Damian McNamara

MIAMI — Private insurers are likely to follow the lead set by the Centers for Medicare and Medicaid Services and expand coverage for cardiac rehabilitation services, according to a presentation at the annual meeting of the American Medical Society for Sports Medicine.

“In March 2006, Medicare made a big shift for cardiac rehab,” the first major coverage change in decades, Steven Keteyian, Ph.D., said. Since the 1980s, Medicare has covered cardiac rehabilitation for patients following a heart attack, coronary artery bypass surgery, or angina.

The expanded coverage includes heart valve repair or replacement, percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, and heart or combined heart-lung transplantation. These CMS changes are important because private insurers usually follow suit, said Dr. Keteyian, director of Preventive Cardiology at Henry Ford Hospital in Detroit.

“Missing for me is the heart failure patient,” Dr. Keteyian said. “They are awaiting further evidence.” Data are insufficient regarding benefits of cardiac rehabilitation in patients with heart failure, although studies are underway that might provide some answers, according to a CMS news release.

Previously, CMS reimbursed only the exercise component of cardiac rehabilitation. Now coverage also includes medical evaluation, risk factor modification, exercise, and education.

Historically, duration of rehabilitation was limited to 36 visits in 12 weeks. Now physicians have up to 18 weeks to complete the same number of visits, Dr. Keteyian said. “For us, having access to these patients for 4–6 months is very helpful. This will give us a lot of flexibility in how we manage these patients.” In addition, following a review and approval, rehabilitation can be extended up to 72 visits over 36 weeks.

ECG rhythm strips were mandatory for reimbursement prior to the policy change. Now the need for such monitoring is at the discretion of the physician.

Previously, requirements for physician supervision of cardiac rehabilitation patients were unclear, Dr. Keteyian said. CMS only stipulated that physicians were proximal to the exercise area. More specific requirements now state that physicians are expected to be on hospital premises or within 250 yards if the area is in a separate building on the hospital campus. They must be immediately available if the cardiac rehabilitation unit is freestanding, Dr. Keteyian said.

CMS originally proposed identifying the “incident to” physician as the ordering physician only. However, the agency ultimately decided it would not be appropriate to have “incident to” rules specific for cardiac rehabilitation.

MIAMI — Private insurers are likely to follow the lead set by the Centers for Medicare and Medicaid Services and expand coverage for cardiac rehabilitation services, according to a presentation at the annual meeting of the American Medical Society for Sports Medicine.

“In March 2006, Medicare made a big shift for cardiac rehab,” the first major coverage change in decades, Steven Keteyian, Ph.D., said. Since the 1980s, Medicare has covered cardiac rehabilitation for patients following a heart attack, coronary artery bypass surgery, or angina.

The expanded coverage includes heart valve repair or replacement, percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, and heart or combined heart-lung transplantation. These CMS changes are important because private insurers usually follow suit, said Dr. Keteyian, director of Preventive Cardiology at Henry Ford Hospital in Detroit.

“Missing for me is the heart failure patient,” Dr. Keteyian said. “They are awaiting further evidence.” Data are insufficient regarding benefits of cardiac rehabilitation in patients with heart failure, although studies are underway that might provide some answers, according to a CMS news release.

Previously, CMS reimbursed only the exercise component of cardiac rehabilitation. Now coverage also includes medical evaluation, risk factor modification, exercise, and education.

Historically, duration of rehabilitation was limited to 36 visits in 12 weeks. Now physicians have up to 18 weeks to complete the same number of visits, Dr. Keteyian said. “For us, having access to these patients for 4–6 months is very helpful. This will give us a lot of flexibility in how we manage these patients.” In addition, following a review and approval, rehabilitation can be extended up to 72 visits over 36 weeks.

ECG rhythm strips were mandatory for reimbursement prior to the policy change. Now the need for such monitoring is at the discretion of the physician.

Previously, requirements for physician supervision of cardiac rehabilitation patients were unclear, Dr. Keteyian said. CMS only stipulated that physicians were proximal to the exercise area. More specific requirements now state that physicians are expected to be on hospital premises or within 250 yards if the area is in a separate building on the hospital campus. They must be immediately available if the cardiac rehabilitation unit is freestanding, Dr. Keteyian said.

CMS originally proposed identifying the “incident to” physician as the ordering physician only. However, the agency ultimately decided it would not be appropriate to have “incident to” rules specific for cardiac rehabilitation.

MIAMI — Private insurers are likely to follow the lead set by the Centers for Medicare and Medicaid Services and expand coverage for cardiac rehabilitation services, according to a presentation at the annual meeting of the American Medical Society for Sports Medicine.

“In March 2006, Medicare made a big shift for cardiac rehab,” the first major coverage change in decades, Steven Keteyian, Ph.D., said. Since the 1980s, Medicare has covered cardiac rehabilitation for patients following a heart attack, coronary artery bypass surgery, or angina.

The expanded coverage includes heart valve repair or replacement, percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, and heart or combined heart-lung transplantation. These CMS changes are important because private insurers usually follow suit, said Dr. Keteyian, director of Preventive Cardiology at Henry Ford Hospital in Detroit.

“Missing for me is the heart failure patient,” Dr. Keteyian said. “They are awaiting further evidence.” Data are insufficient regarding benefits of cardiac rehabilitation in patients with heart failure, although studies are underway that might provide some answers, according to a CMS news release.

Previously, CMS reimbursed only the exercise component of cardiac rehabilitation. Now coverage also includes medical evaluation, risk factor modification, exercise, and education.

Historically, duration of rehabilitation was limited to 36 visits in 12 weeks. Now physicians have up to 18 weeks to complete the same number of visits, Dr. Keteyian said. “For us, having access to these patients for 4–6 months is very helpful. This will give us a lot of flexibility in how we manage these patients.” In addition, following a review and approval, rehabilitation can be extended up to 72 visits over 36 weeks.

ECG rhythm strips were mandatory for reimbursement prior to the policy change. Now the need for such monitoring is at the discretion of the physician.

Previously, requirements for physician supervision of cardiac rehabilitation patients were unclear, Dr. Keteyian said. CMS only stipulated that physicians were proximal to the exercise area. More specific requirements now state that physicians are expected to be on hospital premises or within 250 yards if the area is in a separate building on the hospital campus. They must be immediately available if the cardiac rehabilitation unit is freestanding, Dr. Keteyian said.

CMS originally proposed identifying the “incident to” physician as the ordering physician only. However, the agency ultimately decided it would not be appropriate to have “incident to” rules specific for cardiac rehabilitation.

MIAMI — Not enough diabetic patients exercise, but even when they do, greater attention needs to be paid to how to best manage the effects of exertion on their type of disease, Dr. Dennis A. Cardone said at the annual meeting of the American Medical Society for Sports Medicine.

“More than 50% of diabetics are not meeting exercise goals,” said Dr. Cardone, who is in private practice at Pediatric Orthopedics of Southwest Florida in Fort Myers.

In the setting of type 1 diabetes, exercise can reduce the severity of microvascular complications and improve lipid profiles. And although there is no evidence that exercise prevents type 1 diabetes, it has been shown to prevent type 2 diabetes.

Dr. Cardone advises diabetics, regardless of their disease type, to use a bracelet or shoe tag that identifies them as diabetic, to exercise with a partner, and to bring snacks and a glucagon kit (complete with instructions on how to use it).

As far as making sure that type 1 disease is well managed during workouts, get a thorough history of what steps patients have taken while exercising in the past. “If they are newly diagnosed, have them do frequent monitoring of their glucose during an initial exercise regimen, and use that information for their exercise and diabetes management plan.” And obviously, patients need to choose their form of exercise wisely. “For risky sports, such as skydiving, scuba diving, climbing, and motor racing, it is common sense: If they have a hypoglycemic episode, the results could be disastrous,” Dr. Cardone said.

Marathon runners with type 1 diabetes are at increased risk of complications related to dehydration, Dr. Cardone said. Other risks involve their tendency toward peripheral and autonomic neuropathy. “You may recommend they check blood sugar every 6 miles,” but the reality is that management should be highly individualized and tailored to factors such as the frequency of hypoglycemic episodes.

Alcohol should be avoided 24 hours prior to exercise. Instruct type 1 patients to inject insulin about 1 hour before exercise at a nonexercising site, such as the abdomen. Drop short-acting insulin by 30% prior to exercising for 1 hour, by 40% for 2 hours, and by 50% for 3 hours, he suggested.

Avoid evening exercise to minimize risk of nighttime hypoglycemia. “Usually morning is the best time for exercise for type 1 diabetics, especially before the morning dose of insulin,” Dr. Cardone said.

“The general rule is that if glucose is greater than 250 before exercise, it is better to hold off until their number lowers. If glucose is less than 100, supplement before exercising,” he said.

The most effective combination for type 1 diabetics is insulin lispro plus Ultralente, Dr. Cardone said. It is easier to control blood sugar while exercising. The literature supports a good response, especially in high-level athletes, he said.

For the nondiabetic athlete, glucose falls off slowly over time but stays within a therapeutic range. In contrast, “glucose can be all over the place” for the exercising diabetic, Dr. Cardone said. Instruct patients to monitor glucose, hydrate, and increase caloric intake 12–24 hours after exercise, he said.

Causes of hypoglycemia include too much preexercise insulin, increased absorption from the injection site, inadequate caloric intake, and spontaneous activity.

