Somatic Disorders

Existential issues were significantly correlated with the will to live in a study of 189 end-stage cancer patients.

Harvey Max Chochinov, M.D., professor of psychiatry at the University of Manitoba (Canada), and his colleagues examined the simultaneous influences of existential, psychiatric, and physical issues on the will to live in terminally ill patients (Psychosomatics 2005;46:7–10).

In a multiple regression analysis, each of the existential issues assessed–hopelessness, sense of dignity, and being a burden to others–was significantly correlated with the will to live.

In addition, psychiatric issues such as depression, anxiety, and concentration were significantly associated with the will to live. Social variables–including support from family friends and health care providers, and patient satisfaction with this support–also were significantly correlated with the will to live.

Physical issues, particularly dyspnea, appetite, and appearance, were significantly correlated as well, but to a lesser degree than were existential, psychiatric, and social issues.

The patients, who were recruited from two Canadian palliative care facilities, shared information about their end-of-life experiences, which were rated on a symptom distress scale developed for cancer patients and an index of independence in activities of daily living. The mean age of patients was 69 years, and almost half were men. The most common cancers were lung (29%), gastrointestinal tract (26%), genitourinary system (16%), and breast (15%).

In a univariate analysis, hopelessness was highly predictive of suicidal ideation, as was a feeling of being a burden to others and a wish to die with dignity. The inclusion of dignity in the model suggests that patients who lose their sense of self and feel that their lives are no longer valued have less will to live. “It would appear that losing one's sense of meaning and purpose–experiencing life as having become redundant or futile–is an important existential underpinning of the loss of will to live among the dying,” Dr. Chochinov and his associates noted.

Although the study was limited by its focus on cancer patients, the results highlight the need to examine the factors driving terminal patients' wills to live in order to provide appropriate palliative care. The study was supported in part by the National Cancer Institute of Canada.

Existential issues were significantly correlated with the will to live in a study of 189 end-stage cancer patients.

Harvey Max Chochinov, M.D., professor of psychiatry at the University of Manitoba (Canada), and his colleagues examined the simultaneous influences of existential, psychiatric, and physical issues on the will to live in terminally ill patients (Psychosomatics 2005;46:7–10).

In a multiple regression analysis, each of the existential issues assessed–hopelessness, sense of dignity, and being a burden to others–was significantly correlated with the will to live.

In addition, psychiatric issues such as depression, anxiety, and concentration were significantly associated with the will to live. Social variables–including support from family friends and health care providers, and patient satisfaction with this support–also were significantly correlated with the will to live.

Physical issues, particularly dyspnea, appetite, and appearance, were significantly correlated as well, but to a lesser degree than were existential, psychiatric, and social issues.

The patients, who were recruited from two Canadian palliative care facilities, shared information about their end-of-life experiences, which were rated on a symptom distress scale developed for cancer patients and an index of independence in activities of daily living. The mean age of patients was 69 years, and almost half were men. The most common cancers were lung (29%), gastrointestinal tract (26%), genitourinary system (16%), and breast (15%).

In a univariate analysis, hopelessness was highly predictive of suicidal ideation, as was a feeling of being a burden to others and a wish to die with dignity. The inclusion of dignity in the model suggests that patients who lose their sense of self and feel that their lives are no longer valued have less will to live. “It would appear that losing one's sense of meaning and purpose–experiencing life as having become redundant or futile–is an important existential underpinning of the loss of will to live among the dying,” Dr. Chochinov and his associates noted.

Although the study was limited by its focus on cancer patients, the results highlight the need to examine the factors driving terminal patients' wills to live in order to provide appropriate palliative care. The study was supported in part by the National Cancer Institute of Canada.

Existential issues were significantly correlated with the will to live in a study of 189 end-stage cancer patients.

Harvey Max Chochinov, M.D., professor of psychiatry at the University of Manitoba (Canada), and his colleagues examined the simultaneous influences of existential, psychiatric, and physical issues on the will to live in terminally ill patients (Psychosomatics 2005;46:7–10).

In a multiple regression analysis, each of the existential issues assessed–hopelessness, sense of dignity, and being a burden to others–was significantly correlated with the will to live.

In addition, psychiatric issues such as depression, anxiety, and concentration were significantly associated with the will to live. Social variables–including support from family friends and health care providers, and patient satisfaction with this support–also were significantly correlated with the will to live.

Physical issues, particularly dyspnea, appetite, and appearance, were significantly correlated as well, but to a lesser degree than were existential, psychiatric, and social issues.

The patients, who were recruited from two Canadian palliative care facilities, shared information about their end-of-life experiences, which were rated on a symptom distress scale developed for cancer patients and an index of independence in activities of daily living. The mean age of patients was 69 years, and almost half were men. The most common cancers were lung (29%), gastrointestinal tract (26%), genitourinary system (16%), and breast (15%).

In a univariate analysis, hopelessness was highly predictive of suicidal ideation, as was a feeling of being a burden to others and a wish to die with dignity. The inclusion of dignity in the model suggests that patients who lose their sense of self and feel that their lives are no longer valued have less will to live. “It would appear that losing one's sense of meaning and purpose–experiencing life as having become redundant or futile–is an important existential underpinning of the loss of will to live among the dying,” Dr. Chochinov and his associates noted.

Although the study was limited by its focus on cancer patients, the results highlight the need to examine the factors driving terminal patients' wills to live in order to provide appropriate palliative care. The study was supported in part by the National Cancer Institute of Canada.

BOSTON – Patients diagnosed with carpel tunnel syndrome are more likely to be anxious and depressed and to have lower levels of mental and physical health functioning and job satisfaction, compared with individuals without the common wrist condition, Jason Goodson said at the annual meeting of the Society of Behavioral Medicine.

Findings in a study suggest that brief assessments of psychosocial functioning when evaluating patients for carpel tunnel syndrome (CTS) might be useful for understanding and treating the condition, as well as for improving the prognosis, Mr. Goodson said at the annual meeting of the Society of Behavioral Medicine.

The case-control study compared the psychosocial functioning of 87 patients diagnosed with CTS (based on clinical symptoms and electrodiagnostic confirmation) with that of 74 gender-matched control patients from the same orthopedic clinic. All of the study participants completed self-report questionnaires that included measures of depression, anxiety, somatization, health locus of control, job satisfaction, and mental and physical functioning.

Univariate analyses showed that the CTS patients had significantly higher levels of anxiety, depression, and other health locus of control beliefs. They had significantly lower levels of job satisfaction and mental and physical health functioning, said Mr. Goodson of Utah State University, Logan.

Measures of job satisfaction and physical health functioning were statistically significant predictors of CTS in a multiple logistic regression analysis, with adjusted odds ratios of 0.92 and 0.70, respectively, noted Mr. Goodson, who conducted the study under the direction of M. Scott DeBerard, Ph.D.

Previous studies have identified biologic and work variables as risk factors for CTS, but potential psychosocial variables have received less attention, Mr. Goodson said. And those studies that do exist “have frequently used nonspecific measures of psychosocial functioning, such as general distress, rather than specific measures, such as anxiety, depression, and somatization, he said, noting that the specific measures have more relevance when it comes to designing interventions.

By assessing patients psychosocial functioning when evaluating CTS, clinicians can refer patients who are struggling emotionally for appropriate mental health care to enhance coping resources and improve their ability to understand and manage the associated pain and disability. Cognitive-behavioral therapy and stress management are among the techniques that have shown promise for mitigating the emotional pain of the condition, Mr. Goodson said.

BOSTON – Patients diagnosed with carpel tunnel syndrome are more likely to be anxious and depressed and to have lower levels of mental and physical health functioning and job satisfaction, compared with individuals without the common wrist condition, Jason Goodson said at the annual meeting of the Society of Behavioral Medicine.

Findings in a study suggest that brief assessments of psychosocial functioning when evaluating patients for carpel tunnel syndrome (CTS) might be useful for understanding and treating the condition, as well as for improving the prognosis, Mr. Goodson said at the annual meeting of the Society of Behavioral Medicine.

The case-control study compared the psychosocial functioning of 87 patients diagnosed with CTS (based on clinical symptoms and electrodiagnostic confirmation) with that of 74 gender-matched control patients from the same orthopedic clinic. All of the study participants completed self-report questionnaires that included measures of depression, anxiety, somatization, health locus of control, job satisfaction, and mental and physical functioning.

Univariate analyses showed that the CTS patients had significantly higher levels of anxiety, depression, and other health locus of control beliefs. They had significantly lower levels of job satisfaction and mental and physical health functioning, said Mr. Goodson of Utah State University, Logan.

Measures of job satisfaction and physical health functioning were statistically significant predictors of CTS in a multiple logistic regression analysis, with adjusted odds ratios of 0.92 and 0.70, respectively, noted Mr. Goodson, who conducted the study under the direction of M. Scott DeBerard, Ph.D.

Previous studies have identified biologic and work variables as risk factors for CTS, but potential psychosocial variables have received less attention, Mr. Goodson said. And those studies that do exist “have frequently used nonspecific measures of psychosocial functioning, such as general distress, rather than specific measures, such as anxiety, depression, and somatization, he said, noting that the specific measures have more relevance when it comes to designing interventions.

By assessing patients psychosocial functioning when evaluating CTS, clinicians can refer patients who are struggling emotionally for appropriate mental health care to enhance coping resources and improve their ability to understand and manage the associated pain and disability. Cognitive-behavioral therapy and stress management are among the techniques that have shown promise for mitigating the emotional pain of the condition, Mr. Goodson said.

BOSTON – Patients diagnosed with carpel tunnel syndrome are more likely to be anxious and depressed and to have lower levels of mental and physical health functioning and job satisfaction, compared with individuals without the common wrist condition, Jason Goodson said at the annual meeting of the Society of Behavioral Medicine.

Findings in a study suggest that brief assessments of psychosocial functioning when evaluating patients for carpel tunnel syndrome (CTS) might be useful for understanding and treating the condition, as well as for improving the prognosis, Mr. Goodson said at the annual meeting of the Society of Behavioral Medicine.

The case-control study compared the psychosocial functioning of 87 patients diagnosed with CTS (based on clinical symptoms and electrodiagnostic confirmation) with that of 74 gender-matched control patients from the same orthopedic clinic. All of the study participants completed self-report questionnaires that included measures of depression, anxiety, somatization, health locus of control, job satisfaction, and mental and physical functioning.

Univariate analyses showed that the CTS patients had significantly higher levels of anxiety, depression, and other health locus of control beliefs. They had significantly lower levels of job satisfaction and mental and physical health functioning, said Mr. Goodson of Utah State University, Logan.

Measures of job satisfaction and physical health functioning were statistically significant predictors of CTS in a multiple logistic regression analysis, with adjusted odds ratios of 0.92 and 0.70, respectively, noted Mr. Goodson, who conducted the study under the direction of M. Scott DeBerard, Ph.D.

Previous studies have identified biologic and work variables as risk factors for CTS, but potential psychosocial variables have received less attention, Mr. Goodson said. And those studies that do exist “have frequently used nonspecific measures of psychosocial functioning, such as general distress, rather than specific measures, such as anxiety, depression, and somatization, he said, noting that the specific measures have more relevance when it comes to designing interventions.

By assessing patients psychosocial functioning when evaluating CTS, clinicians can refer patients who are struggling emotionally for appropriate mental health care to enhance coping resources and improve their ability to understand and manage the associated pain and disability. Cognitive-behavioral therapy and stress management are among the techniques that have shown promise for mitigating the emotional pain of the condition, Mr. Goodson said.

SANTA FE, N.M.–Clinical depression is common in cancer patients and can affect outcomes of cancer therapy if not treated.

About 13% of cancer patients develop a major depressive disorder within 2 years of diagnosis, Karen Weihs, M.D., said at a psychiatric symposium sponsored by the University of Arizona. Some cancers have much higher rates, according to Dr. Weihs, a psychiatrist at the university, in Tucson.

