Could I be Depressed?

The diagnosis of depression includes several subgroups including major depression, dysthymia and minor depression. Taking these three entities into consideration, it has been estimated that as many as one-in-five patients seen in primary care offices are depressed.
The diagnosis of major depression is based on exhibiting five or more of the following symptoms for a period of at least 2 weeks:

• Low or irritable mood most of the time
• A loss of pleasure in usual activities
• Trouble sleeping or sleeping too much
• A big change in appetite, often with weight gain or loss
• Tiredness and lack of energy
• Feelings of worthlessness, self-hate, and
  guilt
• Difficulty concentrating
• Slow or fast movements
• Lack of activity and avoiding usual activities
• Feeling hopeless or helpless
• Repeated thoughts of death or suicide

Dysthymia, sometimes considered to be “chronic depression” has symptoms that are less severe than major depression but may have been present for a much longer period of time. Minor depression is similar to major depression except it only has two to four of the symptoms mentioned above.
In spite of how common depression is in the general population, it frequently goes undetected and untreated. The U.S. Preventive Services Task Force (USPSTF) has found that screening performed during doctor’s visits increases the identification of depressed individuals.
A number of different screening tests for depression are used by doctors in the primary care setting. Most of these are self-administered, meaning that the patient completes a questionnaire that asks about various symptoms and physical signs that could indicate depression. Specific tests, such as the Beck Depression Inventory and the Zung Self-Rating Depression Scale, include around 20 questions and are “graded” in order to determine if depression is present, and if so, how severe is it.
More recently, a 2-question depression screening tool was found to have close to the same accuracy as the more extensive questionnaires. Answering “yes” to both of the following questions about mood and pleasure from activities usually found to be enjoyable makes the diagnosis of depression likely:

1. "Over the past 2 weeks, have you felt down, depressed, or hopeless?"
   
2. "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"

This 2-question tool is felt to have fairly good sensitivity (correctly identifying people with depression) but only fair specificity (correctly identifying people who aren’t depressed). In other words this screening test did a good job of detecting people who were truly depressed but tended to over diagnose those in whom depression was not a significant issue. For this reason, when the answers to both questions suggest that someone is depressed, a more formal psychological investigation is needed.
Physical problems are not the only reason for seeing the doctor. If you recognize several of the depression symptoms mentioned above or answer “yes” to the 2-question screening test, a visit to your doctor to discuss your feelings is in order. In addition to advising screening for the depression, the USPSTF also found that treating depressed adults with antidepressants, psychotherapy, or both is effective in reducing symptoms and improving productivity. Large-scale studies have, in fact, shown that following initiation of treatment approximately two thirds of individuals achieve remission from their depression within a year.

Need Another Reason to Stop Smoking?

The percentage of US adults who smoke cigarettes has been decreasing over the past several decades. In 1965 approximately 42% of adults smoked cigarettes as compared to 18% today. In spite of warnings regarding health risks associated with smoking, however, nearly 42 million adults and over 3.5 million middle and high school students continue to smoke cigarettes.
If the well-known increased risk of developing lung cancer and coronary heart disease wasn’t enough to convince smokers to stop, new information released by the US Surgeon General should be of concern to the most ardent smokers. In the 2014 Surgeon General's Report, The Health Consequences of Smoking—50 Years of Progress, an expert panel found that there was sufficient evidence to confirm that cigarette smoking was a cause for the following diseases:

• Colorectal Cancer – Most colon cancer starts from pre-cancerous polyps. It has been confirmed that such polyps could develop as a result of smoking.
  
• Chronic Obstructive Pulmonary Disease (COPD) – For some time, smoking has been a known cause for the development of COPD (emphysema). This report went one step further, however, in identifying cigarette smoking as the dominant cause of COPD among men and women in the US.
  
• Liver Cancer— A causal relationship between smoking and the development of hepatocellular carcinoma (liver cancer) was confirmed.
  
• Congenital Malformations – Cigarette smoking during early pregnancy was found to be a cause for the development of cleft palates.
• Male Sexual Dysfunction – Smoking was found to be a cause for erectile dysfunction in men.
  
• Diabetes – The risk of developing diabetes was found to be 30–40% higher for active smokers than nonsmokers. Also, the likelihood of developing diabetes increased along with the number of cigarettes smoked.
  
• Eye Disease – A causative link between cigarette smoking and macular degeneration, a leading cause of vision loss in Americans 60 and older, was confirmed.
  
• Rheumatoid Arthritis (RA) – Some cases of RA are caused by cigarette smoking-related impairment of immune system function.

In addition to the diseases in which cigarette smoking was considered to be the causative, the report noted a number of other health issues which have been linked, but not proven to be caused, by cigarette smoking including:

• Dental cavities
  
• Miscarriage
  
• Attention deficit hyperactivity disorder among children
  
• Asthma
  
• Breast Cancer
  
• Idiopathic pulmonary fibrosis.
  