“Most of the athletes with diabetes who become hypoglycemic run into problems after exercise, up to 24 hours after activity. They don't have the mechanism to shut off endogenous insulin.” Whole milk and sports drinks can be effective prevention, he added.

MIAMI — Not enough diabetic patients exercise, but even when they do, greater attention needs to be paid to how to best manage the effects of exertion on their type of disease, Dr. Dennis A. Cardone said at the annual meeting of the American Medical Society for Sports Medicine.

“More than 50% of diabetics are not meeting exercise goals,” said Dr. Cardone, who is in private practice at Pediatric Orthopedics of Southwest Florida in Fort Myers.

In the setting of type 1 diabetes, exercise can reduce the severity of microvascular complications and improve lipid profiles. And although there is no evidence that exercise prevents type 1 diabetes, it has been shown to prevent type 2 diabetes.

Dr. Cardone advises diabetics, regardless of their disease type, to use a bracelet or shoe tag that identifies them as diabetic, to exercise with a partner, and to bring snacks and a glucagon kit (complete with instructions on how to use it).

As far as making sure that type 1 disease is well managed during workouts, get a thorough history of what steps patients have taken while exercising in the past. “If they are newly diagnosed, have them do frequent monitoring of their glucose during an initial exercise regimen, and use that information for their exercise and diabetes management plan.” And obviously, patients need to choose their form of exercise wisely. “For risky sports, such as skydiving, scuba diving, climbing, and motor racing, it is common sense: If they have a hypoglycemic episode, the results could be disastrous,” Dr. Cardone said.

Marathon runners with type 1 diabetes are at increased risk of complications related to dehydration, Dr. Cardone said. Other risks involve their tendency toward peripheral and autonomic neuropathy. “You may recommend they check blood sugar every 6 miles,” but the reality is that management should be highly individualized and tailored to factors such as the frequency of hypoglycemic episodes.

Alcohol should be avoided 24 hours prior to exercise. Instruct type 1 patients to inject insulin about 1 hour before exercise at a nonexercising site, such as the abdomen. Drop short-acting insulin by 30% prior to exercising for 1 hour, by 40% for 2 hours, and by 50% for 3 hours, he suggested.

Avoid evening exercise to minimize risk of nighttime hypoglycemia. “Usually morning is the best time for exercise for type 1 diabetics, especially before the morning dose of insulin,” Dr. Cardone said.

“The general rule is that if glucose is greater than 250 before exercise, it is better to hold off until their number lowers. If glucose is less than 100, supplement before exercising,” he said.

The most effective combination for type 1 diabetics is insulin lispro plus Ultralente, Dr. Cardone said. It is easier to control blood sugar while exercising. The literature supports a good response, especially in high-level athletes, he said.

For the nondiabetic athlete, glucose falls off slowly over time but stays within a therapeutic range. In contrast, “glucose can be all over the place” for the exercising diabetic, Dr. Cardone said. Instruct patients to monitor glucose, hydrate, and increase caloric intake 12–24 hours after exercise, he said.

Causes of hypoglycemia include too much preexercise insulin, increased absorption from the injection site, inadequate caloric intake, and spontaneous activity.

“Most of the athletes with diabetes who become hypoglycemic run into problems after exercise, up to 24 hours after activity. They don't have the mechanism to shut off endogenous insulin.” Whole milk and sports drinks can be effective prevention, he added.

MIAMI — Not enough diabetic patients exercise, but even when they do, greater attention needs to be paid to how to best manage the effects of exertion on their type of disease, Dr. Dennis A. Cardone said at the annual meeting of the American Medical Society for Sports Medicine.

“More than 50% of diabetics are not meeting exercise goals,” said Dr. Cardone, who is in private practice at Pediatric Orthopedics of Southwest Florida in Fort Myers.

In the setting of type 1 diabetes, exercise can reduce the severity of microvascular complications and improve lipid profiles. And although there is no evidence that exercise prevents type 1 diabetes, it has been shown to prevent type 2 diabetes.

Dr. Cardone advises diabetics, regardless of their disease type, to use a bracelet or shoe tag that identifies them as diabetic, to exercise with a partner, and to bring snacks and a glucagon kit (complete with instructions on how to use it).

As far as making sure that type 1 disease is well managed during workouts, get a thorough history of what steps patients have taken while exercising in the past. “If they are newly diagnosed, have them do frequent monitoring of their glucose during an initial exercise regimen, and use that information for their exercise and diabetes management plan.” And obviously, patients need to choose their form of exercise wisely. “For risky sports, such as skydiving, scuba diving, climbing, and motor racing, it is common sense: If they have a hypoglycemic episode, the results could be disastrous,” Dr. Cardone said.

Marathon runners with type 1 diabetes are at increased risk of complications related to dehydration, Dr. Cardone said. Other risks involve their tendency toward peripheral and autonomic neuropathy. “You may recommend they check blood sugar every 6 miles,” but the reality is that management should be highly individualized and tailored to factors such as the frequency of hypoglycemic episodes.

Alcohol should be avoided 24 hours prior to exercise. Instruct type 1 patients to inject insulin about 1 hour before exercise at a nonexercising site, such as the abdomen. Drop short-acting insulin by 30% prior to exercising for 1 hour, by 40% for 2 hours, and by 50% for 3 hours, he suggested.

Avoid evening exercise to minimize risk of nighttime hypoglycemia. “Usually morning is the best time for exercise for type 1 diabetics, especially before the morning dose of insulin,” Dr. Cardone said.

“The general rule is that if glucose is greater than 250 before exercise, it is better to hold off until their number lowers. If glucose is less than 100, supplement before exercising,” he said.

The most effective combination for type 1 diabetics is insulin lispro plus Ultralente, Dr. Cardone said. It is easier to control blood sugar while exercising. The literature supports a good response, especially in high-level athletes, he said.

For the nondiabetic athlete, glucose falls off slowly over time but stays within a therapeutic range. In contrast, “glucose can be all over the place” for the exercising diabetic, Dr. Cardone said. Instruct patients to monitor glucose, hydrate, and increase caloric intake 12–24 hours after exercise, he said.

Causes of hypoglycemia include too much preexercise insulin, increased absorption from the injection site, inadequate caloric intake, and spontaneous activity.

“Most of the athletes with diabetes who become hypoglycemic run into problems after exercise, up to 24 hours after activity. They don't have the mechanism to shut off endogenous insulin.” Whole milk and sports drinks can be effective prevention, he added.

SAN JUAN, P.R. – Women who experience stressful life events, especially trauma, together with depression have a shorter time to breast cancer progression than women with no such history, Dr. David Spiegel said at the annual meeting of the American College of Psychiatrists.

Based on this study, which is under review, screening women with breast cancer for depression and stressful and/or traumatic life events might be worthwhile, said Dr. Spiegel, Willson Professor at Stanford (Calif.) University.

In a second study he conducted with Janine Giese-Davis, Ph.D., antidepressant treatment improved survival in this population. Improving depression might improve breast cancer prognosis independent of other risk factors that affect survival, such as metastatic spread of disease, he said.

So what is the connection? The combination of trauma and depression may dysregulate the hypothalamic-pituitary-adrenal (HPA) axis and lead to more stress among women with breast cancer. “Our breast cancer patients look more like depressed patients than healthy people, which means they may share some aspect of HPA dysregulation,” Dr. Spiegel said.

Stressful life events can diminish a person's ability to handle subsequent challenges, including cancer. Diminished physical capability, changes in social environment and family roles, difficult treatments, fear, pain, and facing mortality can all cause stress in women with breast cancer.

“Cancer is a chronic and severe stressor with constant reminders because of its effects on the body,” said Dr. Spiegel, who is also a member of the university's comprehensive cancer center.

Chronic stress causes changes to brain structures and the endocrine system, according to neuroimaging and other studies in humans and animals. Specifically, researchers have found that stress alters the size and/or activation of the hippocampus and amygdala.

“A smaller amygdala and hippocampus do not buffer a patient from the effects of stressful life situations as well,” he said.

Other researchers determined that serious life events increase risk of cancer (Am. J. Epidemiol. 2003;157:415–23).

This prospective study included 10,808 women in Finland surveyed in 1981 about adverse life events. A total of 180 incident cases of breast cancer occurred between 1982 and 1996. Participants who reported any single event had a slightly elevated risk of breast cancer compared with controls (hazard ratio, 1.07). The risk increased with a major event (1.35), death of close relative or friend (1.36), death of husband (2.00), and divorce or separation (2.26). “The findings suggest a role for life events in breast cancer etiology through hormonal or other mechanisms,” the researchers wrote.

“We looked at our own data, and those with an early stress, especially early trauma, have a shorter time to progression of breast cancer from diagnosis compared to women with no such history,” Dr. Spiegel said.

Stress is not the only culprit. “A shorter disease-free interval has also been shown with depression,” and the study he conducted with Dr. Giese-Davis showed that “if you treat depression, you can improve survival,” he said.

Stress can also adversely affect the endocrine system. People with posttraumatic stress disorder or depression tend to have constant levels of cortisol throughout the day. Normally, cortisol levels increase and decrease according to a circadian rhythm. “Waking up is stressful–think of getting up this morning,” Dr. Spiegel said, “and in healthy individuals, cortisol levels are five times higher in the morning compared to at bedtime.”

He and another group of investigators have published data showing that these abnormal cortisol patterns predict shorter survival with breast cancer (J. Natl. Cancer Inst. 2000;92:994–1000).

