My Writings. My Thoughts.

Obesity: A problem in the United States

Obesity as an excessive weight of a body is considered to be quite an essential problem in the United States affecting different aspects of people’s life. The problem of an obese people is relevant and timely in the US as American nation is said to be “infected” with obesity while living in one of the most prosperous, developed country in the world. Economical strength, technological progress, unfortunately, do not rule out the contemporary condition of the obese nation as the most uninformed and ignorant in the way of nourishment.

Obesity is truly considered to be one of the fastest growing health problems in the United States today. Interviewed by me the weight loss doctor Dr. Juan Remos admits, that the complication of obesity is really essential health problem as he works with the patients who seeks to solve this difficulty and great trouble for them. Doctor is confirmed that there are several reasons for cases of occurrence of the obesity. First of all, will force that affects a persons daily life, secondly, it is genetics and that it is just so hard for these patients to fight it. It has appeared to be a point of issue nowadays “affecting not only the patients but also every aspect of these people’s lives; even the others that are living with these people of have any sort of contact with them” (Dr. Juan Remos, 2010). Moreover, as stated by the CDC (Center for Disease Control and Prevention), obesity among grown-up population grew on 60 percent during the last twenty years and cases of obese children has grown in tree times more in the past thirty years.

A perplexing number of 33 percent among American people of mature age are corpulent obesity-related deaths have grown to more than 300,000 a year, exceeding only tobacco-related deaths (Obesity in America, 2010).

Obesity problem affects health care costs nowadays in a greater degree collating to the past.  Quite often healthcare companies won’t take a person suffering from obesity as they consider this person as a preexisting condition, it is generally believed, that obese people have more health problems than others. “With obesity come more health complications that are hidden and that can come up at any moment,” assures the doctor Remos (Dr. Juan Remos, 2010). Additionally, according to the new research organized by RTI International, the Agency for Healthcare Research and Quality, and the US Centers for Disease Control and Prevention (CDC) the yearly health care costs connected with obesity in the United States increased twice more comparing to the past ten years and nearly equal to the 147 billion dollars a year. In this research it was established that medical costst of obesity have grown up from 78 billion dollars in 1998 to 147 billion in 2008. Comparing to the medical care costs of people with normal weight, the difference is in 42 percent, that is financial expenses of those with obesity almost 50 percent higher (Catharine Paddock, 2009).

Besides the health care costs, obesity bears another meaningful effect – it influences the quality of life of American obese people, to a great degree deteriorating it. All the spheres of well-being of an obese people deteriorate, including education, recreation, leisure time, social belonging. Speaking about education, sometimes people with obesity would not chose remote universities that require travelling, or would subconsciously avoid success on their job never trying to improve their qualification (in some cases of serious degrees of obesity), their recreation and leisure time would be quite limited, monotonous and, probably, to some extent dull.

The reason of an effect on the quality of life may be outlined as the following: a corpulent person feels psychological pressure from the society and its members. This pressure results in inner inferiority complexes and full unwillingness and reluctance to live healthy, entirely enjoyable life. The result may be that these people are limited to the things they can and even want to do, moreover, ”there are many things that obese people can’t even do because of their size” (Dr. Juan Remos, 2010). People feel embarrassed and they don’t feel that they can be accepted by society because of the way they look. Continue Reading

Azithromycin (Zithromax)

Azithromycin (Zithromax), one of the newer macrolides, has been attracting attention as a treatment for sexually transmitted bacterial diseases (STDs) such as gonorrhea, chlamydia, and syphilis. People who staff STD clinics will tell you that their main concern in cases where patients have bacterial STDs is patient compliance. The clinics have the antibiotics that will cure these infections, but unless the full course is taken, the antibiotics can be ineffective. Patients who come into the clinics may have a drug or alcohol problem or may be prostitutes. Even if told to take even a week-long course of antibiotics, such patients may stop taking the antibiotic the minute symptoms subside, an outcome that occurs before the bacteria are completely eliminated. Worse, they may continue to be sexually active immediately after leaving the clinic.

In this context, Zithromax seemed like a godsend. One or two pills, administered while the patient was still at the clinic, successfully treat the patient’s infection. The problem, at least for inner city clinics, is that Zithromax is a new drug still under patent control. Translation: expensive. This is the quandary faced by STD clinics, especially in low-income areas. How can you practice the best medicine for your patients and their potential sexual contacts within your budget? On the other side, how can a pharmaceutical company afford to continue to develop and test new antibiotics like Zithromax if the company cannot recoup the cost?

