Depression

When medical professionals think of the health consequences of obesity, we usually think of increased prevalence of coronary artery disease, stroke, some cancers, diabetes, and hypertension. If we think a bit more, osteoarthritis, gallstones, asthma, and sleep disorders come to mind.1 How many of us are aware of the connection between obesity and the increased risk of various mental illnesses and conditions?

Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of these drugs is prominent in patients with chronic pain. Recognition and early prevention of misuse helps physicians identify the causes and proceed with patient care. Most persons with chronic pain have a significant medical comorbidity (eg, asthma) that affects treatment decisions.

In some patients, venipuncture either for blood withdrawal or insertion of an intravenous line presents considerable difficulties.

Using the Patient Health Questionnaire– 9 (PHQ-9) makes office visits for depression (both initial and follow- up) go faster and more smoothly.

The edges of some toenails curve inward and grow into the side of the toe, resulting in infection and the need for office surgery.

Silent myocardial ischemia (SMI)- objective documented ischemia in the absence of chest discomfort or other anginal equivalents-is a major component of the total ischemic burden for patients with ischemic heart disease.1 In the United States, an estimated 2 to 3 million persons with stable coronary artery disease (CAD) have evidence of silent ischemia. 2

Generic drug utilization has reached its highest levels to date-60.4% for retail prescriptions and 49.3% for mail-service prescriptions (Cover Figure), while pharmacy reimbursement continues its downward trend.

Premenstrual disorders affect many women in the United States. These disorders range in severity from the mild, bothersome symptoms that occur in more than 75% of women with regular menstrual cycles, to premenstrual syndrome (PMS) and, finally, to the most severe and disabling, premenstrual dysphoric disorder (PMDD). Nearly 5 million American women have PMDD.

I sometimes get depressed myself (just a little!) when I see the latest offerings from pharmaceutical manufacturers. There are many new medications, but almost all are re-workings of familiar molecules-typically launched just before patent life is about to expire on the original formulation.

Sleep disturbance, especially insomnia, is common, with up to 25% of the population in industrialized countries reporting severe chronic insomnia.1 Medications to improve sleep patterns are plentiful but are not always effective. New research on sleep disturbance focuses on the role of the hypothalamic-pituitary-adrenal (HPA) axis.

In the past 15 years, there has been an increasing awareness of the syndromal persistence of attention-deficit/ hyperactivity disorder (ADHD) into adulthood.

A 49-year-old man presented to the emergency department (ED) with substernal chest pain that had started an hour earlier. The pain radiated to the left arm, was constant, and was associated with diaphoresis, nausea, and dyspnea. A similar episode 4 days earlier had spontaneously resolved. He denied fever or chills, pleuritic chest pain, vomiting, and diarrhea.

Acute hospital care is not always what it’s cracked up to be. Nosocomial infections acquired by hospital inpatients can produce less than satisfactory outcomes. Prolonged bed rest can result in pulmonary emboli. Parenteral medication errors may lead to death.

A 9-year-old asymptomatic boy was referred to our tertiary care facility with a blood lead level (BLL) of 59 μg/dL. A diagnosis of attention deficit hyperactivity disorder, which was managed with amphetamine/dextroamphetamine, had been made when the patient was 6 years old.

The numerous symptom domains of fibromyalgia syndrome (FMS) include pain, fatigue, sleep disturbance, mood disturbance, function impairment, irritable bowel syndrome, tension and migraine headache, and cognitive dysfunction. Its pathophysiology is rooted in neural dysregulation in the spinal cord and brain.

Survivors of childhood cancer frequently present to primary care practitioners for a routine physical examination or for urgent care. Knowledge of the patient's cancer history and of the specifics of the treatment are essential to providing proper care and addressing his or her unique risks.

A 16-year-old boy with a history of leukemia at age 12 years complains of right hip pain of several months' duration. A 34-year-old woman who had Hodgkin lymphoma at age 14 years comes in for a routine physical.

I have a patient who has taken escitalopram for a number of years, and he complains of increased sweating, particularly during the summer. Are SSRIs associated with hyperhidrosis? Would it be worthwhile to switch to a different SSRI?

The highest rate of nonspecific serious psychological distress (SPD) (14.4%) among persons aged 18 and older in 2005 and 2006 was found in Utah, but overall, national SPD rates declined slightly. The rates of major depressive episodes (MDEs) among youths aged 12 to 17 years in Utah decreased significantly, from 10.1% in 2004 to 2005 to 8.2% from 2005 to 2006, according to a report released on March 6 by the Substance Abuse and Mental Health Services Administration (SAMHSA). MDE and SPD rates across all age groups were highest in the Midwest (7.8% and 11.8%, respectively) and lowest in the Northeast (7% and 10.8%, respectively). The study is based on data from 136,110 respondents collected for the 2005-2006 National Survey on Drug Use and Health.

