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QUESTION OF THE WEEK |
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September 24, 2007
Q
"My husband is undergoing treatment for prostate cancer. I think he is very,
very depressed, but his doctor is not catching on."
A
"Patients with advanced and terminal cancer often
experience emotional distress and psychological disorders, which can adversely
affect quality of life. There is an important role that oncologists can play in
screening for these conditions, as well as in helping to reduce psychological
distress by effective communication, providing support and first-line treatment,
and making appropriate referrals.
Even though data show that emotional distress and psychological disorders are
common among advanced cancer patients, oncologists often do not recognize these
symptoms in their patients.
Psychiatric disorders are common in cancer patients and are undertreated but
usually treatable, and treating them improves quality of life.
Less than half of patients receiving palliative care who are also exhibiting
symptoms of moderate to severe depression receive antidepressants, even though
depression may be more instrumental in moderating the desire for hastened death
than the presence of pain.
Adjustment disorders are the most common psychiatric syndromes that oncologists
will encounter in this patient population .
Symptoms of major depression have been associated with a shorter survival time
among some cancer patients, and depression is also linked to a reduction in
treatment adherence, prolonged hospitalization, and a lower quality of life. In
addition, it is estimated that as many as 59% of patients with a terminal
illness who desire assisted suicide suffer from depression.
Patients need access to psychiatric care in cancer facilities, as they are
generally too overwhelmed and tired to travel to yet another site. It is also
important to have a network of mental health providers who are familiar with
oncology patients and their specific needs.
Empathic listening is the most important communication skill that oncologists
can use with their patients, as it allows patients to express fears, concerns,
hopes, and final wishes, as well as just giving them a chance to be heard, the
researchers write. When physicians take time to listen to them, it also shows
that they are not too preoccupied, too frightened, or too tired to be present
for the patient, and that the patient is valued."
Cancer. Published online September 10, 2007.
September 17, 2007
Q "I
can see why we are more concerned about obesity than depression. Obesity
is a major health concern, but I doubt that depression is."
A
"Worldwide, depression worsens health more than 4 common chronic diseases —
angina, arthritis, asthma, and diabetes — most people who are mentally ill are
not treated.
The lifetime prevalence of depression is 2% to 15% and it accounts for almost
12% of total years lived with disability. There has been no worldwide comparison
of depression with other chronic diseases and their effect on health.
Having more than 2 chronic physical diseases without depression was consistently
linked with a smaller negative impact on heath compared with having depression
alone or having depression and 1 other chronic physical disease.
Depression produces the greatest decrement in health compared with the chronic
diseases angina, arthritis, asthma, and diabetes.
The use of mental health services was lower in low-income countries; for
example, 2% of respondents in Nigeria vs 18% of respondents in the United States
had used mental health services in the previous year. The percentage of
respondents who received care for severe mental health disorders ranged from 11%
(in China) to 61% (in Belgium). The proportion of respondents who received at
least minimally adequate treatment ranged from only 10% (in Nigeria) to 42% (in
France). In a few countries, less use of mental health services was reported by
individuals who were male, married, less educated, or at the extremes of age or
income.
Although up to 30% of the population is expected to have clear-cut mental
illness every year, in every country studied, at least two-thirds of people who
are mentally ill receive no treatment. In the United States, 31% of the
population is affected by mental illness every year, but 67% are not treated; in
Europe, the comparable percentages are 27% and 74%, respectively, whereas only
8% of diabetics receive no care.
In the [United States], every year a staggering 10% of the population is treated
despite not being mentally ill. Worldwide, depression worsens health more than 4
common chronic diseases — angina, arthritis, asthma, and diabetes.
Having more than 2 chronic physical diseases without depression was consistently
linked with a smaller negative impact on heath compared with having depression
alone or having depression and 1 other chronic physical disease.
Depression produces the greatest decrement in health compared with the chronic
diseases angina, arthritis, asthma, and diabetes.
Lancet. 2007;370:851-858, 808-809, 841-850, 807-808.
September 10, 2007
Q "I
gather that hypnosis is rarely used except for gimmicks and tricks on stage,
correct?"