“Depression really is an overrepresented phenomenon, even compared to other kinds of illness,” she said, describing the likelihood of depression as more than twice the experience in patients diagnosed with heart disease (Arch. Intern. Med. 2005;165:1260–6).

A recent monograph reported depression to be most prevalent in patients with oropharyngeal (22%–57%), pancreatic (33%–50%), breast (1%–46%), and lung (11%–44%) cancers (J. Natl. Cancer Inst. Monogr. 2004;32:57–71). Depression was also common for patients with colon cancer (13%–25%), gynecological cancer (12%–23%), and lymphoma (9%–19%).

Depressed breast cancer patients have higher mortality than those who are not treated, according to Dr. Weihs. One study put their relative risk at 1.42 (J. Am. Geriatr. Soc. 2004;52:106–11).

Often depression is accompanied by symptoms of post-traumatic stress disorder, though not the full syndrome, she added. About 75% of depressed breast cancer patients will have intrusive memories 19 months after diagnosis.

Along with cancer type, she cited disease severity (threat of early death), pain, declining physical status, and the effects of cancer treatment as general risk factors for depression. Changing from caregiver to care receiver can cause distress, she said, and patients with a history of depression are vulnerable.

Physical and psychological symptoms are more common with chemotherapy, according to Dr. Weihs. One study found clinical depression in 28% of women who underwent chemotherapy and mastectomy but only 17% of women who had mastectomy without chemotherapy (J. Natl. Cancer Inst. 2004;96;376–87).

Cytokines probably play a role in cancer-related depression, she said, noting that pancreatic tumors are characterized by high cytokine release. Depressed cancer patients have elevated cytokines compared with cancer patients who are not depressed, she added.

Some cancer drugs may promote depression. Dr. Weihs noted that procarbazine inhibits dopamine beta-hydroxylase, while vincristine and vinblastine decrease conversion of dopamine to norepinephrine.

In addition, higher depression rates have been reported in women on tamoxifen: 15%, versus 3% in a control group (Breast Cancer Res. Treat. 1993;27:277–81).

Interferon-α, used to treat malignant melanoma and renal cell cancer, has been linked to major depressive disorder in 21%–58% of patients, she added. Increasing dosage and duration increases risk.

Most of what is known about depression and cancer comes from breast cancer studies, according to Dr. Weihs. While most enrolled well-educated white women, she noted that high point prevalence of depression has also been found in low-income, Hispanic women (J. Clin. Oncol. 2005;23:3052–60).

Distinguishing clinical depression from grief over a cancer diagnosis is challenging, especially in patients with a terminal prognosis. “For people who don't see a lot of cancer patients, it is hard to know what is disproportionate,” said Dr. Weihs.

She recommended approaching cancer patients on a mental health continuum. Many will function well at diagnosis, she said, and some who react poorly improve over time. About 12% deteriorate and need intervention. Accordingly, Dr. Weihs suggested staging depression in cancer patients as follows:

▸ Prior history that recurs with the cancer.

▸ First episode occurs during acute treatment for cancer.

▸ Related to medication or a medical complication.

▸ Starts after acute treatment in survivorship phase.

Few studies have tested antidepressants in cancer patients, but Dr. Weihs said the results were consistent: Treatment reduces depression scores on standard measures. One caveat is that paroxetine (Paxil) should not be given to patients who are taking tamoxifen, as it may inhibit the drug's activity.

She also recommended psychosocial interventions, including education, behavioral therapy, and individual and group psychotherapy for cancer-related distress. Psychostimulants should be reserved for patients with short life expectancy, as tolerance is not a risk and rapid action is needed, Dr. Weihs said.

SANTA FE, N.M.–Clinical depression is common in cancer patients and can affect outcomes of cancer therapy if not treated.

About 13% of cancer patients develop a major depressive disorder within 2 years of diagnosis, Karen Weihs, M.D., said at a psychiatric symposium sponsored by the University of Arizona. Some cancers have much higher rates, according to Dr. Weihs, a psychiatrist at the university, in Tucson.

“Depression really is an overrepresented phenomenon, even compared to other kinds of illness,” she said, describing the likelihood of depression as more than twice the experience in patients diagnosed with heart disease (Arch. Intern. Med. 2005;165:1260–6).

A recent monograph reported depression to be most prevalent in patients with oropharyngeal (22%–57%), pancreatic (33%–50%), breast (1%–46%), and lung (11%–44%) cancers (J. Natl. Cancer Inst. Monogr. 2004;32:57–71). Depression was also common for patients with colon cancer (13%–25%), gynecological cancer (12%–23%), and lymphoma (9%–19%).

Depressed breast cancer patients have higher mortality than those who are not treated, according to Dr. Weihs. One study put their relative risk at 1.42 (J. Am. Geriatr. Soc. 2004;52:106–11).

Often depression is accompanied by symptoms of post-traumatic stress disorder, though not the full syndrome, she added. About 75% of depressed breast cancer patients will have intrusive memories 19 months after diagnosis.

Along with cancer type, she cited disease severity (threat of early death), pain, declining physical status, and the effects of cancer treatment as general risk factors for depression. Changing from caregiver to care receiver can cause distress, she said, and patients with a history of depression are vulnerable.

Physical and psychological symptoms are more common with chemotherapy, according to Dr. Weihs. One study found clinical depression in 28% of women who underwent chemotherapy and mastectomy but only 17% of women who had mastectomy without chemotherapy (J. Natl. Cancer Inst. 2004;96;376–87).

Cytokines probably play a role in cancer-related depression, she said, noting that pancreatic tumors are characterized by high cytokine release. Depressed cancer patients have elevated cytokines compared with cancer patients who are not depressed, she added.

Some cancer drugs may promote depression. Dr. Weihs noted that procarbazine inhibits dopamine beta-hydroxylase, while vincristine and vinblastine decrease conversion of dopamine to norepinephrine.

In addition, higher depression rates have been reported in women on tamoxifen: 15%, versus 3% in a control group (Breast Cancer Res. Treat. 1993;27:277–81).

Interferon-α, used to treat malignant melanoma and renal cell cancer, has been linked to major depressive disorder in 21%–58% of patients, she added. Increasing dosage and duration increases risk.

Most of what is known about depression and cancer comes from breast cancer studies, according to Dr. Weihs. While most enrolled well-educated white women, she noted that high point prevalence of depression has also been found in low-income, Hispanic women (J. Clin. Oncol. 2005;23:3052–60).

Distinguishing clinical depression from grief over a cancer diagnosis is challenging, especially in patients with a terminal prognosis. “For people who don't see a lot of cancer patients, it is hard to know what is disproportionate,” said Dr. Weihs.

She recommended approaching cancer patients on a mental health continuum. Many will function well at diagnosis, she said, and some who react poorly improve over time. About 12% deteriorate and need intervention. Accordingly, Dr. Weihs suggested staging depression in cancer patients as follows:

▸ Prior history that recurs with the cancer.

▸ First episode occurs during acute treatment for cancer.

▸ Related to medication or a medical complication.

▸ Starts after acute treatment in survivorship phase.

Few studies have tested antidepressants in cancer patients, but Dr. Weihs said the results were consistent: Treatment reduces depression scores on standard measures. One caveat is that paroxetine (Paxil) should not be given to patients who are taking tamoxifen, as it may inhibit the drug's activity.

She also recommended psychosocial interventions, including education, behavioral therapy, and individual and group psychotherapy for cancer-related distress. Psychostimulants should be reserved for patients with short life expectancy, as tolerance is not a risk and rapid action is needed, Dr. Weihs said.

SANTA FE, N.M.–Clinical depression is common in cancer patients and can affect outcomes of cancer therapy if not treated.

About 13% of cancer patients develop a major depressive disorder within 2 years of diagnosis, Karen Weihs, M.D., said at a psychiatric symposium sponsored by the University of Arizona. Some cancers have much higher rates, according to Dr. Weihs, a psychiatrist at the university, in Tucson.

“Depression really is an overrepresented phenomenon, even compared to other kinds of illness,” she said, describing the likelihood of depression as more than twice the experience in patients diagnosed with heart disease (Arch. Intern. Med. 2005;165:1260–6).

A recent monograph reported depression to be most prevalent in patients with oropharyngeal (22%–57%), pancreatic (33%–50%), breast (1%–46%), and lung (11%–44%) cancers (J. Natl. Cancer Inst. Monogr. 2004;32:57–71). Depression was also common for patients with colon cancer (13%–25%), gynecological cancer (12%–23%), and lymphoma (9%–19%).

Depressed breast cancer patients have higher mortality than those who are not treated, according to Dr. Weihs. One study put their relative risk at 1.42 (J. Am. Geriatr. Soc. 2004;52:106–11).

Often depression is accompanied by symptoms of post-traumatic stress disorder, though not the full syndrome, she added. About 75% of depressed breast cancer patients will have intrusive memories 19 months after diagnosis.

Along with cancer type, she cited disease severity (threat of early death), pain, declining physical status, and the effects of cancer treatment as general risk factors for depression. Changing from caregiver to care receiver can cause distress, she said, and patients with a history of depression are vulnerable.

Physical and psychological symptoms are more common with chemotherapy, according to Dr. Weihs. One study found clinical depression in 28% of women who underwent chemotherapy and mastectomy but only 17% of women who had mastectomy without chemotherapy (J. Natl. Cancer Inst. 2004;96;376–87).

Cytokines probably play a role in cancer-related depression, she said, noting that pancreatic tumors are characterized by high cytokine release. Depressed cancer patients have elevated cytokines compared with cancer patients who are not depressed, she added.

Some cancer drugs may promote depression. Dr. Weihs noted that procarbazine inhibits dopamine beta-hydroxylase, while vincristine and vinblastine decrease conversion of dopamine to norepinephrine.

In addition, higher depression rates have been reported in women on tamoxifen: 15%, versus 3% in a control group (Breast Cancer Res. Treat. 1993;27:277–81).

Interferon-α, used to treat malignant melanoma and renal cell cancer, has been linked to major depressive disorder in 21%–58% of patients, she added. Increasing dosage and duration increases risk.

Most of what is known about depression and cancer comes from breast cancer studies, according to Dr. Weihs. While most enrolled well-educated white women, she noted that high point prevalence of depression has also been found in low-income, Hispanic women (J. Clin. Oncol. 2005;23:3052–60).

Distinguishing clinical depression from grief over a cancer diagnosis is challenging, especially in patients with a terminal prognosis. “For people who don't see a lot of cancer patients, it is hard to know what is disproportionate,” said Dr. Weihs.

She recommended approaching cancer patients on a mental health continuum. Many will function well at diagnosis, she said, and some who react poorly improve over time. About 12% deteriorate and need intervention. Accordingly, Dr. Weihs suggested staging depression in cancer patients as follows:

▸ Prior history that recurs with the cancer.

▸ First episode occurs during acute treatment for cancer.

▸ Related to medication or a medical complication.

▸ Starts after acute treatment in survivorship phase.

Few studies have tested antidepressants in cancer patients, but Dr. Weihs said the results were consistent: Treatment reduces depression scores on standard measures. One caveat is that paroxetine (Paxil) should not be given to patients who are taking tamoxifen, as it may inhibit the drug's activity.

She also recommended psychosocial interventions, including education, behavioral therapy, and individual and group psychotherapy for cancer-related distress. Psychostimulants should be reserved for patients with short life expectancy, as tolerance is not a risk and rapid action is needed, Dr. Weihs said.

The dramatic rise in obesity over the last decade has heightened debate among psychiatrists about whether “binge eating disorder” is a distinct clinical entity that deserves to move from the appendix of the DSM-IV up to a full-fledged psychiatric diagnosis in the DSM-V.

Since the DSM-IV was published in 1994, the prevalence of obesity among adults in the United States has risen by at least 30%. One-third of the U.S. population is currently considered obese, with a body mass index of 30 kg/m2 or greater, and more than two-thirds are overweight, with BMIs at or above 25.