MDCM

The MDCM is one of the largest contract manufacturers for medical devices, which specializes in manufacturing special medical devices and their assembly, clean room medical injection molding, and the design and fabrication of specially assembling equipment for medical device manufacturers (MDCM, 2006). In fact, the company has proved to be quite successful but in the late 1990s and the early 2000s, the company has started to stumble in its business development because technologies it used and information system the company used suffered from technological backwardness. In such a situation, the necessity to change consistently the organizational structure and information system of the company became essential. For this purpose the company has started to develop its IT department along with consistent structural changes within the organization to increase the efficiency of the organizational performance and to keep pace with the major rivals of the company in the market.

First of all, it is important to dwell upon the development and current position of the MDCM in the market. In this regard, it is important to refer to the changes which have been introduced in the company since the 2000s because these changes aimed at the consistent, qualitative improvement of the organizational performance. One of the first step made by MDCM CEO, McMullen, was the creation of subsidiaries working with customers in their own country, including the US, the UK, and Canada. Each subsidiary focused on its market and local customers specifically. The company granted its subsidiaries with substantial autonomy in regard to their development and formation of company-customer relationships. Managers of subsidiaries had to develop close relationships with customers. In such a way, the company attempted to optimize its organizational performance in different countries, where it operated.

The next step to optimize the organizational performance and to increase its efficiency the company focused on the reduction of the number of suppliers from thousands to hundreds. The consistent reduction of suppliers improved the efficiency of operations of the company to the extent that the consistent reduction of suppliers helped the company to increase the stability and reliability of supply and, thus, to improve the efficiency of manufacturing. The reduction of suppliers allowed the company to increase the efficiency of the manufacturing process.

Finally, the reorganization of the production facilities helped to increase their efficiency as well. The reorganization was crucial and effective, although it led to consistent job cuts, which reached 30% (MDCM, 2006). Nevertheless this step was essential to optimize the organizational performance and to make the organizational structure more flexible. The latter is particularly important in the contemporary business environment because the company has to respond fast and effectively to challenges it faces in its business development. In addition, the high flexibility contributes to the consistent increase of the efficiency of the organizational performance because the company does not need to waste time on the coordination of its operations between units and headquarters. At the same time, the reorganization raised the problem of the development of the IT department in the organization to optimize the effectiveness of its performance and to improve the organizational relationships between units and departments as well as subsidiaries. Continue Reading

Sleep disorders

Sleep disorders

The sleep activity is one of the most mysterious and sophisticated processes of human bodies, which has been studied by various specialists and theorists. Nowadays we have much more information about the nature of sleep and possible sleep disorders along with their reasons, still there is probably unlimited space for further research. Unfortunately the problem of sleep disorders remains one the most actual for millions of people nowadays.

In this paper we are going to briefly study the major stages of sleep, the features they are characterized by, the length of each stage and possible cycles of their change; also some examples of sleep disorders and the main causes, why they develop along with their negative results.

Starting from the sleep stages, we are to mention, that at the very early stage people are not really asleep, rather still awake. The brain products at this moment are the so-called beta waves, being fast and small. Consequently the human brain starts to relax and a different type of waves is produced – namely the alpha waves. The period of time, when a person is not quite asleep and not operating actively any more, is usually characterized by hypnagogic hallucinations. Most commonly met examples of them are the sensation, that you are falling or hearing somebody calling you. Myoclonic jerk is another event, which is most likely to happen during this period, it is described as a sudden startle without any evident reason. So, passing from general description to singling out the concrete stages of sleep we should mention, that during the first stage of sleep the transition from being awake to the process of sleeping happens. The length of this period is usually estimated by 5 to 10 minutes, and if a person is awoken during this stage – he would state, that he was not sleeping yet. The second stage lasts longer, namely around 20 minutes. Sleep spindles or quick rhythmic brain waves are generated in the brain. The rate of heartbeat changes to the slower one and the temperature of the body decreases. The third stage of sleep is characterized by deep and slow delta waves, forming the transition from light sleep towards the deepest sleep. During the next, the fourth stage, the same delta waves may be found in the brain. This is the longest sleep stage, lasting for 30 minutes. If a person is inclined to sleepwalking, then this happens exactly during this stage.

