ANXIETY DISORDERS: COMMON AND VERY TREATABLE



 

ANXIETY DISORDERS: COMMON AND VERY TREATABLE

 

 

Our expert is Heidi L. Combs, MD, Associate Professor, Department of Psychiatry, University of Washington, Harborview Medical Center.  Dr. Combs is a graduate of the University of Washington, where she also completed her Psychiatry Residency.

 

If there is a medical topic you would like to see explored here, please let me know!

 

Very best,

Mitzi Perdue

mperdue@liebert.com

 

 

ANXIETY DISORDERS ARE COMMON, UNDER-DIAGNOSED, AND DEBILITATING

 

Anxiety disorders are the most common psychiatric diagnosis in the U.S.  In primary care clinics, 11% of the patients seen will have generalized anxiety disorder, and there’s a two-to-one female predominance.  Other anxiety disorders include: panic disorder, social anxiety disorder, obsessive-compulsive disorder(OCD), and post-traumatic stress disorder (PTSD).  Many of the individuals will present complaining about pain, sleep disturbance, fatigue, or distress, not realizing their symptoms may stem from an underlying anxiety disorder. If the healthcare provider is not looking for anxiety disorders, he or she may end up focusing on the symptoms and not the cause.  Chasing symptoms that don’t get better can mean years of unnecessary suffering for the patient and frustration for the provider. It is important to realize that anxiety disorders are similar to major depression when it comes to functional impairment and decreased quality of life, yet we are far more likely to miss the diagnosis.

 

SIMPLE SCREENING QUESTIONS CAN QUICKLY REVEAL ANXIETY DISORDERS

 

With the time pressures that clinicians are under, it feels as if there is never enough time to do a screening.  However, an effective screen can be done in roughly one minute, simply by asking a series of quick questions. This upfront screening can save years spent trying to manage symptoms without treating the cause. The questions I recommend are:

 

*          For generalized anxiety disorder: “Do you consider yourself a worrier?”  If the answer is yes, you might say, “Give me a sense of how much you worry in the course of a day?”  Someone with an anxiety disorder may give an answer like, “Every moment of the day.” You are on the lookout for something that impairs her quality of life.

 

*          For panic disorder: “Do you have panic attacks?”  Often someone who has panic attacks knows it and can tell you. If they are not sure, describe a panic attack as “a wave of nervousness that comes out of the blue and you notice changes in your body, like your heart is racing, it is hard to breathe, you break out in a sweat.”

*          For PTSD: “Has something traumatic that happened to you still haunt you?” We often think of PTSD as combat-related, but in fact, it can come from such experiences as sexual assault, domestic violence, a natural disaster, or a car accident. More women have PTSD than men.

 

*          For OCD, ask, “Do you get thoughts stuck in your head that really bother you, or do you need to do things over and over, like washing your hands?” To distinguish between normal and abnormal, it’s normal to check that you unplugged the iron, and you may even check several times.  However, a woman who has to go back to check that she unplugged the iron over and over again for more than 2 hours has a disorder that impairs her ability to function.

 

*          For social anxiety disorder, ask, “When you’re in a situation where people can observe you, do you feel nervous and worry that they will judge you?”  What you are looking for is not garden-variety slight discomfort, but a level of discomfort that impairs her ability to function.

 

 

ANXIETY DISORDERS ARE HIGHLY TREATABLE

 

Pharmacotherapy and psychotherapy can be highly effective, and for mild to moderate cases, either of these two approaches can be equally effective. However, in severe cases, both may be needed.

 

Psychotherapy alone can be a good choice in mild to moderate cases because often the individual with an anxiety disorder is worried about taking medications. Psychotherapy, particularly cognitive behavioral therapy, has the added advantage that the skills for handling anxiety will be available long-term, while the medications are only effective while the individual is taking them. Anxiety disorders can wax and wane throughout an individual’s lifetime, so having skills available to deal with them is an important advantage.

 

Pharmacotherapy is a good choice for those with moderate to severe symptoms or those who don’t want to do or don’t improve with psychotherapy. The cornerstone of pharmacotherapy in these cases is increasing serotonin. A variety of antidepressants are available for this, and I start my patients off with half a dose.  These medications often have side effects that transiently increase the patient’s anxiety, so I invite the patient to tell me when she is ready to increase the dose. When she feels she has control, she is apt to feel less anxiety about the medication.




