ITEMS IN AFP WITH MESH TERM:
Treatment of Panic Disorder - Article
ABSTRACT: Panic disorder with or without agoraphobia occurs commonly in patients in primary care settings. This article assesses multiple evidence-based reviews of effective treatments for panic disorder. Antidepressant medications successfully reduce the severity of panic symptoms and eliminate panic attacks. Selective serotonin reuptake inhibitors and tricyclic antidepressants are equally effective in the treatment of panic disorder. The choice of medication is based on side effect profiles and patient preferences. Strong evidence supports the effectiveness of cognitive behavior therapy in treating panic disorder. Family physicians who are not trained in cognitive behavior therapy may refer patients with panic disorder to therapists with such training. Cognitive behavior therapy can be used alone or in combination with antidepressants to treat patients with panic disorder. Benzodiazepines are effective in treating panic disorder symptoms, but they are less effective than antidepressants and cognitive behavior therapy.
Cognitive Therapy for Depression - Article
ABSTRACT: Cognitive therapy is a treatment process that enables patients to correct false self-beliefs that can lead to negative moods and behaviors. The fundamental assumption is that a thought precedes a mood; therefore, learning to substitute healthy thoughts for negative thoughts will improve a person's mood, self-concept, behavior, and physical state. Studies have shown that cognitive therapy is an effective treatment for depression and is comparable in effectiveness to antidepressants and interpersonal or psychodynamic therapy. The combination of cognitive therapy and antidepressants has been shown to effectively manage severe or chronic depression. Cognitive therapy also has proved beneficial in treating patients who have only a partial response to adequate antidepressant therapy. Good evidence has shown that cognitive therapy reduces relapse rates in patients with depression, and some evidence has shown that cognitive therapy is effective for adolescents with depression.
Medications for Migraine Prophylaxis - Article
ABSTRACT: Sufficient evidence and consensus exist to recommend propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate as first-line agents for migraine prevention. There is fair evidence of effectiveness with gabapentin and naproxen sodium. Botulinum toxin also has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention. Limited evidence is available to support the use of candesartan, lisinopril, atenolol, metoprolol, nadolol, fluoxetine, magnesium, vitamin B2 (riboflavin), coenzyme Q10, and hormone therapy in migraine prevention. Data and expert opinion are mixed regarding some agents, such as verapamil and feverfew; these can be considered in migraine prevention when other medications cannot be used. Evidence supports the use of timed-release dihydroergotamine mesylate, but patients should be monitored closely for adverse effects.
Vulvodynia: Diagnosis and Management - Article
ABSTRACT: The diagnosis of vulvodynia is made after taking a careful history, ruling out infectious or dermatologic abnormalities, and eliciting pain in response to light pressure on the labia, introitus, or hymenal remnants. Several treatment options have been used, although the evidence for many of these treatments is incomplete. Treatments include oral medications that decrease nerve hypersensitivity (e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors, anticonvulsants), pelvic floor biofeedback, cognitive behavioral therapy, local treatments, and (rarely) surgery. Most women experience substantial improvement when one or more treatments are used.
Antidepressant Discontinuation Syndrome - Article
ABSTRACT: Antidepressant discontinuation syndrome occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks. Typical symptoms of antidepressant discontinuation syndrome include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. These symptoms usually are mild, last one to two weeks, and are rapidly extinguished with reinstitution of antidepressant medication. Antidepressant discontinuation syndrome is more likely with a longer duration of treatment and a shorter half-life of the treatment drug. A high index of suspicion should be maintained for the emergence of discontinuation symptoms, which should prompt close questioning regarding accidental or purposeful self-discontinuation of medication. Before antidepressants are prescribed, patient education should include warnings about the potential problems associated with abrupt discontinuation. Education about this common and likely underrecognized clinical phenomenon will help prevent future episodes and minimize the risk of misdiagnosis.
