May 22, 2005
Q
"I had an argument with a friend over whether old people
commit suicide when they are sick. Have you come across
anything about that topic?"
A Here's a summary of an article on
this topic: "In the very elderly, the risk of suicide is significantly higher
among those who have been hospitalized for a medical illness in the previous 2
years than among those not hospitalized, according to researchers. However, the
suicide risk in this population is still lower than that in the middle-age
population.
The oldest-old men
who had been hospitalized during the previous 2 years had an increased risk of
suicide, at 113 per 100,000 versus 80 per 100,000 in the general population of
men of the same age. The oldest-old women who had been hospitalized also had
higher suicide rates than their peer group.
Comparing the relative risk within each age group showed that hospitalization
was associated with a lower increase in risk in the oldest old than in the
middle-aged.
The risk for the oldest-old men doubled and the risk for the middle-age men
tripled, they note. The risk for the oldest-old and the middle-aged women who
had been hospitalized recently quadrupled and quintupled, respectively.
The suicide risk also increased among those who experienced three or more
different medical diagnoses during the previous 2 years.
Considering that hospitalization with medical illness often precedes suicide in
the oldest old, hospitalization may play an important role in identification of
suicidal ideation in older people."
J Am Geriatr Soc 2005;53:771-776.
May 15, 2005
Q "Both
my mother and, I believe, my grandmother have suffered from
depression as has my sister. Is there an inherited
tendency to be depressed and is their current research on
this?"
A
Look up the whole article,
but: "A polymorphism in a serotonin transporter gene has
been associated with an increased risk of depression. Now,
new research suggests that the mechanism involves alteration
of cingulate-amygdala interactions.
In addition to the elevated risk of depression, this variant
has been tied to an increase in anxiety-related
temperamental traits and to increased amygdala reactivity.
Cingulate-amygdala feedback circuit plays a key role in
emotion regulation. In patients with the variant, relative
uncoupling of this circuit is seen.
Findings suggest a causal mechanism linking developmental
alterations in serotonin-dependent neuronal pathways to
impaired interactions in a regulatory network mediating
emotional reactivity.
Nat Neurosci 2005.
May 8, 2005
Q "My
wife has been in treatment for depression for three years.
Neither of us believe that she has made progress. Are
there other things we should know?"
A
This may be of assistance:
"Depressed patients who fail to respond to initial treatment
with an antidepressant or psychotherapy may do better if
they are switched to the alternative treatment.
Surprisingly few studies have evaluated the role of
medication following nonresponse to psychotherapy...and none
have evaluated the efficacy of psychotherapy following
nonresponse to medication...how important it is that
clinicians not be discouraged -- though their chronically
depressed patients may be -- by initial treatment
resistance...Arch Gen Psychiatry 2005;62:513-520.
May 1, 2005
Q "Aside
from depression and fear of dying are their other
psychological disorders that arise from having testicular
cancer?"
A You
might want to read the whole article: "Long-term survivors
of testicular cancer appear to be at increased risk of
anxiety disorder. Further analysis showed that anxiety
disorder was associated with younger age, peripheral
neuropathy, and alcohol and sexual problems.
The researchers conclude that testicular cancer survivors
require clinical attention and that the "use of a simple
screening test...assists the identification of testicular
cancer survivors with anxiety disorder."
J Clin Oncol 2005;23:2389-2395.
April 25, 2005
Q
."My daughter is asthmatic,
and the school counselor says that she is very anxious in
school. I work and am not home when she gets home from
school each day. Do you think the asthma is the cause of the
anxiety?"
A
There are several factors to
consider, not the least of which is whether her response to
her medication is being interpreted (or causing) anxiety,
how she feels about coming home and your not being there,
and whether being asthmatic has created social/interpersonal
problems at school. That said, the following is also
interesting: "There appears to be a high prevalence of
anxiety and depression among patients with chronic breathing
disorders...measure the prevalence of anxiety and depression
in 1334 patients who received care for chronic breathing
disorders...862 (65%) screened positive for depression and
anxiety, 133 (10%) for anxiety only, and 72 (5%) for
depression only. A total of 267 (20%) screened negative for
depression and anxiety. The predictive value of a positive
screen according to the PRIME-MD for either depression or
anxiety was 80%.
A subset of 204 patients who had COPD underwent the
Structured Clinical Interview for DSM-IV. "In total, 132
patients (65%) received an anxiety and/or depressive
disorder diagnosis, 77 patients (39%) received a depressive
disorder diagnosis, and 101 patients (51%) had an anxiety
disorder.