Largely hidden in these statistics are roughly 2% of the population who meet the proposed binge eating disorder (BED) criteria (See box)–and who make up about one-third of individuals who seek help in weight loss treatment programs–as well as the unknown but undoubtedly huge number of people who don't meet the BED criteria but exhibit abnormal eating behavior linked to negative emotional states.

“There's a lot of interest in this topic, much of it related to how the fields of behavioral medicine and psychiatry can make a contribution to both the understanding and treatment of obesity,” said B. Timothy Walsh, M.D., who chaired the DSM-IV committee on eating disorders.

The term “binge eating disorder” is widely used in research and clinical settings, but BED is not an official diagnostic category. It is included in the DSM-IV under “criteria sets and axes for further study.” Patients who now meet the definition are classified either by other comorbid conditions such as depression or anxiety, and/or under the heading of “eating disorders not otherwise specified” (EDNOS).

The EDNOS category has proved problematic, because it lumps BED in the same category with a young woman who meets all the criteria for anorexia nervosa except that she still menstruates. It also refers to the patient who binges and purges but not quite often enough to qualify for bulimia nervosa. “There's been a lot of discussion about how to handle the EDNOS issue. It's a heterogeneous mix,” noted Dr. Walsh, director of the eating disorders research unit at New York State Psychiatric Institute/Columbia University, New York.

And BED patients are demographically very different from those with either anorexia or bulimia. They tend to be middle-aged at the time of diagnosis as opposed to an adolescent or young adult, and are as likely to be black or Hispanic as white, while patients with the other common eating disorders are primarily white. And, although BED is seen more often in women than in men, the ratio is about 60/40, compared with the 90/10 female/male ratio seen with anorexia and bulimia.

So, although BED is a distinct entity–these patients eat more in a shorter period of time than do other obese individuals–the primary reason that it didn't make it into DSM-IV is that “there are not compelling data that people who meet the criteria have a different need for treatment and/or a different prognosis than people who could be described equally well by existing categories. That evidence is still lacking,” Dr. Walsh said.

“The fact that most people with BED are obese, and most have some symptoms of anxiety or depression makes one wonder if those labels aren't sufficient. I don't think we should be casual about applying labels. We have to be rigorous in our insistence that the evidence backs up the utility of labels, because once they get created and formally approved, it's very hard to erase them,” he remarked.

Carlos M. Grilo, Ph.D., professor of psychiatry and director of the eating disorders program at Yale University, New Haven, Conn., agrees. “There is still active debate about the BED term. There is a clinical reality: Patients do suffer from problems described by the term. The research shows that persons who binge eat have increased psychiatric problems and psychological distress. But, do they benefit less from obesity treatment programs than do obese individuals who don't binge eat? That's not clear.”

Indeed, the only clear conclusion about BED treatment is that both cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) effectively reduce binge eating behavior. Both seem to work equally well, although more data are available for CBT. In one randomized comparison of CBT and IPT conducted in group settings for 20 weeks, binge eating recovery rates were equivalent among 81 patients in each group: 64 (79%) with CBT, compared with 59 (73%) with IPT post treatment. At 1 year follow-up, 59% who received CBT and 62% with IPT were still in remission (Arch. Gen. Psychiatry 2002;59:713–21).

But neither CBT nor IPT alone has proven useful for weight loss. Thus far, however, adding concurrent pharmacologic agents or other therapeutic modalities to CBT has yielded inconsistent results.

In a recent randomized, placebo-controlled study by Dr. Grilo and his associates, CBT was significantly superior to fluoxetine, and the addition of fluoxetine to CBT did not produce any further benefit than did the addition of placebo to CBT in either binge eating behavior or weight loss among 108 patients (Biol. Psychiatry 2005;57:301–9).

In an older randomized study that compared the addition of fluoxetine or placebo to behavior modification in 45 obese subjects–22 with binge eating problems and 23 without–weight loss was significantly greater among those taking fluoxetine, but the results did not differ between the binge eaters and the nonbinge eaters (Am. J. Psychiatry 1990;147:876–81).

In another of Dr. Grilo's recent studies, 50 obese BED patients on guided self-help CBT were randomized to receive 12-week concurrent treatment with either 120 mg orlistat three times a day or placebo. In the intent-to-treat analysis, 36% of the orlistat group achieved weight loss of 5% or greater, compared with just 8% of the placebo group. At 3 months' follow-up, those rates were 32% and 8%, with comparable rates of improvement in both eating disorder psychopathology and psychological distress (Biol. Psychiatry 2005;57:1193–201).

Studies of sibutramine (Meridia), an antiobesity medication (Arch. Gen. Psychiatry 2003;60:1109–16), and the antiepileptic topiramate (Topamax) have also shown significant reductions in binge eating and weight loss compared with placebo, although the latter had a high discontinuation rate (J. Clin. Psychiatry 2004;65:1463–9).

Finally, recent data have reinforced the benefits of guided self-help CBT over guided self-help behavioral weight loss (BWL) programs in reducing the frequency of binge eating (Behav. Res. Ther. 2005;43:1509–25) and of individual CBT in reducing binge eating behavior, compared with those who did not receive CBT among 116 overweight/obese BED patients who all received BWL treatment over 20 weeks (Obes. Res. 2005;13:1077–88).

“It's very clear that CBT is the best available treatment for obese persons who binge eat,” Dr. Grilo said. “It's superior to medications and behavioral weight loss in producing remission in binging and improving psychological profile. But, it does not appear to be useful for weight loss. Adding orlistat might be one way to go, but we need more data.”

But Dr. Walsh pointed out, there are no data looking at the efficacy of commercial weight loss programs such as Weight Watchers in people who meet the BED criteria. “Do they really need CBT, or are standard weight loss programs just as good? That's a very important question.”

Dr. Grilo and Dr. Walsh think the answers might come from two particular ongoing studies, both funded by the National Institutes of Health. One, being conducted at Washington University in St. Louis, is looking at the long-term impact of 24 weeks' treatment with the three major psychological approaches (CBT, interpersonal therapy, and behavioral weight loss) in BED. The other trial, from Dr. Grilo's group, is comparing CBT and BWL (“dieting”) separately and also in sequence to see whether CBT followed by BWL is effective in reducing both binge eating and weight for up to 1 year post treatment.

Data from both studies are expected in mid-2007.

DSM-IV Research Criteria for BED

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge eating episodes are associated with three (or more) of the following:

(1) eating much more rapidly than normal

(2) eating until feeling uncomfortably full

(3) eating large amounts of food when not feeling physically hungry

(4) eating alone because of being embarrassed by how much one is eating

(5) feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.

E. The binge eating is not associated with regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Source: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision

The dramatic rise in obesity over the last decade has heightened debate among psychiatrists about whether “binge eating disorder” is a distinct clinical entity that deserves to move from the appendix of the DSM-IV up to a full-fledged psychiatric diagnosis in the DSM-V.

Since the DSM-IV was published in 1994, the prevalence of obesity among adults in the United States has risen by at least 30%. One-third of the U.S. population is currently considered obese, with a body mass index of 30 kg/m2 or greater, and more than two-thirds are overweight, with BMIs at or above 25.

Largely hidden in these statistics are roughly 2% of the population who meet the proposed binge eating disorder (BED) criteria (See box)–and who make up about one-third of individuals who seek help in weight loss treatment programs–as well as the unknown but undoubtedly huge number of people who don't meet the BED criteria but exhibit abnormal eating behavior linked to negative emotional states.

“There's a lot of interest in this topic, much of it related to how the fields of behavioral medicine and psychiatry can make a contribution to both the understanding and treatment of obesity,” said B. Timothy Walsh, M.D., who chaired the DSM-IV committee on eating disorders.

The term “binge eating disorder” is widely used in research and clinical settings, but BED is not an official diagnostic category. It is included in the DSM-IV under “criteria sets and axes for further study.” Patients who now meet the definition are classified either by other comorbid conditions such as depression or anxiety, and/or under the heading of “eating disorders not otherwise specified” (EDNOS).

The EDNOS category has proved problematic, because it lumps BED in the same category with a young woman who meets all the criteria for anorexia nervosa except that she still menstruates. It also refers to the patient who binges and purges but not quite often enough to qualify for bulimia nervosa. “There's been a lot of discussion about how to handle the EDNOS issue. It's a heterogeneous mix,” noted Dr. Walsh, director of the eating disorders research unit at New York State Psychiatric Institute/Columbia University, New York.

And BED patients are demographically very different from those with either anorexia or bulimia. They tend to be middle-aged at the time of diagnosis as opposed to an adolescent or young adult, and are as likely to be black or Hispanic as white, while patients with the other common eating disorders are primarily white. And, although BED is seen more often in women than in men, the ratio is about 60/40, compared with the 90/10 female/male ratio seen with anorexia and bulimia.

So, although BED is a distinct entity–these patients eat more in a shorter period of time than do other obese individuals–the primary reason that it didn't make it into DSM-IV is that “there are not compelling data that people who meet the criteria have a different need for treatment and/or a different prognosis than people who could be described equally well by existing categories. That evidence is still lacking,” Dr. Walsh said.

“The fact that most people with BED are obese, and most have some symptoms of anxiety or depression makes one wonder if those labels aren't sufficient. I don't think we should be casual about applying labels. We have to be rigorous in our insistence that the evidence backs up the utility of labels, because once they get created and formally approved, it's very hard to erase them,” he remarked.

Carlos M. Grilo, Ph.D., professor of psychiatry and director of the eating disorders program at Yale University, New Haven, Conn., agrees. “There is still active debate about the BED term. There is a clinical reality: Patients do suffer from problems described by the term. The research shows that persons who binge eat have increased psychiatric problems and psychological distress. But, do they benefit less from obesity treatment programs than do obese individuals who don't binge eat? That's not clear.”

Indeed, the only clear conclusion about BED treatment is that both cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) effectively reduce binge eating behavior. Both seem to work equally well, although more data are available for CBT. In one randomized comparison of CBT and IPT conducted in group settings for 20 weeks, binge eating recovery rates were equivalent among 81 patients in each group: 64 (79%) with CBT, compared with 59 (73%) with IPT post treatment. At 1 year follow-up, 59% who received CBT and 62% with IPT were still in remission (Arch. Gen. Psychiatry 2002;59:713–21).

But neither CBT nor IPT alone has proven useful for weight loss. Thus far, however, adding concurrent pharmacologic agents or other therapeutic modalities to CBT has yielded inconsistent results.

In a recent randomized, placebo-controlled study by Dr. Grilo and his associates, CBT was significantly superior to fluoxetine, and the addition of fluoxetine to CBT did not produce any further benefit than did the addition of placebo to CBT in either binge eating behavior or weight loss among 108 patients (Biol. Psychiatry 2005;57:301–9).

In an older randomized study that compared the addition of fluoxetine or placebo to behavior modification in 45 obese subjects–22 with binge eating problems and 23 without–weight loss was significantly greater among those taking fluoxetine, but the results did not differ between the binge eaters and the nonbinge eaters (Am. J. Psychiatry 1990;147:876–81).

In another of Dr. Grilo's recent studies, 50 obese BED patients on guided self-help CBT were randomized to receive 12-week concurrent treatment with either 120 mg orlistat three times a day or placebo. In the intent-to-treat analysis, 36% of the orlistat group achieved weight loss of 5% or greater, compared with just 8% of the placebo group. At 3 months' follow-up, those rates were 32% and 8%, with comparable rates of improvement in both eating disorder psychopathology and psychological distress (Biol. Psychiatry 2005;57:1193–201).

Studies of sibutramine (Meridia), an antiobesity medication (Arch. Gen. Psychiatry 2003;60:1109–16), and the antiepileptic topiramate (Topamax) have also shown significant reductions in binge eating and weight loss compared with placebo, although the latter had a high discontinuation rate (J. Clin. Psychiatry 2004;65:1463–9).