When a person attending the meeting asked about changes in catecholamine levels, Dr. Spiegel said, “We did not measure that–cortisol is easier to measure.”

Dr. Spiegel said that patients with relatively flat cortisol slopes have fewer natural killer cells. As breast cancer progresses, natural killer cell levels tend to decrease “so it's a salient finding, because this component of the immune system is linked to cancer progression.

“We are trying to construct a model that links a history of stress or trauma to progression of cancer,” he said.

'Our breast cancer patients look more like depressed patients than healthy people.' DR. SPIEGEL

SAN JUAN, P.R. – Women who experience stressful life events, especially trauma, together with depression have a shorter time to breast cancer progression than women with no such history, Dr. David Spiegel said at the annual meeting of the American College of Psychiatrists.

Based on this study, which is under review, screening women with breast cancer for depression and stressful and/or traumatic life events might be worthwhile, said Dr. Spiegel, Willson Professor at Stanford (Calif.) University.

In a second study he conducted with Janine Giese-Davis, Ph.D., antidepressant treatment improved survival in this population. Improving depression might improve breast cancer prognosis independent of other risk factors that affect survival, such as metastatic spread of disease, he said.

So what is the connection? The combination of trauma and depression may dysregulate the hypothalamic-pituitary-adrenal (HPA) axis and lead to more stress among women with breast cancer. “Our breast cancer patients look more like depressed patients than healthy people, which means they may share some aspect of HPA dysregulation,” Dr. Spiegel said.

Stressful life events can diminish a person's ability to handle subsequent challenges, including cancer. Diminished physical capability, changes in social environment and family roles, difficult treatments, fear, pain, and facing mortality can all cause stress in women with breast cancer.

“Cancer is a chronic and severe stressor with constant reminders because of its effects on the body,” said Dr. Spiegel, who is also a member of the university's comprehensive cancer center.

Chronic stress causes changes to brain structures and the endocrine system, according to neuroimaging and other studies in humans and animals. Specifically, researchers have found that stress alters the size and/or activation of the hippocampus and amygdala.

“A smaller amygdala and hippocampus do not buffer a patient from the effects of stressful life situations as well,” he said.

Other researchers determined that serious life events increase risk of cancer (Am. J. Epidemiol. 2003;157:415–23).

This prospective study included 10,808 women in Finland surveyed in 1981 about adverse life events. A total of 180 incident cases of breast cancer occurred between 1982 and 1996. Participants who reported any single event had a slightly elevated risk of breast cancer compared with controls (hazard ratio, 1.07). The risk increased with a major event (1.35), death of close relative or friend (1.36), death of husband (2.00), and divorce or separation (2.26). “The findings suggest a role for life events in breast cancer etiology through hormonal or other mechanisms,” the researchers wrote.

“We looked at our own data, and those with an early stress, especially early trauma, have a shorter time to progression of breast cancer from diagnosis compared to women with no such history,” Dr. Spiegel said.

Stress is not the only culprit. “A shorter disease-free interval has also been shown with depression,” and the study he conducted with Dr. Giese-Davis showed that “if you treat depression, you can improve survival,” he said.

Stress can also adversely affect the endocrine system. People with posttraumatic stress disorder or depression tend to have constant levels of cortisol throughout the day. Normally, cortisol levels increase and decrease according to a circadian rhythm. “Waking up is stressful–think of getting up this morning,” Dr. Spiegel said, “and in healthy individuals, cortisol levels are five times higher in the morning compared to at bedtime.”

He and another group of investigators have published data showing that these abnormal cortisol patterns predict shorter survival with breast cancer (J. Natl. Cancer Inst. 2000;92:994–1000).

When a person attending the meeting asked about changes in catecholamine levels, Dr. Spiegel said, “We did not measure that–cortisol is easier to measure.”

Dr. Spiegel said that patients with relatively flat cortisol slopes have fewer natural killer cells. As breast cancer progresses, natural killer cell levels tend to decrease “so it's a salient finding, because this component of the immune system is linked to cancer progression.

“We are trying to construct a model that links a history of stress or trauma to progression of cancer,” he said.

'Our breast cancer patients look more like depressed patients than healthy people.' DR. SPIEGEL

SAN JUAN, P.R. – Women who experience stressful life events, especially trauma, together with depression have a shorter time to breast cancer progression than women with no such history, Dr. David Spiegel said at the annual meeting of the American College of Psychiatrists.

Based on this study, which is under review, screening women with breast cancer for depression and stressful and/or traumatic life events might be worthwhile, said Dr. Spiegel, Willson Professor at Stanford (Calif.) University.

In a second study he conducted with Janine Giese-Davis, Ph.D., antidepressant treatment improved survival in this population. Improving depression might improve breast cancer prognosis independent of other risk factors that affect survival, such as metastatic spread of disease, he said.

So what is the connection? The combination of trauma and depression may dysregulate the hypothalamic-pituitary-adrenal (HPA) axis and lead to more stress among women with breast cancer. “Our breast cancer patients look more like depressed patients than healthy people, which means they may share some aspect of HPA dysregulation,” Dr. Spiegel said.

Stressful life events can diminish a person's ability to handle subsequent challenges, including cancer. Diminished physical capability, changes in social environment and family roles, difficult treatments, fear, pain, and facing mortality can all cause stress in women with breast cancer.

“Cancer is a chronic and severe stressor with constant reminders because of its effects on the body,” said Dr. Spiegel, who is also a member of the university's comprehensive cancer center.

Chronic stress causes changes to brain structures and the endocrine system, according to neuroimaging and other studies in humans and animals. Specifically, researchers have found that stress alters the size and/or activation of the hippocampus and amygdala.

“A smaller amygdala and hippocampus do not buffer a patient from the effects of stressful life situations as well,” he said.

Other researchers determined that serious life events increase risk of cancer (Am. J. Epidemiol. 2003;157:415–23).

This prospective study included 10,808 women in Finland surveyed in 1981 about adverse life events. A total of 180 incident cases of breast cancer occurred between 1982 and 1996. Participants who reported any single event had a slightly elevated risk of breast cancer compared with controls (hazard ratio, 1.07). The risk increased with a major event (1.35), death of close relative or friend (1.36), death of husband (2.00), and divorce or separation (2.26). “The findings suggest a role for life events in breast cancer etiology through hormonal or other mechanisms,” the researchers wrote.

“We looked at our own data, and those with an early stress, especially early trauma, have a shorter time to progression of breast cancer from diagnosis compared to women with no such history,” Dr. Spiegel said.

Stress is not the only culprit. “A shorter disease-free interval has also been shown with depression,” and the study he conducted with Dr. Giese-Davis showed that “if you treat depression, you can improve survival,” he said.

Stress can also adversely affect the endocrine system. People with posttraumatic stress disorder or depression tend to have constant levels of cortisol throughout the day. Normally, cortisol levels increase and decrease according to a circadian rhythm. “Waking up is stressful–think of getting up this morning,” Dr. Spiegel said, “and in healthy individuals, cortisol levels are five times higher in the morning compared to at bedtime.”

He and another group of investigators have published data showing that these abnormal cortisol patterns predict shorter survival with breast cancer (J. Natl. Cancer Inst. 2000;92:994–1000).

When a person attending the meeting asked about changes in catecholamine levels, Dr. Spiegel said, “We did not measure that–cortisol is easier to measure.”

Dr. Spiegel said that patients with relatively flat cortisol slopes have fewer natural killer cells. As breast cancer progresses, natural killer cell levels tend to decrease “so it's a salient finding, because this component of the immune system is linked to cancer progression.

“We are trying to construct a model that links a history of stress or trauma to progression of cancer,” he said.

'Our breast cancer patients look more like depressed patients than healthy people.' DR. SPIEGEL

MIAMI – People with anxiety often present with insomnia, but evidence suggests that untreated insomnia might precipitate anxiety disorders, according to a presentation at the annual conference of the Anxiety Disorders Association of America.

“We know as psychiatrists that anxiety disorders produce insomnia. But now we have evidence that insomnia is a risk factor for future psychiatric disorders, in particular, anxiety disorder,” Dr. John W. Winkelman said.

Anxiety disorders are the most common psychiatric disorders, affecting more than 19 million Americans per year (N. Engl. J. Med. 2005;353:803–10). In addition, insomnia is the most common sleep disorder–an estimated 10%–15% of the general population has chronic insomnia (J. Clin. Psychiatry 2005;66[Suppl. 9]:14–7).

“By no other mechanism, these would have a significant overlap, but it's not just coincidence,” said Dr. Winkelman of the Sleep Health Center, Brigham and Women's Hospital, Boston.

“Often, patients with insomnia are referred to us by a primary care provider with the assumption that there is a psychiatric disorder, but 60% do not have one,” Dr. Winkelman said. “But if they do, anxiety disorders are the most common.”

Differential diagnosis between insomnia and anxiety can be challenging because of substantial overlap in presenting symptoms. Worry, agitation, irritability, loss of appetite, impaired concentration, loss of interest, sleep disturbance, hopelessness, and fatigue are examples. These shared signs “might tell us something about the underlying physiology,” he said.

Insomnia is a presenting symptom of anxiety disorders (Clin. Ther. 2000;22[Suppl A]:A3–19). Insomnia can also be a side effect of anxiety treatment or a residual symptom after treatment (Biol. Psychiatry 1995;37:85–98). Both subjective and objective studies in generalized anxiety disorder (GAD) document increased sleep latency, decreased sleep efficiency, and decreased total sleep time, he said.

