ITEMS IN AFP WITH MESH TERM:
Treatment-Resistant Depression - Article
ABSTRACT: Up to two thirds of patients with major unipolar depression will not respond to the first medication prescribed. Depression may be considered resistant to treatment when at least two trials with antidepressants from different pharmacologic classes (adequate in dose, duration, and compliance) fail to produce a significant clinical improvement. Evidence regarding the effectiveness of psychotherapy for treatment-resistant depression is limited. A recent high-quality trial found that patients who did not respond to citalopram and who received cognitive behavior therapy (with or without continued citalopram) had similar response and remission rates to those who received other medication regimens. Initial remission rates in that trial were 37 percent, and even after three additional trials of different drugs or cognitive behavior therapy, the cumulative remission rate was only 67 percent. In general, patients who require more treatment steps have higher relapse rates, and fewer than one half of patients achieve sustained remission. No treatment strategy appears to be better than another. Electroconvulsive therapy is effective as short-term therapy of treatment-resistant depression. There is no good-quality evidence that vagal nerve stimulation is an effective treatment for this condition.
ABSTRACT: Obsessive-compulsive disorder is an illness that can cause marked distress and disability. It often goes unrecognized and is undertreated. Primary care physicians should be familiar with the various ways obsessive-compulsive disorder can present and should be able to recognize clues to the presence of obsessions or compulsions. Proper diagnosis and education about the nature of the disorder are important first steps in recovery. Treatment is rarely curative, but patients can have significant improvement in symptoms. Recommended first-line therapy is cognitive behavior therapy with exposure and response prevention or a selective serotonin reuptake inhibitor. The medication doses required for treatment of obsessive-compulsive disorder are often higher than those for other indications, and the length of time to response is typically longer. There are a variety of options for treatment-resistant obsessive-compulsive disorder, including augmentation of a selective serotonin reuptake inhibitor with an atypical antipsychotic. Obsessive-compulsive disorder is a chronic condition with a high rate of relapse. Discontinuation of treatment should be undertaken with caution. Patients should be closely monitored for comorbid depression and suicidal ideation.
Fibromyalgia - Article
ABSTRACT: Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Nearly 2 percent of the general population in the United States suffers from fibromyalgia, with females of middle age being at increased risk. The diagnosis is primarily based on the presence of widespread pain for a period of at least three months and the presence of 11 tender points among 18 specific anatomic sites. There are certain comorbid conditions that overlap with, and also may be confused with, fibromyalgia. Recently there has been improved recognition and understanding of fibromyalgia. Although there are no guidelines for treatment, there is evidence that a multidimensional approach with patient education, cognitive behavior therapy, exercise, physical therapy, and pharmacologic therapy can be effective.
ABSTRACT: Generalized anxiety disorder is common among patients in primary care. Affected patients experience excessive chronic anxiety and worry about events and activities, such as their health, family, work, and finances. The anxiety and worry are difficult to control and often lead to physiologic symptoms, including fatigue, muscle tension, restlessness, and other somatic complaints. Other psychiatric problems (e.g., depression) and nonpsychiatric factors (e.g., endocrine disorders, medication adverse effects, withdrawal) must be considered in patients with possible generalized anxiety disorder. Cognitive behavior therapy and the first-line pharmacologic agents, selective serotonin reuptake inhibitors, are effective treatments. However, evidence suggests that the effects of cognitive behavior therapy may be more durable. Although complementary and alternative medicine therapies have been used, their effectiveness has not been proven in generalized anxiety disorder. Selection of the most appropriate treatment should be based on patient preference, treatment success history, and other factors that could affect adherence and subsequent effectiveness.
ABSTRACT: Bulimia nervosa is characterized by binge eating and inappropriate compensatory behaviors, such as vomiting, fasting, excessive exercise and the misuse of diuretics, laxatives or enemas. Although the etiology of this disorder is unknown, genetic and neurochemical factors have been implicated. Bulimia nervosa is 10 times more common in females than in males and affects up to 3 percent of young women. The condition usually becomes symptomatic between the ages of 13 and 20 years, and it has a chronic, sometimes episodic course. The long-term outcome has not been clarified. Other psychiatric conditions, including substance abuse, are frequently associated with bulimia nervosa and may compromise its diagnosis and treatment. Serious medical complications of bulimia nervosa are uncommon, but patients may suffer from dental erosion, swollen salivary glands, oral and hand trauma, gastrointestinal irritation and electrolyte imbalances (especially of potassium, calcium, sodium and hydrogen chloride). Treatment strategies are based on medication, psychotherapy or a combination of these modalities.
Managing Somatic Preoccupation - Article
ABSTRACT: Somatically preoccupied patients are a heterogeneous group of persons who have no genuine physical disorder but manifest psychologic conflicts in a somatic fashion; who have a notable psychologic overlay that accompanies or complicates a genuine physical disorder; or who have psychophysiologic symptoms in which psychologic factors play a major role in physiologic symptoms. In the primary care setting, somatic preoccupation is far more prevalent among patients than are the psychiatric disorders collectively referred to as somatoform disorders (e.g., somatization disorder, hypochondriasis). Diagnostic clues include normal results from physical examination and diagnostic tests, multiple unexplained symptoms, high health care utilization patterns and specific factors in the family and the social history. Treatment may include a physician behavior management strategy, antidepressants, psychiatric consultation and cognitive-behavior therapy.
ABSTRACT: Body dysmorphic disorder is an under-recognized chronic problem that is defined as an excessive preoccupation with an imagined or a minor defect of a localized facial feature or body part, resulting in decreased social, academic and occupational functioning. Patients who have body dysmorphic disorder are preoccupied with an ideal body image and view themselves as ugly or misshapen. Comorbid psychiatric disorders may also be present in these patients. Body dysmorphic disorder is distinguished from eating disorders such as anorexia nervosa that encompass a preoccupation with overall body shape and weight. Psychosocial and neurochemical factors, specifically serotonin dysfunction, are postulated etiologies. Treatment approaches include cognitive-behavioral psychotherapy and psychotropic medication. To relieve the symptoms of body dysmorphic disorder, selective serotonin reuptake inhibitors, in higher dosages than those typically recommended for other psychiatric disorders, may be necessary. A trusting relationship between the patient and the family physician may encourage compliance with medical treatment and bridge the transition to psychiatric intervention.
ABSTRACT: Social phobia is a highly prevalent yet often overlooked psychiatric disorder that can cause severe disability but fortunately has shown responsiveness to specific pharmacotherapy and psychotherapy. Recognition of its essential clinical features and the use of brief, targeted screening questions can improve detection within family practice settings. Cognitive behavioral therapy, with or without specific antidepressant therapy, is the evidence-based treatment of choice for most patients. Adjunctive use of benzodiazepines can facilitate the treatment response of patients who need initial symptom relief. The use of beta blockers as needed has been found to be helpful in the treatment of circumscribed social and performance phobias. Treatment planning should consider the patient's preference, the severity of presenting symptoms, the degree of functional impairment, psychiatric and substance-related comorbidity, and long-term treatment goals.
Early Diagnosis and Empathy in Managing Somatization - Editorials
ABSTRACT: Obesity is a chronic disease that affects a substantial number of Americans. Obesity significantly increases a person's risk of cardiovascular diseases and morbidity. Modification of lifestyle behaviors that contribute to obesity (e.g., inappropriate diet and inactivity) is the cornerstone of treatment. Behavior modification involves using such techniques as self-monitoring, stimulus control, cognitive restructuring, stress management and social support to systematically alter obesity-related behaviors. In addition, adjunctive pharmacotherapy can play an important role in the routine medical management of obesity.