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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 |
October 4, 2004
Q
"My husband had problems
with awakening during the night and could not fall back to
sleep. His internist started him on (anti-depressant) and
that seemed to help. I have problems falling asleep
but not staying asleep; should I be taking the medicine too?"
A You should also consider the
following option: "Cognitive behavior therapy (CBT) should be the first line of
therapy for sleep-onset insomnia...Sleeping pills are the most frequent
treatment for insomnia, yet CBT techniques clearly were more successful in
helping the majority of study participants to become normal sleepers.
For most outcomes, CBT was the most sleep effective intervention, producing the
greatest changes in sleep-onset latency and sleep efficiency. CBT resulted in
the greatest number of normal sleepers after treatment, as measured by
subjective and objective sleep-onset latency of 30 minutes or less, and sleep
efficiency of 85% or more. CBT maintained therapeutic gains at long-term
follow-up, with a posttreatment mean of less than 30 minutes on
Nightcap-measured sleep-onset latency.
Combined treatment (with medication) provided no benefit over CBT alone. At
midtreatment, CBT and combination groups both had a 44% reduction in sleep-onset
latency compared with 29% in the pharmacotherapy group and 10% for the placebo
group. After eight weeks of treatment, the CBT and combination treatment groups
had a 52% reduction in sleep-onset latency.
Pharmacotherapy produced moderate improvements during drug administration, but
sleep measures returned toward their baseline values when patients discontinued
the drug. Treatment was unsuccessful in 38% of the pharmacotherapy group and in
43% of the placebo group.
Because CBT required about two hours of treatment time by predoctoral and
postdoctoral psychologists, the authors suggest that CBT is cost-effective
relative to pharmacotherapy.
These findings suggest that young and middle-age patients with sleep-onset
insomnia can derive significantly greater benefit from CBT than pharmacotherapy
and that CBT should be considered a firstline intervention for chronic insomnia.
Arch Intern Med. 2004;164:1888-1896
September 27, 2004
Q "I
have heard that many of these anti-depressants stop sexual
urge...could I not have my son put on them and stop him from
being sexually active until he is an adult?"
A There are many things implied in
your question, but in general "Selective serotonin reuptake inhibitors (SSRIs)
may commonly lead to sexual dysfunction in adolescents as in adults...Out of 22
patients treated with an SSRI, five (23%) experienced either anorgasmia or
decreased libido...SSRI-induced sexual dysfunction in adults is known to cause
an impaired quality of life and lead to poor treatment compliance.
In a paper in the same issue of the journal, Dr. Scharko reviews the existing
literature on SSRI-induced sexual dysfunction in adolescents. Out of 31 clinical
trials in which 1,346 children were treated with an SSRI, only one patient was
reported to have experienced sexual dysfunction.
...because the relative trends in the incidence of other side effects were
similar to those observed in larger adult studies, "it is reasonable to conclude
that SSRI-induced adverse effects in general occur at approximately the same
rates as in adults,"
...parents
and clinicians alike may perceive the dampening of the adolescent libido
secondary to SSRI use as a benefit.
But that leaves many questions unanswered...could SSRI use in childhood
negatively influence sexual functioning in adulthood? Is it affecting
developmentally appropriate expressions of sexuality?"
J Am Acad Child Adolesc Psychiatry 2004;43:1067-1068,1071-1079.
September 20, 2004
Q
"Do people who worry...have
anxiety disorders or whatever...misperceive what is going on
in their body...is that the problem?"
A "Patients
who have anxiety disorders appear to be more sensitive to bodily changes, which
in turn suggests that the perception of panic attacks is reflective of central
rather than peripheral responses....Physiologic responses of patients with
anxiety disorders to everyday events are poorly understood...Compared with
controls, patients with anxiety disorders rated higher on psychic and somatic
anxiety symptoms. Patients with anxiety disorders also rated themselves higher
on disability scales and on sensitivity to body sensations. Both patients with
panic disorder and those with generalized anxiety disorder experienced
diminished autonomic flexibility and less precise perception of bodily states.
Patients with panic disorder had a heightened sensitivity to body sensations
compared with generalized anxiety disorder patients. Autonomic arousal levels
were slightly higher in patients with panic disorder, and this manifested itself
in faster heart rates throughout the day.
These findings suggest that, after having experienced anxiety attacks that are
associated with strong bodily changes, patients become sensitized to such
changes and may experience physiological symptoms of panic attacks with
minimally altering peripheral physiological function...Thus, the perception of
anxiety attacks may reflect central rather than peripheral responses and become
an 'as if sensation.'"