Finally, recent data have reinforced the benefits of guided self-help CBT over guided self-help behavioral weight loss (BWL) programs in reducing the frequency of binge eating (Behav. Res. Ther. 2005;43:1509–25) and of individual CBT in reducing binge eating behavior, compared with those who did not receive CBT among 116 overweight/obese BED patients who all received BWL treatment over 20 weeks (Obes. Res. 2005;13:1077–88).

“It's very clear that CBT is the best available treatment for obese persons who binge eat,” Dr. Grilo said. “It's superior to medications and behavioral weight loss in producing remission in binging and improving psychological profile. But, it does not appear to be useful for weight loss. Adding orlistat might be one way to go, but we need more data.”

But Dr. Walsh pointed out, there are no data looking at the efficacy of commercial weight loss programs such as Weight Watchers in people who meet the BED criteria. “Do they really need CBT, or are standard weight loss programs just as good? That's a very important question.”

Dr. Grilo and Dr. Walsh think the answers might come from two particular ongoing studies, both funded by the National Institutes of Health. One, being conducted at Washington University in St. Louis, is looking at the long-term impact of 24 weeks' treatment with the three major psychological approaches (CBT, interpersonal therapy, and behavioral weight loss) in BED. The other trial, from Dr. Grilo's group, is comparing CBT and BWL (“dieting”) separately and also in sequence to see whether CBT followed by BWL is effective in reducing both binge eating and weight for up to 1 year post treatment.

Data from both studies are expected in mid-2007.

DSM-IV Research Criteria for BED

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge eating episodes are associated with three (or more) of the following:

(1) eating much more rapidly than normal

(2) eating until feeling uncomfortably full

(3) eating large amounts of food when not feeling physically hungry

(4) eating alone because of being embarrassed by how much one is eating

(5) feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.

E. The binge eating is not associated with regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Source: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision

The dramatic rise in obesity over the last decade has heightened debate among psychiatrists about whether “binge eating disorder” is a distinct clinical entity that deserves to move from the appendix of the DSM-IV up to a full-fledged psychiatric diagnosis in the DSM-V.

Since the DSM-IV was published in 1994, the prevalence of obesity among adults in the United States has risen by at least 30%. One-third of the U.S. population is currently considered obese, with a body mass index of 30 kg/m2 or greater, and more than two-thirds are overweight, with BMIs at or above 25.

Largely hidden in these statistics are roughly 2% of the population who meet the proposed binge eating disorder (BED) criteria (See box)–and who make up about one-third of individuals who seek help in weight loss treatment programs–as well as the unknown but undoubtedly huge number of people who don't meet the BED criteria but exhibit abnormal eating behavior linked to negative emotional states.

“There's a lot of interest in this topic, much of it related to how the fields of behavioral medicine and psychiatry can make a contribution to both the understanding and treatment of obesity,” said B. Timothy Walsh, M.D., who chaired the DSM-IV committee on eating disorders.

The term “binge eating disorder” is widely used in research and clinical settings, but BED is not an official diagnostic category. It is included in the DSM-IV under “criteria sets and axes for further study.” Patients who now meet the definition are classified either by other comorbid conditions such as depression or anxiety, and/or under the heading of “eating disorders not otherwise specified” (EDNOS).

The EDNOS category has proved problematic, because it lumps BED in the same category with a young woman who meets all the criteria for anorexia nervosa except that she still menstruates. It also refers to the patient who binges and purges but not quite often enough to qualify for bulimia nervosa. “There's been a lot of discussion about how to handle the EDNOS issue. It's a heterogeneous mix,” noted Dr. Walsh, director of the eating disorders research unit at New York State Psychiatric Institute/Columbia University, New York.

And BED patients are demographically very different from those with either anorexia or bulimia. They tend to be middle-aged at the time of diagnosis as opposed to an adolescent or young adult, and are as likely to be black or Hispanic as white, while patients with the other common eating disorders are primarily white. And, although BED is seen more often in women than in men, the ratio is about 60/40, compared with the 90/10 female/male ratio seen with anorexia and bulimia.

So, although BED is a distinct entity–these patients eat more in a shorter period of time than do other obese individuals–the primary reason that it didn't make it into DSM-IV is that “there are not compelling data that people who meet the criteria have a different need for treatment and/or a different prognosis than people who could be described equally well by existing categories. That evidence is still lacking,” Dr. Walsh said.

“The fact that most people with BED are obese, and most have some symptoms of anxiety or depression makes one wonder if those labels aren't sufficient. I don't think we should be casual about applying labels. We have to be rigorous in our insistence that the evidence backs up the utility of labels, because once they get created and formally approved, it's very hard to erase them,” he remarked.

Carlos M. Grilo, Ph.D., professor of psychiatry and director of the eating disorders program at Yale University, New Haven, Conn., agrees. “There is still active debate about the BED term. There is a clinical reality: Patients do suffer from problems described by the term. The research shows that persons who binge eat have increased psychiatric problems and psychological distress. But, do they benefit less from obesity treatment programs than do obese individuals who don't binge eat? That's not clear.”

Indeed, the only clear conclusion about BED treatment is that both cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) effectively reduce binge eating behavior. Both seem to work equally well, although more data are available for CBT. In one randomized comparison of CBT and IPT conducted in group settings for 20 weeks, binge eating recovery rates were equivalent among 81 patients in each group: 64 (79%) with CBT, compared with 59 (73%) with IPT post treatment. At 1 year follow-up, 59% who received CBT and 62% with IPT were still in remission (Arch. Gen. Psychiatry 2002;59:713–21).

But neither CBT nor IPT alone has proven useful for weight loss. Thus far, however, adding concurrent pharmacologic agents or other therapeutic modalities to CBT has yielded inconsistent results.

In a recent randomized, placebo-controlled study by Dr. Grilo and his associates, CBT was significantly superior to fluoxetine, and the addition of fluoxetine to CBT did not produce any further benefit than did the addition of placebo to CBT in either binge eating behavior or weight loss among 108 patients (Biol. Psychiatry 2005;57:301–9).

In an older randomized study that compared the addition of fluoxetine or placebo to behavior modification in 45 obese subjects–22 with binge eating problems and 23 without–weight loss was significantly greater among those taking fluoxetine, but the results did not differ between the binge eaters and the nonbinge eaters (Am. J. Psychiatry 1990;147:876–81).

In another of Dr. Grilo's recent studies, 50 obese BED patients on guided self-help CBT were randomized to receive 12-week concurrent treatment with either 120 mg orlistat three times a day or placebo. In the intent-to-treat analysis, 36% of the orlistat group achieved weight loss of 5% or greater, compared with just 8% of the placebo group. At 3 months' follow-up, those rates were 32% and 8%, with comparable rates of improvement in both eating disorder psychopathology and psychological distress (Biol. Psychiatry 2005;57:1193–201).

Studies of sibutramine (Meridia), an antiobesity medication (Arch. Gen. Psychiatry 2003;60:1109–16), and the antiepileptic topiramate (Topamax) have also shown significant reductions in binge eating and weight loss compared with placebo, although the latter had a high discontinuation rate (J. Clin. Psychiatry 2004;65:1463–9).

Finally, recent data have reinforced the benefits of guided self-help CBT over guided self-help behavioral weight loss (BWL) programs in reducing the frequency of binge eating (Behav. Res. Ther. 2005;43:1509–25) and of individual CBT in reducing binge eating behavior, compared with those who did not receive CBT among 116 overweight/obese BED patients who all received BWL treatment over 20 weeks (Obes. Res. 2005;13:1077–88).

“It's very clear that CBT is the best available treatment for obese persons who binge eat,” Dr. Grilo said. “It's superior to medications and behavioral weight loss in producing remission in binging and improving psychological profile. But, it does not appear to be useful for weight loss. Adding orlistat might be one way to go, but we need more data.”

But Dr. Walsh pointed out, there are no data looking at the efficacy of commercial weight loss programs such as Weight Watchers in people who meet the BED criteria. “Do they really need CBT, or are standard weight loss programs just as good? That's a very important question.”

Dr. Grilo and Dr. Walsh think the answers might come from two particular ongoing studies, both funded by the National Institutes of Health. One, being conducted at Washington University in St. Louis, is looking at the long-term impact of 24 weeks' treatment with the three major psychological approaches (CBT, interpersonal therapy, and behavioral weight loss) in BED. The other trial, from Dr. Grilo's group, is comparing CBT and BWL (“dieting”) separately and also in sequence to see whether CBT followed by BWL is effective in reducing both binge eating and weight for up to 1 year post treatment.

Data from both studies are expected in mid-2007.

DSM-IV Research Criteria for BED

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge eating episodes are associated with three (or more) of the following:

(1) eating much more rapidly than normal

(2) eating until feeling uncomfortably full

(3) eating large amounts of food when not feeling physically hungry

(4) eating alone because of being embarrassed by how much one is eating

(5) feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.

E. The binge eating is not associated with regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Source: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision

BOSTON – A worksite-based stress and anger management program may improve the cardiovascular health of at-risk employees, Lynn Clemow, Ph.D., said in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Preliminary results from a randomized, controlled trial indicate that participants who underwent a brief psychoeducational intervention program had reductions in systolic blood pressure. The participants were a diverse group of hospital employees classified as hypertensive on screening.

The employees in the intervention group also reported significant reductions in stress, hostility, burnout, and passive interpersonal behavior, all of which have been implicated in the development of cardiovascular disease, said Dr. Clemow of the behavioral cardiovascular health and hypertension program at Columbia University, New York.

Participants underwent baseline and posttrial blood pressure testing and structured interviews to measure hostility, perceived stress, depression, work stress, and interpersonal behavior. The 32 individuals in the intervention group participated in 10 weekly, 1-hour stress and anger management sessions based on materials from the Williams LifeSkills program. The intervention was delivered in small groups by trained clinicians, Dr. Clemow said.

Individuals randomized to the control group received usual care, which included apprising the participants' primary care providers of blood pressure readings at screening and giving the participants a summary of blood pressure management guidelines. Individuals in both groups were stratified by hostility level.

The intervention group participants with a high level of hostility had reductions from baseline in systolic blood pressure during the high stress periods of the stress/anger structured interview, while their control counterparts did not show reductions. No differences were found in resting clinical blood pressure readings between the two groups over time, but the preliminary findings suggest the utility of such workplace interventions with respect to improving blood pressure under stressful conditions, according to Dr. Clemow.

The intervention group also showed posttreatment improvement in scores of self-reported stress, job burnout, hostility, and passive-unassertive behavior. As hypothesized, “the effects were more pronounced among individuals with higher baseline hostility,” Dr. Clemow said.

BOSTON – A worksite-based stress and anger management program may improve the cardiovascular health of at-risk employees, Lynn Clemow, Ph.D., said in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Preliminary results from a randomized, controlled trial indicate that participants who underwent a brief psychoeducational intervention program had reductions in systolic blood pressure. The participants were a diverse group of hospital employees classified as hypertensive on screening.

The employees in the intervention group also reported significant reductions in stress, hostility, burnout, and passive interpersonal behavior, all of which have been implicated in the development of cardiovascular disease, said Dr. Clemow of the behavioral cardiovascular health and hypertension program at Columbia University, New York.

Participants underwent baseline and posttrial blood pressure testing and structured interviews to measure hostility, perceived stress, depression, work stress, and interpersonal behavior. The 32 individuals in the intervention group participated in 10 weekly, 1-hour stress and anger management sessions based on materials from the Williams LifeSkills program. The intervention was delivered in small groups by trained clinicians, Dr. Clemow said.

Individuals randomized to the control group received usual care, which included apprising the participants' primary care providers of blood pressure readings at screening and giving the participants a summary of blood pressure management guidelines. Individuals in both groups were stratified by hostility level.

