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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 |
September 30, 2002
Q
"My daughter was caught using Ecstasy, and he defense was "well
this is no different than your having a drink." Are there any
studies that show that this drug is worse than having an occasional
glass of wine."
A
Yes, there are. In animal studies,
striatal dopaminergic deficits are apparent following administration
of MDMA ("ecstasy") in doses akin to those commonly used by
individuals participating in all-night dance parties, researchers at
Johns Hopkins report. Doses of 2 mg/kg of MDMA used in their
studies, delivered two or three times at 3-hour intervals, were
lower than those sometimes used by party-goers. The investigators
suggest that recreational MDMA users may be increasing their risk
for such disorders as parkinsonism.
Of five monkeys and five baboons treated, one of each died within
hours because of malignant hyperthermia. One of each species also
became unstable after the second dose and so they were given no
more.
In the three spiders monkeys that tolerated treatment well,
examination 2 weeks later revealed reduced levels of regional brain
serotonin, 5-hydroxyindoleacetic acid and serotonin transporter. The
fourth surviving monkey was similarly examined 6 weeks after
treatment, and it was found that the three markers were reduced by
37%, 48% and 40%, respectively, compared with levels in
saline-treated control animals.
These "severe, long-lasting decrements" were similarly observed in
the baboons.
Whether their findings extend to humans is unknown. It may be that
taking multiple doses in a night, known as "stacking," is required
for dopaminergic neurotoxicity to occur.
Earlier this month, US health officials reported that the number of
Americans using MDMA went up 25% between 2000 and 2001.
Science 2002;297:2260-2263.
September 23, 2002
Q
"My family doctor put me on antidepressants. I took them for three
weeks, felt strange while taking them, and stopped. I am still
depressed, and this obviously did not cure me."
A In
JAMA 2002;288:1403-1409.: "Ineffective
patient-physician communication may be largely responsible for
patients' discontinuation or switching of antidepressants before
completion of the recommended treatment period, according to newly
published study findings.
The primary endpoints were treatment discontinuation or medication
switching within three months of starting SSRI therapy.
Seventy-two percent of physicians reported that they told their
patients that SSRIs must be taken for at least six months. However,
only 34% of patients reported being told this and 56% said that they
had received no instructions. Nine percent reported being told to
take their medication for less than six months.
Compared with patients who reported being told to take their
medication for at least 6 months, those who reported being told to
take their medication for less than 6 months were more than three
times as likely to discontinue therapy.
Treatment discontinuation was less likely when the adverse effects
of the drug were discussed with the patient. However, switching
medications was more common when the adverse effects were discussed,
the authors note.
Other factors associated with treatment discontinuation included
less than three follow-up visits for depression, the occurrence of
adverse effects, and lack of a therapeutic response.
September 16, 2002
Q
"My teenage son is in treatment for depression. He takes
medication and is in psychotherapy. He is gaining a lot of weight,
and his psychologist says that it is not likely from the medication."
A This
article may be helpful: "Adolescents with depression are at
increased risk for the development and persistence of obesity.
Body mass index goes up incrementally as depression worsens. If you
treat depression in adolescents you may stave off the onset of
obesity or prevent an obese child from becoming more obese.
The serotonin pathway or altered functioning of the
hypothalamus-pituitary-adrenal axis share neurobiological mechanisms
between obesity and depression. For example, Bupropion (BuSpar)
treatment was effective against weight gain in adults.
Pediatrics 2002;109:497-504.
September 9, 2002
Q
"My daughter was diagnosed with asthma as a child. She is now
grown and was diagnosed with panic attacks last year. Is there a
relationship between the two....the symptoms seem so similar."
A You
might find the following of interest:
Asthmatics and people with chronic bronchitis or other respiratory
diseases may be at increased risk for panic attacks--or vice
versa--recent study findings suggest.
The investigators found that adults who reported having asthma,
chronic bronchitis or emphysema were more likely than others (odds
ratio 1.7) to experience panic attacks. For adults with other types
of lung disease, the odds ratio was 2.3 for panic attacks.
Furthermore, for those who reported having some type of respiratory
disease and another lung disorder, the odds ratio for panic attacks
was 4.1.
These findings remained true even after controlling for other mental
disorders, physical problems, and demographic characteristics, the
investigators state.
Chest 2002;122;645-650.
September 2, 2002
Q
"Our parents always told us that a sour outlook on life would
turn against us and make us physically sick. Was this just an "ol'
wives' tale"?
A
Patients classified as pessimistic after completing a personality
assessment have poorer self-reported physical health and mental
functioning 30 years later, compared with patients classified as
optimistic, Mayo Clinic researchers report.
