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ScienceWeek
PUBLIC HEALTH: ON COLLEGE-STUDENT USE OF STIMULANTS
The following points are made by Richard Kadison (New Engl. J. Med. 2005 353:1089):
1) The current rates of depression, stress-related symptoms, insomnia, and eating disorders in US colleges and universities are staggering; not surprisingly, so are the rates of substance abuse. In a recent national survey of 13,500 college students, nearly 45 percent reported being so depressed that they had difficulty functioning, and 94 percent reported feeling overwhelmed by everything they had to do.[1] Various studies have shown that about 45 percent of college students intermittently engage in binge drinking.[2]
2) Some of these students no doubt meet the criteria for therapy with effective, new psychotropic medications. The trouble is that many more of them, affected by the increased stress of college life -- overextended by extracurricular activities taken on in order to build their résumés, sleeping even less than their predecessors, and worrying more than ever about financial, social, and academic pressures -- are at risk for misusing or abusing these drugs, which can have serious adverse effects.
3) The emergence of the selective serotonin-reuptake inhibitor (SSRI) antidepressants and a variety of drugs for treating attention deficit-hyperactivity disorder ADHD has changed the landscape of prescribing for the college-age population. Unfortunately, beyond the legitimate prescription of such medications lies new territory marked by illegitimate, or at least inappropriate, uses of stimulants and antidepressants --practices that are often not even covert. Increasing numbers of students, and sometimes their families, request medication to provide an "edge," even if the students have no clinically significant impairment of functioning. They think of such drugs as safe "brain steroids" that help to maximize performance with minimal risk, and they know the symptoms to describe in order to persuade a doctor to write a prescription. Thus, the number of prescriptions has increased dramatically over the past decade; it is estimated, for example, that 25 to 50 percent of U.S. college students who are seen in counseling and at student health centers are taking antidepressants.
4) At least in part, such consumer demand reflects our bombardment with advertisements imploring us to "ask your doctor if this pill is right for you." This type of marketing is a double-edged sword, not only raising awareness of common problems such as depression and attention deficits but also implying that there is a magic bullet for complex problems and enticing some healthy people to seek their own magical boost. The challenge for physicians is to determine which patients have a legitimate need for psychotropic medication, particularly given recent warnings about the safety of some of these compounds.
References:
1. National College Health Assessment: reference group report. Baltimore: American College Health Association, 2004
2. Wechsler H, Lee JE, Kuo M, Nelson TF, Lee H. Trends in college binge drinking during a period of increased prevention efforts: findings from four Harvard School of Public Health college alcohol study surveys: 1993-2001. J Am Coll Health 2002;50:203-217
New Engl. J. Med. http://www.nejm.org
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ON ADOLESCENT DEPRESSION
The following points are made by D.A. Brent and B. Birmaher (New Engl. J. Med. 2002 347:667):
1) In children and adolescents, depression is not always characterized by sadness, but instead by irritability, boredom, or an inability to experience pleasure. Depression is a chronic, recurrent, and often familial illness that frequently first occurs in childhood or adolescence. Any child can be sad, but depression is characterized by a persistent irritable, sad, or bored mood and difficulty with familial relationships, school, and work(1). In the absence of treatment, a major depressive episode lasts an average of eight months. The risk of recurrence is approximately 40 percent at two years and 72 percent at five years.(2) Longer depressive episodes occur in patients who have a dysthymic disorder (a milder, but chronic and insidious form of depression) that gradually evolves into major depression. More prolonged episodes are also associated with coexisting psychiatric conditions, parental depression, and parent-child discord.(2)
2) At least 20 percent of those with early-onset depressive disorders (those beginning in childhood or adolescence) are at risk for bipolar disorder, particularly if they have a family history of bipolar disorder, psychotic symptoms, or a manic response to antidepressant treatment.(2,3) Bipolar disorder is characterized by depressive episodes that alternate with periods of mania, defined by a decreased need for sleep, increased energy, grandiosity, euphoria, and an increased propensity for risk-taking behavior. Often in children and adolescents, mania and depression occur as "mixed states", in which the lability of mania is combined with depression, or there is rapid cycling between depression and mania over a period of days or even hours.(4)
3) Suicidal behavior is closely associated with depression. Risk factors for suicide during a depressive episode include chronic depression, coexisting substance abuse, impulsivity and aggression, a history of physical or sexual abuse, same-sex attraction and sexual activity, a personal or family history of a suicide attempt, and access to an effective means of suicide, such as a gun.(5) Girls are more likely to attempt suicide, and boys to complete suicide. Among adolescents, the annual rate of suicide attempts requiring medical attention is 2.6 percent. Completed suicide is much rarer: among 15-to-19-year-olds, the rates in 1998 were 14.6 per 100,000 in boys and 2.9 per 100,000 in girls.
