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."
ABSTRACT: Antidepressants and psychotherapy are effective treatments for major depression. In selecting an antidepressant, consider any previous response or family history of a response to a medication as well as anticipated side effects. Advise patients that antidepressants take at least 4 to 6 weeks to have a full therapeutic effect and that only about half of patients respond to the first drug prescribed. If the patient fails to respond or experiences intolerable side effects, it is usually advisable to substitute an antidepressant with a different mechanism of action. A combined approach using medication and psychotherapy often produces optimal results.
The diagnostic criteria for major depression are anhedonia, depressed mood, feelings of worthlessness or inappropriate guilt, inability to concentrate, fatigue, insomnia or hypersomnia, psychomotor agitation or retardation, significant weight loss or gain, and recurrent thoughts of death or suicide. Five or more of these symptoms must be present for at least 2 weeks, and one of them must be anhedonia or depressed mood. Conditions that can present with depression include dysthymia, bipolar disorder, cyclothymia, and adjustment disorder. Depression may also result from substance abuse or from the physiological conditions associated with a medical disorder, such as spinal or head injury, AIDS, or cancer.
I am an adult psychiatric nurse practitioner, and a significant part of my practice has been the treatment of subclinical hypothyroidism. Whenever a patient has depression and low energy, I measure free T4, free T3, and thyroid-stimulating hormone (TSH) levels. In most of the subclinical hypothyroidism I have detected, the TSH level is normal. In many cases, the only level that is low is the free T3. When liothyronine is prescribed for these patients, their symptoms of depression and tiredness decrease and their need for antidepressants has, in a few cases, been eliminated.
The headaches vary in severity, but she usually has severeheadaches (8 on a 10-point visual analog scale[VAS]) once or twice a week; she describes the latter assevere throbbing or pounding pain on the top of thehead but also involving the occipital and frontalareas and occasionally one or the other temple.
ABSTRACT: Many patients with diabetes are anxious or fearful about the disease. These negative emotions stem in part from the fact that the patient is responsible for many facets of diabetes management, such as exercise, dietary modification, and blood glucose measurement. For example, failure to adhere to a regimen may engender guilt. Up to 30% of patients with diabetes are depressed, and hemoglobin A1c levels are higher in such patients. Even patients with good metabolic control may not be doing well psychologically. It is thus essential to ask about patients' concerns and fears, identify their psychosocial needs, and provide emotional support.
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.
ABSTRACT: Our knowledge of chronic diseases has advanced significantly in recent decades, but patient outcomes have not kept pace. This is largely because the traditional acute care model does not adequately address the needs of patients with chronic disease. Patients play an active role in the management of chronic disease, and successful outcomes are highly dependent on adherence to treatment. Thus, clinicians need to have skills in coaching and encouraging as well as an awareness of factors in patients' backgrounds that are likely to affect their ability or willingness to follow treatment plans. Provider- and system-related factors, such as lack of reimbursement for counseling and high copayments, can also act as barriers to compliance. Among the strategies that can improve adherence are the use of community resources, multidisciplinary approaches, and regular follow-up.
Over the past few decades, the management of chronic disease has assumed a greater role in health care. Diseases such as diabetes, chronic obstructive pulmonary disease, and depression have replaced acute disorders as the leading cause of morbidity, mortality, and health care expenditures.
Studies have indicated that depression occurs more frequently in adults with asthma than in the general population; however, few studies have investigated the relationship between depression and asthma outcomes. A recent study by Eisner and associates revealed noteworthy findings: depressive symptoms appear to be associated with poorer outcomes, including increased risk of hospitalization for asthma.