Somatic Disorders

SAN FRANCISCO – Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients, reported Michael V. Vitiello, Ph.D.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, Dr. Vitiello and his associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in the control group. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes before therapy to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (with a higher score indicating less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as measured by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive CBT for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

CBT for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said.

The intervention consisted of a fairly standard series of behavioral manipulations, such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom,” Dr. Vitiello said.

The study was limited by its small size and the lack of 1-year follow-up in the control group, among other factors, he said.

SAN FRANCISCO – Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients, reported Michael V. Vitiello, Ph.D.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, Dr. Vitiello and his associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in the control group. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes before therapy to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (with a higher score indicating less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as measured by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive CBT for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

CBT for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said.

The intervention consisted of a fairly standard series of behavioral manipulations, such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom,” Dr. Vitiello said.

The study was limited by its small size and the lack of 1-year follow-up in the control group, among other factors, he said.

SAN FRANCISCO – Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients, reported Michael V. Vitiello, Ph.D.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, Dr. Vitiello and his associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in the control group. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes before therapy to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (with a higher score indicating less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as measured by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive CBT for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

CBT for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said.

The intervention consisted of a fairly standard series of behavioral manipulations, such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom,” Dr. Vitiello said.

The study was limited by its small size and the lack of 1-year follow-up in the control group, among other factors, he said.

NEW ORLEANS – Mothers of young children aren't likely to be surprised by a recent study showing that they are more sleep deprived than are their male partners and women without children, but the findings are important because they underscore the need for sleep education in families with children, the investigators said.

Dr. Daniel P. Chapman and his colleagues at the Centers for Disease Control and Prevention in Atlanta used data from the 2002 Behavioral Risk Factor Surveillance System (BRFSS) for the study, which included 72,576 adult participants from the ongoing, state-based, random-digit dialing survey of community-based adults.

Married women with children were significantly more likely than were married men to report insufficient sleep (34% vs. 27%), and both married women and married men with children were more likely than were their married, gender-matched counterparts without children to report insufficient sleep (34% vs. 21%, and 27% vs. 16%, respectively).

The same was true among unmarried women with and without children (36% vs. 27%), and for unmarried men with and without children (31% vs. 25%), Dr. Chapman reported in a poster at the American Psychiatric Association's Institute on Psychiatric Services.

Of note, married women without children reported significantly more sleep insufficiency than did married men without children (21% vs. 16%), but the same did not hold true for unmarried women and men, who reported similar rates of sleep insufficiency (27% and 25%, respectively).

The findings indicate that sleep insufficiency is more prevalent in households with children and among women with children, compared with their partners, Dr. Chapman noted. “These findings suggest the need for sleep education among families with children–particularly for mothers–and corroborate the importance of sleep as a facet of women's health,” he concluded.

Respondents in this study were considered to have insufficient sleep if they reported feeling that they did not get enough sleep on 14 or more of the 30 days prior to the survey. The survey was conducted in 18 states and the District of Columbia.

NEW ORLEANS – Mothers of young children aren't likely to be surprised by a recent study showing that they are more sleep deprived than are their male partners and women without children, but the findings are important because they underscore the need for sleep education in families with children, the investigators said.

Dr. Daniel P. Chapman and his colleagues at the Centers for Disease Control and Prevention in Atlanta used data from the 2002 Behavioral Risk Factor Surveillance System (BRFSS) for the study, which included 72,576 adult participants from the ongoing, state-based, random-digit dialing survey of community-based adults.

Married women with children were significantly more likely than were married men to report insufficient sleep (34% vs. 27%), and both married women and married men with children were more likely than were their married, gender-matched counterparts without children to report insufficient sleep (34% vs. 21%, and 27% vs. 16%, respectively).

The same was true among unmarried women with and without children (36% vs. 27%), and for unmarried men with and without children (31% vs. 25%), Dr. Chapman reported in a poster at the American Psychiatric Association's Institute on Psychiatric Services.

Of note, married women without children reported significantly more sleep insufficiency than did married men without children (21% vs. 16%), but the same did not hold true for unmarried women and men, who reported similar rates of sleep insufficiency (27% and 25%, respectively).

The findings indicate that sleep insufficiency is more prevalent in households with children and among women with children, compared with their partners, Dr. Chapman noted. “These findings suggest the need for sleep education among families with children–particularly for mothers–and corroborate the importance of sleep as a facet of women's health,” he concluded.

Respondents in this study were considered to have insufficient sleep if they reported feeling that they did not get enough sleep on 14 or more of the 30 days prior to the survey. The survey was conducted in 18 states and the District of Columbia.

NEW ORLEANS – Mothers of young children aren't likely to be surprised by a recent study showing that they are more sleep deprived than are their male partners and women without children, but the findings are important because they underscore the need for sleep education in families with children, the investigators said.

Dr. Daniel P. Chapman and his colleagues at the Centers for Disease Control and Prevention in Atlanta used data from the 2002 Behavioral Risk Factor Surveillance System (BRFSS) for the study, which included 72,576 adult participants from the ongoing, state-based, random-digit dialing survey of community-based adults.

Married women with children were significantly more likely than were married men to report insufficient sleep (34% vs. 27%), and both married women and married men with children were more likely than were their married, gender-matched counterparts without children to report insufficient sleep (34% vs. 21%, and 27% vs. 16%, respectively).

The same was true among unmarried women with and without children (36% vs. 27%), and for unmarried men with and without children (31% vs. 25%), Dr. Chapman reported in a poster at the American Psychiatric Association's Institute on Psychiatric Services.

Of note, married women without children reported significantly more sleep insufficiency than did married men without children (21% vs. 16%), but the same did not hold true for unmarried women and men, who reported similar rates of sleep insufficiency (27% and 25%, respectively).

The findings indicate that sleep insufficiency is more prevalent in households with children and among women with children, compared with their partners, Dr. Chapman noted. “These findings suggest the need for sleep education among families with children–particularly for mothers–and corroborate the importance of sleep as a facet of women's health,” he concluded.

Respondents in this study were considered to have insufficient sleep if they reported feeling that they did not get enough sleep on 14 or more of the 30 days prior to the survey. The survey was conducted in 18 states and the District of Columbia.

MINNEAPOLIS – The need to unite sleep specialists from multiple academic departments challenges the field of sleep medicine, Dr. Ronald D. Chervin said at the annual meeting of the Associated Professional Sleep Societies.

“Because sleep is relevant to so many different departments, there is not always good integration across campus,” said Dr. Chervin, a professor of sleep medicine at the University of Michigan, Ann Arbor. Dr. Chervin is also a professor of neurology and the director of the university's sleep disorders center.

For example, a sleep scientist may not rub elbows daily with a pulmonologist or ENT specialist, he said.

The structural challenges that persist at many research universities can make interdisciplinary integration difficult, even though such integration may be the way to provide the best patient care, Dr. Chervin noted.

But the tug-of-war persists between clinician desires to provide good multidisciplinary care versus departmental concerns for the bottom line.

Most sleep specialists agree that patients receive the best care when they see clinicians from a variety of medical fields, Dr. Chervin said. But sharing human resources is not always a priority for any given academic department, and it is not always easy to give up billing opportunities to another department in order to serve a higher goal and allow faculty to pursue diverse interests, he explained.

The role of sleep medicine can be difficult to explain to administrators and faculty outside the field, in part because there often is inadequate investment in sleep medicine specifically.

For example, even at the University of Michigan, which has a large and successful sleep disorders center, there is no administrator dedicated to sleep medicine to help the director manage budgets and financial spreadsheets, “which we are not trained in medical school to do,” Dr. Chervin said. Also, billing and hiring issues still create interdepartmental friction. “I'm proud of our faculty here at Michigan, but we have lost some opportunities to hire qualified personnel because of these departmental issues,” he said.

One strategy that the university has used to overcome some of the interdepartmental barriers has been the creation of an “Alternatives to CPAP” clinic.

“We can see patients shoulder to shoulder with an ENT specialist, maxillofacial surgeon, and dentist. It serves the patients' interests and is wonderful for education,” he said. “And we managed to satisfy all the departments in terms of billing.” The university has developed two other clinics that follow the CPAP program model–a multidisciplinary pediatric sleep and behavior clinic and another behavioral sleep medicine clinic for adults.