During the fifth stage of sleep people usually see their dreams. This stage got the name of rapid eye movement or REM. Logically the eyes are moving rather quickly during REM sleep, respiration rate is increased as well as the brain activity itself. Most scientists call REM a paradoxical sleep, because along with activation of brain and other body systems, muscles of a person still remain relaxed. The increase in the brain activity is considered to be the main reason of dreaming. The sleeping process doesn’t go through all the above mentioned stages in consequence, it starts during the first stage, goes then to stages two, three and four. After the fourth stage stages three and two are repeated, then followed by REM. After REM the body comes back to the second stage. The repetition of the sleep stages happens around four or five times during the night. According to average parameters the REM stage is entered in 90 minutes after a person falls asleep. Each cycle of REM sleep is longer and longer up to an hour sometimes.

Apart of studying the phenomenon of normal sleep, the scientist had also to pay sufficient attention towards the sleep disorders, as according to the data of the American Psychiatric Association sleep disorders are directly related to distress and breaking of normal functioning of people during the day (Mahowald, 108). Almost all people have to face some type of sleep disorders during their lives, and unfortunately these disorders are able to do harm to psychological state as well as cause problems in functioning of other organism systems. The National Sleep Foundation of America conducted a research within a year, the result was, that more than a half of all Americans experience insomnia problems at least two times a week (Billiard, 13).

The general definition of a sleep disorder is formulated like this: “A sleep disorder (somnipathy) is a medical disorder of the sleep patterns of a person or animal” (Billiard, 13). As it was already mentioned the main danger from sleep disorders is related to their negative impact upon normal emotional, physical and mental functioning of an individual. There are a lot of sleep disorders, defined by the scientists, in this paper we are going to stop just at some examples of them.

The most frequently reported type of sleep disorders is insomnia. Usually insomnia is diagnosed in case of positive answer to one of the following questions: “”Do you experience difficulty sleeping?” or “Do you have difficulty falling or staying asleep?” (Mahowald, 120). If a patient really suffers from insomnia, there is usually the need to continue the medical check of his organism, as insomnia often serves as sigh or even symptom of some other disorders. The definition of insomnia is: “difficulties initiating and/or maintaining sleep, or nonrestorative sleep, associated with impairments of daytime functioning or marked distress for more than 1 month.” (Mahowald, 111). Insomnia is split into primary and secondary (comorbid) insomnia. Primary insomnia is not related to any other medical or psychiatric reasons, whereas secondary is related to other condition. Researchers name several types on insomnia, including acute, transient and chronic. Transient insomnia lasts usually not longer than seven days. It might have various reasons, from work stress or change of sleep environment and to severe depression. The consequence of this type of insomnia would be impaired psychomotor performance (Mahowald, 120) .Acute insomnia is defined by a longer period of inability to sleep normally – namely up to one month. Chronic insomnia correspondingly lasts longer than a month. Chronic disorder may be a primary disorder itself or be a consequence of some other disorder. The effects of chronic insomnia depend on its initial cause, they can be different, including hallucinations, mental emaciation, nervous exhaustion, sometimes double vision is a result of chronic insomnia as well.

Restless legs syndrome (RLS) is another type of sleep disorder. A person, suffering from it experiences constant prickling sensation in his legs, which can be removed for some time by moving them. Thus there is a need to move the legs in order to avoid pain. Certainly such patients face problems with both falling asleep and with sleeping. People with RLS may experience the problem in one or both legs, in some rare cases even in the arms. There is a list of other symptoms apart of painful tingling and difficulties with sleep: “Periodic limb movement in sleep (PLMS), which are brief, sudden movements of the legs every five to 90 seconds; painful sensations in the legs when sitting or lying down for a long period of time (for example, while sitting in a car or behind a desk)” (Karatas, 295). According to statistical data the percentage of the RLS patients is between 5 and 15. RLS is closely related to the age, thus the older the person is, the greater is the chance to develop this disorder. Some researchers state, that RLS is a hereditary type of disorder, most often female patients suffer from it due to problems during pregnancies, kidney diseases, wrong nutrition. The limb movement is controlled by dopamine, produced in the brain. If there is lack of iron, then the brain is not able to produce it correctly, thus the lack of iron is considered to be one of the major causes of this disorder. Important is that testing for iron in blood is not useful for RLS diagnostics, only the iron in the fluid around brain plays an important role. “Recent studies show that blood pressure may elevate by an average of 22 points systolic (top number) and 11 points diastolic (bottom number) during episodes of RLS. In addition, the blood pressure could spike every 20 to 40 seconds many times during the night” (Karatas, 300). In this case the risk of heart disease is extremely increased.