• Inflammatory Bowel Disease (Crohn's Disease)

Unfortunately, even non-smokers are at risk of developing certain diseases as a result of exposure to secondhand smoke. The report noted that secondhand smoking increases the risk of someone having a stroke by 20-30%. Additionally, the annual cost attributed to lost productivity from premature death due to exposure to secondhand smoke was estimated to be around 5 billion dollars.
Hopefully, information from this report along with ongoing government-sponsored efforts, such as smoke-free indoor air policies and funding statewide tobacco control programs, will help to achieve the goal of a smoke-free America.

Shoulder Injuries-Overuse to Trauma: Part 2

Part 2—Traumatic Shoulder Injuries
Last week, common overuse conditions of the shoulder were described along with their treatment. This week’s Health Tip describes common shoulder conditions that develop as a result of trauma. First let’s review the anatomy of the shoulder. The shoulder is made up of three bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The head of the humerus fits into a curved socket, called the glenoid, which is part of the shoulder blade. A group of muscles and tendons, known collectively as the rotator cuff, keep the arm bone centered in the shoulder socket and allow for movement in many different directions.
In contrast to the overuse conditions discussed in last week’s Health Tip, the injuries described above sometimes require surgery to restore function and/or relieve pain.

• Rotator Cuff Tears--- One of the most serious shoulder injuries involving soft tissue (muscle, tendon, ligament, etc.) is a rotator cuff tear. These may occur suddenly (acute tears) or slowly over time (chronic tears). Acute tears usually occur from a sudden jerk, as when lifting a heavy object, or from falling on an outstretched arm. Chronic tears occur most commonly in someone with longstanding “wear and tear” (degenerative) changes in rotator cuff. The primary symptoms of a rotator cuff tear are: 1) pain and weakness in the shoulder and 2) difficulty moving the shoulder, especially with overhead movements. In roughly half of people with rotator cuff tears, non-surgical treatment involving activity modification, anti-inflammatory medication, and physical therapy will restore the individual to an acceptable level of activity. If the cuff has torn completely, or the tear results in persistent pain, surgery to reattach the torn tendon back to bone may be necessary. The surgery can often be done as an outpatient, although several months of rehabilitation are usually required to regain full strength and mobility.
  
  
• Instability---Shoulder instability occurs when the structures that stabilize the shoulder joint fail to keep the ball of the upper arm bone tightly within its socket. In a shoulder dislocation, the head of the humerus comes completely out of its socket. When the head comes only part way out of the socket, it’s known as subluxation. Initial episodes of instability usually occur as a result of an injury. Severe pain and inability to move the shoulder are typically present following an acute dislocation. If the ligaments, tendons and muscles supporting the shoulder become stretched or damaged following the initial episode, chronic instability with recurrent dislocations may occur. With the first dislocation, physical therapy directed at strengthening the shoulder stabilizers is usually the best course of treatment. If the shoulder joint is so lax that repeated dislocations occur, surgery may be necessary to repair torn or stretched ligaments.
  
  
• Acromioclavicular Joint Sprain. The acromioclavicular (A-C) joint is located where the clavicle (collar bone) connects with a portion of the scapula known as the acromion. Its location is at the tip or highest point of the shoulder. The two bones forming the A-C joint are held together by ligaments. An A-C joint sprain occurs when these ligaments are stretched or torn. The common name for this injury is “shoulder separation”. A-C joint sprains and can range from a mild stretching of the ligaments that hold the joint together (Grade 1) to a complete tear of the ligaments (Grade 3-4 sprain). This injury occurs most often when someone falls directly on the point of the shoulder. Measures to reduce pain (sling, cold packs, and pain medication) along with time for healing are usually all that is required in mild sprains. When a complete tear of the A-C joint ligaments causes persistent pain or significant deformity, surgery to repair the damaged ligaments may be necessary.
  
  
• Fractures---The clavicle (collar bone) is the most commonly fractured shoulder bone. This fracture is seen most often in younger individuals, often due to landing on the shoulder as could occur during a bicycle crash. Fractures of the upper part of the arm (humerus) occur more often in older (65 years of age or older) individuals as a result of falling. The scapula is fractured less commonly that the other two bones of the shoulder and is usually the result of high-energy trauma, such as a motor vehicle accident. With each of these fractures, as long as the bone fragments are not shifted out of position (displaced), healing can occur without the need for surgery. Non-surgical treatment typically involves immobilization with a sling or shoulder immobilizer, application of ice packs, and taking medications for pain. Surgery for clavicle fractures may be necessary if a bone fragment has broken through the skin or if the bone is severely out of place. Surgery to correct a clavicle fracture may involve securing the fracture with plates and screws or by placing rods inside the bone. Surgery for a displaced fracture of the upper arm bone usually involves fixation of the fracture fragments with plates, screws, or pins. Only rarely is surgery necessary in the case of a fractured scapula.