The investigators
conclude that practical screening instruments may increase the recognition of
anxiety and depression in medical patients."
Chest 2005;127:1205-1211.
April 18, 2005
Q
Are there any studies on
Alzheimer's Disease and Vitamin E? I heard that it
helps."
A
I found reference to the
following: "Supplemental vitamin E at dosages of 2,000 IU
per day is not effective for the treatment of mild cognitive
impairment...Oxidative damage accompanies Alzheimer's
disease, and cholinesterase inhibitors are recommended for
use in mild-to-moderate Alzheimer's disease...treatment with
the antioxidant vitamin E could delay the time to important
milestones in patients with moderately severe Alzheimer's
disease. (however) Vitamin E had no benefit in patients with
mild cognitive impairment...the disappointing lack of
efficacy of vitamin E in a well-powered trial that used the
high doses previously shown to slow the progression of
Alzheimer's Disease..."
N Engl J Med. Posted online April 13, 2005.
April 11, 2005
Q
Our Daughter is 32 years old. She has had two
hospitalizations and years of medication for depression. She
seems to do well and then she becomes depressed again. We
think this is highly unusual, and we are suspicious that she
is not being adequately treated."
A
"Recurrence rates of major
depression are high, despite the use of maintenance
pharmacotherapy.
Major depressive disorder is usually a recurring illness,
and maintenance treatment is used to forestall or prevent
recurrent episodes.
To investigate the rate of recurrence, despite maintenance
pharmacotherapy (tachyphylaxis), researchers evaluated 103
participants in the NIMH Collaborative Depression Study. The
subjects were diagnosed with unipolar major depressive
disorder between 1978 and 1981, and were prospectively
followed for 20 years.
The subjects received antidepressant medication to treat a
recurrent episode of major depressive disorder, recovered
from this depressive episode, and subsequently received
maintenance pharmacotherapy. Some patients experienced
multiple episodes of major depression and after successful
treatment, received maintenance medication. As a result,
there were multiple maintenance treatment intervals in some
individuals.
There were 171 maintenance treatment intervals in which
major depressive disorder occurred while subjects were
receiving antidepressant medication. The median duration of
maintenance treatment was 20 weeks.
Tricyclic antidepressants and related cyclic compounds were
used in 101 (59%) episodes, monoamine oxidase inhibitors in
33 (19%), selective serotonin reuptake inhibitors in 26
(15%), and other antidepressants in 11 (6%). Lithium
augmentation and antipsychotics were used in 33 (19%) and 13
(8%) of the maintenance treatment intervals, respectively.
The investigators report that tachyphylaxis occurred during
43 (25%) of the 171 maintenance treatment intervals.
Twenty-eight (27%) of the 103 patients accounted for all
episodes of tachyphylaxis. The median time to recurrence for
these episodes was 31 weeks.
Tachyphylaxis was twice as likely to occur in subjects with
melancholic major depression prior to the maintenance
treatment interval, compared to those with non-melancholic
major depression.
"The melancholic subtype of major depression may serve as a
proxy for severity of illness, as melancholia occurs more
frequently in severe episodes and in inpatients and is
associated with higher rates of suicidality," the
researchers conclude.
J Clin Psychiatry 2005;66:283-290.
April 4, 2005
Q "....we
are no spring chickens...and I cannot tell if my husband is
depressed because of his health or is in failing health
because of his depression...."
A
"Effectively treating depression in older adults improves
physical function, researchers report in the study of the
impact of collaborative care management for depression on
physical functioning in older adults.
A total of 1801
subjects at least 60 years of age with major depressive disorder were randomly
assigned to an intervention or usual care control group. Overall, 45% of
subjects rated their health as fair or poor.
Patients in the control group had access to all health services available as
part of usual care.
Those in the
intervention group had access to a depression clinical specialist for 12 months.
Depression care was coordinated with the patients' primary care physicians.
A substantial
improvement in depression -- at least 50% reduction in depressive symptoms --
was observed in 44.6% of the intervention patients. The corresponding proportion
in control patients was 19.3%.
At 12 months, intervention patients were also significantly to less likely to
rate their health as fair or poor than were control patients (37.4% versus
52.4%).
Moreover, combining
both study groups, the team found that patients whose depression improved were
significantly more likely to experience improvement in physical functioning."
J Am Geriatr Soc
2005;53:367-373.
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