Depression

Sometimes we try to distill long experience into words, whether aphorisms or full paragraphs. Rilke’s wonderful prose poem expresses this very well in the part that begins, “For the sake of a single verse, one must see many cities, men and things. . . . ” While medicine has only some features in common with poetry, what reverberates is the wish to impart an affecting draught of beauty or wisdom or insight, in the case of poetry, after many years and decades of immersion in life; and I here offer some fruits of long observation and participation “hip deep” in clinical care and in the teaching of residents.

A study published in the November issue of the Journal of Adolescent Health shows that young persons with asthma are twice as likely to have anxiety and depressive disorders than youths without asthma. Researchers at the University of Washington School of Medicine, Seattle; Group Health Cooperative (GHC); and Seattle Children’s Hospital Research Institute interviewed 1379 youths aged 11 to 17 years enrolled in the GHC HMO. Of the study participants, 781 had received a diagnosis of asthma or had been treated for asthma; 598 participants were randomly selected youths with no history of asthma.

About 50% of pregnanciesin the United States areunplanned.

Nearly one-fifth (19%) of US employers are taking steps to discontinue providing health care benefits during the next 3 to 5 years, up from just 4% in 2008, according to results of The Road Ahead: Emerging Health Trends 2009, a survey conducted for Hewitt Associates by project leader Jeffrey D. Munn. The team interviewed benefit executives at 343 large employers representing more than 5 million employees in December 2008 and January 2009.

Persons with chronic pain who participated in a collaborative care program with primary care physicians and psychologists showed improvement in depression, pain severity, and pain-related disability compared with those who received treatment by primary care physicians only, according to a study published in the March 25 issue of the Journal of the American Medical Association.

The media is full of alarming stories about veterans who return from the conflicts in Iraq and Afghanistan with various behavioral health issues, notably posttraumatic stress disorder (PTSD), major depression, traumatic brain injury (TBI), and alcohol abuse. Let’s review the professional literature data on the prevalence of these conditions in war veterans.

Medicare Advantage (MA) plans will feel a major effect next year from the switchover from the Bush administration to the Obama administration. One of the first actions taken by President Barack Obama-just 2 days after his inauguration-was to revoke the 2010 draft Call Letter that the Centers for Medicare & Medicaid Services (CMS) had issued for MA plans. The new draft Call Letter suggests harsher rules and more oversight in a number of specific areas.

Many persons with chronic conditions are not getting the care and support they seek from the health care system, according to findings of a survey of 1109 persons aged 44 years and older with at least 1 chronic condition, stratified as baby boomers (aged 44 to 63) and seniors (aged 65 and older). Among their biggest complaints, persons with chronic health conditions say their physicians do not spend enough time with them. They also report having had to put off care because of cost.

About 50% of pregnancies in the United States are unplanned.1 Thus, an awareness of which medications are safe and which are contraindicated in pregnancy is essential for good primary care-even in practices that do not include obstetrics.

Most uncomplicated anxiety disorders can be treated in the primary care setting. Following the initial treatment, patients require ongoing care, which combines psychosocial and psychopharmacological therapies. Treatment of anxiety disorders can lead to improved interpersonal, social, and vocational functioning.

A 50-year-old woman presents to the emergency department with severe dizziness, weakness, and dyspnea of 1 week’s duration. Ten days earlier, an upper respiratory tract infection (URTI) was diagnosed; over-the-counter cough syrup and acetaminophen were prescribed. However, the patient’s condition has steadily deteriorated since then. In addition, her urine has darkened over the past few days.

Genetic studies are slowly leading to a better understanding of certain diseases as well as progress toward individualized drug therapy. Developments in DNA sequencing make it relatively simple to look for allelic (ie, alternative) versions of a gene by examining samples of a specific gene taken from different members of a population (or from a heterozygous individual). Genetic variants that appear in at least 1% of a population are called polymorphisms. With the cutoff at 1%, one does not get sidetracked by spontaneous mutations that may have occurred in-and spread by the descendants of-a single family.

Researchers at Northwestern University, Evanston, Ill, report that insulin, by shielding memory-forming synapses from injury, may slow or prevent the damage and memory loss caused by amyloid b–derived diffusible ligands (ADDLs)-toxic neuroproteins associated with Alzheimer disease (AD). Findings of the study, which provides additional evidence that AD may be caused by a new, third form of diabetes, were published in the February 10 issue of the Proceedings of the National Academy of Sciences of the United States of America.

New guidelines from the Centers for Medicare & Medicaid Services (CMS) that increase the number of compendia health insurers rely on to determine whether a drug use is appropriate will greatly expand the number of off-label uses of chemotherapy agents for which the agency will reimburse.

Anxiety disorders are as prevalent and disabling as depression; they affect about 19.1 million adults in the United States at some point during their lifetimes.1-3 Because of the high suicide risk associated with depression, patients who have anxiety may attract less attention from their primary care providers. Thus, anxiety disorders often go undiagnosed and untreated.

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.