The investigators note that the diminished autonomic flexibility found in both
panic disorder and generalized anxiety disorder patients may result from
dysfunctional information processing during heightened anxiety that does not
discriminate between anxiety-related and neutral stimuli.
It is important to measure physiological responses and not rely on verbal
reports...A demonstration that physiological responses during anxiety attacks
are milder than perceived can be reassuring to patients," he said. "However, the
long-term effect of diminished physiological flexibility is unknown."
Arch Gen Psychiatry 2004;61:913-921
September 13, 2004
Q "My
wife has had arthritic complaints for years but also has a
bunch of mental problems. They seem to have started right
after the other...the arthritis was first...is there
research on this?"
A "Frequent
mental distress (FMD) is common among adults with
arthritis -- and these individuals also have a high
prevalence of impaired quality of life and modifiable
arthritis risk behaviors, according to researchers. The
prevalence of FMD in subjects with arthritis was 13.4%,
the researchers report. They estimate the prevalence if
FMD to be 5.4% in subjects without arthritis who were
included in the surveillance study. In subjects with
arthritis, those with FMD were 1.7 times more likely to
be underweight than normal weight and 1.2 times more
likely to be obese than normal weight compared with
those without FMD. In addition, arthritic subjects with
FMD were 1.2 times as likely to be insufficiently active
and 1.6 times as likely to be inactive. Compared with
arthritis subjects without FMD, those with arthritis and
FMD were more likely to report their health as fair or
poor and were more likely to have at least 14 physically
unhealthy days in the past 30 days. Patients with FMD
were also more likely to report an inability to do daily
activities due to joint symptoms and were more likely to
use special equipment.
Arthritis Rheum 2004;51:533-537."
September 6, 2004
Q "My
doctor thinks I am depressed. I think I have chronic fatigue
syndrome. How do I find out who is right?"
A "Chronic fatigue syndrome (CFS)
and depression have distinct neurobiological properties. Unlike depression, CFS
is characterized by decreased skin conductance levels but increased peripheral
skin temperature.
Electrodermal analysis may represent a useful tool in the process of
differential diagnosis of CFS and depression. The considerable overlap between
the symptoms of CFS and of depression has led many to question whether CFS is
really a different condition, or if it is actually a manifestation of
depression.
Mean tonic skin conductance levels were significantly lower in the CFS group
compared with the control group and the depression group. The depression group
and the control group did not differ significantly from each other with regard
to this measurement, however.
Both these findings point to down-regulation of autonomic sympathetic tone, as
the sympathetic system is responsible for vasoconstriction in the periphery."
Int J Psychophysiol 2004;53:171-182.
August 30, 2004
Q "My
cousin sees a psychologist whom she talks to on the
telephone as often as she goes to the office. Can someone
receive any kind of good care over the phone?"
A I found the following to be
interesting, and so may you: "Psychotherapy and case management via telephone is
helpful for patients with depression. This alternative may help patients who
have been unable or unwilling to stick to a conventional treatment program.
Currently, only 25% to 30% of the population receives an effective level of
counseling or antidepressants, research has shown. Barriers that prevent
patients from seeking treatment include the stigma associated with depression,
the time lag before a patient realizes benefits, and an ongoing commitment of
time and effort.
Among the Group Health participants assigned to the telephone care management
protocol, 97% completed at least one telephone contact and 85% completed all
three. Seven percent of the participants in the telephone psychotherapy
intervention failed to attend any sessions, 1% completed the first session
(history and motivational enhancement), 84% completed four or more sessions
(including behavioral activation), and 63% completed seven or more sessions.
Further research is needed to compare the outcomes of depressed individuals who
receive telephone counseling compared with those receiving face-to-face
counseling. "The issue for us is if in-person treatment is better, but it's not
happening, telephone treatment is an alternative...It's a question of the
optimal versus the possible.""
JAMA. 2004;292:935-942
August 23, 2004
Q "I
am teenager on Prozac and worry that it will make me
suicidal from what I read in the newspaper?"
A "Adolescents with major depressive
disorder showed improvement after treatment that combined fluoxetine (Prozac)
and cognitive behavioral therapy (CBT). Major depressive disorder (MDD) is
common in adolescence. "… depression in adolescence is a major risk factor for
MDD, suicide, and long-term psycho-social impairment in adulthood. Thus,
improvements in the treatment of MDD among adolescents should positively affect
public health.