“In PTSD, things get even uglier,” he said. Hypervigilance is a diagnostic criterion for posttraumatic stress disorder. Most patients will have sleep problems, including nightmares and difficulty with sleep onset and duration. “However, objectively, we have not been able to demonstrate worse sleep in people with PTSD in sleep lab studies.”

Some patients with insomnia develop conditioned fear of the sleep environment. Typically, this “insomnia phobia” begins with repeated episodes of acute insomnia, and is maintained by negative associations that produce anxiety and hyperarousal. “From my perspective, this is an anxiety disorder,” Dr. Winkelman said. “Perpetuating factors increase in strength, and this is where we see patients.”

Whole brain hypermetabolism is present during both wake and sleep in insomniacs, he said. “There is a relationship between cognitive arousal and insomnia–we can't prove it is causal yet–but it is why cognitive-behavioral therapy is effective.”

Cognitive-behavioral therapy, or CBT, helps people with insomnia fall asleep faster and stay asleep, Dr. Winkelman said, but it does not extend total sleep time. CBT gives people more confidence that they can sleep. Although CBT has a role, he added, “For the subset of people with very severe insomnia, I would start with medication to quell the situation first.” He suggested use of benzodiazepines rather than antidepressants because the latter can significantly alter sleep architecture.

And insomnia might precipitate an anxiety disorder. In one study, researchers found that persistent insomnia lasting at least a year was associated with new onset of an anxiety disorder (Gen. Hosp. Psychiatry 1997;19:245–50).

These studies are only suggestive, Dr. Winkelman said, and data are not strong enough yet to establish a causal relationship. In the meantime, he said, “we should aggressively treat insomnia. It's not just a minor quality of life issue.”

MIAMI – People with anxiety often present with insomnia, but evidence suggests that untreated insomnia might precipitate anxiety disorders, according to a presentation at the annual conference of the Anxiety Disorders Association of America.

“We know as psychiatrists that anxiety disorders produce insomnia. But now we have evidence that insomnia is a risk factor for future psychiatric disorders, in particular, anxiety disorder,” Dr. John W. Winkelman said.

Anxiety disorders are the most common psychiatric disorders, affecting more than 19 million Americans per year (N. Engl. J. Med. 2005;353:803–10). In addition, insomnia is the most common sleep disorder–an estimated 10%–15% of the general population has chronic insomnia (J. Clin. Psychiatry 2005;66[Suppl. 9]:14–7).

“By no other mechanism, these would have a significant overlap, but it's not just coincidence,” said Dr. Winkelman of the Sleep Health Center, Brigham and Women's Hospital, Boston.

“Often, patients with insomnia are referred to us by a primary care provider with the assumption that there is a psychiatric disorder, but 60% do not have one,” Dr. Winkelman said. “But if they do, anxiety disorders are the most common.”

Differential diagnosis between insomnia and anxiety can be challenging because of substantial overlap in presenting symptoms. Worry, agitation, irritability, loss of appetite, impaired concentration, loss of interest, sleep disturbance, hopelessness, and fatigue are examples. These shared signs “might tell us something about the underlying physiology,” he said.

Insomnia is a presenting symptom of anxiety disorders (Clin. Ther. 2000;22[Suppl A]:A3–19). Insomnia can also be a side effect of anxiety treatment or a residual symptom after treatment (Biol. Psychiatry 1995;37:85–98). Both subjective and objective studies in generalized anxiety disorder (GAD) document increased sleep latency, decreased sleep efficiency, and decreased total sleep time, he said.

“In PTSD, things get even uglier,” he said. Hypervigilance is a diagnostic criterion for posttraumatic stress disorder. Most patients will have sleep problems, including nightmares and difficulty with sleep onset and duration. “However, objectively, we have not been able to demonstrate worse sleep in people with PTSD in sleep lab studies.”

Some patients with insomnia develop conditioned fear of the sleep environment. Typically, this “insomnia phobia” begins with repeated episodes of acute insomnia, and is maintained by negative associations that produce anxiety and hyperarousal. “From my perspective, this is an anxiety disorder,” Dr. Winkelman said. “Perpetuating factors increase in strength, and this is where we see patients.”

Whole brain hypermetabolism is present during both wake and sleep in insomniacs, he said. “There is a relationship between cognitive arousal and insomnia–we can't prove it is causal yet–but it is why cognitive-behavioral therapy is effective.”

Cognitive-behavioral therapy, or CBT, helps people with insomnia fall asleep faster and stay asleep, Dr. Winkelman said, but it does not extend total sleep time. CBT gives people more confidence that they can sleep. Although CBT has a role, he added, “For the subset of people with very severe insomnia, I would start with medication to quell the situation first.” He suggested use of benzodiazepines rather than antidepressants because the latter can significantly alter sleep architecture.

And insomnia might precipitate an anxiety disorder. In one study, researchers found that persistent insomnia lasting at least a year was associated with new onset of an anxiety disorder (Gen. Hosp. Psychiatry 1997;19:245–50).

These studies are only suggestive, Dr. Winkelman said, and data are not strong enough yet to establish a causal relationship. In the meantime, he said, “we should aggressively treat insomnia. It's not just a minor quality of life issue.”

MIAMI – People with anxiety often present with insomnia, but evidence suggests that untreated insomnia might precipitate anxiety disorders, according to a presentation at the annual conference of the Anxiety Disorders Association of America.

“We know as psychiatrists that anxiety disorders produce insomnia. But now we have evidence that insomnia is a risk factor for future psychiatric disorders, in particular, anxiety disorder,” Dr. John W. Winkelman said.

Anxiety disorders are the most common psychiatric disorders, affecting more than 19 million Americans per year (N. Engl. J. Med. 2005;353:803–10). In addition, insomnia is the most common sleep disorder–an estimated 10%–15% of the general population has chronic insomnia (J. Clin. Psychiatry 2005;66[Suppl. 9]:14–7).

“By no other mechanism, these would have a significant overlap, but it's not just coincidence,” said Dr. Winkelman of the Sleep Health Center, Brigham and Women's Hospital, Boston.

“Often, patients with insomnia are referred to us by a primary care provider with the assumption that there is a psychiatric disorder, but 60% do not have one,” Dr. Winkelman said. “But if they do, anxiety disorders are the most common.”

Differential diagnosis between insomnia and anxiety can be challenging because of substantial overlap in presenting symptoms. Worry, agitation, irritability, loss of appetite, impaired concentration, loss of interest, sleep disturbance, hopelessness, and fatigue are examples. These shared signs “might tell us something about the underlying physiology,” he said.

Insomnia is a presenting symptom of anxiety disorders (Clin. Ther. 2000;22[Suppl A]:A3–19). Insomnia can also be a side effect of anxiety treatment or a residual symptom after treatment (Biol. Psychiatry 1995;37:85–98). Both subjective and objective studies in generalized anxiety disorder (GAD) document increased sleep latency, decreased sleep efficiency, and decreased total sleep time, he said.

“In PTSD, things get even uglier,” he said. Hypervigilance is a diagnostic criterion for posttraumatic stress disorder. Most patients will have sleep problems, including nightmares and difficulty with sleep onset and duration. “However, objectively, we have not been able to demonstrate worse sleep in people with PTSD in sleep lab studies.”

Some patients with insomnia develop conditioned fear of the sleep environment. Typically, this “insomnia phobia” begins with repeated episodes of acute insomnia, and is maintained by negative associations that produce anxiety and hyperarousal. “From my perspective, this is an anxiety disorder,” Dr. Winkelman said. “Perpetuating factors increase in strength, and this is where we see patients.”

Whole brain hypermetabolism is present during both wake and sleep in insomniacs, he said. “There is a relationship between cognitive arousal and insomnia–we can't prove it is causal yet–but it is why cognitive-behavioral therapy is effective.”

Cognitive-behavioral therapy, or CBT, helps people with insomnia fall asleep faster and stay asleep, Dr. Winkelman said, but it does not extend total sleep time. CBT gives people more confidence that they can sleep. Although CBT has a role, he added, “For the subset of people with very severe insomnia, I would start with medication to quell the situation first.” He suggested use of benzodiazepines rather than antidepressants because the latter can significantly alter sleep architecture.

And insomnia might precipitate an anxiety disorder. In one study, researchers found that persistent insomnia lasting at least a year was associated with new onset of an anxiety disorder (Gen. Hosp. Psychiatry 1997;19:245–50).

These studies are only suggestive, Dr. Winkelman said, and data are not strong enough yet to establish a causal relationship. In the meantime, he said, “we should aggressively treat insomnia. It's not just a minor quality of life issue.”

SAN JUAN, P.R. – Stress can cause structural remodeling of the brain that can have short-term advantages, but if left unchecked, the changes can contribute to psychopathology, according to a presentation by a neuroendocrinologist at the annual meeting of the American College of Psychiatrists.

“The brain is capable of a lot of structural remodeling. The amygdala, hippocampus, and prefrontal cortex show remodeling that may be coordinated among these areas via neural connections,” said Bruce S. McEwen, Ph.D. Many mediators play a role, including insulin, glucose, and cytokines, neuroendocrinology studies show.