MEDICATIONS AND MOOD DISORDERS IN A PRIMARY CARE SETTING



 

MEDICATIONS AND MOOD DISORDERS IN A PRIMARY CARE SETTING

 

Our expert is C. Neill Epperson, MD from the Perelman School of Medicine at the University of Pennsylvania.  She holds dual appointments in the Departments of Psychiatry and Obstetrics/Gynecology and is internationally renowned for her research in women’s mental health, specifically with respect to the pathophysiology and treatment of premenstrual dysphoric disorder and perinatal depression. Dr. Epperson is a frequent lecturer on topics in women’s behavioral health, and will be a featured speaker during Women’s Health 2015:  The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. To register for the Congress, click here.

 

If there is a medical topic you would like to see explored here, please let me know!

 

Very best,

Mitzi Perdue

mperdue@liebert.com

 

 

 

WHEN TREATING BEHAVIORAL HEALTH ISSUES, BE AWARE THAT YOUR PATIENT MAY BE AMBIVALENT ABOUT TAKING MEDICATION

 

Many patients feel ambivalent about taking psychotropic medications, and this has a direct impact on how compliant they are in taking them. We health care providers expect that when we prescribe medications–for example, an antibiotic for pneumonia—the patient will take what we prescribe, because she wants to feel better. However, in the case of antidepressants, the patient may perceive a stigma attached to taking a psychiatric medication. She may not like thinking of herself as someone who needs this type of medication, and she may worry what others would think of her if they knew. When she tells you, “I’m feeling terrible, do something for me,” be aware that this doesn’t automatically mean she’ll actually take the medication that you prescribe.

 

 

 

MENTAL HEALTH CARE IN A PRIMARY CARE SETTING CAN BE CHALLENGING

 

Let’s say you have a patient who is not chronically mentally ill, but recently she has started experiencing debilitating panic attacks.  As her primary care provider, you prescribe an antidepressant, and then (assuming she even takes the medication), two or three days into her treatment, she experiences a spike in anxiety. Having had a bad experience with the medication, she quits taking it and spends the next several months feeling terrible. In the end, she winds up going to a psychiatrist.

 

MENTAL HEALTH CARE IN A PRIMARY CARE SETTING CAN ALSO BE HIGHLY EFFECTIVE

 

Let’s take this same patient. Her experience can have a different outcome if, before prescribing an antidepressant, you let her know that before she feels better, she may briefly feel more anxious. Tell her if this happens, you can make available benzodiazepines to get her through the difficult part of starting the antidepressant. Further, tell her to call if she’s having difficulty.  At the time you first prescribe an antidepressant, you might want to schedule a ten-minute follow-up office visit for a week later. You can tell her if everything is fine 24-48 hours before her appointment, she can go ahead and cancel it. For the woman who is ambivalent about taking medication, the mere fact of knowing ahead of time that she has a professional who will monitor closely how she is doing, and who can help her adjust the plan if things aren’t going well, can greatly decrease her anxiety and increase the likelihood that she will not only take her medication but also stick with it.  If a brief follow-up consultation is impractical, then have someone from your office call her just to make sure things are going well.  The follow-up visit or phone call means a small investment in time, but the payoff can be that she avoids months of unnecessary suffering and may avoid having to see a specialist.

 

Your thoughts? Comment below.




DO ASK, DO TELL



DO ASK, DO TELL

 

Our expert is Dr. Sheryl Kingsberg, Chief of Behavioral Medicine at MacDonald Women’s Hospital/University Hospitals Case Medical Center. She is also Professor of Reproductive Biology and Psychiatry at Case Western Reserve University. Her areas of clinical specialization include sexual medicine, female sexual disorders, cognitive behavioral psychotherapy, menopause, pregnancy and postpartum mood disorders, psychological aspects of infertility, and psychological and sexual aspects of cancer. She was the popular and much-appreciated speaker at the Saturday lunch during last spring’s Women’s Health 2014 Congress in Washington, DC.

 

 

If there is a medical topic you would like to see explored here, please let me know!

