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Questions of the Week between April and
June, 2007 |
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June 25, 2007
Q "What
is the relationship, if any, between depressive disorders and anxiety disorder?"
A
"Contrary to prevailing belief, it is nearly as
likely that major depressive disorder (MDD) develops into generalized anxiety
disorder (GAD) as is the reverse pattern. Moreover, the lifetime prevalence of
comorbid anxiety and depression has probably been underestimated.
The close association between GAD and MDD prompts questions about how to
characterize this association in future diagnostic systems. Most information
about GAD-MDD comorbidity comes from patient samples and retrospective surveys.
Using data from a prospective, longitudinal cohort study, the researchers
examined the sequential and cumulative comorbidity between GAD and MDD.
The researchers report that anxiety began before or concurrently in 37% of
depression cases. Depression began before or concurrently in 32% of anxiety
cases.
Forty-eight percent of lifetime depression cases had lifetime anxiety disorder,
and 72% of lifetime anxiety cases had lifetime depression.
Overall, 12% of the subjects had comorbid GAD and MDD during adulthood. Of
these, 66% had recurrent MDD and 47% had recurrent GAD.
Sixty-four percent of the cohort utilized mental health services and 47% took
psychoactive medications. The team reports that 8% of the patients were
hospitalized and 11% attempted suicide.
Because of the strong relation between GAD and MDD, the disorders could be
classified as a single category of distress disorders.
They also conclude from their findings that GAD-MDD comorbidity may affect more
of the adult population and constitute a greater health burden than previously
thought."
Arch Gen Psychiatry 2007;64:651-660.
June 18, 2007
Q
"I have read that if I keep my stress low, then I will have better control of my
diabetes. I am insulin dependent."
A
"Most patients with type 1 diabetes maintain good
glycemic control without adjusting insulin dose when they are exposed to
short-term mental stress.
Patients with diabetes and health care providers are often confronted with
questions concerning psychological stress as a possible reason for glucose
excursions; chronic psychosocial stress has been associated with higher levels
of A1C and poor adherence to treatment.
Despite the evident stress, the investigators report that glucose concentrations
were not significantly different during the control period and stress-testing
period in the 10 patients investigated in the fasting state. For the 10 patients
investigated in the postprandial state, glucose levels increased similarly in
response to the meal on the control and stress-testing days, and returned to
baseline within 3 hours of the meal.
Severe, short lived mental stress barely affected glucose control in patients
with type 1 diabetes, the investigators conclude. However, they point out that
the subjects in this experiment were in fairly good metabolic control. The
results might not be the same for the many patients who face mental stress with
poor glycemic control or have chronic mental stress."
Diabetes Care 2007;30:1599-1601.
June 11, 2007
Q "No
one uses shock [ECT] therapy anymore right?"
A
ECT is actually a very effective intervention for severely depressed patients.
"For patients with major depression, relapse rates after acute electroconvulsive
therapy (ECT) are higher without maintenance medications, and the lowest rates
of relapse appeared to occur in patients who received combination therapy
including lithium.
The success of ECT in acute cases of depression is commonly followed by a high
relapse rate, up to 100%. Among the different strategies developed to minimize
relapse rates is the use of maintenance medications following ECT; however, the
optimal medication has yet to be determined.
The relapse rate without lithium was much higher; for all patients the relapse
rate is highest within the first 2 months after treatment. Currently recommended
therapy is 1 antidepressant with or without lithium.
The researchers concluded that a lithium combination therapy seems more
effective following acute ECT in minimizing relapse rates."
June 4, 2007
Q "Is
it normal to become depressed when you try to quite smoking?"
A
Please read this (and look up the original
article): "Persistent smoking appears to be a predictor of depression symptoms,
but this association was not seen in individuals who stopped smoking many years
ago.
Although nicotine in cigarettes has some mood-elevating properties, in the
long-run chronic exposure to cigarette smoke may have a more important role in
the etiology of depressive symptoms.
The underlying mechanism linking smoking and depression has not been identified.
Persistent smoking appears to be the strongest predictor of depressive symptoms.
In terms of the underlying mechanism, "it is very important to distinguish
between the effects of acute nicotine ingestion and the consequences of chronic
exposure to the multitude of noxious compounds contained in cigarette smoke
(over 4000 compounds, many of them bioactive, cytotoxic, carcinogenic, or
mutagenic).
When people start smoking, the immediate effects of nicotine in the brain are
rewarding and pleasurable. This suggests self-medication, where a person who has
mood problems seeks relief via cigarette.