The last in the list of the most often met sleep disorders is sleepwalking, or somnambulism. During the slow wave sleep stage a person stands up from his bad and starts performing activities, without being conscious, about what he or she is doing. Such individuals don’t only sit in their beds or walk around the house, they are able to cook, to drive or to perform various violent actions, especially if they are suffering from hallucinations. Usually, the actions of such a person are simple and constantly repeated, however there are cases reported, when people perform rather sophisticated actions and even illegal ones. Certainly they can not be legally punished for their actions, while they are sleeping, however this might cause a lot of problems to them and to the people around. This is quite normal, if a sleepwalker has no idea, about what he was doing during his being asleep, or has some abrupt pictures of the events in his mind. The eyes of sleepwalkers are opened, but their expression is dim. The process might last from 30 second to 30 minutes (Billiard, 89).

Overall, we have looked through the main stages of sleep, their characteristics and length; we have provided the generalized definition for the notion of sleep order along with some statistical data as for number of people suffering from these disorders; we have briefly analyzed the three most often met examples of sleep disorders, including insomnia, RLS and sleepwalking, their main causes and possible consequences. In spite of the fact, that there is a lot of information about sleep, which can be found in scientific sources, there seems to be limitless directors for enriching this information, as sleep is actually a unique and sophisticated “quality” of human body and brains.

Adjustment Disorder with Depression

Adjustment disorder with depression is the term for the condition commonly referred to as situational depression or reactive depression. Individuals with this malady feel sadness about a loss or a major life change. The sadness, depressed mood, or sense of hopelessness begins within three months of a major stress and is excessive. People with this form of depression may find it difficult to carry on routine activities at home, at work, or at school. The depression gradually disappears once the stress is over and is not usually considered a serious depression, although it may be very uncomfortable. Often the support and advice of concerned friends, loved ones, or a doctor are enough to help sufferers manage until their mood improves following removal of stress or a decrease in its intensity.

Bereavement

Bereavement, or grief, is a normal feeling of sadness that occurs following the loss of a loved one. Uncomplicated grief is believed to advance through a series of stages that, in many aspects, mimic the illness depression, raising questions as to where normal bereavement ends and major depressive illness begins. The initial stage of grief occurs during the first few weeks after the loss and is experienced as feelings of disbelief and shock. It is commonly associated with bouts of crying, loss of appetite, loss of sexual drive, restless sleep or insomnia, lack of energy, and difficulty concentrating. In women, disturbances in the menstrual cycle are common.

The intermediate stage of grief takes place during the first year after the death of the loved one. During that phase, feelings of intense loneliness and sadness are accompanied by persistent thoughts about the death, the events leading up to the death, why it happened, and how it could have been prevented. Limited capacity for pleasure, lack of energy, sleep and appetite problems, and bouts of tearfulness persist to varying degrees.

The recovery phase of grief is the time when people begin to return to their social lives and “get on with life.” That usually begins about the second year following the loss.

Little is known about the actual duration of normal grief. Studies of spouses and parents dealing with unexpected loss point to normal grief processes lasting up to seven years. Sudden death often causes bouts of grief that are more severe and longer lasting than the bereavement following an anticipated death.

Death of a spouse can have significant impact on the health of the surviving partner. Women tend to be at increased risk for health problems within the first three months after the loss. Men whose spouses die are particularly likely to develop emotional or physical problems during the first year after the loss and have an increased mortality rate. Bereaved men who remarry tend to have lower mortality rates than those who do not.

Death of a child is particularly likely to produce severe grief reactions regardless of the age of the parent and child. Bereaved parents experience high levels of psychological distress that are accompanied by changes in physical health, functional activities, and family cohesion, including an increased risk of divorce.