“Neuroscientists tended to think from the neck up, and endocrinologists tend to think from the neck down. So for a long time I was in between. But there is a growing appreciation of the mind-body connection [regarding stress],” said Dr. McEwen, Alfred E. Mirsky professor and head of the Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, Rockefeller University, N.Y.

The downside of stress is well known. Dr. McEwen defined it as “the general process through which environmental demands result in outcomes deleterious to health.” Less appreciated are the positive aspects of stress, he said. For example, the stress response is how the body adapts in the face of a real or imagined threat to homeostasis. “Many people think of stress as a bad word with damaging effect on the body. The other side is stress is a challenge, and without our stress response hormones, we would not live long,” Dr. McEwen said. “A challenge can be invigorating as long as we can feel in command of the situation.” Dr. McEwen's insights come in part from his animal studies and in part from his work on humans in his neuroendocrinology lab.

Glucocorticoids such as cortisol can have beneficial and damaging effects, depending on the timing and duration of their release. For example, during acute stress, cortisol enhances immunity, memory, energy replenishment, and cardiovascular function, Dr. McEwen said. However, everything changes when chronic stress induces chronically high levels of cortisol. In this setting, cortisol suppresses immune function and memory, promotes bone mineral loss and muscle wasting, and increases long-term risks for metabolic syndrome and cardiovascular disease.

The body releases stress hormones in an attempt to return to homeostasis after an acutely stressful event. Chronic stress, however, can cause the body to maintain a different baseline state, called allostasis, Dr. McEwen said. Many elements–together called the “allostatic load”–can contribute to this altered state. Sleep deprivation, for example, is a common chronic stressor. People who are sleep deprived have increased blood pressure; elevated evening cortisol, glucose, and insulin levels; elevated inflammatory cytokine levels; increased appetite; depressed mood; and impaired cognitive function.

The adverse effects are many. “When you are 'stressed out,' you feel overwhelmed, out of control, exhausted, anxious, frustrated, or angry,” Dr. McEwen said. “Often you lose sleep, eat too much of the wrong things, drink excess alcohol, smoke, and neglect regular, moderate exercise.” The stress response spurs activation of many other mediators besides cortisol. Examples include the autonomic nervous system, prolactin, thyroid hormone, inflammatory cytokines, and other components of the neuroendocrine system and immune system.

“We have to recognize that the body works in this nonlinear fashion,” Dr. McEwen said.

He and his associates study “social neuroscience,” or how a person's social environment can have profound effects on brain function. Influences include daily stressors at home and work as well as major life events. “The brain's response determines not only the physiologic response to stress that leads to allostasis, but [also] the healthy behavioral responses, such as exercising, or detrimental responses, such as overeating or smoking, that can lead to allostatic overload.”

The hippocampus is a target for stress hormones. Structural changes are mostly seen in depression, he said. Patients with depression are more likely to have atrophy of the hippocampus and prefrontal cortex. Glucose, insulin, insulinlike growth factor 1, lipopolysaccharide, proinflammatory cytokines, and sex hormones are external factors that affect the hippocampus. “All of these may have an influence on mood and memory,” he said. “Recent evidence suggests [that the] hippocampus plays a bigger role than we thought in mood.”

SAN JUAN, P.R. – Stress can cause structural remodeling of the brain that can have short-term advantages, but if left unchecked, the changes can contribute to psychopathology, according to a presentation by a neuroendocrinologist at the annual meeting of the American College of Psychiatrists.

“The brain is capable of a lot of structural remodeling. The amygdala, hippocampus, and prefrontal cortex show remodeling that may be coordinated among these areas via neural connections,” said Bruce S. McEwen, Ph.D. Many mediators play a role, including insulin, glucose, and cytokines, neuroendocrinology studies show.

“Neuroscientists tended to think from the neck up, and endocrinologists tend to think from the neck down. So for a long time I was in between. But there is a growing appreciation of the mind-body connection [regarding stress],” said Dr. McEwen, Alfred E. Mirsky professor and head of the Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, Rockefeller University, N.Y.

The downside of stress is well known. Dr. McEwen defined it as “the general process through which environmental demands result in outcomes deleterious to health.” Less appreciated are the positive aspects of stress, he said. For example, the stress response is how the body adapts in the face of a real or imagined threat to homeostasis. “Many people think of stress as a bad word with damaging effect on the body. The other side is stress is a challenge, and without our stress response hormones, we would not live long,” Dr. McEwen said. “A challenge can be invigorating as long as we can feel in command of the situation.” Dr. McEwen's insights come in part from his animal studies and in part from his work on humans in his neuroendocrinology lab.

Glucocorticoids such as cortisol can have beneficial and damaging effects, depending on the timing and duration of their release. For example, during acute stress, cortisol enhances immunity, memory, energy replenishment, and cardiovascular function, Dr. McEwen said. However, everything changes when chronic stress induces chronically high levels of cortisol. In this setting, cortisol suppresses immune function and memory, promotes bone mineral loss and muscle wasting, and increases long-term risks for metabolic syndrome and cardiovascular disease.

The body releases stress hormones in an attempt to return to homeostasis after an acutely stressful event. Chronic stress, however, can cause the body to maintain a different baseline state, called allostasis, Dr. McEwen said. Many elements–together called the “allostatic load”–can contribute to this altered state. Sleep deprivation, for example, is a common chronic stressor. People who are sleep deprived have increased blood pressure; elevated evening cortisol, glucose, and insulin levels; elevated inflammatory cytokine levels; increased appetite; depressed mood; and impaired cognitive function.

The adverse effects are many. “When you are 'stressed out,' you feel overwhelmed, out of control, exhausted, anxious, frustrated, or angry,” Dr. McEwen said. “Often you lose sleep, eat too much of the wrong things, drink excess alcohol, smoke, and neglect regular, moderate exercise.” The stress response spurs activation of many other mediators besides cortisol. Examples include the autonomic nervous system, prolactin, thyroid hormone, inflammatory cytokines, and other components of the neuroendocrine system and immune system.

“We have to recognize that the body works in this nonlinear fashion,” Dr. McEwen said.

He and his associates study “social neuroscience,” or how a person's social environment can have profound effects on brain function. Influences include daily stressors at home and work as well as major life events. “The brain's response determines not only the physiologic response to stress that leads to allostasis, but [also] the healthy behavioral responses, such as exercising, or detrimental responses, such as overeating or smoking, that can lead to allostatic overload.”

The hippocampus is a target for stress hormones. Structural changes are mostly seen in depression, he said. Patients with depression are more likely to have atrophy of the hippocampus and prefrontal cortex. Glucose, insulin, insulinlike growth factor 1, lipopolysaccharide, proinflammatory cytokines, and sex hormones are external factors that affect the hippocampus. “All of these may have an influence on mood and memory,” he said. “Recent evidence suggests [that the] hippocampus plays a bigger role than we thought in mood.”

SAN JUAN, P.R. – Stress can cause structural remodeling of the brain that can have short-term advantages, but if left unchecked, the changes can contribute to psychopathology, according to a presentation by a neuroendocrinologist at the annual meeting of the American College of Psychiatrists.

“The brain is capable of a lot of structural remodeling. The amygdala, hippocampus, and prefrontal cortex show remodeling that may be coordinated among these areas via neural connections,” said Bruce S. McEwen, Ph.D. Many mediators play a role, including insulin, glucose, and cytokines, neuroendocrinology studies show.

“Neuroscientists tended to think from the neck up, and endocrinologists tend to think from the neck down. So for a long time I was in between. But there is a growing appreciation of the mind-body connection [regarding stress],” said Dr. McEwen, Alfred E. Mirsky professor and head of the Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, Rockefeller University, N.Y.

The downside of stress is well known. Dr. McEwen defined it as “the general process through which environmental demands result in outcomes deleterious to health.” Less appreciated are the positive aspects of stress, he said. For example, the stress response is how the body adapts in the face of a real or imagined threat to homeostasis. “Many people think of stress as a bad word with damaging effect on the body. The other side is stress is a challenge, and without our stress response hormones, we would not live long,” Dr. McEwen said. “A challenge can be invigorating as long as we can feel in command of the situation.” Dr. McEwen's insights come in part from his animal studies and in part from his work on humans in his neuroendocrinology lab.

Glucocorticoids such as cortisol can have beneficial and damaging effects, depending on the timing and duration of their release. For example, during acute stress, cortisol enhances immunity, memory, energy replenishment, and cardiovascular function, Dr. McEwen said. However, everything changes when chronic stress induces chronically high levels of cortisol. In this setting, cortisol suppresses immune function and memory, promotes bone mineral loss and muscle wasting, and increases long-term risks for metabolic syndrome and cardiovascular disease.

The body releases stress hormones in an attempt to return to homeostasis after an acutely stressful event. Chronic stress, however, can cause the body to maintain a different baseline state, called allostasis, Dr. McEwen said. Many elements–together called the “allostatic load”–can contribute to this altered state. Sleep deprivation, for example, is a common chronic stressor. People who are sleep deprived have increased blood pressure; elevated evening cortisol, glucose, and insulin levels; elevated inflammatory cytokine levels; increased appetite; depressed mood; and impaired cognitive function.

The adverse effects are many. “When you are 'stressed out,' you feel overwhelmed, out of control, exhausted, anxious, frustrated, or angry,” Dr. McEwen said. “Often you lose sleep, eat too much of the wrong things, drink excess alcohol, smoke, and neglect regular, moderate exercise.” The stress response spurs activation of many other mediators besides cortisol. Examples include the autonomic nervous system, prolactin, thyroid hormone, inflammatory cytokines, and other components of the neuroendocrine system and immune system.