In previous work, the researchers had found that those with an
optimistic explanatory style had a 50% reduced risk of death over a
30-year period compared with patients with a mixed explanatory
style.
They add that knowledge of patients' explanatory style may help
healthcare providers understand patients who are prone to
noncompliance with treatment regimens, have excess health care
utilization, and report lower patient satisfaction with health care
episodes.
Mayo Clin Proc 2002;77:748-753.
August 26, 2002
Q
"My aunt recently died from cancer. She was in agony. As a
family we talked many times about how needless her suffering had
been. Does anyone even study why we do not permit assisted suicide
or investigate why people request it?"
A In a
study of Oregon nurses and social workers who care for hospice
patients, control issues were among the most important reasons why
patients requested physician-assisted suicide, according to a new
report. In contrast, depression, lack of social support, and fear of
draining the family's financial resources were among the least
important reasons given. With the passing of the Death with Dignity
Act in 1997, physician-assisted suicide became legal in Oregon. From
1998 to 2001, 91 individuals died by assisted suicide.
Eighty-two patients had received prescriptions for lethal
medications from 1997 to 2001, the report indicates. Nearly all of
the nurses who were presented with a suicide request discussed it
with a coworker and 77% of the requests were discussed at an
interdisciplinary conference.
Reasons rated as very important for seeking assisted suicide
included a desire to control the circumstances of death, a readiness
for death, and a desire to die at home, the authors note. A fear of
burdening others was rated as somewhat important, but only 11% of
respondents reported that family caregivers of suicide-requesting
patients were more burdened than caregivers of other hospice
residents.
N Engl J Med 2002;347:582-588.
August 19, 2002
Q
"You do not read much about burnout among doctors?"
A About
one in five US physicians are dissatisfied with their career, but
this figure varies by specialty and geographic location, recent
study findings indicate. For example, physicians practicing
geriatric internal medicine, neonatal-perinatal medicine or
pediatrics, and dermatology reported high levels of career
satisfaction.
Less satisfied with their career were doctors specializing in
otolaryngology, obstetrics-gynecology, ophthalmology, orthopedics
and internal medicine.
Physicians practicing in New England or in west north Central
states, such as Minnesota, Iowa, Missouri, North Dakota, South
Dakota and Kansas, were more satisfied than those in other parts of
the country.
The relatively high dissatisfaction among obstetrician/gynecologists
may be "related to rising expectations for perfect birth outcomes
and high medicolegal risk, in contrast, has frequently been
considered one of the most attractive specialties because of its
"controllable lifestyle" and "relatively narrow focus," according to
the report.
"A high percentage of young physicians are very satisfied and an
even higher percentage of physicians aged 65 and older report being
very satisfied," the authors state. "This may be owing to the
enthusiasm and idealism of youth and self-selection among the
elderly. Physicians who do not retire by age 65 years probably
derive considerable satisfaction from their jobs."
Physicians who reported working many hours were less likely to be
satisfied with their job, while those who reported a high
income--$250,000 to $299,999--were more likely to say they were very
satisfied with their career, the findings indicate.
Arch Intern Med 2002;162:1577-1584.
August 12, 2002
Q
"The anniversary of the terrorist attacks upon the U.S. is
approaching. Has anyone studied the impact upon those in New York
for example?"
A The
likelihood of posttraumatic stress disorder (PTSD) following the
events of September 11 was associated with direct exposure to the
attacks on the World Trade Center.
Geographic proximity to the WTC crash site, time spent watching
television coverage of the attacks, and the number of different
kinds of potentially traumatic events participants reported seeing
were significantly associated with the prevalence of probable PTSD.
The long-term consequences of these findings remain to be determined
but about half of Vietnam veterans diagnosed with PTSD upon their
return to the US still had the disorder 15 years later.
The prevalence was not elevated among those residing in Washington,
DC, compared with other US residents. The Pentagon was not as
centrally located as the World Trade Center, attenuating the
reaction to its attack. It was also perceived as a military target
instead of a civilian target.
In 60% of New York City households with children, the adults
reported that at least one child had such symptoms as difficulty
sleeping, being irritable or easily upset, or displaying separation
anxiety. However, that rate was not significantly higher than those
reported in other areas of the US.
As the anniversary of the terror attack approaches, researchers
believe that many individuals will find their symptoms increasing.
JAMA 2002;288:581-588,633-636.
August 5, 2002
Q
"My husband and I are worried about our teenage daughter and
her potential for an eating disorder. Are there any new studies
regarding warning signs for which we should look?"