A new FDA policy requires pharmaceutical manufacturers to examine whether study participants become suicidal during clinical trials of new medications.1 The policy derives from the belated recognition that antidepressants seem to slightly increase suicidality in children, adolescents, and young adults early in the course of treatment. This is not the only news about medications linked to possible increases in suicidal ideation or behavior.

Parents of young children know that colds are extremely common, especially from fall until spring. Colds account for a large number of pediatric office visits and telephone calls-particularly during "cold season."

Medical residents with depression are approximately 6 times more likely to make medication errors than those without depression, according to a study published online on February 7 in the British Medical Journal. A team led by Amy M. Fahrenkopf, MD, instructor of pediatrics, Harvard Medical School, Boston, conducted the prospective cohort study.

Major depression is twice as likely to develop in post-stroke patients (approximately 20%) than in nonstroke patients of the same age.1 Other psychiatric symptoms that are also more common in post-stroke patients include minor depression, anxiety, anger, and inappropriate or excessive laughing or crying (emotional incontinence).2

Cumulative research with animal, normative, and clinical populations over several decades shows that the mechanisms underlying anxiety disorders differ from those of the normal emotion of anxiety. In persons with anxiety disorders, fear and tension are disproportionate to the actual threat and may be present when no real threat exists, thereby generating an expectation of danger and distorted perceptions related to danger and various types of threats. The most common anxiety disorders are social anxiety disorder (SAD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). Persons with SAD can experience a wide range of social fears as well as severe functional consequences, whereas persons with GAD tend to experience emotional, interpersonal, and somatic symptoms of high levels of chronic anxiety. Persons with PTSD have vivid memories of and thoughts about a terrifying event or ordeal that lead to the development of anxiety, depression, and functional impairment. Effective treatment options-pharmacotherapy; psychotherapy, particularly cognitive-behavioral therapy; or a combination-can be discussed openly with the patient to make a collaborative, informed decision. A variety of medications can be used to successfully manage anxiety disorders, of which SSRIs and serotonin-norepinephrine reuptake inhibitors are the most effective. When properly used, medications can enhance a patient's own efforts to master anxiety; overcome fearful avoidance; and address troubling behaviors, patterns, or memories. (Drug Benefit Trends. 2008;20:101-113)

Depression was diagnosed 6 years earlier in a 37-year-old woman; it has been successfully managed since then with fluoxetine and outpatient psychotherapy. Since her teenage years, the patient has also experienced sporadic (fewer than 3 or 4 per year) mild or occasionally severe headaches, which she has usually self-treated with over-thecounter (OTC) agents or "just slept off."

An analysis of data from the National Comorbidity Survey, a nationally representative sample of persons aged 15 to 54 years (N = 8098), suggests that those who exercise regularly are less likely to report being depressed or having an anxiety disorder.1 The association between regular physical activity and lower prevalence of major depression (odds ratio [OR], 0.75) is fairly specific. Dysthymia, for example, was only minimally responsive to exercise, and there was no correlation between regular exercise and reduced risk of bipolar disorder. Psychotic disorders and substance abuse also were not substantially affected by regular physical activity. However, certain anxiety disorders, particularly panic attacks and phobias, were found to be less prevalent among self-reported exercisers.

The American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP) renewed their 2004 call for a mandatory public clinical trial registry to be established and overseen by the federal government. This is in response to a study that showed that research on antidepressants is published selectively-effectively suppressing trials deemed negative and overstating the benefits of antidepressant therapy. The study was published in the January 17 issue of the New England Journal of Medicine.

Adherence is a complex behavioral process strongly influenced by environmental factors. Six posters designed to improve medication adherence were displayed in a medical clinic, with each poster displayed for 1 month. These posters were seen by clinic patients but, as passive measures, required no additional time on the part of clinicians. Medication adherence to antidepressant therapy was assessed for two 18-month periods. Days of therapy and median gap (the number of days a patient goes without medication before filling the next prescription) were similar between the periods. Medication possession ratio (MPR) was increased in the intervention period (0.974 vs 0.994 days). During the 6-month period that the adherence posters were displayed, persistence decreased by only 10% (versus 22% for the nonintervention period). Use of passive measures may improve patient medication adherence. In this prospective study, both the MPR and persistence were improved. (Drug Benefit Trends. 2008:20:17-24)

Premenopausal women with major depressive disorder (MDD) have less bone mineral density (BMD) than those without MDD, according to findings of a study published in the November 26 issue of Archives of Internal Medicine. Researchers reported that the level of bone loss in premenopausal women with MDD was at least as high as that associated with recognized risk factors for osteoporosis. The study was funded by the National Institute of Mental Health, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Center for Complementary and Alternative Medicine, and the Warren Magnuson Clinical Center of the NIH.

An 81-year-old woman with a history of moderate Alzheimer dementia, depression, coronary artery disease, hypertension, and type 2 diabetes mellitus was accompanied to the office by her son for a routine follow-up appointment.