 

Very best,

 

Mitzi Perdue

mperdue@liebert.com

 

 

FEMALE SEXUAL DYSFUNCTION IS AN IMPORTANT AND UNMET MEDICAL NEED

 

Sexual function is not just about procreation; it is about the physical and psychological benefits that healthy sexual function provides. In addition, healthy sexual function is critical for successful intimate relationships. When sex is good, it adds 15-20% additional value to a relationship; when it’s bad or non-existent, it plays an inordinately powerful role in draining the relationship of all positive value by about 50-70%. Sexual function is so critical to our overall quality of life that the WHO considers sexuality a basic human right. Yet in spite of all of this, few doctors address female sexual dysfunction.

 

TALK WITH YOUR PATIENTS ABOUT SEXUAL FUNCTION

 

There are a host of medical issues vying for our time, but your patients deserve to consider their sexual health as important to the overall quality of their lives. Even if you have no background in sexual health, you are still being helpful if you let your patients know that they are entitled to a healthy sexual life. And as for when to practice screening for sexual problems, my answer is, any time you are willing. It can be during major life events such as puberty, postpartum or menopause, or it can be during a routine office visit or during discussions relating to a medical procedure, or basically any time.

 

 

WAYS OF BRINGING UP THIS SENSITIVE TOPIC

 

You might bring up the topic of sexual function with patients by saying something like, “After they have a baby, many women notice a change in their sexual desire or arousal. What, if any, changes have you noticed?” Adjust the question depending on the circumstances, such as menopause or cancer.  Then continue the inquiry with specific questions:

 

– Are you having any problems with desire or interest in sex?

– Are you having any problems with lubrication or dryness?

– Are you having any problems with orgasm?

 

If there is a yes answer to any of these, follow up with an open-ended question such as, “Tell me about it.”

 

 

INTERVENTIONS ARE AVAILABLE ALTHOUGH NOT AS MANY AS WE WOULD LIKE

 

There are 26 FDA approved treatments for male sexual dysfunction. Meanwhile, there are zero FDA-approved pharmacological treatments for female hypoactive sexual desire disorder (HSDD). However, psychotherapy can be very effective when there are relationship issues or stress or cultural or religious barriers. Psychotherapy can also help if there are anxiety components or problems with rekindling sexual connection after a pause due to a medical problem. It’s a different story when the source of HSDD is biologically based. Interestingly, off-label use of testosterone for HSDD has been proved to be efficacious, but it is not FDA-approved because of concerns about long-term safety. Even so, 20% of prescriptions for testosterone are for off-label use with women.

 

 

BREAST CANCER IS A PARTICULARLY SENSITIVE TIME FOR SEXUAL HEALTH

 

Patients with breast cancer may have trouble reengaging in sexual relations. There are a host of problems that can create a downward spiral in intimate communication. The woman may worry that her partner will no longer be attracted to her. Meanwhile, her partner may be hesitant to initiate sexual relations, thinking, “I don’t want to impose my needs on my partner.” The partner’s not initiating sex may leave the breast cancer patient feeling that she is no longer attractive. This kind of dynamic happens a lot, and it can be hard to restart sexual relations once there’s been a stop. As mentioned earlier, the problem is that unsatisfactory sex can play an inordinately damaging role in a relationship. An important resource for dealing with these kinds of issues is Leslie Schover’s book, Sexuality and Fertility After Cancer.

 

SIGN THE PETITION AT www.womendeserve.org

 

Help encourage the FDA to provide women with more options for the treatment of sexual dysfunction.  Sign the online petition and become an advocate for women’s sexual health equity.

 

Your thoughts? Comment below.

 




ABNORMAL UTERINE BLEEDING



ABNORMAL UTERINE BLEEDING

 

 

Our expert is Christine Isaacs, M.D., Associate Professor, Obstetrics and Gynecology, Virginia Commonwealth University.  She is the Division Head of General Ob/Gyn and the Director of Midwifery Services. Her clinical specialties include Natural Childbirth, Laparoscopic and Abdominal Surgery, Women’s Reproductive Health, Contraceptive Management, and Peri- and Postmenopausal Health.

 

If there is a medical topic you would like to see explored here, please let me know!

