Abstracts: For Psychosomatic Medicine

Promoting Evidence-based Psychosocial Care for Cancer Patients

Jacobsen PB

Psychooncology 2009 1; 18( 1): 6– 13

With numerous studies demonstrating that psychosocial care reduces distress and improves quality of life, practitioners have an obligation to treat cancer patients in a manner consistent with this evidence. Although the rationale is straightforward, major challenges exist in achieving the goal of translating research into clinical practice. One challenge has been the nature of the evidence, with many studies of psychosocial interventions characterized by poor methodological quality, absence of eligibility criteria specifying heightened distress, and minimal consideration of dissemination potential. A second challenge has been to make practitioners aware of relevant evidence. Targeted efforts at dissemination, such as the issuance of clinical practice guidelines and evidence-based recommendations and the distribution of intervention materials via the Internet, appear to be more effective than passive efforts in providing practitioners with useful information. Perhaps the most challenging aspect has been to persuade practitioners to change how they practice. One approach currently under development would allow practitioners and health-care organizations to perform self-evaluations of the quality of their psychosocial care based on review of medical records. Feedback showing quality of care to be less than optimal is likely to motivate change, especially if the quality indicators assessed are considered to be important and reliable and point to specific actions that can be taken. The use of evidence to promote changes in clinical practice represents one of the major ways in which the field of psycho-oncology can fully realize its potential to positively affect the lives of people with cancer.

Antidepressant Drugs and Cardiovascular Pathology: a Clinical Overview of Effectiveness and Safety

Taylor D

Acta Psychiatr Scand 2008 12; 118( 6): 434– 42

Objective: To review data examining the relationships between depression, antidepressants and cardiovascular disease. Method: Structured searches of PubMed, Medline and Embase conducted in March 2008. Results: Depression and cardiovascular disease are closely associated clinical entities. Depression appears both to cause and worsen cardiovascular disease. Cardiovascular disease is in turn associated with a high incidence of depression. Depression is associated with increased mortality in cardiovascular disease, and after myocardial infarction (MI) and stroke. Many antidepressants have cardiotoxic properties. Tricyclic drugs are highly cardiotoxic in overdose and may induce cardiovascular disease and worsen outcome in established cardiovascular disease. Reboxetine, duloxetine and venlafaxine are known to increase blood pressure. Other antidepressants have neutral or beneficial effects in various cardiovascular disorders. Conclusion: Sertraline, fluoxetine, citalopram, bupropion and mirtazapine appear to be safe to use after MI; the use of sertraline, and response to citalopram and mirtazapine may improve mortality. Paroxetine and citalopram appear to be safe to use in patients with established coronary artery disease. Limited data suggest that a variety of antidepressants are effective and safe to use after stroke.

Prevalence of Depression and Anxiety in Patients Requesting Physicians' Aid in Dying: Cross Sectional Survey

Ganzini L, Goy ER, Dobscha SK

BMJ 2008 10 7; 337: a1682

Objective: To determine the prevalence of depression and anxiety in terminally ill patients pursuing aid in dying from physicians. Design: Cross sectional survey. Setting: State of Oregon, USA. Participants: 58 Oregonians, most terminally ill with cancer or amyotrophic lateral sclerosis, who had either requested aid in dying from a physician or contacted an aid in dying advocacy organisation. Main Outcome Measures: Diagnosis of depression or anxiety according to the hospital anxiety and depression scale and the structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders. Results: 15 study participants met “caseness” criteria for depression, and 13 met criteria for anxiety. 42 patients died by the end of the study; 18 received a prescription for a lethal drug under the Death with Dignity Act, and nine died by lethal ingestion. 15 participants who received a prescription for a lethal drug did not meet criteria for depression; three did. All three depressed participants died by legal ingestion within two months of the research interview. Conclusion: Although most terminally ill Oregonians who receive aid in dying do not have depressive disorders, the current practice of the Death with Dignity Act may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug.

Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions

Rosenblum A, Marsch LA, Joseph H, Portenoy RK

Exp Clin Psychopharmacol 2008 10; 16( 5): 405– 16

Opioids have been regarded for millennia as among the most effective drugs for the treatment of pain. Their use in the management of acute severe pain and chronic pain related to advanced medical illness is considered the standard of care in most of the world. In contrast, the long-term administration of an opioid for the treatment of chronic noncancer pain continues to be controversial. Concerns related to effectiveness, safety, and abuse liability have evolved over decades, sometimes driving a more restrictive perspective and sometimes leading to a greater willingness to endorse this treatment. The past several decades in the United States have been characterized by attitudes that have shifted repeatedly in response to clinical and epidemiological observations, and events in the legal and regulatory communities. The interface between the legitimate medical use of opioids to provide analgesia and the phenomena associated with abuse and addiction continues to challenge the clinical community, leading to uncertainty about the appropriate role of these drugs in the treatment of pain. This narrative review briefly describes the neurobiology of opioids and then focuses on the complex issues at this interface between analgesia and abuse, including terminology, clinical challenges, and the potential for new agents, such as buprenorphine, to influence practice. Copyright (c) 2008 APA, all rights reserved.