"Compared with fluoxetine alone and CBT alone, treatment [combining] fluoxetine
with CBT was superior," the authors report. "Fluoxetine alone is a superior
treatment to CBT alone. "Clinically significant suicidal thinking, which was
present in 29 percent of the sample at baseline, improved significantly in all 4
treatment groups. Fluoxetine with CBT showed the greatest reduction. Seven (1.6
percent) of 439 patients attempted suicide; there were no completed suicides."
The researchers also found treatment with fluoxetine alone elevated the risk for
psychiatric adverse events. "While fluoxetine did not appear to increase
suicidal ideation [thoughts], harm-related adverse events may occur more
frequently in fluoxetine-treated patients and CBT may protect against these
events," the researchers add.
In conclusion, the authors write: "First, given the high prevalence, morbidity,
and significant mortality associated with MDD, the identification of depressed
adolescents and provision of evidence-based treatment should be mandatory in
health care systems.
"Second, despite calls to restrict access to medications, medical management of
MDD with fluoxetine, including careful monitoring for adverse events, should be
made widely available, not discouraged.
"Third, given incremental improvement in outcome when CBT is combined with
medication and, as importantly, increased protection from suicidality, CBT also
should be readily available as part of comprehensive treatment for depressed
adolescents.
"The reduction of suicidal ideation over time is reassuring, but the increased
risk for harm-related adverse events observed in the patients receiving
fluoxetine suggests that the increase in activation, irritability, or
disinhibition sometimes associated with SSRI [selective serotonin reuptake
inhibitor] treatment warrants careful monitoring in clinical practice.
"Furthermore, the current evidence suggests that the likelihood of a good
outcome is enhanced by the combination of appropriate and carefully monitored
drug treatment with an empirically validated psychotherapy.""
August 16, 2004
Q
"My dad had a heart attack. He
seems real depressed. Is depression normal or something we
should be concerned about?"
A Depression is always a concern
associated with or independent of, a physical disorder. Depression with
cardiac disease is a concern, but there is likely more concern when a patient
has kidney disease: "In comparing hospitalized patients with congestive heart
disease, depression was more common among patient with chronic kidney disease,
Patients with severe chronic kidney disease had an odds ratio of 2.89 for
depressive symptoms. Depression and severe chronic renal dysfunction were both
significant predictors of mortality.
"Depression was more prevalent among patients with than without severe chronic
kidney disease and had at least as strong an association with mortality as
compared with depression in patients with no or less severe chronic kidney
disease," the researchers write.
They conclude, "Studies assessing the efficacy of antidepressants among patients
with chronic kidney disease are needed to determine whether, in addition to
treating depression, pharmacotherapy impacts mortality."
Am J Kidney Dis 2004;44:207-215.
August 9, 2004
Q "Is
schizophrenia due to early childhood experiences?"
A No. It is a biological
condition. Certainly, early trauma can worsen the symptoms of schizophrenia and
other disorders. As to causes, aside from heredity: "Influenza in early
pregnancy may be associated with schizophrenia...an antibody response, rather
than infection, may explain this association.
IInfluenza exposure during the first trimester increased the risk of
schizophrenia sevenfold, but exposure during the second or third trimester did
not affect risk. Exposure during early to midpregnancy increased the risk of
schizophrenia threefold. Adjustment for potential confounders did not affect
these results.
The results may have implications for the prevention
of schizophrenia and for unraveling pathogenic mechanisms of the disorder....
Although the precise mechanisms need to be delineated, it may be worth
considering the question of routine vaccination of nonpregnant women, given the
possibility that the antibody response to influenza, rather than direct
infection, may be resposible for the observed increase in risk of
schizophrenia."
Arch Gen Psychiatry. 2004;61:774-780
August 2, 2004
Q
"Am I better off taking
medications or going to talk to someone?"
A
Here is a brief excerpt you may find helpful: "Combined pharmacotherapy and psychological treatment of
depression is more effective than drug treatment alone..in
addition to being a possible alternative to drug treatment,
psychotherapeutic intervention in combination with drug
therapy has produced outstanding results--a 12% improvement
in response rates to drug treatment due to its effect on
drop-out rates...Psychotherapy helps to keep patients in
treatment....compliance-encouraging interventions might be
one way of improving the response rate to antidepressant
therapy."
Arch Gen Psychiatry 2004;61:714-719.
July 26, 2004
Q
"I
am very hesitant to let my wife take Prozac because of
increased risk of suicide that they reported years ago. Is
that a true problem with that medication?"
A You may wish to begin with this
recent article: "The risk of suicidal behavior is similar for amitriptyline,
fluoxetine, and paroxetine.