A
"Hypnosis before breast surgery reduces the amount
of medication required during the procedure and lessens postsurgical pain and
nausea. Hospitals also benefit cost-wise from the intervention as a result of
the shortened duration of surgery.
Patients in the hypnosis group required less lidocaine and less propofol during
surgery than patients in the control group, Dr. Guy H. Montgomery.
The hypnosis intervention reduced patient-reported postsurgical pain intensity
and nausea. Patients' assessments of discomfort, fatigue, and emotional upset
were also statistically significantly better after hypnosis. According to the
investigators, all outcomes were "clinically meaningful."
A brief hypnosis intervention appears to be one of the rare clinical
interventions that can simultaneously reduce both symptom burden and costs.
It is now abundantly clear that we can retrain the brain to reduce pain."
J Natl Cancer Inst 2007;99:1304-1312.
September 1, 2007
Q "It
seems that depression is like ADD...everyone has it or wants you to believe they
have it."
A
There is a debate over this at present: Is depression being over
diagnosed: "A low depression threshold risks treating normal mental health as
illness, but on other hand, underdiagnosis can mean missed opportunities to
provide treatment for a life-threatening condition. One side argues that it is
normal to feel depressed. The overdiagnosis in depression is due to changes in
1980 in the DSM-III, which introduced the diagnostic categories of "major" and
"minor" depression. The gravity of the term "major depression" gave it cachet
with clinicians, but its descriptive criteria were set at a low threshold, and
"minor depression" required even fewer and less substantive symptoms. Extending
the diagnostic model to include "subsyndromal or subclinical depression" means
that it encompasses an even less severe condition, which is widely prevalent.
Marketing depression treatments beyond their true usefulness in a climate of
heightened expectations is also contributing to the current overdiagnosis.
The current classification of depression risks "medicalizing normal human
distress and viewing any expression of depression as mandating treatment."
Falsely detecting depression in individuals with less severe conditions could
result in treatment that raises hopes but is ineffective and inappropriate, he
observes.
The other side of the debate counters that if increased treatment has led to
demonstrable benefits and is cost effective, then depression is not being
overdiagnosed, and this is the case, since "more adults are alive and well and
we can easily afford to treat more.
He explains that increased depression treatment decreases suicides and increases
productivity. The increased rate of diagnosis of depression over the past 15
years has also led to reduced stigma, improved physical health outcomes, reduced
drug and alcohol misuse, wider public understanding of risks and benefits of
coming for care, and abandonment of demeaning labels of stress, nervous
breakdown, and adolescent angst.
The promotion of safer antidepressants during the 1990s awakened broader
interest in depression. The use of new antidepressant drugs often results in
reducing the prescriptions of less desirable sedatives or more dangerous older
antidepressants.
The low recognition rates of major depression means that clinicians are missing
opportunities to intervene early and change the course of this illness, and real
harm, as evidenced by suicide statistics, comes from not receiving a diagnosis
or lifesaving treatment."
BMJ. 2007;335:328-329
August 27, 2007
Q
"Don't people take anti-anxiety drugs for obsessive compulsive disorder. I read
where they use anti-depressants. Is that accurate?"
A
"Obsessive-compulsive disorder (OCD) preferentially responds to a class of
antidepressants called serotonin reuptake inhibitors. The SRIs are equally
effective in treating OCD. Meta-analyses suggest that clomipramine may be
superior to other SRIs. OCD tends to respond to higher doses of SRIs than that
used to treat depression. Response to treatment is usually delayed and may take
up to 8-12 weeks. Atypical antipsychotics are the only proven augmenting agents
in SRI non-responders. Cognitive behavior therapy (CBT) is an effective
treatment strategy in treating OCD and possibly has a role in treating SRI
non-responders. Side effect profile and drug-drug interactions largely determine
the choice of SRI. Those who fail to respond to one SRI trial may well respond
to another SRI trial. Clomipramine is recommended if 2-3 trials of SRIs fail to
produce response. Atypical antipsychotics are the first-line augmenting agents
in SRI non-responders. CBT should be considered in all patients with OCD and is
a potential option in SRI non-responders. OCD is a chronic and debilitating
disorder. In responders, SRIs have to be continued in the same doses (if
possible) for a minimum of 1-2 years and may be lifelong in those with
persistent symptoms and in those with multiple relapses. CBT has to be offered
in combination with SRIs wherever facilities for CBT exist."