What does the future hold for sleep medicine? Dr. Chervin said he believes that creating comprehensive sleep centers at universities would improve patient care and promote the basic scientific research that continues to drive advances in sleep medicine.

Ideally, a “center for sleep science” would unite sleep specialists on campus, at least for joint grand rounds, for training, and for promoting grant submissions that could cross department boundaries, he said.

In his view, sleep centers should uphold a tripartite mission that includes research, education, and patient care and provide both clinical and preclinical programs.

Sleep centers need their own physical space and dedicated funding, in part to allow them to bill for clinical and laboratory services and then reimburse other departments for faculty effort, Dr. Chervin said. And sleep centers should have a greater say in hiring decisions, he added.

As more data emerge to support the impact of sleep and sleep problems on a range of medical conditions, support for interdisciplinary work in sleep medicine and the establishment of sleep centers may gain traction. “How does a new interdisciplinary field fit within a traditional, department-based academic medical center?” Dr. Chervin asked. “It's like trying to put a square peg in a round hole.”

MINNEAPOLIS – The need to unite sleep specialists from multiple academic departments challenges the field of sleep medicine, Dr. Ronald D. Chervin said at the annual meeting of the Associated Professional Sleep Societies.

“Because sleep is relevant to so many different departments, there is not always good integration across campus,” said Dr. Chervin, a professor of sleep medicine at the University of Michigan, Ann Arbor. Dr. Chervin is also a professor of neurology and the director of the university's sleep disorders center.

For example, a sleep scientist may not rub elbows daily with a pulmonologist or ENT specialist, he said.

The structural challenges that persist at many research universities can make interdisciplinary integration difficult, even though such integration may be the way to provide the best patient care, Dr. Chervin noted.

But the tug-of-war persists between clinician desires to provide good multidisciplinary care versus departmental concerns for the bottom line.

Most sleep specialists agree that patients receive the best care when they see clinicians from a variety of medical fields, Dr. Chervin said. But sharing human resources is not always a priority for any given academic department, and it is not always easy to give up billing opportunities to another department in order to serve a higher goal and allow faculty to pursue diverse interests, he explained.

The role of sleep medicine can be difficult to explain to administrators and faculty outside the field, in part because there often is inadequate investment in sleep medicine specifically.

For example, even at the University of Michigan, which has a large and successful sleep disorders center, there is no administrator dedicated to sleep medicine to help the director manage budgets and financial spreadsheets, “which we are not trained in medical school to do,” Dr. Chervin said. Also, billing and hiring issues still create interdepartmental friction. “I'm proud of our faculty here at Michigan, but we have lost some opportunities to hire qualified personnel because of these departmental issues,” he said.

One strategy that the university has used to overcome some of the interdepartmental barriers has been the creation of an “Alternatives to CPAP” clinic.

“We can see patients shoulder to shoulder with an ENT specialist, maxillofacial surgeon, and dentist. It serves the patients' interests and is wonderful for education,” he said. “And we managed to satisfy all the departments in terms of billing.” The university has developed two other clinics that follow the CPAP program model–a multidisciplinary pediatric sleep and behavior clinic and another behavioral sleep medicine clinic for adults.

What does the future hold for sleep medicine? Dr. Chervin said he believes that creating comprehensive sleep centers at universities would improve patient care and promote the basic scientific research that continues to drive advances in sleep medicine.

Ideally, a “center for sleep science” would unite sleep specialists on campus, at least for joint grand rounds, for training, and for promoting grant submissions that could cross department boundaries, he said.

In his view, sleep centers should uphold a tripartite mission that includes research, education, and patient care and provide both clinical and preclinical programs.

Sleep centers need their own physical space and dedicated funding, in part to allow them to bill for clinical and laboratory services and then reimburse other departments for faculty effort, Dr. Chervin said. And sleep centers should have a greater say in hiring decisions, he added.

As more data emerge to support the impact of sleep and sleep problems on a range of medical conditions, support for interdisciplinary work in sleep medicine and the establishment of sleep centers may gain traction. “How does a new interdisciplinary field fit within a traditional, department-based academic medical center?” Dr. Chervin asked. “It's like trying to put a square peg in a round hole.”

MINNEAPOLIS – The need to unite sleep specialists from multiple academic departments challenges the field of sleep medicine, Dr. Ronald D. Chervin said at the annual meeting of the Associated Professional Sleep Societies.

“Because sleep is relevant to so many different departments, there is not always good integration across campus,” said Dr. Chervin, a professor of sleep medicine at the University of Michigan, Ann Arbor. Dr. Chervin is also a professor of neurology and the director of the university's sleep disorders center.

For example, a sleep scientist may not rub elbows daily with a pulmonologist or ENT specialist, he said.

The structural challenges that persist at many research universities can make interdisciplinary integration difficult, even though such integration may be the way to provide the best patient care, Dr. Chervin noted.

But the tug-of-war persists between clinician desires to provide good multidisciplinary care versus departmental concerns for the bottom line.

Most sleep specialists agree that patients receive the best care when they see clinicians from a variety of medical fields, Dr. Chervin said. But sharing human resources is not always a priority for any given academic department, and it is not always easy to give up billing opportunities to another department in order to serve a higher goal and allow faculty to pursue diverse interests, he explained.

The role of sleep medicine can be difficult to explain to administrators and faculty outside the field, in part because there often is inadequate investment in sleep medicine specifically.

For example, even at the University of Michigan, which has a large and successful sleep disorders center, there is no administrator dedicated to sleep medicine to help the director manage budgets and financial spreadsheets, “which we are not trained in medical school to do,” Dr. Chervin said. Also, billing and hiring issues still create interdepartmental friction. “I'm proud of our faculty here at Michigan, but we have lost some opportunities to hire qualified personnel because of these departmental issues,” he said.

One strategy that the university has used to overcome some of the interdepartmental barriers has been the creation of an “Alternatives to CPAP” clinic.

“We can see patients shoulder to shoulder with an ENT specialist, maxillofacial surgeon, and dentist. It serves the patients' interests and is wonderful for education,” he said. “And we managed to satisfy all the departments in terms of billing.” The university has developed two other clinics that follow the CPAP program model–a multidisciplinary pediatric sleep and behavior clinic and another behavioral sleep medicine clinic for adults.

What does the future hold for sleep medicine? Dr. Chervin said he believes that creating comprehensive sleep centers at universities would improve patient care and promote the basic scientific research that continues to drive advances in sleep medicine.

Ideally, a “center for sleep science” would unite sleep specialists on campus, at least for joint grand rounds, for training, and for promoting grant submissions that could cross department boundaries, he said.

In his view, sleep centers should uphold a tripartite mission that includes research, education, and patient care and provide both clinical and preclinical programs.

Sleep centers need their own physical space and dedicated funding, in part to allow them to bill for clinical and laboratory services and then reimburse other departments for faculty effort, Dr. Chervin said. And sleep centers should have a greater say in hiring decisions, he added.

As more data emerge to support the impact of sleep and sleep problems on a range of medical conditions, support for interdisciplinary work in sleep medicine and the establishment of sleep centers may gain traction. “How does a new interdisciplinary field fit within a traditional, department-based academic medical center?” Dr. Chervin asked. “It's like trying to put a square peg in a round hole.”

NEW ORLEANS – For neurologic and psychiatric issues in HIV patients, several factors should be considered, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

Psychopharmacology should be used carefully, and patients should be monitored for CNS effects.

In addition, drug-drug interactions should be considered. It is important to keep in mind, for example, that HIV medications may alter absorption of other medications and that induction/inhibition of CP450 may alter drug levels, Dr. Forstein noted.

Common treatments for depression in HIV include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, novel antidepressants, tricyclic antidepressants, psychostimulants, and hormonal treatments.

The start-low/go-slow approach often taken with elderly patients should be applied here as well.

Comorbid substance abuse should be monitored; several dangerous interactions can occur between HIV treatments and recreational drugs, said Dr. Forstein, who is with the department of psychiatry at the Harvard School of Medicine, Boston.

As for psychotherapy, several common themes among HIV patients have emerged and should be addressed, including:

▸ Loss.

▸ Anger.

▸ Control (decision making).

▸ Death and dying.

▸ Impact of HIV on partners and children.

▸ Fear.

▸ Disclosure.

▸ Sexuality.

▸ Spirituality.

▸ Guilt and regret.

▸ Self-criticism and self-esteem issues.

▸ Stigma and discrimination.