Because addiction to nicotine is as strong as an addiction to heroin, abstinence
is difficult. The mechanism of addiction together with all those toxic compounds
in tobacco smoke may explain why long-term, persistent smoking may increase the
risk of depression.
For patients who want to quit smoking and who are depressed, the first thing is
to encourage them to quit. Clinicians must make sure to explain that the
patient's symptoms of depression may worsen for a while. But for those who don't
relapse, their risk for depression goes down.
Smokers who are vulnerable to depression may need specific pharmacological
treatment and behavioral support to overcome the earlier phase of abstinence.
After that, their chances to quit successfully improve.
During their trial, the Finnish research team observed evidence of shared
genetic vulnerability contributing to the link between smoking and depression.
The data were pretty moderate, and were only significant among men."
Psychol Med. 2007;37:705-715.
May 28, 2007
Q "I
have irritable bowel syndrome...I think...can psychological care be of benefit
to me?"
A
"Patients with irritable bowel syndrome (IBS) may respond to a psychological
approach to treatment if conventional medical therapy fails. The symptoms of IBS
are an integrated response to a variety of complex factors. The condition can be
managed by primary care physicians.
IBS should not be considered a "diagnosis by exclusion as many physicians are
still taught. Instead, diagnosis can usually be made based on the patient's
history. Patients are likely to be reassured by a positive clinical diagnosis of
IBS.
Drugs that alter intestinal motility and dietary changes often fail to control
the symptoms, and patients may believe their symptoms are being ignored or
misunderstood. In this case, the clinician can educate the patient about IBS as
a "complex interaction of biological and psychological factors," in such a way
that the patient is amenable to exploration of the psychological dimension as a
logical next step.
For those with severe IBS, particular benefit may be derived from gut-directed
hypnotherapy, in which patients are guided to focus on imagery and techniques
aimed at normalizing gut function.
Tricyclic antidepressants are beneficial when the main symptoms are pain and
diarrhea. Evidence suggests that selective serotonin reuptake inhibitors are
more effective in cases of constipation and pain or bloating.
Another option is cognitive behavior therapy, which "shows patients how events,
thoughts, emotions, actions and physiological responses are interlinked."
Research suggests that cognitive behavioral therapy is as effective as
antidepressant drugs and that its benefits last longer."
BMJ 2007;334:1105-1109.
May 21, 2007
Q "Depression is a serious health
risk in the elderly, is it not?"
A
"Previous research has shown that depression is
independently associated with mortality risk in older adults, and now new
research indicates that this risk can be reduced through primary care-based
depression management.
In the study, subjects in the depression intervention group were 33% less likely
to die than those in the usual care group.
Further analysis showed that the benefit of the intervention was confined to
patients with major depression, in whom it cut the risk of death by 45%, the
researchers report. Patients with minor depression experienced no significant
drop in mortality.
In looking at the reasons for the survival benefit, researchers found that the
depression intervention primarily worked by reducing cancer mortality and had
relatively little effect on the risk of death from other causes. "The mechanism
for an effect on deaths due to cancer is unclear.
The study underscores the public health effect that could accrue by providing
resources to help primary care clinicians better manage psychological distress
and psychiatric disturbances.
If we are to prepare for the increasing need for mental health services among
older persons and to ease the burden of disability associated with depression,
we must engage primary care practices as partners in developing services that
interrupt the pathway from depression to death."
Ann Intern Med 2007;146:689-698.
May 14, 2007
Q
"How hard is it to diagnose manic-depression?"
A
You are referring to bipolar disorder which presents
in three subconditions. "The estimated lifetime prevalence of bipolar spectrum
disorder is doubled when subthreshold bipolar disorder is included along with
bipolar-1 and bipolar-2 disorders -- to approximately 4%.
Regardless of classification, however, impairment is often severe and few
patients with bipolar disorder receive appropriate treatment, the evidence
suggests.
Fifty percent of patients have had symptoms of bipolar disorder by the time
they're in their 20s. If we don't recognize the early manifestations of the
disease, the degree of impairment at this time of life can lead to major
consequences and lifelong disability. Without appropriate diagnosis and
treatment during young adulthood, the disorder can interfere with personal
relationships, social life, education, and job performance.
The lifetime prevalence estimate was 1.0% for bipolar disorder-1, 1.1% for
bipolar disorder-2, and 2.4% for subthreshold bipolar disorder, the
investigators report. During the previous 12 months, prevalence was 0.6%, 0.8%,
and 1.4%, respectively.