 

Very best,

 

Mitzi Perdue

mperdue@liebert.com

 

 

 

WHAT IS NORMAL UTERINE BLEEDING?

 

To understand abnormal bleeding, we need to know what is normal.  Most ovulatory menstrual cycles occur in intervals of 21-35 days, with the average duration of flow being 4-7 days. For two years after menarche, irregular menses are common and usually considered normal, but after that, the length of the menstrual cycle remains relatively constant throughout the reproductive years, and during this period in a woman’s life, blood loss should be relatively predictable and consistent.

 

CATEGORIZING ABNORMAL UTERINE BLEEDING IS IMPORTANT FOR TREATING IT

 

We need to use universal nomenclature for describing abnormal uterine bleeding (AUB). This is an important issue because one-third of all outpatient visits to the gynecologist are for AUB, and AUB accounts for more than 70% of all gynecologic consults in the perimenopausal and postmenopausal years.

 

Knowing the nomenclature is important to clinicians because being able to categorize the different causes of AUB helps with establishing the diagnosis and treatment of various conditions. It also provides an opportunity to collect data, promote research, and further advance women’s health globally. 

 

THE PALM-COEIN CLASSIFICATION SYSTEM

 

The acronym PALM-COEIN helps the clinician create and think through the different diagnoses for AUB. The PALM part refers to structural causes, including Polyps, Adenomyosis, Leiomyomas, and Malignancies. The COEIN part of the acronym refers to nonstructural causes including Coagulopathy, Ovulatory dysfunction, Endometrial origins, Iatrogenic causes, and etiologies Not yet classified.

 

 

THE DESCRIPTIONS A PATIENT GIVES OF HER SYMPTOMS MAY NOT MATCH CLINICAL REALITY

 

If a patient is close to menarche or menopause, irregular menses can be expected. Otherwise, something to keep in mind is that when she’s describing “heavy” or “light” bleeding, she might not mean what you are thinking by these terms. Her frame of reference is subjective, and what she perceives as heavy bleeding may in fact be relatively normal and what she perceives as normal may be excessive. Since her subjective experience may not reflect the actual clinical severity of the situation, try to clarify and elaborate on the extent to which there’s a significant change in what she’s used to.

 

RULE OUT PREGNANCY

 

It’s important always to rule out pregnancy when making the diagnosis of AUB.  It’s rare for a contraceptive device, when used correctly, to fail, but it can occasionally happen, even in the case when the contraception being used is a tubal ligation or long-active reversible contraception such as an implantable device or intrauterine device.  Therefore, an appropriate first step may be a pregnancy test. As an example, if a 38-year-old woman with a normal menstrual history is suddenly having unexplained bleeding, the possibility of pregnancy is something to consider.

 

 

WHEN AN ENDOMETRIAL BIOPSY IS NEEDED

 

An endometrial biopsy should be performed when trying to rule out malignancy or premalignant endometrial cells.  In general, this should be part of the work-up for a woman over age 45 with AUB.  If she is less than 45 but there is a clinical suspicion that she is at risk for endometrial hyperplasia/cancer, such as in the case of morbid obesity or polycystic ovarian syndrome (PCOS), an endometrial biopsy may be warranted. 

 

SYMPTOMS OF COAGULOPATHY

 

Some young women will present for the first time to an urgent care center, emergency room, or women’s health office with recurrent excessive menstrual bleeding noted since menarche.  These women should have a medical history directed to screen for an underlying disorder of hemostasis.  A history that also includes bleeding associated with dental work or surgery, and easy bruising, epistaxis, gum bleeding, or a family history of bleeding should prompt testing for coagulopathies such as von Willebrand’s Disease.  A 16-year-old female who is found to be newly anemic and fatigued should raise some clinical suspicion for a coagulopathy.  While she may describe her monthly menses as “normal” upon initial questioning, her frame of reference is limited and may understate a true pathology. 

 




NEWS YOU CAN USE: RECENT STUDIES THAT MAY CHANGE YOUR PRACTICE



 

NEWS YOU CAN USE: RECENT STUDIES THAT MAY CHANGE YOUR PRACTICE

 

Our expert is Melissa McNeil, MD, MPH, Chief, Section of Women’s Health, Division of General Internal Medicine, University of  Pittsburgh. She is affiliated with multiple hospitals in the area, including Magee-Women’s Hospital of UPMC and UPMC Presbyterian Shadyside. She received her medical degree from the University of Pittsburgh School of Medicine and has been in practice for 34 years.