▸ Suicide, including physician-assisted suicide.

Importantly, several effective strategies are available for the management of mood disorders and psychiatric complications in HIV patients, Dr. Forstein said.

One study showed that about half of depressed HIV patients were not treated with antidepressants, and those not treated had 50% lower survival than those who were treated.

All HIV patients who have mood disorders or other psychiatric symptoms should be offered aggressive and timely treatment, he concluded.

NEW ORLEANS – For neurologic and psychiatric issues in HIV patients, several factors should be considered, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

Psychopharmacology should be used carefully, and patients should be monitored for CNS effects.

In addition, drug-drug interactions should be considered. It is important to keep in mind, for example, that HIV medications may alter absorption of other medications and that induction/inhibition of CP450 may alter drug levels, Dr. Forstein noted.

Common treatments for depression in HIV include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, novel antidepressants, tricyclic antidepressants, psychostimulants, and hormonal treatments.

The start-low/go-slow approach often taken with elderly patients should be applied here as well.

Comorbid substance abuse should be monitored; several dangerous interactions can occur between HIV treatments and recreational drugs, said Dr. Forstein, who is with the department of psychiatry at the Harvard School of Medicine, Boston.

As for psychotherapy, several common themes among HIV patients have emerged and should be addressed, including:

▸ Loss.

▸ Anger.

▸ Control (decision making).

▸ Death and dying.

▸ Impact of HIV on partners and children.

▸ Fear.

▸ Disclosure.

▸ Sexuality.

▸ Spirituality.

▸ Guilt and regret.

▸ Self-criticism and self-esteem issues.

▸ Stigma and discrimination.

▸ Suicide, including physician-assisted suicide.

Importantly, several effective strategies are available for the management of mood disorders and psychiatric complications in HIV patients, Dr. Forstein said.

One study showed that about half of depressed HIV patients were not treated with antidepressants, and those not treated had 50% lower survival than those who were treated.

All HIV patients who have mood disorders or other psychiatric symptoms should be offered aggressive and timely treatment, he concluded.

NEW ORLEANS – For neurologic and psychiatric issues in HIV patients, several factors should be considered, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

Psychopharmacology should be used carefully, and patients should be monitored for CNS effects.

In addition, drug-drug interactions should be considered. It is important to keep in mind, for example, that HIV medications may alter absorption of other medications and that induction/inhibition of CP450 may alter drug levels, Dr. Forstein noted.

Common treatments for depression in HIV include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, novel antidepressants, tricyclic antidepressants, psychostimulants, and hormonal treatments.

The start-low/go-slow approach often taken with elderly patients should be applied here as well.

Comorbid substance abuse should be monitored; several dangerous interactions can occur between HIV treatments and recreational drugs, said Dr. Forstein, who is with the department of psychiatry at the Harvard School of Medicine, Boston.

As for psychotherapy, several common themes among HIV patients have emerged and should be addressed, including:

▸ Loss.

▸ Anger.

▸ Control (decision making).

▸ Death and dying.

▸ Impact of HIV on partners and children.

▸ Fear.

▸ Disclosure.

▸ Sexuality.

▸ Spirituality.

▸ Guilt and regret.

▸ Self-criticism and self-esteem issues.

▸ Stigma and discrimination.

▸ Suicide, including physician-assisted suicide.

Importantly, several effective strategies are available for the management of mood disorders and psychiatric complications in HIV patients, Dr. Forstein said.

One study showed that about half of depressed HIV patients were not treated with antidepressants, and those not treated had 50% lower survival than those who were treated.

All HIV patients who have mood disorders or other psychiatric symptoms should be offered aggressive and timely treatment, he concluded.

MONTREAL – When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things–like raw meat–that they would not normally eat in the daytime. They can get up and drive in a confused state, and go pick up food from the store. Or they can cut or burn themselves trying to prepare something.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders–making the treatment of these conditions quite different, Dr. Fleming said.

“The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said. In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight. Because the underlying etiology is sleep disorder, this is where treatment of SRED is directed, Dr. Fleming said.

Dr. Fleming said he advises use of the parasomnia protocol for SRED patients, which can be remembered with the mnemonic SIS: Secure the bedroom and home environment; avoid intoxicant use; and keep the sleep schedule constant.

MONTREAL – When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things–like raw meat–that they would not normally eat in the daytime. They can get up and drive in a confused state, and go pick up food from the store. Or they can cut or burn themselves trying to prepare something.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders–making the treatment of these conditions quite different, Dr. Fleming said.

“The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said. In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight. Because the underlying etiology is sleep disorder, this is where treatment of SRED is directed, Dr. Fleming said.

Dr. Fleming said he advises use of the parasomnia protocol for SRED patients, which can be remembered with the mnemonic SIS: Secure the bedroom and home environment; avoid intoxicant use; and keep the sleep schedule constant.

MONTREAL – When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things–like raw meat–that they would not normally eat in the daytime. They can get up and drive in a confused state, and go pick up food from the store. Or they can cut or burn themselves trying to prepare something.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders–making the treatment of these conditions quite different, Dr. Fleming said.

“The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said. In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight. Because the underlying etiology is sleep disorder, this is where treatment of SRED is directed, Dr. Fleming said.

Dr. Fleming said he advises use of the parasomnia protocol for SRED patients, which can be remembered with the mnemonic SIS: Secure the bedroom and home environment; avoid intoxicant use; and keep the sleep schedule constant.

NEW ORLEANS – The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that effective HIV treatment can help, but long-standing adverse effects can occur as a result of subcortical and cortical insult in those who go untreated.

Furthermore, the effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain–all of which are common in HIV patients, and thus may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a history of or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems, such as sleep and pain disorders; fatigue; and sexual dysfunction also occur frequently, and like mood and other psychiatric disorders, should be addressed in these patients.

Probable Risk Factors for Depression

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ Inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure, and in some cases–treatment success (for example, when a patient expects to die but is treated successfully and then fears constantly that the treatment will subsequently fail and he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression, regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

NEW ORLEANS – The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that effective HIV treatment can help, but long-standing adverse effects can occur as a result of subcortical and cortical insult in those who go untreated.

Furthermore, the effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain–all of which are common in HIV patients, and thus may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a history of or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems, such as sleep and pain disorders; fatigue; and sexual dysfunction also occur frequently, and like mood and other psychiatric disorders, should be addressed in these patients.

Probable Risk Factors for Depression

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ Inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure, and in some cases–treatment success (for example, when a patient expects to die but is treated successfully and then fears constantly that the treatment will subsequently fail and he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression, regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

NEW ORLEANS – The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that effective HIV treatment can help, but long-standing adverse effects can occur as a result of subcortical and cortical insult in those who go untreated.

Furthermore, the effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain–all of which are common in HIV patients, and thus may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a history of or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems, such as sleep and pain disorders; fatigue; and sexual dysfunction also occur frequently, and like mood and other psychiatric disorders, should be addressed in these patients.

Probable Risk Factors for Depression

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ Inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure, and in some cases–treatment success (for example, when a patient expects to die but is treated successfully and then fears constantly that the treatment will subsequently fail and he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression, regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

VIENNA – Irritable bowel syndrome can be conceptualized as an anxiety disorder–and, as such, responsive to cognitive-behavioral therapy, according to Dr. Sergej Andreewitch.

“Core symptomatology of IBS is clearly physiological, but the cause of suffering and severe loss of function affecting many patients is better accounted for by the catastrophizing appraisal of symptoms and the related avoidance behavior,” Dr. Andreewitch said at the annual congress of the European College of Neuropsychopharmacology.

A program of cognitive-behavioral therapy (CBT) targeting the negative evaluation of GI symptoms and resultant dysfunctional avoidance behaviors associated with IBS brought substantial improvement to participants in his pilot study. Next, Dr. Andreewitch, who is affiliated with the Karolinska Institute, Stockholm, plans to develop the treatment program into an Internet-based intervention.

He reported on 13 consecutive women with a mean age of 32 years and an 11.5-year history of IBS who had been referred for CBT from Stockholm-area GI clinics. The treatment program involved a 2-hour session weekly for 10 weeks, with four or five patients per group. The therapeutic strategy was modeled on well-established CBT programs for a variety of anxiety disorders.