“We have to recognize that the body works in this nonlinear fashion,” Dr. McEwen said.

He and his associates study “social neuroscience,” or how a person's social environment can have profound effects on brain function. Influences include daily stressors at home and work as well as major life events. “The brain's response determines not only the physiologic response to stress that leads to allostasis, but [also] the healthy behavioral responses, such as exercising, or detrimental responses, such as overeating or smoking, that can lead to allostatic overload.”

The hippocampus is a target for stress hormones. Structural changes are mostly seen in depression, he said. Patients with depression are more likely to have atrophy of the hippocampus and prefrontal cortex. Glucose, insulin, insulinlike growth factor 1, lipopolysaccharide, proinflammatory cytokines, and sex hormones are external factors that affect the hippocampus. “All of these may have an influence on mood and memory,” he said. “Recent evidence suggests [that the] hippocampus plays a bigger role than we thought in mood.”

MIAMI – Higher self-reported alcohol consumption among men with panic attacks carries important implications for patient screening, according to a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“The take-home message for physicians is to look for comorbidity in men with panic attacks for alcohol use and other substances,” Erin Marshall said in an interview.

Previous research indicated a relationship between panic attacks and drinking behaviors. “It could be a coping mechanism–people with panic attacks drink more than people without panic attacks,” said Ms. Marshall, doctoral student in clinical psychology at the University of Vermont at Burlington.

To assess associations between panic attacks, alcohol consumption, and gender, Ms. Marshall and her colleagues studied 413 college students in Mexico City. One of the collaborators, Samuel J. Cardenas, Ph.D., of the Universidad Nacional Autonoma de Mexico, facilitated recruitment of participants.

A total of 61% of participants were female. Each student completed self-report measures about substance use patterns and panic attack history. “We found men with panic are drinking the most,” Ms. Marshall said.

As predicted, individuals experiencing panic attacks were significantly more likely to drink alcohol (P less than .01), as were males (P less than .001). In addition, “the interaction of panic attacks and gender incrementally predicted levels of alcohol consumption (P less than .001), such that the association between panic attacks and alcohol consumption was stronger in men than women,” the authors wrote.

“There was a nonsignificant difference in women between those with panic attacks and those with no panic,” Ms. Marshall said.

The findings of this study are a starting point for future research. The present research only assessed alcohol consumption and, she added, it might be useful next to study people with alcohol abuse.

MIAMI – Higher self-reported alcohol consumption among men with panic attacks carries important implications for patient screening, according to a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“The take-home message for physicians is to look for comorbidity in men with panic attacks for alcohol use and other substances,” Erin Marshall said in an interview.

Previous research indicated a relationship between panic attacks and drinking behaviors. “It could be a coping mechanism–people with panic attacks drink more than people without panic attacks,” said Ms. Marshall, doctoral student in clinical psychology at the University of Vermont at Burlington.

To assess associations between panic attacks, alcohol consumption, and gender, Ms. Marshall and her colleagues studied 413 college students in Mexico City. One of the collaborators, Samuel J. Cardenas, Ph.D., of the Universidad Nacional Autonoma de Mexico, facilitated recruitment of participants.

A total of 61% of participants were female. Each student completed self-report measures about substance use patterns and panic attack history. “We found men with panic are drinking the most,” Ms. Marshall said.

As predicted, individuals experiencing panic attacks were significantly more likely to drink alcohol (P less than .01), as were males (P less than .001). In addition, “the interaction of panic attacks and gender incrementally predicted levels of alcohol consumption (P less than .001), such that the association between panic attacks and alcohol consumption was stronger in men than women,” the authors wrote.

“There was a nonsignificant difference in women between those with panic attacks and those with no panic,” Ms. Marshall said.

The findings of this study are a starting point for future research. The present research only assessed alcohol consumption and, she added, it might be useful next to study people with alcohol abuse.

MIAMI – Higher self-reported alcohol consumption among men with panic attacks carries important implications for patient screening, according to a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“The take-home message for physicians is to look for comorbidity in men with panic attacks for alcohol use and other substances,” Erin Marshall said in an interview.

Previous research indicated a relationship between panic attacks and drinking behaviors. “It could be a coping mechanism–people with panic attacks drink more than people without panic attacks,” said Ms. Marshall, doctoral student in clinical psychology at the University of Vermont at Burlington.

To assess associations between panic attacks, alcohol consumption, and gender, Ms. Marshall and her colleagues studied 413 college students in Mexico City. One of the collaborators, Samuel J. Cardenas, Ph.D., of the Universidad Nacional Autonoma de Mexico, facilitated recruitment of participants.

A total of 61% of participants were female. Each student completed self-report measures about substance use patterns and panic attack history. “We found men with panic are drinking the most,” Ms. Marshall said.

As predicted, individuals experiencing panic attacks were significantly more likely to drink alcohol (P less than .01), as were males (P less than .001). In addition, “the interaction of panic attacks and gender incrementally predicted levels of alcohol consumption (P less than .001), such that the association between panic attacks and alcohol consumption was stronger in men than women,” the authors wrote.

“There was a nonsignificant difference in women between those with panic attacks and those with no panic,” Ms. Marshall said.

The findings of this study are a starting point for future research. The present research only assessed alcohol consumption and, she added, it might be useful next to study people with alcohol abuse.

JACKSONVILLE, FLA. — A majority of privately insured women tested for chlamydia are also checked for gonorrhea, which may be unnecessary given its significantly lower incidence, according to a study presented at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

“Gonorrhea is much more rare. Chlamydia incidence is 5%–7% versus less than 1% for gonorrhea,” Thomas L. Gift, Ph.D., said in an interview at his poster session.

Screening of all sexually active adolescents and females 25 years or younger for chlamydia is recommended by the CDC. However, screening for gonorrhea is recommended only for those at high risk of sexually transmitted diseases.

Dr. Gift and his associate Michele K. Bohm identified 61,183 females aged 15–65 years who were tested for chlamydia, gonorrhea, or both in 2001. They searched outpatient claims in the Medstat Marketscan Database of approximately 4 million privately insured patients. They looked for current procedures terminology codes specific to chlamydia testing or gonorrhea testing. DNA direct or amplified dual-assay codes were also included in the study.

Patients were tested for chlamydia on 66,070 occasions and for gonorrhea on 58,163 occasions. They were tested for both chlamydia and gonorrhea on 56,371 of these occasions, suggesting frequent use of dual testing assays. “Eighty-five percent of the time we found a gonorrhea test on the same day on the chart as the chlamydia test,” said Dr. Gift, an economist in the division of STD prevention at the CDC.

“There are a lot of people being tested for gonorrhea when they shouldn't be,” he said.

The costs can be more than economic—there are false-positive concerns with sexually transmitted infections (STIs), Dr. Gift said. “There is such a host of undefinable costs—for example, an STD diagnosis in a monogamous relationship. The prudent thing is to treat just in case, but there is wreckage strewn around by suggesting someone has an STI.”

JACKSONVILLE, FLA. — A majority of privately insured women tested for chlamydia are also checked for gonorrhea, which may be unnecessary given its significantly lower incidence, according to a study presented at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

“Gonorrhea is much more rare. Chlamydia incidence is 5%–7% versus less than 1% for gonorrhea,” Thomas L. Gift, Ph.D., said in an interview at his poster session.

Screening of all sexually active adolescents and females 25 years or younger for chlamydia is recommended by the CDC. However, screening for gonorrhea is recommended only for those at high risk of sexually transmitted diseases.

Dr. Gift and his associate Michele K. Bohm identified 61,183 females aged 15–65 years who were tested for chlamydia, gonorrhea, or both in 2001. They searched outpatient claims in the Medstat Marketscan Database of approximately 4 million privately insured patients. They looked for current procedures terminology codes specific to chlamydia testing or gonorrhea testing. DNA direct or amplified dual-assay codes were also included in the study.

Patients were tested for chlamydia on 66,070 occasions and for gonorrhea on 58,163 occasions. They were tested for both chlamydia and gonorrhea on 56,371 of these occasions, suggesting frequent use of dual testing assays. “Eighty-five percent of the time we found a gonorrhea test on the same day on the chart as the chlamydia test,” said Dr. Gift, an economist in the division of STD prevention at the CDC.

“There are a lot of people being tested for gonorrhea when they shouldn't be,” he said.

The costs can be more than economic—there are false-positive concerns with sexually transmitted infections (STIs), Dr. Gift said. “There is such a host of undefinable costs—for example, an STD diagnosis in a monogamous relationship. The prudent thing is to treat just in case, but there is wreckage strewn around by suggesting someone has an STI.”

JACKSONVILLE, FLA. — A majority of privately insured women tested for chlamydia are also checked for gonorrhea, which may be unnecessary given its significantly lower incidence, according to a study presented at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

“Gonorrhea is much more rare. Chlamydia incidence is 5%–7% versus less than 1% for gonorrhea,” Thomas L. Gift, Ph.D., said in an interview at his poster session.

Screening of all sexually active adolescents and females 25 years or younger for chlamydia is recommended by the CDC. However, screening for gonorrhea is recommended only for those at high risk of sexually transmitted diseases.

