Depression

Managing Managed Care: Health Literacy, HIV, and Outcomes

abstract: Depression and anxiety are common comorbidities in patients with chronic obstructive pulmonary disease (COPD), and like COPD, they are often underrecognized. Both of these comorbidities can adversely affect the course of COPD. Anxiety, for example, is associated with more severe dyspnea, greater disability, and impaired functional status; it also is a significant predictor of hospitalizations for acute exacerbations of COPD. When evaluating depressive symptoms, it is important to rule out cognitive impairment, particularly in patients with severe COPD and hypoxemia. Treatment options include antidepressants and cognitive behavioral therapy. Participation in a pulmonary rehabilitation program also can help reduce anxiety and depressive symptoms in patients with COPD. (J Respir Dis. 2007;28(3):94-103)

ABSTRACT: Antiplatelet agents used to treat non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina include aspirin, clopidogrel, and glycoprotein (GP) IIb/IIIa inhibitors. Aspirin is recommended for all patients with acute coronary syndromes (ACS). Clopidogrel can also be used in all patients with ACS, although this agent increases the risk of major bleeding complications if coronary artery bypass grafting is performed less than 5 days after the last dose. Early use of a GP IIb/IIIa inhibitor provides additional benefit in patients with NSTEMI, particularly those who undergo percutaneous coronary intervention. Agents used for anticoagulation in patients with NSTEMI or unstable angina include unfractionated heparin, low molecular weight heparins (LMWHs), and the direct thrombin inhibitor bivalirudin. Enoxaparin-the only LMWH currently indicated for treatment of patients with NSTEMI-can be considered as an alternative to unfractionated heparin, particularly in those who do not require urgent cardiac catheterization.

NEW HAVEN -- The negative emotions of grief -- yearning, depression, and anger -- following the death of a family member from natural causes usually peak within six months, according to a Yale bereavement study of 233 mourners

GLASGOW, Scotland, Feb. 19 -- There's more evidence women can benefit from moderate exercise during early treatment for breast cancer, researchers here said.

SAN FRANCISCO -- A robot dubbed Howard may help stroke patients regain hand function and strength even when the therapy is begun after a delay of three months, researchers said here.

PITTSBURGH -- Common symptoms of depression such as fatigue, sleep disturbances, and anhedonia may trigger initima-media thickness changes associated with subclinical atherosclerosis, researchers here reported.

NEW YORK -- Low birth weight and child abuse combine synergistically to increase the later risks of depression by 10-fold and social dysfunction by nearly ninefold, researchers here said.

GLASGOW, Scotland -- About half of patients with newly diagnosed epilepsy will have good control of their seizures with the first medication tried, and a majority of responders will be seizure-free at the lowest dose, reported European investigators.

DALLAS, Feb. 5 -- For the acute phase of temporomandibular disorder (TMD), cognitive behavioral training and biofeedback reduces overall and jaw-related care costs, researchers found.

The investigators employed the HIV Epidemiological Research Study, a longitudinal prospective cohort study, along with semiannual interview, physical examination, and laboratory assays. They recruited 773 HIV-positive women aged 16 to 55 years from 4 academic medical facilities in Baltimore; Bronx, New York; Providence, RI; and Detroit.

PARIS -- Treating the families of dying patients with compassion, keeping them informed, and establishing good communications with ICU staffers in a formal process can ease the pain of bereavement, according to investigators here.

MONTREAL -- The selective serotonin reuptake inhibitor (SSRI) Celexa (citalopram) appears effective in treating depression among patients with coronary artery disease, researchers here found.

ANN ARBOR, Mich. -- People who are cynically distrustful tend to have higher levels of inflammatory markers associated with atherosclerosis than those who believe the best of others' motives, investigators here suggested.

MONTREAL -- Commonly used selective serotonin reuptake inhibitors (SSRIs) may increase the risk of osteoporotic fractures among patients 50 and older, researchers here found.

DUBLIN -- Many women taking tamoxifen as adjuvant breast cancer therapy are halting it well before the optimal five-year therapeutic standard and not substituting an aromatase inhibitor, researchers here reported.

NEW YORK -- Gauging the winds of medical advances is an iffy proposition at best, but for psychiatrists the new year is likely to bring much-anticipated data on the safety and efficacy of antipsychotic and bipolar medications in children and adolescents.