As is typical in IBS, psychiatric comorbidity was common. Nine of the 13 patients met diagnostic criteria for a specific phobia, panic disorder, generalized anxiety disorder, or dysthymia.

The psychotherapeutic intervention showed substantial efficacy. Scores on the daily patient-rated GI Symptoms Checklist of abdominal pain, tenderness, bloating, diarrhea, and constipation dropped from a baseline mean of 31.4 to 17.2 at conclusion of the CBT program and remained there at reassessment 4 weeks later.

Similarly, mean scores on the Sheehan Disability Scale plummeted from 13.2 to 3.8, while Montgomery-Asberg Depression Rating Scale scores dropped from a baseline of 12.7 to 6.8.

These outcomes compare quite favorably with conventional treatments, which typically are only moderately effective. These treatments include stool-modifying agents, analgesics, antidepressants, and dietary restriction, Dr. Andreewitch continued.

The etiology of IBS is poorly understood. It is second only to the common cold as a cause of work absences, he noted.

VIENNA – Irritable bowel syndrome can be conceptualized as an anxiety disorder–and, as such, responsive to cognitive-behavioral therapy, according to Dr. Sergej Andreewitch.

“Core symptomatology of IBS is clearly physiological, but the cause of suffering and severe loss of function affecting many patients is better accounted for by the catastrophizing appraisal of symptoms and the related avoidance behavior,” Dr. Andreewitch said at the annual congress of the European College of Neuropsychopharmacology.

A program of cognitive-behavioral therapy (CBT) targeting the negative evaluation of GI symptoms and resultant dysfunctional avoidance behaviors associated with IBS brought substantial improvement to participants in his pilot study. Next, Dr. Andreewitch, who is affiliated with the Karolinska Institute, Stockholm, plans to develop the treatment program into an Internet-based intervention.

He reported on 13 consecutive women with a mean age of 32 years and an 11.5-year history of IBS who had been referred for CBT from Stockholm-area GI clinics. The treatment program involved a 2-hour session weekly for 10 weeks, with four or five patients per group. The therapeutic strategy was modeled on well-established CBT programs for a variety of anxiety disorders.

As is typical in IBS, psychiatric comorbidity was common. Nine of the 13 patients met diagnostic criteria for a specific phobia, panic disorder, generalized anxiety disorder, or dysthymia.

The psychotherapeutic intervention showed substantial efficacy. Scores on the daily patient-rated GI Symptoms Checklist of abdominal pain, tenderness, bloating, diarrhea, and constipation dropped from a baseline mean of 31.4 to 17.2 at conclusion of the CBT program and remained there at reassessment 4 weeks later.

Similarly, mean scores on the Sheehan Disability Scale plummeted from 13.2 to 3.8, while Montgomery-Asberg Depression Rating Scale scores dropped from a baseline of 12.7 to 6.8.

These outcomes compare quite favorably with conventional treatments, which typically are only moderately effective. These treatments include stool-modifying agents, analgesics, antidepressants, and dietary restriction, Dr. Andreewitch continued.

The etiology of IBS is poorly understood. It is second only to the common cold as a cause of work absences, he noted.

VIENNA – Irritable bowel syndrome can be conceptualized as an anxiety disorder–and, as such, responsive to cognitive-behavioral therapy, according to Dr. Sergej Andreewitch.

“Core symptomatology of IBS is clearly physiological, but the cause of suffering and severe loss of function affecting many patients is better accounted for by the catastrophizing appraisal of symptoms and the related avoidance behavior,” Dr. Andreewitch said at the annual congress of the European College of Neuropsychopharmacology.

A program of cognitive-behavioral therapy (CBT) targeting the negative evaluation of GI symptoms and resultant dysfunctional avoidance behaviors associated with IBS brought substantial improvement to participants in his pilot study. Next, Dr. Andreewitch, who is affiliated with the Karolinska Institute, Stockholm, plans to develop the treatment program into an Internet-based intervention.

He reported on 13 consecutive women with a mean age of 32 years and an 11.5-year history of IBS who had been referred for CBT from Stockholm-area GI clinics. The treatment program involved a 2-hour session weekly for 10 weeks, with four or five patients per group. The therapeutic strategy was modeled on well-established CBT programs for a variety of anxiety disorders.

As is typical in IBS, psychiatric comorbidity was common. Nine of the 13 patients met diagnostic criteria for a specific phobia, panic disorder, generalized anxiety disorder, or dysthymia.

The psychotherapeutic intervention showed substantial efficacy. Scores on the daily patient-rated GI Symptoms Checklist of abdominal pain, tenderness, bloating, diarrhea, and constipation dropped from a baseline mean of 31.4 to 17.2 at conclusion of the CBT program and remained there at reassessment 4 weeks later.

Similarly, mean scores on the Sheehan Disability Scale plummeted from 13.2 to 3.8, while Montgomery-Asberg Depression Rating Scale scores dropped from a baseline of 12.7 to 6.8.

These outcomes compare quite favorably with conventional treatments, which typically are only moderately effective. These treatments include stool-modifying agents, analgesics, antidepressants, and dietary restriction, Dr. Andreewitch continued.

The etiology of IBS is poorly understood. It is second only to the common cold as a cause of work absences, he noted.

Both too much sleep and not enough sleep appear to be associated with increased mortality, according to a new longitudinal study.

Sleeping less than 6 hours per night or more than 9 hours per night was associated with almost twice the mortality risk of sleeping 6–8 hours per night, according to an analysis of sleep data from a prospective cohort study of more than 10,000 British civil servants.

The findings were recently presented at a meeting of the British Sleep Society, and the research article has been accepted for publication in the journal Sleep.

The investigators found that a decrease in the amount of time slept was associated with increased mortality from cardiovascular causes. An increase in sleep time was associated with an excess of mortality from all other causes, according to Jane Ferrie, Ph.D., of University College London, and her colleagues.

Previous studies have reported a U-shaped relationship between time spent sleeping and mortality, the investigators said. What has not been looked at by a sleep study before is the effect a change in sleep patterns might have.

The researchers examined sleep data collected from British civil service employees aged 35–55 years who were enrolled beginning in 1985 in a long-term study known as Whitehall II. Baseline sleep duration data were available for 9,781 subjects who were interviewed in 1985–1988, while follow-up data were available for 7,729 who were interviewed again in 1992–1993. Mortality data were available through September 2004.

After adjustment for factors such as age, sex, smoking status, body mass index, cholesterol, and physical activity, those Whitehall II participants who reported sleeping 5 hours or less a night at the first interview had a hazard ratio of death from all causes of 1.24, relative to those who slept 7 hours per night. Those who slept 9 hours or more had a fully adjusted hazard ratio of 1.54.

The fully adjusted hazard ratios of all-cause mortality were slightly higher for those who reported sleep for 5 hours or less and 9 hours or more at the second interview, 1.78 and 1.95, respectively. The risk of death due to cardiovascular causes was relatively greater for those who slept less after the baseline period than for those who slept more.

Participants whose sleep decreased from 6–8 hours a night at the first interview to less than 6 hours at the second interview had a fully adjusted hazard ratio of mortality from cardiovascular cause of 2.04, compared with 1.22 for those who slept more. Those whose sleep increased from 7–8 hours at the first interview to more than 8 hours at the second interview had a fully adjusted hazard ratio of mortality from noncardiovascular causes of 2.06, compared with 1.44 for those who slept less.

Investigators found a positive association between marital status and sleep duration. Married women were more likely to sleep longer, while married men were more likely to average 7–8 hours of sleep per night.

The connection between sleep duration and body mass index wasn't as clear cut. At the Whitehall II study's baseline, higher BMI was associated both with short and long sleep duration in women, but only with short sleep duration in men. By 1992–1993, BMI and sleep duration showed no association in women, but both short and long sleep durations were associated with higher BMI in men.

“Patients reporting a decrease in sleep should be regarded as higher risk populations for cardiovascular and all-cause mortality,” according to the investigators. Advising patients who may sleep too long to curtail their sleep should “at least be considered,” the investigators wrote.

Both too much sleep and not enough sleep appear to be associated with increased mortality, according to a new longitudinal study.

Sleeping less than 6 hours per night or more than 9 hours per night was associated with almost twice the mortality risk of sleeping 6–8 hours per night, according to an analysis of sleep data from a prospective cohort study of more than 10,000 British civil servants.

The findings were recently presented at a meeting of the British Sleep Society, and the research article has been accepted for publication in the journal Sleep.

