Depression

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.

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.