ITEMS IN AFP WITH MESH TERM:
Making Psychotherapy Work in Primary Care Medicine - Editorials
ABSTRACT: Approximately 65 percent of patients with acute myocardial infarction report experiencing symptoms of depression. Major depression is present in 15 to 22 percent of these patients. Depression is an independent risk factor in the development of and mortality associated with cardiovascular disease in otherwise healthy persons. Persons who are depressed and who have pre-existing cardiovascular disease have a 3.5 times greater risk of death than patients who are not depressed and have cardiovascular disease. Physicians can assess patients for depression by using one of several easily administered and scored self-report inventories, including the SIG E CAPS + mood mnemonic. Cognitive-behavior therapy is the preferred psychologic treatment. Selective serotonin reuptake inhibitor antidepressants are the recommended pharmacologic treatment because of the relative absence of effects on the cardiovascular system. The combination of a selective serotonin reuptake inhibitor with cognitive-behavior therapy is often the most effective treatment for depression in patients with cardiovascular disease.
ABSTRACT: Selective serotonin reuptake inhibitors (SSRIs) are the drug of choice for treatment of patients with panic disorder. Most patients have a favorable response to SSRI therapy; however, 30 percent will not be able to tolerate these drugs or will have an unfavorable or incomplete response. Strategies to improve management of such patients include optimizing SSRI dosing (starting at a low dose and slowly increasing the dose to reach the target dose) and ensuring an adequate trial before switching to a different drug. Benzodiazepines should be avoided but, when necessary, may be used for a short duration or may be used long-term in patients for whom other treatments have failed. Slower-onset, longer-acting benzodiazepines are preferred. All patients should be encouraged to try cognitive behavior therapy. Augmentation therapy should be considered in patients who do not have a complete response. Drugs to consider for use in augmentation therapy include benzodiazepines, buspirone, beta blockers, tricyclic antidepressants, and valproate sodium.
Management of Irritable Bowel Syndrome - Article
ABSTRACT: Irritable bowel syndrome is the most common functional disorder of the gastrointestinal tract and is frequently treated by family physicians. Despite patients' worries about the symptoms of irritable bowel syndrome, it is a benign condition. The diagnosis should be made using standard criteria after red flags that may signify organic disease have been ruled out. An effective physician-patient relationship is vital to successful management. Episodes of diarrhea are best managed with loperamide, while constipation often will respond to fiber supplements. Antispasmodics or anticholinergic agents may help relieve the abdominal pain of irritable bowel syndrome. Refractory cases are often treated with tricyclic antidepressants. Newer agents such as tegaserod and ondansetron target neurotransmitter receptors in the gastrointestinal tract Some forms of psychologic treatment may be helpful, and gastroenterology consultation is occasionally needed to reassure the patient. Comorbid conditions such as depression or anxiety should be investigated and treated.
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.
The Patient with Excessive Worry - Article
ABSTRACT: Worry is a normal response to uncertainty. Education, empathetic support, reassurance, and passage of time usually ameliorate ordinary worries. However, these common-sense strategies for dealing with transient worries often prove ineffective for patients with excessive worry, many of whom meet the criteria for disorders in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Evidence-based treatments for such disorders can assist family physicians in management of persistent worry as a self-perpetuating habit across diagnostic categories. Antidepressants and cognitive behavioral therapy are effective treatments for various disorders characterized by excessive worry. Cognitive behavioral strategies that may be adapted to primary care contacts include education about the worry process, repeated challenge of cognitive distortions and beliefs that underpin worry, behavioral exposure assignments (e.g., scheduled worry periods, worry journals), and learning mindfulness meditation.
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.
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.