“The relation
between use of antidepressants, especially selective serotonin reuptake
inhibitors (SSRIs), and suicidal ideation and behaviors has received
considerable public attention recently,” write Hershel Jick, MD, and colleagues,
from the Boston Collaborative Drug Surveillance Program at Boston University in
Massachusetts. “The use of such drugs among teenagers has been of particular
concern.”
Using the U.K. General Practice Research Database for 1993 to 1999, the
investigators identified 159,810 patients starting treatment with fluoxetine,
paroxetine, amitriptyline, or dothiepin, a tricyclic antidepressant not
available in the U.S. Participants had to have used only one of these
antidepressants and had to have received at least one prescription for the drug
within 90 days before the date of suicidal behavior or ideation.
The authors conclude that the risk of suicidal behavior is increased in the
first month after starting antidepressants, especially during the first one to
nine days.
Antidepressant treatment may not be immediately effective, so there is a higher
risk of suicidal behavior in patients newly diagnosed and treated than in those
who have been treated for a longer time," the authors write. “We cannot exclude
what we think is a less likely possibility, namely that the drug itself 'causes'
depression to worsen rapidly, thus leading to suicidal behavior.”
this study confirms that antidepressant prescription is strongly
associated with suicidal behavior, suggesting that antidepressants are being
prescribed for the right indication and that they do not immediately eliminate
suicide risk.
"But the hypothesis being tested is that over and above the known association of
antidepressant prescribing and suicidal behavior (in which the confounder is the
presence of depressive disorder), there is also a specific link in which one
class of antidepressants, the SSRIs, increases that risk further. The results do
not offer much support for the hypothesis," Dr. Wessely writes.
“There was no evidence for the alleged withdrawal
phenomenon, which is another of the concerns that have been raised about the
SSRIs. Stopping medication did not lead to an increased risk, as postulated by
some. Whatever decision clinicians reach, careful monitoring of adolescents (for
activation, agitation, and suicidal ideation) prescribed any antidepressant
remains essential.""
JAMA. 2004;292:338-343, 379-380
July 19, 2004
Q
"Our youngest two daughters
are insulin dependent diabetics. Both are on "the
pump. We are concerned because both go through
repeated behaviors that suggest binging and purging. Can
this be related to their diabetes?"
A You may be interested in this:
"Preteen and early teenage girls with type 1 diabetes experience eating
disturbances significantly more often than do those without the condition...The
same proportion (16%) of diabetic and nondiabetic girls reported at least one
disturbed eating episode in the previous month. However, significantly more
diabetic (8%) than nondiabetic girls (1%) reported currently engaging in at
least two disturbed eating behaviors.
Eleven percent of diabetic girls and 15% of nondiabetic girls reported dieting
in the previous month. However, diabetic girls were significantly more likely to
take part in intense, excessive exercise for weight control than were the other
girls (10% versus 1%).
Binge eating was also significantly more prevalent in diabetic girls (3%) than
in nondiabetic girls (0.3%).
In addition, subthreshold eating disorders were more common in diabetic girls
than in nondiabetic girls (8% versus 1%). No association was observed between
metabolic control and eating disturbances.
Given these findings, the researchers conclude that "screening and prevention
programs for this high-risk group should begin in the preteen years."
Diabetes Care 2004;27:1654-1659.
July 19, 2004
Q "Our
son is back from Iraq. He does not seem himself. He
sleeps much of the time, is irritable or withdrawn and has
made no attempt to find a job. Is this a common response?"
A "Findings from a study of
soldiers involved in combat duty in Iraq and Afghanistan suggest that up to 17%
met criteria for a mental disorder after deployment. Moreover, less than half of
such subjects sought help, researchers report in the July 1, 2004 issue of The
New England Journal of Medicine.
The researchers found that combat exposure was significantly greater with
service in Iraq than in Afghanistan. The rate of the three primary mental
disorders among personnel deployed to Iraq was around 16%, significantly higher
than the 11.2% rate seen among subjects who served in Afghanistan or the 9.3%
rate recorded before deployment to Iraq.
The greatest variability in disease rates occurred with PTSD. For example,
service in Iraq was tied to a PTSD rate of about 13%, more than double the 6.2%
rate seen with deployment to Afghanistan.
Overall, of those with mental problems, between 23% and 40% reported receiving
professional help for the condition. They were also twice as likely as their
peers to show concern about being stigmatized by receiving care for their
problem."
N Engl J Med 2004;351:13-22,75-77.
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