The distinction between “normal” grief and depression can be a difficult one to make. The two states share many similar

physical and emotional symptoms, and the duration of both can be prolonged. Grief can produce a preoccupation with guilt about actions taken or not taken surrounding the death of a loved one and thoughts that the survivor would be better off dead. Experiences of transiently hearing or seeing the deceased loved one can also be a part of the normal grief process, especially in some cultures. Morbid rumination regarding other feelings of guilt, a sense of worthlessness, anticipated death of other loved ones, prolonged decrease in level of function, marked slowness of behavior or speech, reports of unusual beliefs, or persistent or recurring hallucinations should be considered outside the normal grief process and more indicative of a major depressive episode. When symptoms of severe grief extend more than two months beyond the death of a loved one, treatment with antidepressant medication may be needed in addition to supportive psychotherapy.

Grief in young children is most profound when it involves the death of a parent or a primary caretaker. It can produce such behaviors as crying, calling and searching for the deceased loved one, and refusing to be comforted. Emotional withdrawal often occurs and is associated with sad facial expressions, lethargy, and lack of interest in former activities. Eating and sleeping may be disrupted. Children may regress by losing some of their developmental milestones; i.e., toilet-trained toddlers may begin to soil themselves again. Bereaved young children may become detached and lack much facial expression. They often are very sensitive to any reminder of the lost loved one. Grief in young children is generally treated with supportive measures; use of antidepressant medication is usually not required.

Types of Depression

Many different and sometimes complicated systems attempt to classify depressions according to their symptoms, severity, causes, and other characteristics. One reason for these rigorous attempts is the need to conduct research on relatively pure forms of the illness. Such research should result in improved treatment for the various forms of depression.

The two most common systems use similar terms in naming various types of depression. The international version is the ninth edition of the International Classification of Diseases, commonly referred to as ICD-9, which classifies all medical and mental disorders. The system used by most clinicians in the United States is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or DSM-IV, produced by the American Psychiatric Association. Further attempts are made to standardize these common classification systems with each new edition.

Depression can take many forms, and these may be of varying degrees of severity with different natural courses. The types of depression commonly diagnosed in the United States include adjustment disorder with depressed mood; dysthymic disorder; major depressive disorder, single episode or recurrent; major depressive episode associated with bipolar disorder; and mood disorder associated with a general medical condition.

Mild mood alterations do not require help and therefore are not matters for diagnosis. For instance, a bad mood is just that— temporary frustration associated with current circumstances. A person exhibiting a somewhat more persistent alteration of mood is often described as being “blue, ” “bummed out, ” or mildly depressed. People with such negative feelings still enjoy their hobbies, family, and friends. Such mild depressions are usually time-limited and unlikely to require treatment.

Moderate-to-severe forms of depression frequently come to the attention of caregivers, although the initial complaint may not be depression. Those are the forms of depression that fall into formal diagnostic categories.

Depression and Suicide

Every 17.3 minutes someone commits suicide in the United States. According to National Institute of Mental Health statistics, suicide is the ninth leading cause of death in Americans and accounts for more than 30,000 deaths every year. More Americans die of suicide than are victims of homicide. Although most people who become depressed do not commit suicide, depression can be a lethal illness. Contrary to popular belief, not everyone who commits suicide is depressed, but the majority of people who commit suicide do so during a severe depressive episode. The suicide risk in people with severe depression ranges between 15 and 30 percent, with approximately seven suicide attempts for every successful suicide. Women are two to three times more likely to attempt suicide, but men are four to five times more likely to be successful in their attempt.

Over 70 percent of all suicides in the United States are committed by white men, and the majority of those deaths involve firearms. The second highest rate in the country is reported in white women, followed by rates for black women. Black men in the United States currently have the lowest suicide rate; unfortunately, it is rising.

Bob T. was a seventy-two-year-old retired government employee who lived alone in a retirement community. He had been the sole caretaker for his wife, who had been bedridden for two years before her death the previous year. Bob was hypertensive and diabetic. Both conditions had been well controlled with diet and medication until the past few months. Despite repeated visits to his physician, Bob did not feel well. He experienced vague stomach discomfort, joint aches, increasing insomnia, and fatigue, which he reported to his doctor on repeated visits. Bob did not discuss with his physician his fear that his memory was failing rapidly and that he might have “old-timer’s disease.” He often thought of his wife in a “happier place” and longed to join her. One Sunday afternoon after attending church services, Bob went home, wrote his name and the current date in the family Bible below the entry noting his wife’s death, and shot himself in the head.