A In
the July/August issue of the American Journal of Health Promotion,
they report that
while adolescent girls who participate in sports such as gymnastics
are more likely than their peers to develop eating disorders, the
vast majority remain healthy.
Depression, a history of sexual abuse, smoking cigarettes or
marijuana, and drinking alcohol were found to be associated with a
greater likelihood of having disordered eating habits.
Disordered eating habits were defined as forced vomiting, using diet
pills, or taking laxatives or diuretics to lose weight in the past
week.
Participation in a sport that emphasized the maintenance of a
certain weight increased the risk for disordered eating by 50%.
Girls who participated in these sports and reported disordered
eating were also more likely to smoke, drink alcohol or use drugs,
have attempted suicide, have reported a history of sexual abuse, or
feel that they did not communicate well with family members.
However, most girls involved in these sports, who did not have an
eating disorder, were less likely to smoke marijuana and report
symptoms of depression.
The study shows that overall, sports that emphasize weight
maintenance can benefit girls; but participation in these sports,
coupled with specific risk factors, may make some girls more
vulnerable to unhealthy eating habits.
Am J Health Prom 2002;16:341-344.
July 15, 2002
Q
"Does anyone do research regarding men's diseases...like how
men cope with heart attacks or prostate cancer?"
A This
article may interest you: "Men faced with a diagnosis of prostate
cancer appear to fare much worse emotionally if their personal
coping style is one of denial and avoidance, new study findings
suggest.
While much is known about the psychological impact of a cancer
diagnosis, the effect a person's coping strategy has on the
emotional distress caused by such a diagnosis is less clear,
according to researchers.
In general, there was no relationship between reduced stress and
so-called "active" coping styles like "facing the situation and
accepting it," or "having a fighting spirit." In contrast, so-called
avoidant behavior was more likely to lead to an increase in stress
with regard to the diagnosis of prostate cancer.
"This study found that the more avoidant men are when coping with
difficulty--denying or disengaging--the more difficulty they are
likely to have when facing a prostate cancer diagnosis...In other
words, greater use of avoidant coping as a general tendency is
likely to cause greater distress when facing a prostate cancer
diagnosis, regardless of the results of the diagnosis." Cancer
2002;94:2923-2929.
July 8, 2002
Q
"I heard that people living in the country were more likely to
commit suicide than those in the city. That seems illogical since
there are more stressors in the city."
A A
recent article indicates that" "Men in rural areas are increasingly
more likely to commit suicide than their urban counterparts.
Altogether, the suicide rate decreased by about 0.46% annually from
1970 to 1997 among men in the most urban areas, but reportedly
increased by 1.08% annually among men in rural areas.
For women, suicide rates were higher in urban areas than in rural
areas from 1970 to 1989. But the gap narrowed over time, such that
the 52% lower risk among the most rural women in 1970 to 1974 had
dropped to 16% by 1985 to 1989, and by 1995-1997, women in rural
areas had a 55% higher suicide rate than women in the most urban
areas.
Some of the factors that might explain the higher suicide rate in
rural areas may be the greater access to firearms, physical and
social isolation, and the greater social disruption during the past
three decades, such as the excess number of deaths in comparison to
births.
Also, "social and public policies that emphasize investment in
social integration or social capital through job creation, provision
of gainful employment and social services, and improved social
support and networks through community organization and involvement
especially for the rural youth and elderly may lower suicide rates."
Am J Public Health 2002;92:1161-1167.
July 1, 2002
Q
"Our daughter has been treated repeatedly for anorexia. We have
had her in many clinics. She does well for awhile and then relapses.
Are there any new treatment approaches being tried?"
A There
is an interesting article which suggests that: Most patients with
anorexia or bulimia nervosa who participate in a computer-aided
feedback program, combined with rest and limited physical activity,
achieve sustained remission, Swedish researchers report in the
Proceedings of the National Academy of Sciences early online edition
for June 24-28.
For patients in the treatment group, one of the daily meals was
eaten from a plate placed on a scale, which is connected to a
computer. At regular intervals, the computer prompts the patients to
record their level of satiety by manipulating a mouse button. The
computer stores the satiety rating, and this yields a curve of
satiety.
The patients are then asked to follow curves of eating rate and
satiety that were generated by normal people. In this way patients
relearn how to eat and how to feel satiated.
After each meal patients rested in a warm room for 1 hour. In
addition, during treatment, anorexic patients were confined to
wheelchairs or allowed to walk only slowly in the clinic. Bulimic
patients were allowed to walk slowly for 30 minutes per day
accompanied by a staff member. Physical restrictions were reduced
during treatment and eliminated on remission, the researchers note.
PNAS (USA), June 24-28, 2002.
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