The investigators found that a decrease in the amount of time slept was associated with increased mortality from cardiovascular causes. An increase in sleep time was associated with an excess of mortality from all other causes, according to Jane Ferrie, Ph.D., of University College London, and her colleagues.

Previous studies have reported a U-shaped relationship between time spent sleeping and mortality, the investigators said. What has not been looked at by a sleep study before is the effect a change in sleep patterns might have.

The researchers examined sleep data collected from British civil service employees aged 35–55 years who were enrolled beginning in 1985 in a long-term study known as Whitehall II. Baseline sleep duration data were available for 9,781 subjects who were interviewed in 1985–1988, while follow-up data were available for 7,729 who were interviewed again in 1992–1993. Mortality data were available through September 2004.

After adjustment for factors such as age, sex, smoking status, body mass index, cholesterol, and physical activity, those Whitehall II participants who reported sleeping 5 hours or less a night at the first interview had a hazard ratio of death from all causes of 1.24, relative to those who slept 7 hours per night. Those who slept 9 hours or more had a fully adjusted hazard ratio of 1.54.

The fully adjusted hazard ratios of all-cause mortality were slightly higher for those who reported sleep for 5 hours or less and 9 hours or more at the second interview, 1.78 and 1.95, respectively. The risk of death due to cardiovascular causes was relatively greater for those who slept less after the baseline period than for those who slept more.

Participants whose sleep decreased from 6–8 hours a night at the first interview to less than 6 hours at the second interview had a fully adjusted hazard ratio of mortality from cardiovascular cause of 2.04, compared with 1.22 for those who slept more. Those whose sleep increased from 7–8 hours at the first interview to more than 8 hours at the second interview had a fully adjusted hazard ratio of mortality from noncardiovascular causes of 2.06, compared with 1.44 for those who slept less.

Investigators found a positive association between marital status and sleep duration. Married women were more likely to sleep longer, while married men were more likely to average 7–8 hours of sleep per night.

The connection between sleep duration and body mass index wasn't as clear cut. At the Whitehall II study's baseline, higher BMI was associated both with short and long sleep duration in women, but only with short sleep duration in men. By 1992–1993, BMI and sleep duration showed no association in women, but both short and long sleep durations were associated with higher BMI in men.

“Patients reporting a decrease in sleep should be regarded as higher risk populations for cardiovascular and all-cause mortality,” according to the investigators. Advising patients who may sleep too long to curtail their sleep should “at least be considered,” the investigators wrote.

Both too much sleep and not enough sleep appear to be associated with increased mortality, according to a new longitudinal study.

Sleeping less than 6 hours per night or more than 9 hours per night was associated with almost twice the mortality risk of sleeping 6–8 hours per night, according to an analysis of sleep data from a prospective cohort study of more than 10,000 British civil servants.

The findings were recently presented at a meeting of the British Sleep Society, and the research article has been accepted for publication in the journal Sleep.

The investigators found that a decrease in the amount of time slept was associated with increased mortality from cardiovascular causes. An increase in sleep time was associated with an excess of mortality from all other causes, according to Jane Ferrie, Ph.D., of University College London, and her colleagues.

Previous studies have reported a U-shaped relationship between time spent sleeping and mortality, the investigators said. What has not been looked at by a sleep study before is the effect a change in sleep patterns might have.

The researchers examined sleep data collected from British civil service employees aged 35–55 years who were enrolled beginning in 1985 in a long-term study known as Whitehall II. Baseline sleep duration data were available for 9,781 subjects who were interviewed in 1985–1988, while follow-up data were available for 7,729 who were interviewed again in 1992–1993. Mortality data were available through September 2004.

After adjustment for factors such as age, sex, smoking status, body mass index, cholesterol, and physical activity, those Whitehall II participants who reported sleeping 5 hours or less a night at the first interview had a hazard ratio of death from all causes of 1.24, relative to those who slept 7 hours per night. Those who slept 9 hours or more had a fully adjusted hazard ratio of 1.54.

The fully adjusted hazard ratios of all-cause mortality were slightly higher for those who reported sleep for 5 hours or less and 9 hours or more at the second interview, 1.78 and 1.95, respectively. The risk of death due to cardiovascular causes was relatively greater for those who slept less after the baseline period than for those who slept more.

Participants whose sleep decreased from 6–8 hours a night at the first interview to less than 6 hours at the second interview had a fully adjusted hazard ratio of mortality from cardiovascular cause of 2.04, compared with 1.22 for those who slept more. Those whose sleep increased from 7–8 hours at the first interview to more than 8 hours at the second interview had a fully adjusted hazard ratio of mortality from noncardiovascular causes of 2.06, compared with 1.44 for those who slept less.

Investigators found a positive association between marital status and sleep duration. Married women were more likely to sleep longer, while married men were more likely to average 7–8 hours of sleep per night.

The connection between sleep duration and body mass index wasn't as clear cut. At the Whitehall II study's baseline, higher BMI was associated both with short and long sleep duration in women, but only with short sleep duration in men. By 1992–1993, BMI and sleep duration showed no association in women, but both short and long sleep durations were associated with higher BMI in men.

“Patients reporting a decrease in sleep should be regarded as higher risk populations for cardiovascular and all-cause mortality,” according to the investigators. Advising patients who may sleep too long to curtail their sleep should “at least be considered,” the investigators wrote.

VIENNA – Patients with coronary heart disease who carry the short allele of the serotonin transporter gene have significantly higher rates of major depression and perceived stress than do those who are homozygous for the long allele, Dr. Christian Otte said at the annual congress of the European College of Neuropsychopharmacology.

Moreover, patients with coronary heart disease (CHD) who carry the s (or short) allele of a functional polymorphism in the promoter region of the serotonin transporter gene also have higher 24-hour norepinephrine excretion than do those who have two long alleles (the l/l genotype), according to data from the prospective Heart and Soul Study.

“Since both depression and higher norepinephrine values have been associated with worse cardiac outcome, this might be a mechanism by which carriers of the short allele of the serotonin transporter gene might be at greater risk to suffer from cardiac events,” explained Dr. Otte, a psychiatrist at University Hospital Hamburg-Eppendorf (Germany).

The Heart and Soul Study is an ongoing prospective cohort study based at the University of California, San Francisco, and involving 1,024 patients with CHD. The aim of the study is to shed new light on the association between depression and cardiovascular events. For purposes of the genetic study of serotonin transporter gene polymorphism, Dr. Otte restricted the analysis to the 557 whites, the largest racial group in the study. Of this group, 17% were homozygous for the s/s genotype, 52% were s/l, and 31% were l/l.

The prevalence of current major depression as assessed by the Computerized Diagnostic Interview Schedule was 25% among participants carrying an s allele, a significantly higher rate than the 17% in l/l subjects. After statistical adjustment for age and gender, CHD patients with an s allele for the serotonin transporter gene had a 60% increased rate of major depression. They also were 60% more likely to score in the moderate to high range for perceived stress, as reflected in a score greater than 5 on the Perceived Stress Scale.

Moreover, s allele carriers had a mean 24-hour norepinephrine excretion of 55.6 mg/day, compared with 50.2 mg/day in l/l patients, and they were 70% more likely to fall within the top quartile for 24-hour norepinephrine.

Dr. Otte said his research was inspired by a “classic” study of conducted by investigators at King's College London, who demonstrated that carriers of one or two copies of the s allele who experienced stressful life events were much more likely to develop depression than were l/l individuals with a comparable degree of life stress (Science 2003;301:386–9).

The Heart and Soul Study investigators reasoned that a chronic debilitating medical illness such as CHD might operate as an ongoing major stressor that would permit them to learn whether the s allele is related to depression, an extremely common CHD comorbidity.

The study is supported by the Department of Veterans Affairs, the Robert Wood Johnson Foundation, the American Federation for Aging Research, the Ischemia Research and Education Foundation, and NARSAD: The Mental Health Research Association.

ELSEVIER GLOBAL MEDICAL NEWS

VIENNA – Patients with coronary heart disease who carry the short allele of the serotonin transporter gene have significantly higher rates of major depression and perceived stress than do those who are homozygous for the long allele, Dr. Christian Otte said at the annual congress of the European College of Neuropsychopharmacology.