Evidence for Improving Palliative Care at the End of Life: a Systematic Review

Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, Morton SC, Hughes RG, Hilton LK, Maglione M, Rhodes SL, Rolon C, Sun VC, Shekelle PG

Ann Intern Med 2008 1 15; 148( 2): 147– 59

Background: Many persons and their families are burdened by serious chronic illness in late life. How to best support quality of life is an important consideration for care. Purpose: To assess evidence about interventions to improve palliative and end-of-life care. Data Sources: English-language citations (January 1990 to November 2005) from MEDLINE, the Database of Abstracts of Reviews of Effects, the National Consensus Project for Quality Palliative Care bibliography, and November 2005 to January 2007 updates from expert reviews and literature surveillance. Study Selection: Systematic reviews that addressed “end of life,” including terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia), and intervention studies (randomized and nonrandomized designs) that addressed pain, dyspnea, depression, advance care planning, continuity, and caregiving. Data Extraction: Single reviewers screened 24,423 titles to find 6381 relevant abstracts and reviewed 1274 articles in detail to identify 33 high-quality systematic reviews and 89 relevant intervention studies. They synthesized the evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification. Data Synthesis: Strong evidence supports treating cancer pain with opioids, nonsteroidals, radionuclides, and radiotherapy; dyspnea from chronic lung disease with short-term opioids; and cancer-associated depression with psychotherapy, tricyclics, and selective serotonin reuptake inhibitors. Strong evidence supports multi component interventions to improve continuity in heart failure. Moderate evidence supports advance care planning led by skilled facilitators who engage key decision makers and interventions to alleviate caregiver burden. Weak evidence addresses cancer-related dyspnea management, and no evidence addresses noncancer pain, symptomatic dyspnea management in advanced heart failure, or short-acting antidepressants in terminal illness. No direct evidence addresses improving continuity for patients with dementia. Evidence was weak for improving caregiver burdens in cancer and was absent for heart failure. Limitations: Variable literature indexing for advanced chronic illness and end of life limited the comprehensiveness of searches, and heterogeneity was too great to do meta-analysis. Conclusion: Strong to moderate evidence supports interventions to improve important aspects of end-of-life care. Future research should quantify these effects and address the generalizability of insights across the conditions and settings of the last part of life. Many critical issues lack high-quality evidence.

Pharmacologic Management of Neuropathic Pain: Evidence-based Recommendations

Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, Kalso EA, Loeser JD, Miaskowski C, Nurmikko TJ, Portenoy RK, Rice AS, Stacey BR, Treede RD, Turk DC, Wallace MS

Pain 2007 12 5; 132( 3): 237– 51

Patients with neuropathic pain (NP) are challenging to manage and evidence-based clinical recommendations for pharmacologic management are needed. Systematic literature reviews, randomized clinical trials, and existing guidelines were evaluated at a consensus meeting. Medications were considered for recommendation if their efficacy was supported by at least one methodologically-sound, randomized clinical trial (RCT) demonstrating superiority to placebo or a relevant comparison treatment. Recommendations were based on the amount and consistency of evidence, degree of efficacy, safety, and clinical experience of the authors. Available RCTs typically evaluated chronic NP of moderate to severe intensity. Recommended first-line treatments include certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha2-delta ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol are recommended as generally second-line treatments that can be considered for first-line use in select clinical circumstances. Other medications that would generally be used as third-line treatments but that could also be used as second-line treatments in some circumstances include certain antiepileptic and antidepressant medications, mexiletine, N-methyl-D-aspartate receptor antagonists, and topical capsaicin. Medication selection should be individualized, considering side effects, potential beneficial or deleterious effects on comorbidities, and whether prompt onset of pain relief is necessary. To date, no medications have demonstrated efficacy in lumbosacral radiculopathy, which is probably the most common type of NP. Long-term studies, head-to-head comparisons between medications, studies involving combinations of medications, and RCTs examining treatment of central NP are lacking and should be a priority for future research.

Depression and Cardiovascular Comorbidity

Glassman AH.

Dialogues Clin Neurosci 2007; 9( 1): 9– 17

Depression has long had a popular link to cardiovascular disease and death. However, only during the last 15 years has scientific evidence supporting this common wisdom been available. Beginning in the early 1990s, there began to accumulate community-based epidemiological evidence that medically healthy, depressed patients followed for long periods of time were at increased risk of both cardiovascular disease and cardiac death. In the mid-1990s, evidence appeared to indicate that depression following a heart attack increased the risk of death. It is now apparent that depression aggravates the course of multiple cardiovascular conditions. There are two major unanswered questions. One is whether treating depression will reduce the risk of cardiovascular disease and death. Here, preliminary, but not definitive, evidence suggests that the serotonin reuptake inhibitors may be useful. The other unanswered question regards the mechanisms that underlie this link between depression and cardiovascular disease. There is strong evidence linking platelet activation, autonomic activity and inflammatory markers to both depression and heart disease, but why these links exist is far less clear.