Dr. Gift and his associate Michele K. Bohm identified 61,183 females aged 15–65 years who were tested for chlamydia, gonorrhea, or both in 2001. They searched outpatient claims in the Medstat Marketscan Database of approximately 4 million privately insured patients. They looked for current procedures terminology codes specific to chlamydia testing or gonorrhea testing. DNA direct or amplified dual-assay codes were also included in the study.

Patients were tested for chlamydia on 66,070 occasions and for gonorrhea on 58,163 occasions. They were tested for both chlamydia and gonorrhea on 56,371 of these occasions, suggesting frequent use of dual testing assays. “Eighty-five percent of the time we found a gonorrhea test on the same day on the chart as the chlamydia test,” said Dr. Gift, an economist in the division of STD prevention at the CDC.

“There are a lot of people being tested for gonorrhea when they shouldn't be,” he said.

The costs can be more than economic—there are false-positive concerns with sexually transmitted infections (STIs), Dr. Gift said. “There is such a host of undefinable costs—for example, an STD diagnosis in a monogamous relationship. The prudent thing is to treat just in case, but there is wreckage strewn around by suggesting someone has an STI.”

Visit www.cdc.gov/std/gonorrhea

JACKSONVILLE, FLA. — The reasons for prominent increases in reported gonorrhea cases since 2000 in five Western states as well as Hawaii and Alaska remain unknown, Dr. Lori M. Newman said at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

A combination of better gonorrhea detection, increased risky sexual behavior, reduced disease control efforts, and/or increased antimicrobial resistance likely accounts for the 25% or more jump in gonorrhea cases in the “wild West,” said Dr. Newman, medical officer, Division of STD Prevention at the CDC.

Among states with at least 500 gonorrhea cases reported in 2005, preliminary data indicate that the greatest increases since 2000 were seen in Utah (206% increase), Hawaii (107%), California (55%), Washington (53%), Oregon (50%), Alaska (48%), and Nevada (40%).

In contrast to national trends, aggregated data for these seven states indicate a 48% increase in new cases among males and a 40% increase in new cases among females between 2000 and 2005. This disparity suggests increases among men who have sex with men, Dr. Newman said. However, overall increases suggest heterosexual transmission as well.

The overall gender gap for gonorrhea has narrowed. Historically, males have had higher infection rates, but female transmission surpassed that of males slightly during the last 3 reported years. The 2004 transmission rates were 117 females per 100,000 and 110 males per 100,000 in the United States.

CDC researchers have yet to identify any demographic risk factor that might explain the increases in the seven states. The increases are not concentrated in a particular age group, for example. By ethnicity, there has been an 80% increase among whites, an 89% increase among Hispanics, and an 18% increase among blacks since 2000.

The CDC has enhanced gonorrhea surveillance through six sites in the West in the STD Surveillance Network. “Translation of data into action is the most important step,” Dr. Newman said.

Following an impressive overall decline in reported gonorrhea cases in the 1970s and 1980s, the total transmission rate in the United States has not changed much in the past decade, Dr. Newman said. According to the provisional data for 2005, the transmission rate is about 113 people per 100,000. “This is still far from our goal of 19 cases per 100,000.”

Only some states in the Northwest and Northeast (Idaho, Maine, Montana, New Hampshire, North Dakota, Vermont, and Wyoming) have met the national goal.

Racial disparities still exist and are cause for concern, Dr. Newman said. Blacks still have an 18 times higher gonorrhea rate than whites despite a 24% overall decrease in reported cases from 1996 to 2006. “This is the highest disparity for any reported infectious disease,” she said.

“Gonorrhea is of greatest concern for adolescents and the young adult population,” Dr. Newman said. For example, nearly 70% of gonorrhea morbidity occurs in people aged 15–24 years, she said.

Among females, the highest gonorrhea rates are in 15- to 19-year-olds, Dr. Newman said. Among males, the highest rates are in those aged 20–24 years.

Visit www.cdc.gov/std/gonorrhea

JACKSONVILLE, FLA. — The reasons for prominent increases in reported gonorrhea cases since 2000 in five Western states as well as Hawaii and Alaska remain unknown, Dr. Lori M. Newman said at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

A combination of better gonorrhea detection, increased risky sexual behavior, reduced disease control efforts, and/or increased antimicrobial resistance likely accounts for the 25% or more jump in gonorrhea cases in the “wild West,” said Dr. Newman, medical officer, Division of STD Prevention at the CDC.

Among states with at least 500 gonorrhea cases reported in 2005, preliminary data indicate that the greatest increases since 2000 were seen in Utah (206% increase), Hawaii (107%), California (55%), Washington (53%), Oregon (50%), Alaska (48%), and Nevada (40%).

In contrast to national trends, aggregated data for these seven states indicate a 48% increase in new cases among males and a 40% increase in new cases among females between 2000 and 2005. This disparity suggests increases among men who have sex with men, Dr. Newman said. However, overall increases suggest heterosexual transmission as well.

The overall gender gap for gonorrhea has narrowed. Historically, males have had higher infection rates, but female transmission surpassed that of males slightly during the last 3 reported years. The 2004 transmission rates were 117 females per 100,000 and 110 males per 100,000 in the United States.

CDC researchers have yet to identify any demographic risk factor that might explain the increases in the seven states. The increases are not concentrated in a particular age group, for example. By ethnicity, there has been an 80% increase among whites, an 89% increase among Hispanics, and an 18% increase among blacks since 2000.

The CDC has enhanced gonorrhea surveillance through six sites in the West in the STD Surveillance Network. “Translation of data into action is the most important step,” Dr. Newman said.

Following an impressive overall decline in reported gonorrhea cases in the 1970s and 1980s, the total transmission rate in the United States has not changed much in the past decade, Dr. Newman said. According to the provisional data for 2005, the transmission rate is about 113 people per 100,000. “This is still far from our goal of 19 cases per 100,000.”

Only some states in the Northwest and Northeast (Idaho, Maine, Montana, New Hampshire, North Dakota, Vermont, and Wyoming) have met the national goal.

Racial disparities still exist and are cause for concern, Dr. Newman said. Blacks still have an 18 times higher gonorrhea rate than whites despite a 24% overall decrease in reported cases from 1996 to 2006. “This is the highest disparity for any reported infectious disease,” she said.

“Gonorrhea is of greatest concern for adolescents and the young adult population,” Dr. Newman said. For example, nearly 70% of gonorrhea morbidity occurs in people aged 15–24 years, she said.

Among females, the highest gonorrhea rates are in 15- to 19-year-olds, Dr. Newman said. Among males, the highest rates are in those aged 20–24 years.

Visit www.cdc.gov/std/gonorrhea

JACKSONVILLE, FLA. — The reasons for prominent increases in reported gonorrhea cases since 2000 in five Western states as well as Hawaii and Alaska remain unknown, Dr. Lori M. Newman said at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

A combination of better gonorrhea detection, increased risky sexual behavior, reduced disease control efforts, and/or increased antimicrobial resistance likely accounts for the 25% or more jump in gonorrhea cases in the “wild West,” said Dr. Newman, medical officer, Division of STD Prevention at the CDC.

Among states with at least 500 gonorrhea cases reported in 2005, preliminary data indicate that the greatest increases since 2000 were seen in Utah (206% increase), Hawaii (107%), California (55%), Washington (53%), Oregon (50%), Alaska (48%), and Nevada (40%).

In contrast to national trends, aggregated data for these seven states indicate a 48% increase in new cases among males and a 40% increase in new cases among females between 2000 and 2005. This disparity suggests increases among men who have sex with men, Dr. Newman said. However, overall increases suggest heterosexual transmission as well.

The overall gender gap for gonorrhea has narrowed. Historically, males have had higher infection rates, but female transmission surpassed that of males slightly during the last 3 reported years. The 2004 transmission rates were 117 females per 100,000 and 110 males per 100,000 in the United States.

CDC researchers have yet to identify any demographic risk factor that might explain the increases in the seven states. The increases are not concentrated in a particular age group, for example. By ethnicity, there has been an 80% increase among whites, an 89% increase among Hispanics, and an 18% increase among blacks since 2000.

The CDC has enhanced gonorrhea surveillance through six sites in the West in the STD Surveillance Network. “Translation of data into action is the most important step,” Dr. Newman said.

Following an impressive overall decline in reported gonorrhea cases in the 1970s and 1980s, the total transmission rate in the United States has not changed much in the past decade, Dr. Newman said. According to the provisional data for 2005, the transmission rate is about 113 people per 100,000. “This is still far from our goal of 19 cases per 100,000.”

Only some states in the Northwest and Northeast (Idaho, Maine, Montana, New Hampshire, North Dakota, Vermont, and Wyoming) have met the national goal.

Racial disparities still exist and are cause for concern, Dr. Newman said. Blacks still have an 18 times higher gonorrhea rate than whites despite a 24% overall decrease in reported cases from 1996 to 2006. “This is the highest disparity for any reported infectious disease,” she said.

“Gonorrhea is of greatest concern for adolescents and the young adult population,” Dr. Newman said. For example, nearly 70% of gonorrhea morbidity occurs in people aged 15–24 years, she said.

Among females, the highest gonorrhea rates are in 15- to 19-year-olds, Dr. Newman said. Among males, the highest rates are in those aged 20–24 years.