The intervention group participants with a high level of hostility had reductions from baseline in systolic blood pressure during the high stress periods of the stress/anger structured interview, while their control counterparts did not show reductions. No differences were found in resting clinical blood pressure readings between the two groups over time, but the preliminary findings suggest the utility of such workplace interventions with respect to improving blood pressure under stressful conditions, according to Dr. Clemow.

The intervention group also showed posttreatment improvement in scores of self-reported stress, job burnout, hostility, and passive-unassertive behavior. As hypothesized, “the effects were more pronounced among individuals with higher baseline hostility,” Dr. Clemow said.

BOSTON – A worksite-based stress and anger management program may improve the cardiovascular health of at-risk employees, Lynn Clemow, Ph.D., said in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Preliminary results from a randomized, controlled trial indicate that participants who underwent a brief psychoeducational intervention program had reductions in systolic blood pressure. The participants were a diverse group of hospital employees classified as hypertensive on screening.

The employees in the intervention group also reported significant reductions in stress, hostility, burnout, and passive interpersonal behavior, all of which have been implicated in the development of cardiovascular disease, said Dr. Clemow of the behavioral cardiovascular health and hypertension program at Columbia University, New York.

Participants underwent baseline and posttrial blood pressure testing and structured interviews to measure hostility, perceived stress, depression, work stress, and interpersonal behavior. The 32 individuals in the intervention group participated in 10 weekly, 1-hour stress and anger management sessions based on materials from the Williams LifeSkills program. The intervention was delivered in small groups by trained clinicians, Dr. Clemow said.

Individuals randomized to the control group received usual care, which included apprising the participants' primary care providers of blood pressure readings at screening and giving the participants a summary of blood pressure management guidelines. Individuals in both groups were stratified by hostility level.

The intervention group participants with a high level of hostility had reductions from baseline in systolic blood pressure during the high stress periods of the stress/anger structured interview, while their control counterparts did not show reductions. No differences were found in resting clinical blood pressure readings between the two groups over time, but the preliminary findings suggest the utility of such workplace interventions with respect to improving blood pressure under stressful conditions, according to Dr. Clemow.

The intervention group also showed posttreatment improvement in scores of self-reported stress, job burnout, hostility, and passive-unassertive behavior. As hypothesized, “the effects were more pronounced among individuals with higher baseline hostility,” Dr. Clemow said.

WASHINGTON – Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive coping skills training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms aren't known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training–also known as stress reduction, stress management, or a host of other names–reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president. (See box.)

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different.

After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time.

Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure (SBP) fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months.

Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall–that is, the increase that occurs when a patient is reminded of a previous anger-inducing situation–also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

How to Cope With Negative Thoughts

The LifeSkills program starts by teaching patients how to be aware of their negative thoughts and feelings so they can evaluate them objectively and learn to manage them appropriately, Virginia P. Williams, Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

LifeSkills is taught through face-to-face workshops, a video plus workbook, and the Web (

www.williamslifeskills.com

The training focuses on core skills, including awareness of thoughts and feelings, evaluation and management of negative thoughts and feelings, deflection strategies, problem solving, assertion and saying “no,” communication and empathy, and being positive.

Patients keep a log of their thoughts and feelings, the times of day they occur, and what triggered them. This helps them evaluate whether their thoughts are appropriate given the facts. That process, in turn, facilitates deciding whether the correct course of action is to try to change a situation or change one's negative reaction to it. “Patients can't change the fact that they have diabetes, but they can change the way they manage it,” he said.

Patients are taught to use the mnemonic “I AM WORTH IT” to ask: Is the matter Important? Are negative thoughts/feelings Appropriate? Is the situation Modifiable? And, balancing the needs of myself and others, is it Worth It? If the answer to all four questions is “yes,” action skills to change the situation include problem solving, assertion, and saying “no.” If the answer to any of the questions is “no,” then “deflection skills” such as distraction, thought stopping, and relaxation/meditation are the next step.

Among the “action skills” is a systematic approach to problem-solving: Define the problem, generate alternatives through brainstorming, make a decision, implement the decision, evaluate the outcome, and revisit other options if needed. Assertion is another often-needed skill, in which patients are taught to ask others to change their behavior, to listen to them–or importantly, for people with chronic illness–to ask the physician for more information.

If “deflection” is the better course of action, relaxation exercises such as the one that Dr. Williams took the audience through may be in order: Picture a stop sign and say, “Stop” to yourself. Take three deep breaths, and say, “Relax” on each exhale. Inhale while clenching fists, then relax them on exhale. Inhale while clenching feet, then relax on exhale. Inhale while shrugging shoulders, then relax them on exhale. Inhale while tilting head to the right, then straighten on exhale. Inhale while tilting head to the left, then straighten on exhale. Finish with a “plain” inhale/exhale cycle.

WASHINGTON – Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive coping skills training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms aren't known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training–also known as stress reduction, stress management, or a host of other names–reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president. (See box.)

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different.

After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time.

Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure (SBP) fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months.

Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall–that is, the increase that occurs when a patient is reminded of a previous anger-inducing situation–also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

How to Cope With Negative Thoughts

The LifeSkills program starts by teaching patients how to be aware of their negative thoughts and feelings so they can evaluate them objectively and learn to manage them appropriately, Virginia P. Williams, Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

LifeSkills is taught through face-to-face workshops, a video plus workbook, and the Web (

www.williamslifeskills.com

The training focuses on core skills, including awareness of thoughts and feelings, evaluation and management of negative thoughts and feelings, deflection strategies, problem solving, assertion and saying “no,” communication and empathy, and being positive.

Patients keep a log of their thoughts and feelings, the times of day they occur, and what triggered them. This helps them evaluate whether their thoughts are appropriate given the facts. That process, in turn, facilitates deciding whether the correct course of action is to try to change a situation or change one's negative reaction to it. “Patients can't change the fact that they have diabetes, but they can change the way they manage it,” he said.

Patients are taught to use the mnemonic “I AM WORTH IT” to ask: Is the matter Important? Are negative thoughts/feelings Appropriate? Is the situation Modifiable? And, balancing the needs of myself and others, is it Worth It? If the answer to all four questions is “yes,” action skills to change the situation include problem solving, assertion, and saying “no.” If the answer to any of the questions is “no,” then “deflection skills” such as distraction, thought stopping, and relaxation/meditation are the next step.

Among the “action skills” is a systematic approach to problem-solving: Define the problem, generate alternatives through brainstorming, make a decision, implement the decision, evaluate the outcome, and revisit other options if needed. Assertion is another often-needed skill, in which patients are taught to ask others to change their behavior, to listen to them–or importantly, for people with chronic illness–to ask the physician for more information.

If “deflection” is the better course of action, relaxation exercises such as the one that Dr. Williams took the audience through may be in order: Picture a stop sign and say, “Stop” to yourself. Take three deep breaths, and say, “Relax” on each exhale. Inhale while clenching fists, then relax them on exhale. Inhale while clenching feet, then relax on exhale. Inhale while shrugging shoulders, then relax them on exhale. Inhale while tilting head to the right, then straighten on exhale. Inhale while tilting head to the left, then straighten on exhale. Finish with a “plain” inhale/exhale cycle.

WASHINGTON – Increasing evidence suggests that patients with chronic conditions such as diabetes and heart disease who receive coping skills training do better physically and mentally, Redford B. Williams, M.D., said at the annual meeting of the American Association of Diabetes Educators.

Stress and the negative emotions that diabetes engenders can impair control of the disease and increase the risk for major complications, as well as increase the risk of death after myocardial infarction. The exact mechanisms aren't known, but are likely related to changes in sympathetic nervous system activity and cortisol secretion, which could in turn increase depression and lead to noncompliance, said Dr. Williams, director of the Behavioral Medicine Research Center at Duke University, Durham, N.C.

On the positive side, randomized trials have shown that coping skills training–also known as stress reduction, stress management, or a host of other names–reduces psychosocial risk factors and biomarkers of stress such as blood pressure and vascular reactivity. This training may improve metabolic control in diabetic patients, said Dr. Williams, who is also professor of psychiatry, medicine, and psychology at Duke.

“It's not a substitute for diet, exercise, glucose monitoring, and medications,” he said. “Managing the stress of everyday life is another leg of the stool of good diabetes management.”

Among the coping skills programs for which positive data are emerging is Williams LifeSkills Inc., founded by Dr. Williams and his wife, Virginia P. Williams, Ph.D. He serves as chairman of the organization, and she is president. (See box.)

Among 60 patients who had undergone coronary artery bypass grafting, 30 were randomized to receive six sessions of LifeSkills training; the other 30 listened to a 1-hour lecture on the effects of stress on the heart. Baseline scores on the Center for Epidemiological Studies Depression Scale (CES-D) were 11.1 in the intervention group and 13.7 in the control group, which was not significantly different.

After the intervention, the mean CES-D score in the LifeSkills group dropped to 7.2, while it rose to 16.9 in the control group, a significant difference. At 3 months, the CES-D score in the controls had risen to 17.6, which is considered clinical depression, while it had dropped even further, to 4.3, in the LifeSkills group.

Similar differences were seen in questionnaire measures of trait anger, perceived stress, satisfaction with social support, and satisfaction with life. In all cases, the LifeSkills group improved even further at 3 months while the controls worsened with time.

Such findings suggest that when it comes to patients with heart disease or diabetes, “we don't need to label patients as depressed or anxious. Everybody needs this kind of training,” Dr. Williams said.

Systolic blood pressure (SBP) fell among those who received LifeSkills training, from a mean of 122.3 mm Hg at baseline to 118.7 mm Hg post intervention to 118.3 mm Hg at 3 months. In contrast, among control patients, SBP rose from 118.8 mm Hg at baseline to 124.1 mm Hg post intervention to 126.9 mm Hg at 3 months.

Similarly, resting heart rate in the LifeSkills group dropped from 72.1 beats per minute to 65.2 post intervention and 65.4 at 3 months. In the controls, resting heart rate remained essentially the same throughout (73.8 to 73.6 to 74.9 bpm).

Systolic blood pressure reactivity to anger recall–that is, the increase that occurs when a patient is reminded of a previous anger-inducing situation–also differed between the groups, dropping from 26.1 mm Hg at baseline to 16 mm Hg post intervention to 11.4 mm Hg at 3 months in the LifeSkills group, while rising from 21.5 to 23.1 to 27.7 mm Hg in the controls.

The LifeSkills program hasn't been studied specifically in diabetic patients, but other findings suggest that they could benefit from such training.

In a study led by Dr. Williams' colleague at Duke, Richard Surwit, Ph.D., scores on the Cook-Medley hostility scale were significantly correlated with glucose metabolism in nondiabetic patients (Diabetes Care 2002;25:835–9).

Lifeskills training, which has also been shown to decrease hostility scores, might therefore reduce glucose levels in diabetic patients as well, Dr. Williams said.

How to Cope With Negative Thoughts

The LifeSkills program starts by teaching patients how to be aware of their negative thoughts and feelings so they can evaluate them objectively and learn to manage them appropriately, Virginia P. Williams, Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

LifeSkills is taught through face-to-face workshops, a video plus workbook, and the Web (

www.williamslifeskills.com

The training focuses on core skills, including awareness of thoughts and feelings, evaluation and management of negative thoughts and feelings, deflection strategies, problem solving, assertion and saying “no,” communication and empathy, and being positive.

Patients keep a log of their thoughts and feelings, the times of day they occur, and what triggered them. This helps them evaluate whether their thoughts are appropriate given the facts. That process, in turn, facilitates deciding whether the correct course of action is to try to change a situation or change one's negative reaction to it. “Patients can't change the fact that they have diabetes, but they can change the way they manage it,” he said.

Patients are taught to use the mnemonic “I AM WORTH IT” to ask: Is the matter Important? Are negative thoughts/feelings Appropriate? Is the situation Modifiable? And, balancing the needs of myself and others, is it Worth It? If the answer to all four questions is “yes,” action skills to change the situation include problem solving, assertion, and saying “no.” If the answer to any of the questions is “no,” then “deflection skills” such as distraction, thought stopping, and relaxation/meditation are the next step.