Moreover, patients with coronary heart disease (CHD) who carry the s (or short) allele of a functional polymorphism in the promoter region of the serotonin transporter gene also have higher 24-hour norepinephrine excretion than do those who have two long alleles (the l/l genotype), according to data from the prospective Heart and Soul Study.

“Since both depression and higher norepinephrine values have been associated with worse cardiac outcome, this might be a mechanism by which carriers of the short allele of the serotonin transporter gene might be at greater risk to suffer from cardiac events,” explained Dr. Otte, a psychiatrist at University Hospital Hamburg-Eppendorf (Germany).

The Heart and Soul Study is an ongoing prospective cohort study based at the University of California, San Francisco, and involving 1,024 patients with CHD. The aim of the study is to shed new light on the association between depression and cardiovascular events. For purposes of the genetic study of serotonin transporter gene polymorphism, Dr. Otte restricted the analysis to the 557 whites, the largest racial group in the study. Of this group, 17% were homozygous for the s/s genotype, 52% were s/l, and 31% were l/l.

The prevalence of current major depression as assessed by the Computerized Diagnostic Interview Schedule was 25% among participants carrying an s allele, a significantly higher rate than the 17% in l/l subjects. After statistical adjustment for age and gender, CHD patients with an s allele for the serotonin transporter gene had a 60% increased rate of major depression. They also were 60% more likely to score in the moderate to high range for perceived stress, as reflected in a score greater than 5 on the Perceived Stress Scale.

Moreover, s allele carriers had a mean 24-hour norepinephrine excretion of 55.6 mg/day, compared with 50.2 mg/day in l/l patients, and they were 70% more likely to fall within the top quartile for 24-hour norepinephrine.

Dr. Otte said his research was inspired by a “classic” study of conducted by investigators at King's College London, who demonstrated that carriers of one or two copies of the s allele who experienced stressful life events were much more likely to develop depression than were l/l individuals with a comparable degree of life stress (Science 2003;301:386–9).

The Heart and Soul Study investigators reasoned that a chronic debilitating medical illness such as CHD might operate as an ongoing major stressor that would permit them to learn whether the s allele is related to depression, an extremely common CHD comorbidity.

The study is supported by the Department of Veterans Affairs, the Robert Wood Johnson Foundation, the American Federation for Aging Research, the Ischemia Research and Education Foundation, and NARSAD: The Mental Health Research Association.

ELSEVIER GLOBAL MEDICAL NEWS

VIENNA – Patients with coronary heart disease who carry the short allele of the serotonin transporter gene have significantly higher rates of major depression and perceived stress than do those who are homozygous for the long allele, Dr. Christian Otte said at the annual congress of the European College of Neuropsychopharmacology.

Moreover, patients with coronary heart disease (CHD) who carry the s (or short) allele of a functional polymorphism in the promoter region of the serotonin transporter gene also have higher 24-hour norepinephrine excretion than do those who have two long alleles (the l/l genotype), according to data from the prospective Heart and Soul Study.

“Since both depression and higher norepinephrine values have been associated with worse cardiac outcome, this might be a mechanism by which carriers of the short allele of the serotonin transporter gene might be at greater risk to suffer from cardiac events,” explained Dr. Otte, a psychiatrist at University Hospital Hamburg-Eppendorf (Germany).

The Heart and Soul Study is an ongoing prospective cohort study based at the University of California, San Francisco, and involving 1,024 patients with CHD. The aim of the study is to shed new light on the association between depression and cardiovascular events. For purposes of the genetic study of serotonin transporter gene polymorphism, Dr. Otte restricted the analysis to the 557 whites, the largest racial group in the study. Of this group, 17% were homozygous for the s/s genotype, 52% were s/l, and 31% were l/l.

The prevalence of current major depression as assessed by the Computerized Diagnostic Interview Schedule was 25% among participants carrying an s allele, a significantly higher rate than the 17% in l/l subjects. After statistical adjustment for age and gender, CHD patients with an s allele for the serotonin transporter gene had a 60% increased rate of major depression. They also were 60% more likely to score in the moderate to high range for perceived stress, as reflected in a score greater than 5 on the Perceived Stress Scale.

Moreover, s allele carriers had a mean 24-hour norepinephrine excretion of 55.6 mg/day, compared with 50.2 mg/day in l/l patients, and they were 70% more likely to fall within the top quartile for 24-hour norepinephrine.

Dr. Otte said his research was inspired by a “classic” study of conducted by investigators at King's College London, who demonstrated that carriers of one or two copies of the s allele who experienced stressful life events were much more likely to develop depression than were l/l individuals with a comparable degree of life stress (Science 2003;301:386–9).

The Heart and Soul Study investigators reasoned that a chronic debilitating medical illness such as CHD might operate as an ongoing major stressor that would permit them to learn whether the s allele is related to depression, an extremely common CHD comorbidity.

The study is supported by the Department of Veterans Affairs, the Robert Wood Johnson Foundation, the American Federation for Aging Research, the Ischemia Research and Education Foundation, and NARSAD: The Mental Health Research Association.

ELSEVIER GLOBAL MEDICAL NEWS

Children diagnosed with celiac disease usually experience complete remission once they are started on a gluten-free diet, and thus early diagnosis can be beneficial. But early diagnosis may have adverse effects as well. A large British study has found that a diagnosis of celiac disease in childhood, as opposed to adulthood, is associated with threefold higher mortality–largely due to suicide, accidents, and violence.

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation. “One certainly cannot ignore this report; it's a well-done study,” he said in an interview.

The investigators analyzed data on a cohort of 625 celiac patients and found that those who were diagnosed in childhood (47%) had mortality rates three times higher than would be expected in the general, age-matched population, “with the main cause of the increase being deaths from accidents, suicide, and violence,” reported Dr. Masoud Solaymani-Dodoran and colleagues from the University of Nottingham (England). This increase was not seen in the cohort diagnosed in adulthood (Am. J. Gastroenterol. 2007;102:864-70).

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview. The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Effect of Nonadherence

“Unfortunately [the researchers] had no available data to tell us what percentage of the subjects was on a gluten-free diet,” Dr. Guandalini said in an interview. Nonadherence with the diet has been reported, in other studies, in up to 60% of celiac patients during the rebellious teenage years.

This could explain the increased mortality, he suggested, because in some celiac patients, dietary lapses can have a dramatic effect on the brain. Gluten restriction is recommended, both to relieve the myriad and varied symptoms of celiac disease–ranging from dental to dermatologic to neurologic–and to reduce the potential long-term effects of prolonged exposure, including osteoporosis and malignancies.

“My speculation is that most of these deaths occurred in people who were not following the diet, and this caused the behavioral and psychiatric milieu that would lead to that kind of outcome,” he said.

Finnish authors have suggested that exposure to gluten in adolescents with celiac disease can impair the availability of tryptophan “and the possible consequent serotonergic dysfunction may play a role in vulnerability to depressive disorders” (BMC Psychiatry 2005;5:14-9). They noted that five of nine newly diagnosed, untreated adolescent celiac patients had depressive disorders and abnormal tryptophan levels, all of which improved after gluten was removed from their diets.

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old.

The Impact of Adherence

“We know adherence [to the diet] and depression and anxiety are related,” said Jessica Edwards George, Ph.D., psychologist and researcher at The Celiac Center at Beth Israel Deaconess Medical Center in Boston. But the relationship between adherence and psychological symptoms is not well understood, she said in an interview. Just as poor adherence is linked with psychiatric pathology, so too is good adherence–an aspect highlighted by the British authors.

“The actual process of labeling a child with celiac disease and requiring them to adhere to a gluten-free diet may be, in some way, detrimental,” they wrote. “As treatments go, taking a gluten-free diet must rank as one of the most intrusive for a child–more so than something like, for example, epilepsy or asthma,” coauthor Dr. Richard Logan said in an interview. “We wondered what were the psychological effects on a child of being brought up with a condition whose treatment has such a profound effect on daily life–something I suspect most adult gastroenterologists overlook.”

The psychological research on adults regarding this question leaves little open to debate: “There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. Furthermore, “a child doesn't necessarily have the developmental capacities to cope the way an adult might.”

As a former school psychologist, Dr. Edwards George agreed. “Children report feeling different and embarrassed, left out, and angry,” she wrote in a recent article for the National Association of School Psychologists (NASP Communiquè 2006 June;34:8). “It can be heart-breaking for a child to be unable to eat gluten-containing treats at special occasions, such as birthdays or holidays.”

