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Clinical Practice
Depression during Pregnancy
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage. A 24-year-old…
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Clinical Practice
Care of the Adult Patient after Sexual Assault
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage. A 20-year-old…
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Perspective
Electroconvulsive Therapy in the Spotlight
In January, the Food and Drug Administration (FDA) convened a meeting of its Neurological Devices Advisory Panel to help it decide how to classify electroconvulsive therapy (ECT) devices, a decision that could determine the future of ECT in the United States. The meeting revealed sharp differences…
Review Article
Current Concepts: The Gulf Oil Spill
One year after the Gulf oil spill (also known as the Deepwater Horizon oil spill, the BP oil spill, or the Gulf of Mexico oil spill), the full magnitude of the environmental, economic, and human health effects of this major disaster remain unknown. Despite a growing literature describing the impact…
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Clinical Practice
Bipolar Disorder — A Focus on Depression
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage. A 26-year-old…
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Original Article
Collaborative Care for Patients with Depression and Chronic Illnesses
Evidence-based care management for single conditions improves outcomes among patients with diabetes, coronary heart disease, and depression, but organizing diagnosis-specific programs is complex and costly, so such programs are not routinely available. Care for patients with multiple chronic…
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Original Article
Suicide-Related Events in Patients Treated with Antiepileptic Drugs
Suicide is the 13th leading cause of death worldwide, and attempted suicide is a major cause of injury. Psychiatric disorders (especially affective conditions) increase the risk of suicide.– Epilepsy increases both the risk of suicide among patients with psychiatric disorders and the risk of the…
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In this large observational study based on data collected as part of clinical care in the United Kingdom, antiepileptic-drug treatment was not associated with an increased risk of suicide-related events among patients with epilepsy, but the use of these drugs was associated with suicide-related events in patients with depression.
Clinical Practice
Early Alzheimer's Disease
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage. A 72-year-old…
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A 72-year-old man seeks consultation at the urging of his wife for increasing difficulty with memory over the past 2 years. Clients at his brokerage firm have expressed concern about his occasional lapses in memory. His wife reports that he frequently repeats questions about social appointments and becomes angry when she points this out. The physical examination is normal, but the patient has difficulty remembering elements of a brief story and difficulty in adding a small amount of change. Alzheimer's disease is suspected. How should this patient be evaluated and treated?
Original Article
Pallidal versus Subthalamic Deep-Brain Stimulation for Parkinson's Disease
Randomized studies have shown that treatment with deep-brain stimulation, which involves the surgical implantation of a device that sends electrical impulses to specific parts of the brain, is superior to medical therapy for improving motor function and quality of life for patients with advanced…
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In this randomized trial of deep-brain stimulation targeted to either the globus pallidus interna or the subthalamic nucleus in patients with advanced Parkinson's disease, the patients assigned to pallidal stimulation and those assigned to subthalamic stimulation had a similar improvement in motor function.
Case Records of the Massachusetts General Hospital
Case 11-2010 — A 69-Year-Old Woman with Lethargy, Confusion, and Abnormalities on Brain Imaging
Presentation of Case. Dr. Tracey A. Cho (Neurology): A 69-year-old woman was admitted to this hospital because of increasing lethargy, confusion, and abnormalities on brain imaging. The patient had been in her usual state of health until 2 months earlier, when her family noted increasing apathy and…
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A 69-year-old woman presented to this hospital because of a 2-month period of increasing apathy, confusion, and depression. She had a history of connective-tissue disease and idiopathic thrombocytopenic purpura. Ten days before admission, a magnetic resonance image of the brain was obtained, which was abnormal.
Original Article
Deployment and the Use of Mental Health Services among U.S. Army Wives
Mental health research involving past warfare indicates that frequent or extended military deployment leads to increased stress, anxiety, and depression among personnel– and their families.– However, current warfare in Iraq and Afghanistan differs greatly from that of other conflicts involving…
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Review Article
Current Concepts: Medical Evaluation of Patients Undergoing Electroconvulsive Therapy
After a period of declining use, electroconvulsive therapy (ECT) is now used more widely as a treatment for major depression and other psychiatric disorders. Many patients undergoing ECT are elderly and have multiple coexisting medical conditions. Consultants are often asked to provide a medical…
In evaluating patients before electroconvulsive therapy (ECT), especially those with conditions such as hypertension, coronary artery disease, and congestive heart failure, the medical consultant should undertake risk stratification, assess management of coexisting conditions, and use strategies to reduce the risk of such post-ECT complications as prolonged blood-pressure elevation, myocardial ischemia, and headache.