Management of Functional Somatic Syndromes

Henningsen P, Zipfel S, Herzog W

Lancet 2007 3 17; 369( 9565): 946– 55

Although functional somatic syndromes (FSS) show substantial overlap, treatment research is mostly confined to single syndromes, with a lack of valid and generally accepted diagnostic criteria across medical specialties. Here, we review management for the full variety of FSS, drawn from systematic reviews and meta-analyses since 2001, and give recommendations for a stepped care approach that differentiates between uncomplicated and complicated FSS. Non-pharmacological treatments involving active participation of patients, such as exercise and psychotherapy, seem to be more effective than those that involve passive physical measures, including injections and operations. Pharmacological agents with CNS action seem to be more consistently effective than drugs aiming at restoration of peripheral physiological dysfunction. A balance between biomedical, organ-oriented, and cognitive interpersonal approaches is most appropriate at this truly psychosomatic interface. In view of the iatrogenic component in the maintenance of FSS, doctor-centred interventions and close observation of the doctor-patient relationship are of particular importance.

Onset of Major Depression Associated with Acute Coronary Syndromes: Relationship of Onset, Major Depressive Disorder History, and Episode Severity to Sertraline Benefit

Glassman AH, Bigger JT, Gaffney M, Shapiro PA, Swenson JR

Arch Gen Psychiatry 2006 3; 63( 3): 283– 8

Context: Depression observed following acute coronary syndrome (ACS) is common and associated with an increased risk of death. The Sertraline Antidepressant Heart Attack Trial (SADHART) tested the safety and efficacy of a selective serotonin reuptake inhibitor in this population. No evidence of harm was seen, and sertraline hydrochloride had an overall beneficial effect on mood that occurred primarily in patients with a history of episodes of major depressive disorder (MDD). Objectives: To determine how frequently the MDD began before ACS and whether onset of the current MDD episode before or after the ACS event influenced response to sertraline. Design, Settings, and Participants: A randomized, double-blind, placebo-controlled treatment of 369 patients with ACS and MDD was conducted in 40 outpatient clinics in 10 countries between April 1, 1997, and April 30, 2001. Main Outcome Measures: Diagnosis of MDD, number of previous episodes of depression, and episode onset before or after hospitalization were established using the Diagnostic Interview Schedule. Treatment response was measured with the Clinical Global Impression-Improvement scale. Results: Fifty-three percent of MDD episodes began before hospitalization for the index episode of ACS (for 197 of 369 patients), and 94% of the MDD episodes began more than 30 days before the index ACS episode. Episodes of MDD that began prior to ACS responded more frequently to sertraline than to placebo (63% vs 46%, respectively; odds ratio, 2.0; 95% confidence interval, 1.13–3.55) whereas depression with onset beginning after hospitalization showed a high placebo response rate (69% vs 60%, respectively) and low sertraline-placebo response ratio (1.15). Multivariate analysis indicated that time of onset of the current episode, history of MDD, and baseline severity independently predicted the sertraline-placebo response ratio. Conclusions: Half of the episodes of major depression associated with ACS began long before ACS and therefore were not caused by ACS. Patients whose current episodes of MDD begin before ACS, those with a history of MDD, and those whose episodes are severe should be treated because they will benefit considerably from sertraline. Since these 3 predictors of sertraline response are independent, having more than 1 of them substantially increases the benefit of sertraline while reducing the chance of spontaneous recovery.

Pharmacotherapy of Somatoform Disorders

Fallon BA

J Psychosom Res 2004 4; 56( 4): 455– 60

Objective: This paper reviews the published literature on the pharmacologic management of somatoform disorders. Methods: Using Medline, the author identified all articles published between 1970 and 2003 on this topic, selecting the best-designed studies for inclusion. Results: The review reveals that patients with the obsessional cluster of somatoform disorders (hypochondriasis and body dysmorphic disorder [BDD]) respond well to serotonin reuptake inhibitors (SRIs). Less is known about the pharmacologic responsiveness of patients with the primarily somatic cluster of somatoform disorders (somatization, pain), a patient group that is common in the health provider's office. Conclusions: Improvements in the design of future clinical trials are needed. A particular focus needs to be applied to study the neglected area of the pharmacologic treatment of syndromal and subsyndromal somatization and pain disorders.

Given space limitations and varying reprint permission policies, not all of the influential publications the editors considered reprinting in this issue could be included. This section contains abstracts from additional articles the editors deemed well worth reviewing.