 

Dr. McNeil was one of the most popular speakers at the Academy of Women’s Health April 2014 Conference in Washington with her talk on Recent Studies That Changed My Practice. This week’s blog post is a refresher, for those who were lucky enough to hear Dr. McNeil, and an introduction for those who didn’t.  Her clinical pearls involve the latest research that she believes can change how people think about their practice today. If there’s a story relating to women’s health that you’d like to see explored here, just let me know!

 

Very best,

 Mitzi Perdue

Mperdue@liebertpub.com

 

 

 

ORAL ESTRADIOL CARRIES LESS RISK FOR CLOTS THAN CONJUGATED EQUINE ESTROGENS  

 

 

 New research shows considerable variation in the risk of venous thrombosis when using different forms of estrogen therapy.  In a comparison of transdermal estrogen, oral estradiol and conjugated equine estrogens (CEE), the results were: transdermal estrogen posed the least risk of venous thrombosis; oral estradiol was in the middle of the risk category; and  CEE posed the highest risk. All estrogen therapies carry an increased risk for venous thrombosis, but the conjugated equine estrogen carries a higher risk, and in addition, it may pose a higher risk of myocardial infarction. Providers should consider the differences in these risks when making decisions about which hormone therapy preparation to prescribe.

 

 

 EXTEND USE OF TAMOXIFEN FROM 5 YEARS TO 10 YEARS  

 

 

It has long been known that a five-year program of using adjuvant tamoxifen for treating estrogen receptor positive breast cancer reduces recurrence for the first decade and reduces mortality by a third through the first 15 years. However, new data suggest that women should consider continuing with tamoxifen for 10 years rather than stopping at 5 years.  A randomized study of 12,894 women studied the effects on both mortality and recurrence for those who ended their treatment in 5 years and those who continued for 10 years.  Women who continued their treatment for 10 years experienced a further reduction in recurrence and mortality. The take-home message is that longer hormone therapy for breast cancer is better.  

 

RECOMMEND ULIPRISTAL FOR EMERGENCY CONTRACEPTION

 

 

Emergency contraception (EC) is designed to prevent ovulation that has not yet occurred. Since sperm can live for five days, the goal of EC is to prevent follicular rupture during those five days. The traditional emergency contraceptive that we have been using, levonorgestrel (LNG), may be no more effective than a placebo when used in the late follicular phase. Ulipristal, in contrast, can prevent follicular rupture for a full five days.   Ulipristal is therefore the drug of choice for emergency contraception.  It is effective in 75- 80% of cases.  A disadvantage of ulipristal is that it is not currently available over the counter. 

 

RADIOTHERAPY FOR BREAST CANCER INCREASES THE RISK OF LATER CVD

 

 

 A prior history of ionizing radiation for breast cancer is a risk factor for ischemic heart disease and should be assessed when thinking about risk factors for coronary artery disease. The radiation may have been life-saving, but exposure of the heart to ionizing radiation during radiotherapy for breast cancer increases the risk of subsequent ischemic heart disease. The risk begins as early as 5 years after radiotherapy and substantially changes the risk assessment of women for CAD.  

 

 

POPULATON-BASED ANNUAL MAMMOGRAPHY IN WOMEN AGED 40-59 DOES NOT REDUCE MORTALITY 

 

 

Mammogram screening has yet to show mortality benefits for women who are under 60 and who have an average risk for breast cancer. While population-based screening doesn’t provide health benefits, there are also serious costs involved.   Twenty-two percent of screenings result in false positives, which generate unnecessary additional tests and personal anxiety.  Instead of population-based screenings, the timing of when to begin screening and the interval between screenings needs to be individualized according to the patient’s personal risk of breast cancer and her own choices. In the case of women who are at high risk for breast cancer, there are other interventions that have been established to decrease risk by up to 50%. Tamoxifen or raloxifene should be considered for targeted chemoprevention for women who are at high risk.