Seasonal Affective Disorder - Article
ABSTRACT: Patients with seasonal affective disorder have episodes of major depression that tend to recur during specific times of the year, usually in winter. Like major depression, seasonal affective disorder probably is underdiagnosed in primary care settings. Although several screening instruments are available, such screening is unlikely to lead to improved outcomes without personalized and detailed attention to individual symptoms. Physicians should be aware of comorbid factors that could signal a need for further assessment. Specifically, some emerging evidence suggests that seasonal affective disorder may be associated with alcoholism and attention-deficit/hyperactivity disorder. Seasonal affective disorder often can be treated with light therapy, which appears to have a low risk of adverse effects. Light therapy is more effective if administered in the morning. It remains unclear whether light is equivalent to drug therapy, whether drug therapy can augment the effects of light therapy, or whether cognitive behavior therapy is a better treatment choice.
Childhood and Adolescent Depression - Article
ABSTRACT: Major depression affects 3 to 5 percent of children and adolescents. Depression negatively impacts growth and development, school performance, and peer or family relationships and may lead to suicide. Biomedical and psychosocial risk factors include a family history of depression, female sex, childhood abuse or neglect, stressful life events, and chronic illness. Diagnostic criteria for depression in children and adolescents are essentially the same as those for adults; however, symptom expression may vary with developmental stage, and some children and adolescents may have difficulty identifying and describing internal mood states. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies. Current literature supports use of cognitive behavior therapy for mild to moderate childhood depression. If cognitive behavior therapy is unavailable, an antidepressant may be considered. Antidepressants, preferably in conjunction with cognitive behavior therapy, may be considered for severe depression. Tricyclic antidepressants generally are ineffective and may have serious adverse effects. Evidence for the effectiveness of selective serotonin reuptake inhibitors is limited. Fluoxetine is approved for the treatment of depression in children eight to 17 years of age. All antidepressants have a black box warning because of the risk of suicidal behavior. If an antidepressant is warranted, the risk/benefit ratio should be evaluated, the parent or guardian should be educated about the risks, and the patient should be monitored closely (i.e., weekly for the first month and every other week during the second month) for treatment-emergent suicidality. Before an antidepressant is initiated, a safety plan should be in place. This includes an agreement with the patient and the family that the patient will be kept safe and will contact a responsible adult if suicidal urges are too strong, and assurance of the availability of the treating physician or proxy 24 hours a day to manage emergencies.
Somatoform Disorders - Article
ABSTRACT: The somatoform disorders are a group of psychiatric disorders that cause unexplained physical symptoms. They include somatization disorder (involving multisystem physical symptoms), undifferentiated somatoform disorder (fewer symptoms than somatization disorder), conversion disorder (voluntary motor or sensory function symptoms), pain disorder (pain with strong psychological involvement), hypochondriasis (fear of having a life-threatening illness or condition), body dysmorphic disorder (preoccupation with a real or imagined physical defect), and somatoform disorder not otherwise specified (used when criteria are not dearly met for one of the other somatoform disorders). These disorders should be considered early in the evaluation of patients with unexplained symptoms to prevent unnecessary interventions and testing. Treatment success can be enhanced by discussing the possibility of a somatoform disorder with the patient early in the evaluation process, limiting unnecessary diagnostic and medical treatments, focusing on the management of the disorder rather than its cure, using appropriate medications and psychotherapy for comorbidities, maintaining a psychoeducational and collaborative relationship with patients, and referring patients to mental health professionals when appropriate.
Treatment of Bulimia Nervosa - FPIN's Clinical Inquiries
ABSTRACT: Grief and depression present similarly in patients who are dying. Conventional symptoms (e.g., frequent crying, weight loss, thoughts of death) used to assess for depression in these patients may be imprecise because these symptoms are also present in preparatory grief and as a part of the normal dying process. Preparatory grief is experienced by virtually all patients who are dying and can be facilitated with psychosocial support and counseling. Ongoing pharmacotherapy is generally not beneficial and may even be harmful to patients who are grieving. Evidence of disturbed self-esteem, hopelessness, an active desire to die and ruminative thoughts about death and suicide are indicative of depression in patients who are dying. Physicians should have a low threshold for treating depression in patients nearing the end of life because depression is associated with tremendous suffering and poor quality of life.