The investigators observed that many of the subjects were being treated for
depression, but few - no more than 25% -- were taking mood stabilizers. It's
important to make the right diagnosis, because of treatment differences and
consequences. Bipolar disorder is much more likely to be associated with
subsequent substance use disorders, suicide, and some medical disorders."
Arch Gen Psychiatry 2007;64:543-552.
May 7, 2007
Q
Is there a relationship between depression and things like Parkinson's Disease?
A
This has been a topic of research for some time.
Please read: "Use of antidepressants within the previous year was linked with a
higher risk of developing Parkinson's disease. Maybe people who are going to
develop Parkinson's disease start having depressive symptoms, and then later in
their course of their disease, they start developing the typical motor symptoms
of Parkinson's, such as tremor or movement. Since Parkinson's disease followed
closely after depressive symptoms, this suggests that depression could be an
early part of Parkinson's disease.
Previous papers reported that individuals with Parkinson's disease had a higher
risk of developing depression and that patients with Parkinson's disease had a
higher risk of having had prior depression. It was not clear whether depression
could be an early symptom of Parkinson's disease, whether depression causes
changes in the central nervous system that could increase the risk of developing
Parkinson's disease, or whether there are common factors for both depression and
Parkinson's disease.
Current use of antidepressants was associated with an 80% increased risk of
developing Parkinson's disease. The risk was similar for both men and women, for
different age groups, and for use of different classes of antidepressants such
as selective serotonin reuptake inhibitors and tricyclic antidepressants.
Further analysis revealed that past users of antidepressants had an increased
risk of developing Parkinson's disease in the first year after they stopped
taking antidepressants, but the risk was not increased after this.
It is not that antidepressants increase the risk for Parkinson's disease since
the risk of developing Parkinson's disease was the same with different classes
of antidepressants that had different mechanisms of action.
He added that since increased risk of developing Parkinson's disease was
apparent only in the year prior to onset of the disease, this supports the
hypothesis that depressive symptoms might be an early part of Parkinson's
disease, rather than the hypothesis that depression increases the risk of
developing Parkinson's disease."
American Academy of Neurology 59th Annual Meeting: Abstract P01.120. April 28 –
May 5, 2007
April 30, 2007
Q
We run ourselves ragged going to the ER for our son's (only child) asthma.
Is there anything we can do to be calmer?
A
You may find this helpful: "Parents' psychological
responses to asthma attacks are among the strongest motivators of bringing their
child to accident and emergency (A&E) services.
In contrast, characteristics of their home environment, such as dampness,
overcrowding, or living with a smoker, have little effect on use of emergency
departments.
Children with asthma often use A&E services. The authors found that patients who
had attended an outpatient clinic with a family doctor during the previous year
were 13 times more likely to visit A&E.
Parents who reported feeling alone or experiencing panic or fear when their
child's asthma got worse, or who believed they would get quicker service in an
A&E, were 2- to 3-fold more likely to bring their child to the emergency
department.
To reduce A&E use for asthma in children, health service planners should take a
broader approach, considering what is the most appropriate setting for treating
asthma attacks for children of different levels of attack severity, ensuring
that services are accessible and address parents' concerns, and that the
different parts of the health service communicate appropriate care pathways
effectively and consistently to parents."
Thorax 2007.
April 23, 2007
Q My son is in
remission for leukemia. I am so relieved, but I am also
depleted...exhausted and perhaps depressed?
A
"The spouses and partners of cancer survivors
experience emotional stress comparable to that seen in the patients themselves,
and their long-term social costs may actually be greaterests. These findings
highlight the importance of addressing the needs of family members who care for
cancer patients, and who may be suffering in silence. Cancer occurs in the
context of a family that is profoundly affected by the experience, and that
needs intervention for their own well-being.
Compared to the cancer survivors, their partners reported better physical
health, which was on par with that seen in controls. By contrast, partners of
survivors had fatigue and cognitive dysfunction scores that were higher than
controls, but lower than survivors. Depressive symptoms, sleep problems, and
sexual difficulties were also more common in partners of survivors than in
controls.
Depression was more likely to be addressed in survivors than in their partners.
Moreover, relative to survivors and controls, partners of survivors reported
having less social support, dyadic satisfaction, spiritual well-being, and
greater loneliness. Partners of survivors also experienced little psychological
benefit or "post-traumatic growth" for having overcome a stressful experience."