August 20, 2007
Q "Do
they ever screen women (psychologically) who are seeking cosmetic surgery?"
A
"Individuals who experience high levels of
stress and anxiety appear to be more likely to develop irritable bowel syndrome
(IBS) following an episode of gastroenteritis.
A variety of studies suggest a cognitive behavioral model for IBD. This study
shows that various psychological factors, particularly stress, anxiety and a
tendency to push oneself to keep going when ill and then collapse in response,
interact with the physical illness in causing IBS," .
Depression and perfectionism were not significantly associated with the onset of
IBS. However, a variety of other factors were. These included significantly
higher levels of perceived stress, anxiety and somatization.
IBS patients were significantly less likely to rest in the face of their illness
and exhibited "all-or-nothing" behavior, by continuing their activities despite
their symptoms until they were forced to stop.
These patients were prone to view illness in a particularly pessimistic fashion.
Being female was also an important risk factor."
Gut 2007;56:1039-1041,1066-1071.
August 13, 2007
Q "Does
any form of psychotherapy help with these somatoform disorders? I was diagnosed
with conversion disorder years ago, and I still maintain that I am physically
sick, not crazy."
A
"A therapeutic approach similar to
cognitive-behavioral therapy (CBT) significantly relieves symptoms of patients
with multiple medically unexplained physical symptoms.
Even after appropriate physical evaluations and laboratory testing have ruled
out any physical cause, many patients continue to experience symptoms and seek
care from primary health care providers.
CBT is usually used to treat mood disorders. The researchers explain in their
paper that the intervention focuses on the reduction of physical distress and
preoccupation with symptoms through relaxation training, cognitive restructuring
and similar approaches.
When evaluated immediately after completion of the study, subjects in the
intervention group were significantly less likely to report physical symptoms
and depressive symptoms. Substantial relief of medically unexplained physical
symptoms was observed in about 60% of the patients who completed the
intervention, and persisted for months afterward," .
More of the intervention group were rated as "much improved" or "very much
improved" at the end of treatment compared with controls . Assessments for
depression also found that more in the intervention groups were "much/very much
improved".
The effects of the intervention were not only statistically significant but also
clinically meaningful.
The degree of improvement gradually diminished over time. At the 6-month
evaluation, the only variable that remained statistically significantly improved
in the intervention group was the severity rating of somatic symptoms.
A major component of our approach is validating the patients' experience, and
concentrating on how they deal with it."
Ann Fam Med. 2007;5:328-335.
August 6, 2007
Q "Was
there not some research on memory and diabetes mentioned in the news?"
A
"Many patients with type 2 diabetes have hypothalamic-pituitary-adrenal (HPA)
hyperactivity and declarative memory deficits.
Compared with the controls, the diabetic group had elevated plasma cortisol
levels basally and after dexamethasone suppression, and a greater response to
corticotropin-releasing hormone (CRH).
Cortisol levels during the dexamethasone/CRH test were positively associated
with HbA1c. This was independent of age, body mass index and other factors.
A neuropsychological battery assessing declarative and working memory,
attention, and executive function showed that cognitive impairment in the
diabetics was restricted to declarative memory.
Moreover, across all subjects, declarative memory was inversely associated with
cortisol levels. These associations were subsumed by glycemic control (glycosylated
hemoglobin).
Improvements in glycemic control might lead to improvement in cognition. Most
cases of type 2 diabetes are associated with weight problems and a staple of
diabetes treatment is weight control.
A speculative interpretation of the data presented in the article is that given
the dysregulation of the stress system, it may be a good idea to institute
stress reductions strategies, such as relaxation or meditation, as part of the
weight reduction plan in individuals with type 2 diabetes."
J Clin Endocrinol Metab 2007;92:2439-2445.
July 30, 2007
Q "With
all this fear of suicide in children and teens on antidepressants, should they
be used at all?"