JACKSONVILLE, FLA. — A majority of privately insured women tested for chlamydia are also checked for gonorrhea, which may be unnecessary given its significantly lower incidence, according to a study presented at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

“Gonorrhea is much more rare. Chlamydia incidence is 5%–7% versus less than 1% for gonorrhea,” Thomas L. Gift, Ph.D., said in an interview at his poster presentation.

Screening of all sexually active adolescents and females 25 years or younger for chlamydia is recommended by the CDC. However, screening for gonorrhea is only recommended for those at high risk of sexually transmitted diseases.

Dr. Gift and his associate Michele K. Bohm identified 61,183 females aged 15–65 years who were tested for chlamydia, gonorrhea, or both in 2001. They searched outpatient claims in the Medstat Marketscan Database of approximately 4 million privately insured patients. They looked for current procedures terminology codes specific to chlamydia testing or gonorrhea testing. DNA direct or amplified dual-assay codes were also included in the study.

Patients were tested for chlamydia on 66,070 occasions and for gonorrhea on 58,163 occasions. They were tested for both chlamydia and gonorrhea on 56,371 of these occasions, suggesting frequent use of dual testing assays. “Eighty-five percent of the time we found a gonorrhea test on the same day on the chart as the chlamydia test,” said Dr. Gift, an economist in the division of STD prevention at the CDC.

“There are a lot of people being tested for gonorrhea when they shouldn't be,” Dr. Gift said.

The costs can be more than economic—there are false-positive concerns with sexually transmitted infections (STIs), Dr. Gift said. “There is such a host of undefinable costs—for example, an STD diagnosis in a monogamous relationship. The prudent thing is to treat just in case, but there is wreckage strewn around by suggesting someone has an STI.”

JACKSONVILLE, FLA. — A majority of privately insured women tested for chlamydia are also checked for gonorrhea, which may be unnecessary given its significantly lower incidence, according to a study presented at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

“Gonorrhea is much more rare. Chlamydia incidence is 5%–7% versus less than 1% for gonorrhea,” Thomas L. Gift, Ph.D., said in an interview at his poster presentation.

Screening of all sexually active adolescents and females 25 years or younger for chlamydia is recommended by the CDC. However, screening for gonorrhea is only recommended for those at high risk of sexually transmitted diseases.

Dr. Gift and his associate Michele K. Bohm identified 61,183 females aged 15–65 years who were tested for chlamydia, gonorrhea, or both in 2001. They searched outpatient claims in the Medstat Marketscan Database of approximately 4 million privately insured patients. They looked for current procedures terminology codes specific to chlamydia testing or gonorrhea testing. DNA direct or amplified dual-assay codes were also included in the study.

Patients were tested for chlamydia on 66,070 occasions and for gonorrhea on 58,163 occasions. They were tested for both chlamydia and gonorrhea on 56,371 of these occasions, suggesting frequent use of dual testing assays. “Eighty-five percent of the time we found a gonorrhea test on the same day on the chart as the chlamydia test,” said Dr. Gift, an economist in the division of STD prevention at the CDC.

“There are a lot of people being tested for gonorrhea when they shouldn't be,” Dr. Gift said.

The costs can be more than economic—there are false-positive concerns with sexually transmitted infections (STIs), Dr. Gift said. “There is such a host of undefinable costs—for example, an STD diagnosis in a monogamous relationship. The prudent thing is to treat just in case, but there is wreckage strewn around by suggesting someone has an STI.”

JACKSONVILLE, FLA. — A majority of privately insured women tested for chlamydia are also checked for gonorrhea, which may be unnecessary given its significantly lower incidence, according to a study presented at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

“Gonorrhea is much more rare. Chlamydia incidence is 5%–7% versus less than 1% for gonorrhea,” Thomas L. Gift, Ph.D., said in an interview at his poster presentation.

Screening of all sexually active adolescents and females 25 years or younger for chlamydia is recommended by the CDC. However, screening for gonorrhea is only recommended for those at high risk of sexually transmitted diseases.

Dr. Gift and his associate Michele K. Bohm identified 61,183 females aged 15–65 years who were tested for chlamydia, gonorrhea, or both in 2001. They searched outpatient claims in the Medstat Marketscan Database of approximately 4 million privately insured patients. They looked for current procedures terminology codes specific to chlamydia testing or gonorrhea testing. DNA direct or amplified dual-assay codes were also included in the study.

Patients were tested for chlamydia on 66,070 occasions and for gonorrhea on 58,163 occasions. They were tested for both chlamydia and gonorrhea on 56,371 of these occasions, suggesting frequent use of dual testing assays. “Eighty-five percent of the time we found a gonorrhea test on the same day on the chart as the chlamydia test,” said Dr. Gift, an economist in the division of STD prevention at the CDC.

“There are a lot of people being tested for gonorrhea when they shouldn't be,” Dr. Gift said.

The costs can be more than economic—there are false-positive concerns with sexually transmitted infections (STIs), Dr. Gift said. “There is such a host of undefinable costs—for example, an STD diagnosis in a monogamous relationship. The prudent thing is to treat just in case, but there is wreckage strewn around by suggesting someone has an STI.”

MIAMI — Athletic patients with significant musculoskeletal pain should be screened for comorbid depression and panic disorder, according to study findings presented at the annual meeting of the American Medical Society for Sports Medicine.

In a study of 148 consecutively-treated athletic patients who presented to a sports medicine clinic with musculoskeletal complaints, the overall prevalence of a major depressive disorder was 6%; 7% had another form of depression. Dr. William W. Dexter and his associates at the Maine Medical Center sports medicine program in Portland surveyed participants using the Primary Care Evaluation of Mental Disorders (PRIME-MD) patient questionnaire.

Although these overall prevalence rates are similar to those in a general primary care practice, the prevalence of mood disorders was even higher among those patients who presented with pain severity scores of 6 or higher on a scale of 0–10, Dr. Dexter noted in an interview.

Overall, the prevalence of panic disorder was 17%.

Although the association between mood disorders and musculoskeletal pain has been documented in the literature, there are no data on the prevalence of mental health disorders in a primary care sports medicine population. “In our clinic, we felt we were seeing a lot of musculoskeletal complaints in patients who had an undiagnosed or underdiagnosed mood disorder,” Dr. Dexter said.

If comorbid depression and/or panic disorder are not addressed, significant improvements in musculoskeletal pain are unlikely, he added.

Moreover, there was a “strong and significant” association between depression and/or panic attacks in patients with a history of pain lasting more than 6 weeks. “Many of the subjects in the study did not have a prior diagnosis of mood disorder,” Dr. Dexter said.

MIAMI — Athletic patients with significant musculoskeletal pain should be screened for comorbid depression and panic disorder, according to study findings presented at the annual meeting of the American Medical Society for Sports Medicine.

In a study of 148 consecutively-treated athletic patients who presented to a sports medicine clinic with musculoskeletal complaints, the overall prevalence of a major depressive disorder was 6%; 7% had another form of depression. Dr. William W. Dexter and his associates at the Maine Medical Center sports medicine program in Portland surveyed participants using the Primary Care Evaluation of Mental Disorders (PRIME-MD) patient questionnaire.

Although these overall prevalence rates are similar to those in a general primary care practice, the prevalence of mood disorders was even higher among those patients who presented with pain severity scores of 6 or higher on a scale of 0–10, Dr. Dexter noted in an interview.

Overall, the prevalence of panic disorder was 17%.

Although the association between mood disorders and musculoskeletal pain has been documented in the literature, there are no data on the prevalence of mental health disorders in a primary care sports medicine population. “In our clinic, we felt we were seeing a lot of musculoskeletal complaints in patients who had an undiagnosed or underdiagnosed mood disorder,” Dr. Dexter said.

If comorbid depression and/or panic disorder are not addressed, significant improvements in musculoskeletal pain are unlikely, he added.

Moreover, there was a “strong and significant” association between depression and/or panic attacks in patients with a history of pain lasting more than 6 weeks. “Many of the subjects in the study did not have a prior diagnosis of mood disorder,” Dr. Dexter said.

MIAMI — Athletic patients with significant musculoskeletal pain should be screened for comorbid depression and panic disorder, according to study findings presented at the annual meeting of the American Medical Society for Sports Medicine.

In a study of 148 consecutively-treated athletic patients who presented to a sports medicine clinic with musculoskeletal complaints, the overall prevalence of a major depressive disorder was 6%; 7% had another form of depression. Dr. William W. Dexter and his associates at the Maine Medical Center sports medicine program in Portland surveyed participants using the Primary Care Evaluation of Mental Disorders (PRIME-MD) patient questionnaire.

Although these overall prevalence rates are similar to those in a general primary care practice, the prevalence of mood disorders was even higher among those patients who presented with pain severity scores of 6 or higher on a scale of 0–10, Dr. Dexter noted in an interview.

Overall, the prevalence of panic disorder was 17%.

Although the association between mood disorders and musculoskeletal pain has been documented in the literature, there are no data on the prevalence of mental health disorders in a primary care sports medicine population. “In our clinic, we felt we were seeing a lot of musculoskeletal complaints in patients who had an undiagnosed or underdiagnosed mood disorder,” Dr. Dexter said.

If comorbid depression and/or panic disorder are not addressed, significant improvements in musculoskeletal pain are unlikely, he added.

Moreover, there was a “strong and significant” association between depression and/or panic attacks in patients with a history of pain lasting more than 6 weeks. “Many of the subjects in the study did not have a prior diagnosis of mood disorder,” Dr. Dexter said.