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years. “The most important thing we think of with adolescents is the social network,” Dr. Jedel said. “If they are not able to eat what their friends eat, all of the shame, the embarrassment, the frustration associated with these ongoing social situations would I'm sure produce a lot of anger, and depression.”

One Italian study which included 39 adolescent patients pointed to the ages between 12 and 17 years as being the most problematic. “That is the period of life in which the individual tends to oppose the adult world in search of an individual personality,” wrote Dr. M. Cinquetti and colleagues from Verona (Italy) University (Pediatr. Med. Chir. 1999;21:279-83). “In this group, the search for an individual personality is disturbed.”

Even after adolescence, such experiences can have lasting effects. In one study of adult patients, a subset of patients who were diagnosed as children remembered situations from their childhood “with intense emotions, even if the events had occurred many years ago” (J. Hum. Nutr. Dietet. 2005;18:171-80).

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, the British authors noted.

“Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

One way to accomplish this is to behave the way they think their healthy peers are behaving, even though their assumption that “everyone” is drinking, or smoking, or doing drugs is often erroneous, he said in an interview. In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, scoliosis, epilepsy, arthritis, and kidney disease. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

Although Dr. Suris' study did not include patients with celiac disease, he said any condition involving food restriction presents limitations to an adolescent's social life. “It is hard to go out for pizza with your friends and not be able to eat it,” he said. “It has been said that the best contribution for diabetic patients after insulin was the introduction of sugar-free beverages, because this allowed them to socialize with their peers without being seen as different. Maybe we should try to do that with other food problems, so that cafeterias or restaurants have options for them,” he said.

Such options are becoming more widely offered, but Dr. Edwards George said children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious.”

In the meantime, she also believes that vigilance is of utmost importance for physicians. “We need to be more aware of mood factors and more proactive about screening and treatment for depression, anxiety, and suicidal ideation.” Included in this careful follow-up should be targeted screening for eating disorders, she said–a practice soon to be adopted at her center–since her research suggests that these disorders may often be missed in this perhaps more vulnerable population.

“We see a lot of people fearful of eating anything at all” at diagnosis, she said. Patients may have a general fear of long-term consequences, such as cancer or osteoporosis, or may be afraid of short-term consequences, such as becoming violently ill after eating a food containing gluten. Patients also become “hyperfocused on food” as a result of constantly reading labels and asking about ingredients, she said.

Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

As awareness about celiac disease continues to grow, experts agree that the current average 11-year gap between symptom onset and diagnosis will shrink, resulting in more diagnoses in childhood and adolescence.

There was also a consensus among all the experts interviewed that, given the recent findings of an increased mortality rate associated with this earlier diagnosis, any attempts to reduce this higher mortality must begin with a better understanding of the unique burdens that childhood diagnosis and treatment may bring.

Get Help With Celiac Disease

Dr. Edwards George recommends these organizations as good resources for patients and families dealing with celiac disease:

PICeliac Disease Foundation

Phone: 213-654-4085

Web site:

www.celiac.org

PICeliac Sprue Association of the United States of America

Phone: 402-558-0600

Web site:

www.csaceliacs.org

PIGluten Intolerance Group

Phone: 253-833-6655

Web site:

www.gluten.net

PINational Foundation for Celiac Awareness

Phone: 215-325-1306

Web site:

www.celiaccentral.org

Children diagnosed with celiac disease usually experience complete remission once they are started on a gluten-free diet, and thus early diagnosis can be beneficial. But early diagnosis may have adverse effects as well. A large British study has found that a diagnosis of celiac disease in childhood, as opposed to adulthood, is associated with threefold higher mortality–largely due to suicide, accidents, and violence.

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation. “One certainly cannot ignore this report; it's a well-done study,” he said in an interview.

The investigators analyzed data on a cohort of 625 celiac patients and found that those who were diagnosed in childhood (47%) had mortality rates three times higher than would be expected in the general, age-matched population, “with the main cause of the increase being deaths from accidents, suicide, and violence,” reported Dr. Masoud Solaymani-Dodoran and colleagues from the University of Nottingham (England). This increase was not seen in the cohort diagnosed in adulthood (Am. J. Gastroenterol. 2007;102:864-70).

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview. The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Effect of Nonadherence

“Unfortunately [the researchers] had no available data to tell us what percentage of the subjects was on a gluten-free diet,” Dr. Guandalini said in an interview. Nonadherence with the diet has been reported, in other studies, in up to 60% of celiac patients during the rebellious teenage years.

This could explain the increased mortality, he suggested, because in some celiac patients, dietary lapses can have a dramatic effect on the brain. Gluten restriction is recommended, both to relieve the myriad and varied symptoms of celiac disease–ranging from dental to dermatologic to neurologic–and to reduce the potential long-term effects of prolonged exposure, including osteoporosis and malignancies.

“My speculation is that most of these deaths occurred in people who were not following the diet, and this caused the behavioral and psychiatric milieu that would lead to that kind of outcome,” he said.

Finnish authors have suggested that exposure to gluten in adolescents with celiac disease can impair the availability of tryptophan “and the possible consequent serotonergic dysfunction may play a role in vulnerability to depressive disorders” (BMC Psychiatry 2005;5:14-9). They noted that five of nine newly diagnosed, untreated adolescent celiac patients had depressive disorders and abnormal tryptophan levels, all of which improved after gluten was removed from their diets.

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old.

The Impact of Adherence

“We know adherence [to the diet] and depression and anxiety are related,” said Jessica Edwards George, Ph.D., psychologist and researcher at The Celiac Center at Beth Israel Deaconess Medical Center in Boston. But the relationship between adherence and psychological symptoms is not well understood, she said in an interview. Just as poor adherence is linked with psychiatric pathology, so too is good adherence–an aspect highlighted by the British authors.

“The actual process of labeling a child with celiac disease and requiring them to adhere to a gluten-free diet may be, in some way, detrimental,” they wrote. “As treatments go, taking a gluten-free diet must rank as one of the most intrusive for a child–more so than something like, for example, epilepsy or asthma,” coauthor Dr. Richard Logan said in an interview. “We wondered what were the psychological effects on a child of being brought up with a condition whose treatment has such a profound effect on daily life–something I suspect most adult gastroenterologists overlook.”

The psychological research on adults regarding this question leaves little open to debate: “There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. Furthermore, “a child doesn't necessarily have the developmental capacities to cope the way an adult might.”

As a former school psychologist, Dr. Edwards George agreed. “Children report feeling different and embarrassed, left out, and angry,” she wrote in a recent article for the National Association of School Psychologists (NASP Communiquè 2006 June;34:8). “It can be heart-breaking for a child to be unable to eat gluten-containing treats at special occasions, such as birthdays or holidays.”

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years. “The most important thing we think of with adolescents is the social network,” Dr. Jedel said. “If they are not able to eat what their friends eat, all of the shame, the embarrassment, the frustration associated with these ongoing social situations would I'm sure produce a lot of anger, and depression.”

One Italian study which included 39 adolescent patients pointed to the ages between 12 and 17 years as being the most problematic. “That is the period of life in which the individual tends to oppose the adult world in search of an individual personality,” wrote Dr. M. Cinquetti and colleagues from Verona (Italy) University (Pediatr. Med. Chir. 1999;21:279-83). “In this group, the search for an individual personality is disturbed.”

Even after adolescence, such experiences can have lasting effects. In one study of adult patients, a subset of patients who were diagnosed as children remembered situations from their childhood “with intense emotions, even if the events had occurred many years ago” (J. Hum. Nutr. Dietet. 2005;18:171-80).

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, the British authors noted.

“Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

One way to accomplish this is to behave the way they think their healthy peers are behaving, even though their assumption that “everyone” is drinking, or smoking, or doing drugs is often erroneous, he said in an interview. In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, scoliosis, epilepsy, arthritis, and kidney disease. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

Although Dr. Suris' study did not include patients with celiac disease, he said any condition involving food restriction presents limitations to an adolescent's social life. “It is hard to go out for pizza with your friends and not be able to eat it,” he said. “It has been said that the best contribution for diabetic patients after insulin was the introduction of sugar-free beverages, because this allowed them to socialize with their peers without being seen as different. Maybe we should try to do that with other food problems, so that cafeterias or restaurants have options for them,” he said.

Such options are becoming more widely offered, but Dr. Edwards George said children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious.”