Among the “action skills” is a systematic approach to problem-solving: Define the problem, generate alternatives through brainstorming, make a decision, implement the decision, evaluate the outcome, and revisit other options if needed. Assertion is another often-needed skill, in which patients are taught to ask others to change their behavior, to listen to them–or importantly, for people with chronic illness–to ask the physician for more information.

If “deflection” is the better course of action, relaxation exercises such as the one that Dr. Williams took the audience through may be in order: Picture a stop sign and say, “Stop” to yourself. Take three deep breaths, and say, “Relax” on each exhale. Inhale while clenching fists, then relax them on exhale. Inhale while clenching feet, then relax on exhale. Inhale while shrugging shoulders, then relax them on exhale. Inhale while tilting head to the right, then straighten on exhale. Inhale while tilting head to the left, then straighten on exhale. Finish with a “plain” inhale/exhale cycle.

BOSTON – The psychosocial needs of young breast cancer patients should be viewed in a different context than those of older women, said Lidia Schapira, M.D.

“Premenopausal women with breast cancer are at greater risk of psychological distress at diagnosis and during treatment, especially when it coincides with childbearing years or with years spent in active parenting roles,” Dr. Schapira said at a breast cancer meeting sponsored by Harvard Medical School.

Because younger women face such concerns as premature death and the impact that treatment will have on fertility, child rearing, career, finances, and appearance, clinicians must broaden their traditional vertical focus on managing the medical aspects of the disease “and look at the horizontal axis of patients' social functioning as they deal with their diagnosis and treatment,” said Dr. Schapira of Massachusetts General Hospital, Boston.

The nature and extent of a breast cancer patient's psychological distress vary depending on the individual and the phase of the disease. The concerns at diagnosis might be different from those experienced during primary treatment or at treatment completion, Dr. Schapira said.

At all points along the disease trajectory clinicians should address “normal” levels of psychosocial distress and be alert for signs of persistent distress that would benefit from specific mental health intervention. Toward this end, according to guidelines published in a 2004 Institute of Medicine report on the psychosocial needs of women with breast cancer, clinicians should:

▸ Ensure understanding of diagnosis and treatment options and side effects.

▸ Advise that distress is normal and expected and can increase at transition points.

▸ Build trust.

▸ Mobilize resources and direct patients to educational materials and local resources.

▸ Consider medication for symptoms.

▸ Ensure continuity of care.

▸ Monitor and reevaluate for referral to more specialized services if needed.

Additionally, a variety of interventions have been shown to favorably impact psychological status and quality of life, Dr. Schapira said. “Notably, there is strong evidence for the benefit of relaxation, hypnosis, and imagery in early-stage breast cancer, for group interventions in both early and metastatic disease, and for individual interventions primarily in the early setting,” she said.

Finally, clinicians need to be acutely aware of the special issues facing women who are diagnosed during their parenting years. “Being a parent affects preference for adjuvant chemotherapy in women with breast cancer, yet the impact that the side effects of treatment will have on the parenting experience are rarely discussed in the context of a medical encounter,” Dr. Schapira said.

“Studies have shown that parents want to know how to talk about the illness with their kids in a developmentally appropriate way,” she said, and that parents need guidance in understanding and dealing with the impact of maternal disease on children's behavior and level of distress.

One example of how such issues might be addressed is a program developed by Paula Rauch, M.D., at Massachusetts General called Parenting at a Challenging Time (PACT). Through PACT, child psychiatrists and psychologists provide free consultations to adults with cancer or their partners to help them address the needs of their children during cancer treatment, Dr. Schapira explained. “The program recommends that clinicians ask patients if they have children, and follow up with questions about the children and discuss the resources that are available to them,” she said.

Clearly, clinicians cannot be the only source of psychosocial support for their younger breast cancer patients; they should be cognizant of the potential for significant distress and be prepared to help these women get the support they need, Dr. Schapira concluded.

BOSTON – The psychosocial needs of young breast cancer patients should be viewed in a different context than those of older women, said Lidia Schapira, M.D.

“Premenopausal women with breast cancer are at greater risk of psychological distress at diagnosis and during treatment, especially when it coincides with childbearing years or with years spent in active parenting roles,” Dr. Schapira said at a breast cancer meeting sponsored by Harvard Medical School.

Because younger women face such concerns as premature death and the impact that treatment will have on fertility, child rearing, career, finances, and appearance, clinicians must broaden their traditional vertical focus on managing the medical aspects of the disease “and look at the horizontal axis of patients' social functioning as they deal with their diagnosis and treatment,” said Dr. Schapira of Massachusetts General Hospital, Boston.

The nature and extent of a breast cancer patient's psychological distress vary depending on the individual and the phase of the disease. The concerns at diagnosis might be different from those experienced during primary treatment or at treatment completion, Dr. Schapira said.

At all points along the disease trajectory clinicians should address “normal” levels of psychosocial distress and be alert for signs of persistent distress that would benefit from specific mental health intervention. Toward this end, according to guidelines published in a 2004 Institute of Medicine report on the psychosocial needs of women with breast cancer, clinicians should:

▸ Ensure understanding of diagnosis and treatment options and side effects.

▸ Advise that distress is normal and expected and can increase at transition points.

▸ Build trust.

▸ Mobilize resources and direct patients to educational materials and local resources.

▸ Consider medication for symptoms.

▸ Ensure continuity of care.

▸ Monitor and reevaluate for referral to more specialized services if needed.

Additionally, a variety of interventions have been shown to favorably impact psychological status and quality of life, Dr. Schapira said. “Notably, there is strong evidence for the benefit of relaxation, hypnosis, and imagery in early-stage breast cancer, for group interventions in both early and metastatic disease, and for individual interventions primarily in the early setting,” she said.

Finally, clinicians need to be acutely aware of the special issues facing women who are diagnosed during their parenting years. “Being a parent affects preference for adjuvant chemotherapy in women with breast cancer, yet the impact that the side effects of treatment will have on the parenting experience are rarely discussed in the context of a medical encounter,” Dr. Schapira said.

“Studies have shown that parents want to know how to talk about the illness with their kids in a developmentally appropriate way,” she said, and that parents need guidance in understanding and dealing with the impact of maternal disease on children's behavior and level of distress.

One example of how such issues might be addressed is a program developed by Paula Rauch, M.D., at Massachusetts General called Parenting at a Challenging Time (PACT). Through PACT, child psychiatrists and psychologists provide free consultations to adults with cancer or their partners to help them address the needs of their children during cancer treatment, Dr. Schapira explained. “The program recommends that clinicians ask patients if they have children, and follow up with questions about the children and discuss the resources that are available to them,” she said.

Clearly, clinicians cannot be the only source of psychosocial support for their younger breast cancer patients; they should be cognizant of the potential for significant distress and be prepared to help these women get the support they need, Dr. Schapira concluded.

BOSTON – The psychosocial needs of young breast cancer patients should be viewed in a different context than those of older women, said Lidia Schapira, M.D.

“Premenopausal women with breast cancer are at greater risk of psychological distress at diagnosis and during treatment, especially when it coincides with childbearing years or with years spent in active parenting roles,” Dr. Schapira said at a breast cancer meeting sponsored by Harvard Medical School.

Because younger women face such concerns as premature death and the impact that treatment will have on fertility, child rearing, career, finances, and appearance, clinicians must broaden their traditional vertical focus on managing the medical aspects of the disease “and look at the horizontal axis of patients' social functioning as they deal with their diagnosis and treatment,” said Dr. Schapira of Massachusetts General Hospital, Boston.

The nature and extent of a breast cancer patient's psychological distress vary depending on the individual and the phase of the disease. The concerns at diagnosis might be different from those experienced during primary treatment or at treatment completion, Dr. Schapira said.

At all points along the disease trajectory clinicians should address “normal” levels of psychosocial distress and be alert for signs of persistent distress that would benefit from specific mental health intervention. Toward this end, according to guidelines published in a 2004 Institute of Medicine report on the psychosocial needs of women with breast cancer, clinicians should:

▸ Ensure understanding of diagnosis and treatment options and side effects.

▸ Advise that distress is normal and expected and can increase at transition points.

▸ Build trust.

▸ Mobilize resources and direct patients to educational materials and local resources.

▸ Consider medication for symptoms.

▸ Ensure continuity of care.

▸ Monitor and reevaluate for referral to more specialized services if needed.

Additionally, a variety of interventions have been shown to favorably impact psychological status and quality of life, Dr. Schapira said. “Notably, there is strong evidence for the benefit of relaxation, hypnosis, and imagery in early-stage breast cancer, for group interventions in both early and metastatic disease, and for individual interventions primarily in the early setting,” she said.

Finally, clinicians need to be acutely aware of the special issues facing women who are diagnosed during their parenting years. “Being a parent affects preference for adjuvant chemotherapy in women with breast cancer, yet the impact that the side effects of treatment will have on the parenting experience are rarely discussed in the context of a medical encounter,” Dr. Schapira said.

“Studies have shown that parents want to know how to talk about the illness with their kids in a developmentally appropriate way,” she said, and that parents need guidance in understanding and dealing with the impact of maternal disease on children's behavior and level of distress.

One example of how such issues might be addressed is a program developed by Paula Rauch, M.D., at Massachusetts General called Parenting at a Challenging Time (PACT). Through PACT, child psychiatrists and psychologists provide free consultations to adults with cancer or their partners to help them address the needs of their children during cancer treatment, Dr. Schapira explained. “The program recommends that clinicians ask patients if they have children, and follow up with questions about the children and discuss the resources that are available to them,” she said.

Clearly, clinicians cannot be the only source of psychosocial support for their younger breast cancer patients; they should be cognizant of the potential for significant distress and be prepared to help these women get the support they need, Dr. Schapira concluded.

NEW YORK – Schizophrenia and bipolar disorder pose a triple health threat: The conditions themselves are associated with a higher prevalence of serious medical illness, some drugs used to treat them increase disease risk, and affected individuals are likely to have inadequate medical care, Ilise D. Lombardo, M.D., said at a conference on schizophrenia sponsored by Columbia University.

The unhealthful influence is bidirectional: The psychiatric course tends to be worse in individuals with chronic medical conditions or medical risk factors like obesity. (For example, a survey of 1,379 bipolar patients found that 44% had comorbid medical conditions and linked the presence and severity of medical problems to the severity of the psychiatric disorder.)

“Psychiatrists should monitor risk factors, coordinate care with internists, and involve families in medical issues,” said Dr. Lombardo of the university.

Serious mental illness is life-threatening: The rate of mortality from natural causes among patients with bipolar disorder and schizophrenia is double that of the population as a whole; for unipolar depression, the mortality rate is 1.5 times that of the general population. Cardiovascular disease and, to a lesser extent, endocrine disorders are mainly responsible for the higher rates.

This increased mortality is not surprising in light of the high prevalence of cardiovascular risk factors in the psychiatric population, Dr. Lombardo said.

Among patients with schizophrenia, 18% have elevated total cholesterol levels, 20% have hypertension, 75% smoke cigarettes, about 50% are overweight or obese, and 72% are sedentary.

An estimated 30%–60% of schizophrenia patients have metabolic syndrome–a constellation of abdominal obesity, lipid abnormalities, and abnormal glucose metabolism that triples the risk of dying of a myocardial infarction, Dr. Lombardo said at the meeting, which was cosponsored by the New York State Psychiatric Institute.

But although the medical needs of people with severe and persistent mental illness would appear to be greater, they “have less access and less quality medical care,” said Dr. Lombardo, who is also medical director for Pfizer Inc.

A review of 175,653 patients in Veterans Affairs medical centers in Southern California and Nevada found a highly significant association between a diagnosis of schizophrenia and fewer physician visits. Two-thirds of schizophrenia patients did not have such prevalent conditions as diabetes, hypertension, or chronic obstructive pulmonary disease listed among their medical diagnoses.

