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The mainstay of treatment for late-life depression is antidepressant medication, although recently there have been some psychotherapies that have been developed specifically for the older patient, e.g. problem solving therapy, that have proved effective. Although tricyclic antidepressants (TCAs) are used much less frequently in younger patients, they still have a very important role in the treatment of late-life depression. The selective serotonin reuptake inhibitors (SSRIs) are the most prescribed class of antidepressants for late-life depression. Given the number of patients with late-life depression who do not respond to a trial of an antidepressant there is considerable opportunity to study augmentation strategies. This chapter discusses dysthymic disorder and sub-syndromal depressive disorder, which is a heterogenous group of milder forms of depression. In patients with depression and cognitive impairment, there is a need to understand pathophysiology, determine early prognostic indicators, and develop optimal treatment strategies.
Depression secondary to medical illness is an appropriate diagnosis when the physiological effects of the illness on the brain directly result in depressive symptoms. Several medical disorders are associated with depressive symptoms in this way. Occult hypothyroidism exemplifies disorders in which recognition and treatment of the underlying condition may alleviate depression symptoms. In addition to organic causes of depression in the medically ill, other relevant factors to consider and explore with patients include: the meaning of the illness to the patient, the patient's causal attributions about illness, distorted cognitions or maladaptive behavioral responses to illness, coping mechanisms, and strengths or weaknesses which may be imbedded in patients' premorbid personality traits and style. When rapid improvement of depressive symptoms is the goal, psychostimulants have been useful in patients with advanced cancer. The suggestion that antidepressants increase the risk of cancer has been refuted.
This chapter focuses on the issues that arise when prescribing opioids and other controlled substances for chronic headache pain. The majority of headache patients who overuse or develop dependence on opioids and opioid-containing compounds suffer from migraine-type headaches. Tramadol withdrawal often includes symptoms not typically seen in pure opioid withdrawal, such as extreme anxiety, panic or paranoia, hallucinations, and feelings of numbness and tingling in extremities. Butorphanol, an opioid with partial mu-agonist effects, was first developed in injectable form and initially used in hospital settings mainly for post-operative and labor pain. The only barbiturate indicated specifically for the treatment of headache is butalbital, prescribed in the various combination medications. The care of cannabis-using patients may be managed best by coordinating their continuing headache care with an addiction specialist. It is well known that patients with physiologic dependence on caffeine routinely develop caffeine withdrawal headaches.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) classifies mood disorders as major depressive disorder, dysthymic disorder, bipolar I disorder, bipolar II disorder, and cyclothymic disorder, on the basis of the types of mood episodes present in the patient's history. The association between headaches and mood disorders has been demonstrated for many years across various cultures. Suicide is attempted more often when a patient has comorbid mood disorder and headache than when he or she has either alone. Suicidal intent is inversely correlated with quality of life. The treatment of depression is broadly divided into psychopharmacological and psychological therapies. The United States Food and Drug administration (USFDA) has approved the use of fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and vilazodone for the treatment of major depressive disorder. Several treatments that are effective for mood disorders also are efficacious in headache treatment.
Whilst the vast majority of headaches are minor ailments, some patients develop chronic symptoms that have psychiatric dimensions. These symptoms can be immensely challenging to manage and can have a serious impact on the patient's quality of life. The relationship between headache and psychiatric disease is often rationalized as cause and effect; however, the interplay between the two is complex. Management of each of the co-morbid disorders affects the other one in positive and/or negative ways. The Neuropsychiatry of Headache details the current concepts of various headache conditions and the psychiatric syndromes; topics covered include migraine, mood disorders, medication overuse and personality disorders. Headache specialists, neurologists, psychiatrists, neuropsychiatrists and neuropsychologists will find this an invaluable resource for understanding and co-managing these conditions.
Cognitive-behavioral treatments (CBT) for the anxiety disorders are steeped in a tradition of learning theory and empiricism, stemming back to the beginning of the twentieth century and standing the test of time in rigorous clinical trials and experimental research. This chapter reviews the overarching model and standard components of cognitive and behavioral practice, and highlights a number of critical issues and academic debates that now face the discipline. Recent cognitive-behavioral conceptualizations build upon anxious apprehension and focus on the experience of emotion dysregulation. Treatment from the CBT perspective is multifaceted and geared towards addressing each of the three components of anxiety (cognitive, affective/somatic, and behavioral) through specific, empirically derived techniques. These techniques include psychoeducation, self-monitoring, relaxation, cognitive restructuring, and exposures. Providing CBT to individuals suffering from anxiety is a complex and continually evolving process.