J Clin Oncol 2007;25:1403-1411.
April 16, 2007
Q My son-in-law
receives psychotherapy via the telephone. Is this even possible, and does it do
any good?"
A
I would strongly question this approach which has obvious and numerous
limitations. However, you may wish to read: "Combining psychotherapy, delivered
by telephone, with pharmacotherapy improves the outcome of depression treatment
in the primary care setting. Typical depression treatment in the United States
includes an antidepressant prescription (often from a primary care physician)
and no formal psychotherapy. A 1997 U.S. community survey found that only 35% of
adults with depressive disorders received any psychotherapy, and fewer than 20%
made four or more psychotherapy visits.
The researchers report improvement in the Hopkins Symptom Checklist (HSCL)
depression score was greater in patients in the phone therapy group than in
those assigned to usual care. At 18 months, 77% of patients in the phone therapy
group reported their depression was "much improved" or "very much improved,"
compared to 63% of those in the usual-care group.
Subjects in the phone therapy group were slightly better at taking their
antidepressant medication as recommended. Addition of a brief, structured CBT
programs can significantly improve clinical outcomes for the large number of
patients beginning antidepressant treatment in primary care."
J Consult Clin Psych 2007.
April 9, 2007
Q
Our son was arrested for having pot. He also drinks heavily. There are
many programs that purport to help him, but I am not hearing of great successes
at the prevention level (we have another son who is twelve).
A
"Adolescence is defined as emerging adults, aged 12
to 24 years, who are sexually mature and in the final stages of education or in
the early stages of a career. For this age group, the reported prevalence of
mental health disorders ranges from 8% to 57%, and the leading causes of disease
burden include unipolar depressive disorders, self-inflicted injuries,
alcohol-use disorders, schizophrenia, and bipolar affective disorder.
Since age 12 to 24 is when mental health disorders such as depression and
anxiety disorders, psychoses, substance use, and eating and personality
disorders appear, and since these disorders tend to persist into adulthood,
focus should be on early interventions to prevent progression of primary
disorders and the onset of comorbid disorders. Even though evidence has begun
emerging over the past 20 years for effective treatments, health system
responses to youth mental health have been inadequate. Only 7% of countries in
the world (78% of developed countries, and no low-income countries) have a
specific child and adolescent mental health policy, they note.
To address this gap in mental health care for young people, the group proposes a
mental health services model that would take services to where young people feel
comfortable, such as sports associations or schools and colleges (as opposed to
hospitals).
Although New Zealand, Australia, and other developed countries have created
initiatives to increase access for young people to mental health services, the
developing world lags behind.
Evidence suggests that rates of tobacco, alcohol, and illicit drug use in young
adults can be reduced through a concerted application of a combination of
regulatory, early-intervention, and harm-reduction approaches.
They explain that it is estimated that worldwide, hazardous alcohol use is more
problematic than illegal drug use in 15- to 29-year-olds, and it accounts for
86% of the 8.6 million substance-related deaths in this age group. Illicit drug
use contributed to almost 4% of all deaths in this age group in developed
countries.
In most developed countries there are training programs available for primary
healthcare providers to learn how to deliver motivational interviewing, how to
assess and treat problems in a nonjudgmental way, and how to ask questions in a
comfortable way and provide advice."
Lancet. Published online March 27, 2007.
April 2, 2007
Q
My mother has Alzheimer's Disease and is difficult to manage. I wondered
if the drugs they use for psychotic people would help her.
A
Talk to her physician about that, but here is an interesting article: "There is
considerable variation in the rate of decline associated with various drugs
prescribed for patients with Alzheimer's disease. Drugs licensed to treat
dementia tend to correlate with a slower decline, while antipsychotics and
benzodiazepines tend to speed the rate of deterioration.
The risk of deterioration was significantly higher among patients who were
taking antipsychotics or sedatives compared with those who were not. Patients
who were taking both antipsychotics and sedatives had an even higher risk of
rapid deterioration.
Patients on acetylcholinesterase inhibitors or NMDA antagonists, drugs affecting
the renin-angiotensin system and statins had a significantly lower risk of rapid
deterioration than those who did not take any of these drugs. There were no
additive effect in patients taking two or more of these drugs.
Clinicians should be aware that antipsychotics and benzodiazepines, especially
in combination, may hasten decline."
J Neurol Neurosurg Psychiatry 2007;78:233-239.
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