A
"A study of children and teens in Tennessee found a
33% decrease in new prescriptions of antidepressants in the 21 months after vs
the 24 months before a December 2003 regulatory warning about the use of
antidepressants in this age group, which was issued by the Committee on Safety
of Medicines (CSM) in the United Kingdom. They also found a 60% increase in new
prescriptions of fluoxetine (Prozac, Eli Lilly), the only antidepressant
approved for use in pediatric patients, which was excluded from the CSM warning.
Findings show that these regulatory changes affected physician prescribing
practices, adding that the impact on factors such as suicidal thoughts and
behaviors remains to be determined.
The group writes that depression is common and potentially life threatening in
children and adolescents, and antidepressants have been 1 of the mainstays of
pediatric depression treatment. After the CSM reviewed emerging data about
increased suicidality in pediatric patients receiving paroxetine hydrochloride (Paxil,
GlaxoSmithKline), they issued a warning in December 2003 that the risk/benefit
profile for selective serotonin reuptake inhibitors (SSRIs) other than
fluoxetine was unfavorable for the treatment of major depressive disorders in
children and adolescents.
In October 2004, the US Food and Drug Administration (FDA) issued a black-box
warning for all antidepressants (including fluoxetine) that highlighted the
potential increase in suicidal thinking and behavior in children and adolescents
prescribed antidepressants and recommended more intense therapeutic monitoring
but did not suggest avoiding the use of these agents in this population.
During the 2 years preceding the UK warning, there were on average 23 new users
of antidepressants per 10,000 persons per month. This dropped by 33%, to an
average of 15 new users per 10,000 persons per month, by 21 months after the
warning, largely due to the drop in new prescriptions of nonfluoxetine SSRIs and
selective norepinephrine reuptake inhibitors (SNRIs). In contrast, new users of
fluoxetine, which had averaged 1 per 10,000 persons before the warnings, rose by
60%.
Among existing users of antidepressants, there was no evidence of
discontinuation of antidepressants or of switching to other antipsychotic drugs,
which suggests that the primary effect of the warning was to alter the decision
to treat a newly presenting patient, the group writes.
The decrease in new prescriptions for antidepressants may have been beneficial
if the children had marginal indications for these drugs, but on the other hand,
if the children had serious mental disorders, failure to start treatment could
have had undesired consequences.
They conclude: "Thus, while it is now evident that regulatory interventions can
alter patterns of practice, whether this is desirable is uncertain. There is an
urgent need for better data on the efficacy and safety of antidepressants to
guide pediatric practice."
Arch Pediatr Adolesc Med. 2007;161:690-696
July 23, 2007
Q "Does
psychological care help extend life in folks with cancer?"
A
Psychotherapeutic support is associated with improved survival in patients with
gastrointestinal cancer undergoing surgery.
An individualized psycho-oncological approach delivered within an
interdisciplinary surgical team that intervenes as early as possible
preoperatively has a significant impact on long-term survival of patients with
gastrointestinal cancer.
The results of this study stem from a 10-year study of 271 patients with various
gastrointestinal malignancies who were randomized to receive usual in-hospital
care alone or combined with formal counseling provided by a psychotherapist. In
addition to counseling, the therapist provided educational information and a
supportive relationship.
The counseling group had significantly better survival than did controls, even
after accounting for TNM staging, residual tumor classification, and tumor site.
During the study period, 29 of 136 counseling patients survived, compared with
13 of 135 control patients.
The survival benefit seen with counseling was apparent in patients with stomach,
pancreatic, liver, and colorectal cancer.
The researchers believe that psychotherapeutic support could represent a
cost-effective means of improving survival.
In terms of costs and benefits, the provision of time-limited individual
counseling, an average of 222 minutes of patient-therapist contact, and a
similar amount of time with the patient's physicians (an investment of about 7
hours per patient), yields rather substantial benefits to survival.
J Clin Oncol 2007;25:2702-2708
July 16, 2007
Q "Are
some social groups more prone to get some kind of headaches versus other kinds?"