“If a patient with schizophrenia is hospitalized with chest pain, he is less likely to have aggressive cardiac care and more likely to die of a myocardial infarction,” Dr. Lombardo said.

Obesity, a risk factor for both diabetes and cardiovascular disease, is highly prevalent among patients with both schizophrenia and diabetes. In one study of 114 new-onset patients with schizophrenia, the mean body mass index at the time of diagnosis was 24.5 kg/m2–the upper limit of normal. After 1 year, mean body mass index in these patients had climbed to 27.5, within the obesity range. “Most weight gain occurred in the first 6 months,” she said.

“Is it due to the illness itself, lifestyle changes related to the psychological burden of the illness, or treatment? There is good evidence that all three are involved,” Dr. Lombardo said.

The problem is at least as pronounced in bipolar disorder: A study of 644 patients found that 60% were overweight, 20% were obese, and 5% were “extremely obese.”

Not only is being overweight associated with an increased risk of hypertension, arthritis, and diabetes, it apparently has negative psychiatric consequences as well. In one group of bipolar patients, time to relapse was significantly shorter among the 46 who were obese than among the 79 who were not. In 20 weeks, 30% of the obese patients had relapsed, compared with a negligible number of the nonobese.

In a study of individuals with schizophrenia, 26% of normal-weight patients were noncompliant with treatment, compared with 39% of overweight and 47% of obese patients, Dr. Lombardo said.

NEW YORK – Schizophrenia and bipolar disorder pose a triple health threat: The conditions themselves are associated with a higher prevalence of serious medical illness, some drugs used to treat them increase disease risk, and affected individuals are likely to have inadequate medical care, Ilise D. Lombardo, M.D., said at a conference on schizophrenia sponsored by Columbia University.

The unhealthful influence is bidirectional: The psychiatric course tends to be worse in individuals with chronic medical conditions or medical risk factors like obesity. (For example, a survey of 1,379 bipolar patients found that 44% had comorbid medical conditions and linked the presence and severity of medical problems to the severity of the psychiatric disorder.)

“Psychiatrists should monitor risk factors, coordinate care with internists, and involve families in medical issues,” said Dr. Lombardo of the university.

Serious mental illness is life-threatening: The rate of mortality from natural causes among patients with bipolar disorder and schizophrenia is double that of the population as a whole; for unipolar depression, the mortality rate is 1.5 times that of the general population. Cardiovascular disease and, to a lesser extent, endocrine disorders are mainly responsible for the higher rates.

This increased mortality is not surprising in light of the high prevalence of cardiovascular risk factors in the psychiatric population, Dr. Lombardo said.

Among patients with schizophrenia, 18% have elevated total cholesterol levels, 20% have hypertension, 75% smoke cigarettes, about 50% are overweight or obese, and 72% are sedentary.

An estimated 30%–60% of schizophrenia patients have metabolic syndrome–a constellation of abdominal obesity, lipid abnormalities, and abnormal glucose metabolism that triples the risk of dying of a myocardial infarction, Dr. Lombardo said at the meeting, which was cosponsored by the New York State Psychiatric Institute.

But although the medical needs of people with severe and persistent mental illness would appear to be greater, they “have less access and less quality medical care,” said Dr. Lombardo, who is also medical director for Pfizer Inc.

A review of 175,653 patients in Veterans Affairs medical centers in Southern California and Nevada found a highly significant association between a diagnosis of schizophrenia and fewer physician visits. Two-thirds of schizophrenia patients did not have such prevalent conditions as diabetes, hypertension, or chronic obstructive pulmonary disease listed among their medical diagnoses.

“If a patient with schizophrenia is hospitalized with chest pain, he is less likely to have aggressive cardiac care and more likely to die of a myocardial infarction,” Dr. Lombardo said.

Obesity, a risk factor for both diabetes and cardiovascular disease, is highly prevalent among patients with both schizophrenia and diabetes. In one study of 114 new-onset patients with schizophrenia, the mean body mass index at the time of diagnosis was 24.5 kg/m2–the upper limit of normal. After 1 year, mean body mass index in these patients had climbed to 27.5, within the obesity range. “Most weight gain occurred in the first 6 months,” she said.

“Is it due to the illness itself, lifestyle changes related to the psychological burden of the illness, or treatment? There is good evidence that all three are involved,” Dr. Lombardo said.

The problem is at least as pronounced in bipolar disorder: A study of 644 patients found that 60% were overweight, 20% were obese, and 5% were “extremely obese.”

Not only is being overweight associated with an increased risk of hypertension, arthritis, and diabetes, it apparently has negative psychiatric consequences as well. In one group of bipolar patients, time to relapse was significantly shorter among the 46 who were obese than among the 79 who were not. In 20 weeks, 30% of the obese patients had relapsed, compared with a negligible number of the nonobese.

In a study of individuals with schizophrenia, 26% of normal-weight patients were noncompliant with treatment, compared with 39% of overweight and 47% of obese patients, Dr. Lombardo said.

NEW YORK – Schizophrenia and bipolar disorder pose a triple health threat: The conditions themselves are associated with a higher prevalence of serious medical illness, some drugs used to treat them increase disease risk, and affected individuals are likely to have inadequate medical care, Ilise D. Lombardo, M.D., said at a conference on schizophrenia sponsored by Columbia University.

The unhealthful influence is bidirectional: The psychiatric course tends to be worse in individuals with chronic medical conditions or medical risk factors like obesity. (For example, a survey of 1,379 bipolar patients found that 44% had comorbid medical conditions and linked the presence and severity of medical problems to the severity of the psychiatric disorder.)

“Psychiatrists should monitor risk factors, coordinate care with internists, and involve families in medical issues,” said Dr. Lombardo of the university.

Serious mental illness is life-threatening: The rate of mortality from natural causes among patients with bipolar disorder and schizophrenia is double that of the population as a whole; for unipolar depression, the mortality rate is 1.5 times that of the general population. Cardiovascular disease and, to a lesser extent, endocrine disorders are mainly responsible for the higher rates.

This increased mortality is not surprising in light of the high prevalence of cardiovascular risk factors in the psychiatric population, Dr. Lombardo said.

Among patients with schizophrenia, 18% have elevated total cholesterol levels, 20% have hypertension, 75% smoke cigarettes, about 50% are overweight or obese, and 72% are sedentary.

An estimated 30%–60% of schizophrenia patients have metabolic syndrome–a constellation of abdominal obesity, lipid abnormalities, and abnormal glucose metabolism that triples the risk of dying of a myocardial infarction, Dr. Lombardo said at the meeting, which was cosponsored by the New York State Psychiatric Institute.

But although the medical needs of people with severe and persistent mental illness would appear to be greater, they “have less access and less quality medical care,” said Dr. Lombardo, who is also medical director for Pfizer Inc.

A review of 175,653 patients in Veterans Affairs medical centers in Southern California and Nevada found a highly significant association between a diagnosis of schizophrenia and fewer physician visits. Two-thirds of schizophrenia patients did not have such prevalent conditions as diabetes, hypertension, or chronic obstructive pulmonary disease listed among their medical diagnoses.

“If a patient with schizophrenia is hospitalized with chest pain, he is less likely to have aggressive cardiac care and more likely to die of a myocardial infarction,” Dr. Lombardo said.

Obesity, a risk factor for both diabetes and cardiovascular disease, is highly prevalent among patients with both schizophrenia and diabetes. In one study of 114 new-onset patients with schizophrenia, the mean body mass index at the time of diagnosis was 24.5 kg/m2–the upper limit of normal. After 1 year, mean body mass index in these patients had climbed to 27.5, within the obesity range. “Most weight gain occurred in the first 6 months,” she said.

“Is it due to the illness itself, lifestyle changes related to the psychological burden of the illness, or treatment? There is good evidence that all three are involved,” Dr. Lombardo said.

The problem is at least as pronounced in bipolar disorder: A study of 644 patients found that 60% were overweight, 20% were obese, and 5% were “extremely obese.”

Not only is being overweight associated with an increased risk of hypertension, arthritis, and diabetes, it apparently has negative psychiatric consequences as well. In one group of bipolar patients, time to relapse was significantly shorter among the 46 who were obese than among the 79 who were not. In 20 weeks, 30% of the obese patients had relapsed, compared with a negligible number of the nonobese.

In a study of individuals with schizophrenia, 26% of normal-weight patients were noncompliant with treatment, compared with 39% of overweight and 47% of obese patients, Dr. Lombardo said.

MONTREAL – Psychotherapy for eating disorders can be delivered effectively by e-mail and can reach a segment of the population that might otherwise decline treatment, Paul Robinson, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

He recruited 97 participants with eating disorders from a university e-mail list for his study. The diagnoses of bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified (EDNOS) all fulfilled DSM-IV criteria and were made using online questionnaires and assessments.

Roughly 80% of the cohort had received no previous treatment for their eating disorder, said Dr. Robinson, a psychiatrist with the eating disorders service of Royal Free Hospital, London.

“They were a population of people who don't approach mental health care or any sort of health care, and they said they wouldn't have done so if it hadn't been for this program,” Dr. Robinson said in an interview.

Study participants were randomized to e-mail bulimia therapy (EBT), to self-directed writing (SDW), or to a treatment waiting list, which was the control, he said.

The EBT group (36) received 12 weeks of e-mail therapy from professionals who were experienced in the outpatient management of eating disorders. Participants were asked to write twice weekly in a food, behavior, and emotions diary, to which the therapists responded.

“We looked at the diary and annotated it with our own comments,” said Dr. Robinson. “For example, if a patient wrote that she had eaten nothing for breakfast or lunch and then binged in the evening, we might have responded by saying that eating nothing all day might be triggering the binge at night,” he said.

Participants in the SDW group (34) were asked to write about their eating disorder and e-mail their comments to Dr. Robinson twice a week, although he acknowledged the e-mails he sent did not offer specific counseling to this group.

“They knew I was reading [their comments], and they knew that if I thought they were in danger I would act, and I think that was important to them,” he said.

Participants in the control group (27) waited 12 weeks and were then randomized to either EBT or SDW.

At the 12-week assessment, the e-mail therapy and SDW groups were combined into one “E-Therapy” group and compared with the control group.

The results showed that, while none of the control participants lost their eating disorder diagnosis, 18.6% of the E-Therapy group did.

Assessments using the Bulimic Investigatory Test, Edinburgh (BITE), severity and symptom scores showed a mean reduction in BITE severity score of 1.2 in the E-Therapy group, compared with a reduction of 0.2 in the control group. Similarly, the mean reduction in the BITE symptom score was significantly greater in the E-Therapy group (2.1 versus 0.3).

When asked about their desired body mass index (BMI), participants who had completed the e-mail therapy indicated that they were more willing to accept the idea of a higher BMI than were those participants in the control group.

There was a significant correlation between the number of words a participant wrote and the degree of symptom improvements in the e-mail bulimia therapy group only, Dr. Robinson said.

“It is hard to explain the response in the self-directed writing group, although there is quite a lot in the literature about the therapeutic efficacy of writing, and how it can lower depression scores,” he noted.

Although the study found no difference in outcome between EBT and SDW, there was a trend in favor of EBT. “In a bigger study, I would expect and hope that therapy patients would do better,” he said.

E-mail therapy was well accepted by the participants, with 84% saying that they would be willing to engage in further therapy either online or face to face. There also was a feeling among therapists that this form of therapy took about half the time of traditional therapy, although it was not measured, Dr. Robinson said.

MONTREAL – Psychotherapy for eating disorders can be delivered effectively by e-mail and can reach a segment of the population that might otherwise decline treatment, Paul Robinson, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

He recruited 97 participants with eating disorders from a university e-mail list for his study. The diagnoses of bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified (EDNOS) all fulfilled DSM-IV criteria and were made using online questionnaires and assessments.