In the meantime, she also believes that vigilance is of utmost importance for physicians. “We need to be more aware of mood factors and more proactive about screening and treatment for depression, anxiety, and suicidal ideation.” Included in this careful follow-up should be targeted screening for eating disorders, she said–a practice soon to be adopted at her center–since her research suggests that these disorders may often be missed in this perhaps more vulnerable population.

“We see a lot of people fearful of eating anything at all” at diagnosis, she said. Patients may have a general fear of long-term consequences, such as cancer or osteoporosis, or may be afraid of short-term consequences, such as becoming violently ill after eating a food containing gluten. Patients also become “hyperfocused on food” as a result of constantly reading labels and asking about ingredients, she said.

Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

As awareness about celiac disease continues to grow, experts agree that the current average 11-year gap between symptom onset and diagnosis will shrink, resulting in more diagnoses in childhood and adolescence.

There was also a consensus among all the experts interviewed that, given the recent findings of an increased mortality rate associated with this earlier diagnosis, any attempts to reduce this higher mortality must begin with a better understanding of the unique burdens that childhood diagnosis and treatment may bring.

Get Help With Celiac Disease

Dr. Edwards George recommends these organizations as good resources for patients and families dealing with celiac disease:

PICeliac Disease Foundation

Phone: 213-654-4085

Web site:

www.celiac.org

PICeliac Sprue Association of the United States of America

Phone: 402-558-0600

Web site:

www.csaceliacs.org

PIGluten Intolerance Group

Phone: 253-833-6655

Web site:

www.gluten.net

PINational Foundation for Celiac Awareness

Phone: 215-325-1306

Web site:

www.celiaccentral.org

Children diagnosed with celiac disease usually experience complete remission once they are started on a gluten-free diet, and thus early diagnosis can be beneficial. But early diagnosis may have adverse effects as well. A large British study has found that a diagnosis of celiac disease in childhood, as opposed to adulthood, is associated with threefold higher mortality–largely due to suicide, accidents, and violence.

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation. “One certainly cannot ignore this report; it's a well-done study,” he said in an interview.

The investigators analyzed data on a cohort of 625 celiac patients and found that those who were diagnosed in childhood (47%) had mortality rates three times higher than would be expected in the general, age-matched population, “with the main cause of the increase being deaths from accidents, suicide, and violence,” reported Dr. Masoud Solaymani-Dodoran and colleagues from the University of Nottingham (England). This increase was not seen in the cohort diagnosed in adulthood (Am. J. Gastroenterol. 2007;102:864-70).

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview. The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Effect of Nonadherence

“Unfortunately [the researchers] had no available data to tell us what percentage of the subjects was on a gluten-free diet,” Dr. Guandalini said in an interview. Nonadherence with the diet has been reported, in other studies, in up to 60% of celiac patients during the rebellious teenage years.

This could explain the increased mortality, he suggested, because in some celiac patients, dietary lapses can have a dramatic effect on the brain. Gluten restriction is recommended, both to relieve the myriad and varied symptoms of celiac disease–ranging from dental to dermatologic to neurologic–and to reduce the potential long-term effects of prolonged exposure, including osteoporosis and malignancies.

“My speculation is that most of these deaths occurred in people who were not following the diet, and this caused the behavioral and psychiatric milieu that would lead to that kind of outcome,” he said.

Finnish authors have suggested that exposure to gluten in adolescents with celiac disease can impair the availability of tryptophan “and the possible consequent serotonergic dysfunction may play a role in vulnerability to depressive disorders” (BMC Psychiatry 2005;5:14-9). They noted that five of nine newly diagnosed, untreated adolescent celiac patients had depressive disorders and abnormal tryptophan levels, all of which improved after gluten was removed from their diets.

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old.

The Impact of Adherence

“We know adherence [to the diet] and depression and anxiety are related,” said Jessica Edwards George, Ph.D., psychologist and researcher at The Celiac Center at Beth Israel Deaconess Medical Center in Boston. But the relationship between adherence and psychological symptoms is not well understood, she said in an interview. Just as poor adherence is linked with psychiatric pathology, so too is good adherence–an aspect highlighted by the British authors.

“The actual process of labeling a child with celiac disease and requiring them to adhere to a gluten-free diet may be, in some way, detrimental,” they wrote. “As treatments go, taking a gluten-free diet must rank as one of the most intrusive for a child–more so than something like, for example, epilepsy or asthma,” coauthor Dr. Richard Logan said in an interview. “We wondered what were the psychological effects on a child of being brought up with a condition whose treatment has such a profound effect on daily life–something I suspect most adult gastroenterologists overlook.”

The psychological research on adults regarding this question leaves little open to debate: “There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. Furthermore, “a child doesn't necessarily have the developmental capacities to cope the way an adult might.”

As a former school psychologist, Dr. Edwards George agreed. “Children report feeling different and embarrassed, left out, and angry,” she wrote in a recent article for the National Association of School Psychologists (NASP Communiquè 2006 June;34:8). “It can be heart-breaking for a child to be unable to eat gluten-containing treats at special occasions, such as birthdays or holidays.”

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years. “The most important thing we think of with adolescents is the social network,” Dr. Jedel said. “If they are not able to eat what their friends eat, all of the shame, the embarrassment, the frustration associated with these ongoing social situations would I'm sure produce a lot of anger, and depression.”

One Italian study which included 39 adolescent patients pointed to the ages between 12 and 17 years as being the most problematic. “That is the period of life in which the individual tends to oppose the adult world in search of an individual personality,” wrote Dr. M. Cinquetti and colleagues from Verona (Italy) University (Pediatr. Med. Chir. 1999;21:279-83). “In this group, the search for an individual personality is disturbed.”

Even after adolescence, such experiences can have lasting effects. In one study of adult patients, a subset of patients who were diagnosed as children remembered situations from their childhood “with intense emotions, even if the events had occurred many years ago” (J. Hum. Nutr. Dietet. 2005;18:171-80).

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, the British authors noted.

“Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

One way to accomplish this is to behave the way they think their healthy peers are behaving, even though their assumption that “everyone” is drinking, or smoking, or doing drugs is often erroneous, he said in an interview. In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, scoliosis, epilepsy, arthritis, and kidney disease. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

Although Dr. Suris' study did not include patients with celiac disease, he said any condition involving food restriction presents limitations to an adolescent's social life. “It is hard to go out for pizza with your friends and not be able to eat it,” he said. “It has been said that the best contribution for diabetic patients after insulin was the introduction of sugar-free beverages, because this allowed them to socialize with their peers without being seen as different. Maybe we should try to do that with other food problems, so that cafeterias or restaurants have options for them,” he said.

Such options are becoming more widely offered, but Dr. Edwards George said children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious.”

In the meantime, she also believes that vigilance is of utmost importance for physicians. “We need to be more aware of mood factors and more proactive about screening and treatment for depression, anxiety, and suicidal ideation.” Included in this careful follow-up should be targeted screening for eating disorders, she said–a practice soon to be adopted at her center–since her research suggests that these disorders may often be missed in this perhaps more vulnerable population.

“We see a lot of people fearful of eating anything at all” at diagnosis, she said. Patients may have a general fear of long-term consequences, such as cancer or osteoporosis, or may be afraid of short-term consequences, such as becoming violently ill after eating a food containing gluten. Patients also become “hyperfocused on food” as a result of constantly reading labels and asking about ingredients, she said.

Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

As awareness about celiac disease continues to grow, experts agree that the current average 11-year gap between symptom onset and diagnosis will shrink, resulting in more diagnoses in childhood and adolescence.

There was also a consensus among all the experts interviewed that, given the recent findings of an increased mortality rate associated with this earlier diagnosis, any attempts to reduce this higher mortality must begin with a better understanding of the unique burdens that childhood diagnosis and treatment may bring.

Get Help With Celiac Disease

Dr. Edwards George recommends these organizations as good resources for patients and families dealing with celiac disease:

PICeliac Disease Foundation

Phone: 213-654-4085

Web site:

www.celiac.org

PICeliac Sprue Association of the United States of America

Phone: 402-558-0600

Web site:

www.csaceliacs.org

PIGluten Intolerance Group

Phone: 253-833-6655

Web site:

www.gluten.net

PINational Foundation for Celiac Awareness

Phone: 215-325-1306

Web site:

www.celiaccentral.org