A
"A new study finds that among adolescents from
families with no history of migraine, those from low-income households are more
likely to have migraine than those from higher-income households. This suggests
social causation rather than social selection, highlighting the need for
exploration of environmental risk factors related to low income and migraine and
the search for specific comorbidities and stressors in this group.
For those with a family history of migraine, household income did not have a
significant effect on migraine prevalence, probably because of the higher
biologic predisposition.
This relationship between higher migraine prevalence and lower income and
education has been observed in adults, the authors write. The reasons for this
relationship have been the subject of much debate, with 2 major alternative
explanations.
The "social-causation" hypothesis suggests that factors associated with low
socioeconomic status, such as stress, poor diet, or limited access to medical
care, act to increase migraine prevalence, they write. The opposing
social-selection hypothesis suggests that disease-related dysfunction interferes
with educational and occupational functioning, which in turn would lead to low
income.
The social-causation hypothesis would predict that migraine prevalence in
adolescence would be similar to that pattern seen in adults. "Since adolescents
make at most a modest contribution to household income, if the social-selection
hypothesis is correct, income and migraine prevalence should not be related in
adolescents" Neurology. 2007;69:16-25.
July 9, 2007
Q "There
was something on the news about depressed people having more migraine headaches,
true?"
A
"A comprehensive Canadian population-based study looking at the prevalence of
several psychiatric conditions in association with migraine suggests that
health-related outcomes are poorer in those patients suffering from migraines
and a psychiatric disorder than those with either condition alone.
Migraine was associated in their study with major depressive disorder, bipolar
disorder, panic disorder, and social phobia in this sample.
Understanding the psychiatric correlates of migraine is important to adequately
manage this patient population and to guide public health policies regarding
health services utilization and healthcare costs.
The conditions evaluated were major depressive disorder (MDD), bipolar disorder,
panic disorder, agoraphobia, social phobia, and substance dependence. The
prevalence of physician-diagnosed migraine was 15.2% for females and 6.1% for
males. Migraine was most common in those between the ages of 25 and 44 years and
in those with a lower income.
"igraine was associated with major depressive disorder, bipolar disorder, panic
disorder, and social phobia, all occurring more than twice as often in those
with migraines compared with those without.
The higher prevalence of psychiatric disorders in migraineurs was not related to
sociodemographic variables. Health-related outcomes (disability, quality of
life, restriction of activities) were worst in those with both migraines and a
psychiatric disorder and intermediate in those with either condition alone
It is well-known that migraine is often accompanied by neuropsychiatric
conditions such as depression and anxiety, which are characterized as
comorbidities of migraine. By definition, they occur in association with
migraine more frequently than by chance alone. There is evidence that these
conditions share certain biologic and/or genetic commonalities with migraine."
July 2, 2007
Q "I
was wondering if kids with those rather severe handicaps ever really adapt to
their limitations."
A
Children are more resilient than we often conceive. "A new study of children
with cerebral palsy (CP) shows that their self-reported quality of life (QoL) is
similar to children in the general population. Parents can be reassured that
most children aged 8 to 12 years with cerebral palsy will have similar quality
of life to other children. This finding should guide social and educational
policy to ensure that disabled children participate fully in society.
Good quality of life is a key outcome for the individual child and what society
wants for all children. Still, little is known about the quality of life among
disabled children.
Severely limited self-mobility was significantly associated with a reduced mean
score for physical well-being. In addition, intellectual impairment was
associated with a reduced mean score for moods, emotions, and autonomy, and
speech difficulties were associated with a reduced mean for relationships with
parents.
Compared with the general population, children with cerebral palsy had similar
quality of life in all domains except schooling, where the findings were
equivocal, and in physical well-being, where comparison was not possible.
Although there is now widespread acceptance of the need for these children to be
fully integrated into society, what remains is the need for a change of
attitudes. Pity and sorrow should not be directed to disabled children, because
our findings indicate that they experience most of life as do nondisabled
children. Therefore, maximum effort is needed to support social and educational
policies that recognize the similarity between the lives of disabled children
and those of other children and that ensure their rights as citizens, rather
than as disabled children, to participate fully in society."
Lancet. 2007;369:2171-2178.
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