Roughly 80% of the cohort had received no previous treatment for their eating disorder, said Dr. Robinson, a psychiatrist with the eating disorders service of Royal Free Hospital, London.

“They were a population of people who don't approach mental health care or any sort of health care, and they said they wouldn't have done so if it hadn't been for this program,” Dr. Robinson said in an interview.

Study participants were randomized to e-mail bulimia therapy (EBT), to self-directed writing (SDW), or to a treatment waiting list, which was the control, he said.

The EBT group (36) received 12 weeks of e-mail therapy from professionals who were experienced in the outpatient management of eating disorders. Participants were asked to write twice weekly in a food, behavior, and emotions diary, to which the therapists responded.

“We looked at the diary and annotated it with our own comments,” said Dr. Robinson. “For example, if a patient wrote that she had eaten nothing for breakfast or lunch and then binged in the evening, we might have responded by saying that eating nothing all day might be triggering the binge at night,” he said.

Participants in the SDW group (34) were asked to write about their eating disorder and e-mail their comments to Dr. Robinson twice a week, although he acknowledged the e-mails he sent did not offer specific counseling to this group.

“They knew I was reading [their comments], and they knew that if I thought they were in danger I would act, and I think that was important to them,” he said.

Participants in the control group (27) waited 12 weeks and were then randomized to either EBT or SDW.

At the 12-week assessment, the e-mail therapy and SDW groups were combined into one “E-Therapy” group and compared with the control group.

The results showed that, while none of the control participants lost their eating disorder diagnosis, 18.6% of the E-Therapy group did.

Assessments using the Bulimic Investigatory Test, Edinburgh (BITE), severity and symptom scores showed a mean reduction in BITE severity score of 1.2 in the E-Therapy group, compared with a reduction of 0.2 in the control group. Similarly, the mean reduction in the BITE symptom score was significantly greater in the E-Therapy group (2.1 versus 0.3).

When asked about their desired body mass index (BMI), participants who had completed the e-mail therapy indicated that they were more willing to accept the idea of a higher BMI than were those participants in the control group.

There was a significant correlation between the number of words a participant wrote and the degree of symptom improvements in the e-mail bulimia therapy group only, Dr. Robinson said.

“It is hard to explain the response in the self-directed writing group, although there is quite a lot in the literature about the therapeutic efficacy of writing, and how it can lower depression scores,” he noted.

Although the study found no difference in outcome between EBT and SDW, there was a trend in favor of EBT. “In a bigger study, I would expect and hope that therapy patients would do better,” he said.

E-mail therapy was well accepted by the participants, with 84% saying that they would be willing to engage in further therapy either online or face to face. There also was a feeling among therapists that this form of therapy took about half the time of traditional therapy, although it was not measured, Dr. Robinson said.

MONTREAL – Psychotherapy for eating disorders can be delivered effectively by e-mail and can reach a segment of the population that might otherwise decline treatment, Paul Robinson, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

He recruited 97 participants with eating disorders from a university e-mail list for his study. The diagnoses of bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified (EDNOS) all fulfilled DSM-IV criteria and were made using online questionnaires and assessments.

Roughly 80% of the cohort had received no previous treatment for their eating disorder, said Dr. Robinson, a psychiatrist with the eating disorders service of Royal Free Hospital, London.

“They were a population of people who don't approach mental health care or any sort of health care, and they said they wouldn't have done so if it hadn't been for this program,” Dr. Robinson said in an interview.

Study participants were randomized to e-mail bulimia therapy (EBT), to self-directed writing (SDW), or to a treatment waiting list, which was the control, he said.

The EBT group (36) received 12 weeks of e-mail therapy from professionals who were experienced in the outpatient management of eating disorders. Participants were asked to write twice weekly in a food, behavior, and emotions diary, to which the therapists responded.

“We looked at the diary and annotated it with our own comments,” said Dr. Robinson. “For example, if a patient wrote that she had eaten nothing for breakfast or lunch and then binged in the evening, we might have responded by saying that eating nothing all day might be triggering the binge at night,” he said.

Participants in the SDW group (34) were asked to write about their eating disorder and e-mail their comments to Dr. Robinson twice a week, although he acknowledged the e-mails he sent did not offer specific counseling to this group.

“They knew I was reading [their comments], and they knew that if I thought they were in danger I would act, and I think that was important to them,” he said.

Participants in the control group (27) waited 12 weeks and were then randomized to either EBT or SDW.

At the 12-week assessment, the e-mail therapy and SDW groups were combined into one “E-Therapy” group and compared with the control group.

The results showed that, while none of the control participants lost their eating disorder diagnosis, 18.6% of the E-Therapy group did.

Assessments using the Bulimic Investigatory Test, Edinburgh (BITE), severity and symptom scores showed a mean reduction in BITE severity score of 1.2 in the E-Therapy group, compared with a reduction of 0.2 in the control group. Similarly, the mean reduction in the BITE symptom score was significantly greater in the E-Therapy group (2.1 versus 0.3).

When asked about their desired body mass index (BMI), participants who had completed the e-mail therapy indicated that they were more willing to accept the idea of a higher BMI than were those participants in the control group.

There was a significant correlation between the number of words a participant wrote and the degree of symptom improvements in the e-mail bulimia therapy group only, Dr. Robinson said.

“It is hard to explain the response in the self-directed writing group, although there is quite a lot in the literature about the therapeutic efficacy of writing, and how it can lower depression scores,” he noted.

Although the study found no difference in outcome between EBT and SDW, there was a trend in favor of EBT. “In a bigger study, I would expect and hope that therapy patients would do better,” he said.

E-mail therapy was well accepted by the participants, with 84% saying that they would be willing to engage in further therapy either online or face to face. There also was a feeling among therapists that this form of therapy took about half the time of traditional therapy, although it was not measured, Dr. Robinson said.

BOCA RATON, FLA. – Targeting physical symptoms of depression in a primary care setting increases the likelihood of treatment response, according to a multicenter, naturalistic study.

Somatic symptoms of depression are getting increased attention as part of a drive to achieve and sustain asymptomatic remission, according to Sidney H. Kennedy, M.D. He and his associates hypothesized that alleviation of the physical symptoms of depression would improve response and remission rates.

They assessed 205 patients undergoing open-label antidepressant treatment for 8 weeks in 47 primary care settings across Canada. Patients were receiving venlafaxine, citalopram, fluoxetine, paroxetine, sertraline, bupropion, or mirtazapine. Mean patient age was 43 years, and 64% were female; 157 patients completed the study.

At baseline, and every 2 weeks thereafter, researchers compiled an aggregate somatic score for each patient based on eight items culled from the Hamilton Depression Rating Scale (HAMD). This shorter instrument (HAMD-S) assessed gastrointestinal somatic symptoms; weight loss; early, middle, and late insomnia; general somatic symptoms; somatic anxiety; and hypochondriasis.

Two other scales–the Montgomery Asberg Depression Rating Scale (MADRS) and the Clinical Global Impression Scale for Improvement and Severity of Illness–were used to measure depression severity.

Results were presented during a poster session at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

HAMD-S scores decreased from a mean of 10 at baseline to a mean of 3 at week 8, a statistically significant difference. There was a significant correlation between improvements on the HAMD-S and overall reductions in MADRS total score, response score, and remission score. Both HAMD-S and MADRS findings correlated with Clinical Global Impression Scale findings.

“The bottom line is we showed that physical symptoms responded comparably with the other symptoms,” said Dr. Kennedy, a psychiatrist with the University Health Network, Toronto.

The HAMD-S and MADRS scales, however, have not been validated as somatic subscales, he cautioned. This is a possible limitation of the study.

Clinicians should target somatic symptoms of depression to improve treatment outcomes, Dr. Kennedy said.

The study was supported by funding from Wyeth Pharmaceuticals. Dr. Kennedy is a consultant and speaker for the company.

BOCA RATON, FLA. – Targeting physical symptoms of depression in a primary care setting increases the likelihood of treatment response, according to a multicenter, naturalistic study.

Somatic symptoms of depression are getting increased attention as part of a drive to achieve and sustain asymptomatic remission, according to Sidney H. Kennedy, M.D. He and his associates hypothesized that alleviation of the physical symptoms of depression would improve response and remission rates.

They assessed 205 patients undergoing open-label antidepressant treatment for 8 weeks in 47 primary care settings across Canada. Patients were receiving venlafaxine, citalopram, fluoxetine, paroxetine, sertraline, bupropion, or mirtazapine. Mean patient age was 43 years, and 64% were female; 157 patients completed the study.

At baseline, and every 2 weeks thereafter, researchers compiled an aggregate somatic score for each patient based on eight items culled from the Hamilton Depression Rating Scale (HAMD). This shorter instrument (HAMD-S) assessed gastrointestinal somatic symptoms; weight loss; early, middle, and late insomnia; general somatic symptoms; somatic anxiety; and hypochondriasis.

Two other scales–the Montgomery Asberg Depression Rating Scale (MADRS) and the Clinical Global Impression Scale for Improvement and Severity of Illness–were used to measure depression severity.

Results were presented during a poster session at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

HAMD-S scores decreased from a mean of 10 at baseline to a mean of 3 at week 8, a statistically significant difference. There was a significant correlation between improvements on the HAMD-S and overall reductions in MADRS total score, response score, and remission score. Both HAMD-S and MADRS findings correlated with Clinical Global Impression Scale findings.

“The bottom line is we showed that physical symptoms responded comparably with the other symptoms,” said Dr. Kennedy, a psychiatrist with the University Health Network, Toronto.

The HAMD-S and MADRS scales, however, have not been validated as somatic subscales, he cautioned. This is a possible limitation of the study.

Clinicians should target somatic symptoms of depression to improve treatment outcomes, Dr. Kennedy said.

The study was supported by funding from Wyeth Pharmaceuticals. Dr. Kennedy is a consultant and speaker for the company.

BOCA RATON, FLA. – Targeting physical symptoms of depression in a primary care setting increases the likelihood of treatment response, according to a multicenter, naturalistic study.

Somatic symptoms of depression are getting increased attention as part of a drive to achieve and sustain asymptomatic remission, according to Sidney H. Kennedy, M.D. He and his associates hypothesized that alleviation of the physical symptoms of depression would improve response and remission rates.

They assessed 205 patients undergoing open-label antidepressant treatment for 8 weeks in 47 primary care settings across Canada. Patients were receiving venlafaxine, citalopram, fluoxetine, paroxetine, sertraline, bupropion, or mirtazapine. Mean patient age was 43 years, and 64% were female; 157 patients completed the study.

At baseline, and every 2 weeks thereafter, researchers compiled an aggregate somatic score for each patient based on eight items culled from the Hamilton Depression Rating Scale (HAMD). This shorter instrument (HAMD-S) assessed gastrointestinal somatic symptoms; weight loss; early, middle, and late insomnia; general somatic symptoms; somatic anxiety; and hypochondriasis.

Two other scales–the Montgomery Asberg Depression Rating Scale (MADRS) and the Clinical Global Impression Scale for Improvement and Severity of Illness–were used to measure depression severity.

Results were presented during a poster session at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

HAMD-S scores decreased from a mean of 10 at baseline to a mean of 3 at week 8, a statistically significant difference. There was a significant correlation between improvements on the HAMD-S and overall reductions in MADRS total score, response score, and remission score. Both HAMD-S and MADRS findings correlated with Clinical Global Impression Scale findings.

“The bottom line is we showed that physical symptoms responded comparably with the other symptoms,” said Dr. Kennedy, a psychiatrist with the University Health Network, Toronto.

The HAMD-S and MADRS scales, however, have not been validated as somatic subscales, he cautioned. This is a possible limitation of the study.

Clinicians should target somatic symptoms of depression to improve treatment outcomes, Dr. Kennedy said.

The study was supported by funding from Wyeth Pharmaceuticals. Dr. Kennedy is a consultant and speaker for the company.