4) Depression is present in about 1 percent of children and 5 percent of adolescents at any given time. Before puberty, boys and girls are at equal risk for depression, whereas after the onset of puberty, the rate of depression is about twice as high in girls. Having a parent with a history of depression increases a child's risk of a depressive episode by a factor of 2 to 4.7 Anxiety, particularly social phobia, may be a precursor of depression.
References (abridged):
1. Diagnostic and statistical manual of mental disorders, 4th ed.: DSM-IV. Washington, D.C.: American Psychiatric Association, 1994.
2. Birmaher B, Ryan ND, Williamson DE, et al. Child and adolescent depression: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996;35:1427-1439.
3. Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL. Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder. Am J Psychiatry 2001;158:125-127.
4. Geller B, Zimerman B, Williams M, et al. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol 2000;10:157-164.
5. Brent DA. Mood disorders and suicide. In: Green M, Haggerty RJ, eds. Ambulatory pediatrics. 5th ed. Philadelphia: W.B. Saunders, 1999:447-54.
New Engl. J. Med. http://www.nejm.org
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PUBLIC HEALTH: CULTURE AND DEPRESSION
The following points are made by Arthur Kleinman (New Engl. J. Med. 2004 351:951):
1) In many parts of Chinese society, the experience of depression is physical rather than psychological. Many depressed Chinese people do not report feeling sad, but rather express boredom, discomfort, feelings of inner pressure, and symptoms of pain, dizziness, and fatigue. These culturally coded symptoms may confound diagnosis among Chinese immigrants in the US, many of whom find the diagnosis of depression morally unacceptable and experientially meaningless. This cultural pattern changes over time but continues to diverge significantly from the experiences of other groups. The pattern of somatization may be unfamiliar to US clinicians and may further complicate the concept of depression, which, according to biomedicine, can be an emotion, a symptom, or a disease.
2) Depressive feelings are experienced by all people and are a normal component of disappointment and grief. Depression may be a symptom of a mental disorder (such as bipolar disorder, an anxiety disorder, or schizophrenia) or of other medical diseases, ranging from diabetes and thyroid disorders to postviral syndromes. As one of the most prevalent diseases globally and an important cause of disability, depressive disorder is responsible for as many as one of every five visits to primary care doctors; it occurs everywhere and affects members of all ethnic groups. The rates of depression are increasing, and the disorder is nearly twice as common among the poor as among the wealthy.
3) But the way in which depression is confronted, discussed, and managed varies among social worlds, and cultural meanings and practices shape its course. Culture influences the experience of symptoms, the idioms used to report them, decisions about treatment, doctor-patient interactions, the likelihood of outcomes such as suicide, and the practices of professionals. As a result, some conditions are universal and some culturally distinct, but all are meaningful within particular contexts.
4) Among refugees, depressive affect and disorder are common aspects of collective and personal experiences of loss and trauma. Various patterns of somatization are found among depressed patients from many ethnic groups, and even among Latinos. For example, Mexican Americans, Puerto Ricans, and Cuban Americans may report different symptoms. Add differences in sex, age, social class, education, and degree of biculturalism, and the question of cultural influence becomes murky enough to discourage any form of ethnic stereotyping. Inasmuch as black women have lower rates of depression and suicide than white women, and immigrants lower rates of depression than their descendants, some cultural effects may be protective factors rather than risk factors. In a complex, postmodern society like that of the US -- where it is often hard to determine the cultural norm or how experience differs among or within communities -- cultural differences can affect any patient-doctor interaction.
New Engl. J. Med. http://www.nejm.org
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