WATERTOWN, Mass. -- Instead of popping pills, men with erectile dysfunction may be able to improve their performance through weight loss and getting in shape.

TOLEDO, Ohio -- Migraine sufferers often have more than a headache, according to investigators here.

ROCKVILLE, Md. -- Clinical and regulatory developments in psychiatry during the year included extended black box warnings about suicide for antidepressants, new insights for treating schizophrenia gleaned from an old trial, and the possibility of a "taste test" for selecting the best medicine.

LONDON, Ontario -- Binge drinking appears linked to depression, particularly among women, according to a large survey.

PITTSBURGH -- Poor sleep is a frequent companion of depression in children, according to researchers here.

The introduction of effective antiretroviral therapy has resulted in dramatic clinical benefits for those persons who have access to it. Adherence to such therapy has emerged as both the major determinant and the Achilles' heel of this success. Many patients have levels of adherence too low for durable virologic control.

ABSTRACT: Irritable bowel syndrome (IBS) is characterized by abdominal pain or discomfort, bloating, and constipation or diarrhea; the pain is typically relieved by defecation. The diagnosis is not one of exclusion; it can be made based on the answers to a few key questions and the absence of "alarm" symptoms. Fiber therapy, the elimination of particular foods, and regulation of bowel function can help relieve symptoms. Tegaserod or polyethylene glycol can be used to treat IBS with constipation. Loperamide and alosetron are of benefit in IBS with diarrhea (although the latter carries a small risk of ischemic colitis). Low-dose tricyclic antidepressants may be used to treat the abdominal pain associated with IBS. Probiotic therapy or rifaximin may help reduce bloating. Psychological therapies seem to improve well-being in patients with IBS.

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

A 78-year-old widower with hypertension, type 2 diabetes, and hyperlipidemiais referred for a comprehensive geriatric assessment.His daughter is concerned about her father’s decline following her mother’s death a year ago.His memory seems to be deteriorating. His desk is cluttered with bills, but he refuses to lethis daughter help him or even look at his checkbook.

Issues of when and whom to screen for various diseases and conditions have longbeen sources of controversy. The amount of information about screening tests canbe overwhelming, and the costs of the latest preventive technology can be daunting.To provide an evidence base for decision making in one source for busy clinicians,Dr Snow has compiled key previously published reviews of the data behind the latestUS Preventive Services Task Force (USPSTF) screening recommendations fortype 2 diabetes, postmenopausal osteoporosis, breast cancer, colorectal cancer, andprostate cancer. Also included are reviews of the evidence concerning chemoprophylaxisof cardiovascular disease (with aspirin and with hormone replacementtherapy) as well as reviews of the latest data on screening for hypertension and depression,which were specially commissioned for this volume. The reviews containguidelines on which patients to screen and address the issue of screening frequency-in terms of both optimum patient care and maximum cost-effectiveness. Inaddition, a list of key points that summarize important “take-home” messages precedeeach review. The book also contains a valuable introduction (“How to ThinkAbout Screening” by David M. Eddy, MD, PhD) and a concise guide to 25 preventiveservices.

Q:Should hypertensive patients be discouraged from participating inmoderate to vigorous exercise?A:On the contrary, most patients with sustained hypertension should bestrongly encouraged to exercise regularly at moderate to vigorous levels.Randomized controlled clinical trials have demonstrated that increasedphysical activity can lower blood pressure (BP) and delay or prevent the developmentof hypertension and thus the need for antihypertensive medication.1In addition, physical activity can help reduce cardiovascular risk factors by improvinglipid profiles and reducing weight and blood glucose levels. In elderlypersons, exercise is associated with improvements in osteoporosis, depression,and physical functioning, as well as an enhanced sense of well-being.

The FDA has approved injectable Acetadote (acetylcysteine)from Cumberland Pharmaceuticals Incto prevent or lessen liver damage resulting from an overdoseof acetaminophen. According to the FDA, unintentionalacetaminophen overdose is responsible for 100deaths and 56,000 emergency department visits per year.

In his article, “The Primary Care Physician’s Role in Treating Mental Illness”(CONSULTANT supplement, April 15, 2003, page 24), Dr Joseph Lieberman correctlyasserts that “more and more primary care physicians are prescribing psychotropicmedications.”