Case Records of the Massachusetts General Hospital
Case 14-2008 — A 78-Year-Old Man with Anergia and Anhedonia Associated with Cardiovascular Surgery
Presentation of Case. Dr. David T. Plante (Psychiatry): A 78-year-old man was admitted to the inpatient psychiatry service of this hospital because of anergia and anhedonia. Thirty-three months before admission, the patient was told by his physician that he needed surgical repair of an enlarging…
A 78-year-old man was admitted to the inpatient psychiatry service because of anergia and anhedonia of 33 months' duration. His symptoms began shortly after he was told he needed repair of an abdominal aortic aneurysm, persisted despite multiple trials of antidepressant medications, and worsened after repair of the aneurysm. An episode of major depression had occurred at the age of 58 years after coronary-artery bypass surgery and had responded to electroconvulsive therapy. A management decision was made.
Correspondence
Major Depressive Disorder
To the Editor: In their review article, Belmaker and Agam (Jan. 3 issue) examine several mechanisms involved in depressive disorders, but they do not mention evidence that androgen-deprivation therapy, which is frequently used in the management of prostate cancer, can cause major depression. The…
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Correspondence
Case 40-2007: A Man with Weakness in the Hands
To the Editor: In the Case Record involving a 38-year-old man with multifocal motor neuropathy, discussed by Triggs and Cros (Dec. 27 issue), Triggs emphasizes that it is important to distinguish multifocal motor neuropathy from amyotrophic lateral sclerosis or other motor neuron diseases because…
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Correspondence
Electroconvulsive Therapy for Depression
To the Editor: Lisanby (Nov. 8 issue) reports, in her Clinical Therapeutics article, on the use of electroconvulsive therapy (ECT) in patients with depression. ECT is rarely recommended in patients with schizophrenia (except for those with acute catatonia). In the guidelines of the German Medical…
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Editorial
Disentangling Mild Traumatic Brain Injury and Stress Reactions
The study by Hoge and colleagues in this issue of the Journal provides an important profile of the sequelae of mild traumatic brain injury in military personnel after combat. The findings demonstrate that mild traumatic brain injury results in increased rates of psychological, health, and…
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Original Article
Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq
More than 1.5 million U.S. military personnel have deployed to Iraq or Afghanistan since the start of military operations in 2001. Because of improved protective equipment, a higher percentage of soldiers are surviving injuries that would have been fatal in previous wars. Head and neck injuries,…
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In this survey of soldiers who served in Iraq, about 15% reported concussions, also known as mild traumatic brain injuries (injuries resulting in brief loss of consciousness or confusion). Soldiers who had mild traumatic brain injuries were more likely to have post-traumatic stress disorder and physical health problems than were soldiers with other injuries.
Review Article
Mechanisms of Disease: Major Depressive Disorder
Depression is related to the normal emotions of sadness and bereavement, but it does not remit when the external cause of these emotions dissipates, and it is disproportionate to their cause. Classic severe states of depression often have no external precipitating cause. It is difficult, however,…
This review of major depressive disorder is a comprehensive account of the genetic, biochemical, and neurophysiological changes that have been implicated in the disorder. No single mechanism can account for all the clinical variations in this condition. The monoamine oxidase theory can explain many of the actions of antidepressants, but genetic factors, stress, and psychosocial factors also play a part in depression.
Clinical Implications of Basic Research
Molecules That Mediate Mood
Major depressive disorder is now recognized as one of the world's greatest public health problems: it is common, typically follows a relapsing or recurrent course, disrupts the performance of social and vocational roles, and is associated with increased medical morbidity and reduced life expectancy.…