Thoughts of suicide may be intermittent and relatively brief, but they may also be persistent and intrusive, developing into plans for carrying it out. Circumstances that increase the risk for suicide in depressed patients include advancing age, male sex, Caucasian race, living alone, chronic medical illness, a recent major loss, substance abuse, panic attacks, psychotic symptoms, previous episodes of depression, previous suicide attempts, and family history of depression. In addition, people who are depressed and simultaneously have other brain disorders such as schizophrenia, dementia, or brain damage from illness or trauma may be at increased risk for suicide because of impaired judgment and a tendency toward impulsiveness.

Common methods of suicide include gunshot wound to the head or chest, overdose of over-the-counter or prescription medications, overdose of street drugs, laceration of neck or wrists with a sharp object such as a razor blade or a knife or broken glass, asphyxiation by hanging or from the breathing of a toxic gas such as natural gas or carbon monoxide from an automobile exhaust, and purposeful “accidents, ” such as car crashes against trees or off bridges. In the past, women were reported to choose less violent means of suicide, such as overdose or asphyxiation by gas, while men chose more violent means, such as guns. Now, however, suicide by firearms is the most common method for both men and women, accounting for over half of all suicides. Unfortunately, depressed people intent on suicide can be very creative in choosing their method of death, despite the efforts of their doctors and their loved ones to prevent the tragedy.

The risk for suicide, ironically, may be greatest when the sufferers have passed the lowest point in the course of their illness and have begun to recover. The reasons are not clear but may relate to the observation that recovery from depression often begins with an increase in energy level without immediate improvement in mood. When such is the case, depressed people in the early stages of recovery have regained enough energy to plan and carry out a long-desired suicide. It may also be that once seriously depressed individuals finally make the decision to escape the anguish of illness through death, they feel a temporary reprieve from their symptoms.

Suicide may occur without warning, but 80 percent of people who attempt or commit suicide do give some indication of their intent by means such as voicing despair and world-weariness, expressing suicidal thoughts, threatening to harm themselves, increasing the use of alcohol or drugs, or writing suicide notes. Rehearsing suicide or seriously discussing specific methods may also indicate a determination to go forward with it. More often the hints are subtle behavioral changes that may serve as red flags. Such warnings perhaps indicating that the despondent individual is putting his or her house in order may include making out a will, reviewing life insurance coverage, purchasing cemetery plots, giving away valued possessions, or getting in touch with close relatives. Contrary to popular understanding, most people do not leave notes.

Once someone has decided to commit suicide, it may be impossible to prevent the tragedy. Although many suicide attempters are ambivalent about their course of action until the last moment, others are determined to die and give few clues ahead of time.

Symptoms of Depression

There is no blood test for depression. The diagnosis is based on the reports of sufferers about how they feel and on observations of how they look and behave made by doctors and by people who know them well.

John D. was a forty-five-year-old, self-employed, successful businessman when he suddenly initiated negotiations to sell his company. For months preceding the decision to sell, John had experienced increasing fatigue and decreasing ability to concentrate, which he attributed to the pressures of work. He quit meeting his friends for golf on Sunday afternoons, preferring to sleep in front of the television, but then had problems going to sleep at night. John’s appetite, energy level, and sex drive gradually diminished, while he experienced a growing sense of restlessness, irritability, and futility. John’s wife became concerned when she learned of her husband’s recent purchase of additional life insurance and of his revision of his will. She convinced John to see his family physician for a “good physical.”

The symptoms of depression fall into four categories: mood, cognitive, behavioral, and physical. In other words, depression affects how individuals feel, think, and behave as well as how their bodies work. People with depression may experience symptoms in any or all of the categories, depending on personal characteristics and the severity and type of depression.

Depressed people generally describe their mood as sad, depressed, anxious, or flat. Victims of depression often report additional feelings of emptiness, hopelessness, pessimism, uselessness, worthlessness, helplessness, unreasonable guilt, and profound apathy. Their self-esteem is usually low, and they may feel overwhelmed, restless, or irritable. Loss of interest in activities previously enjoyed is common and is usually accompanied by a diminished ability to feel pleasure, even in sexual activity.
As the illness worsens, the cognitive ability of the brain is affected. Slowed thinking, difficulty with concentration, memory lapses, and problems with decision-making become obvious. Those losses lead to frustration and further aggravate the person’s mounting sense of being overwhelmed. The sufferer longs for escape, and thoughts of death intrude, sometimes taking the form of wishful thinking, as in “I wish God would just take me” or “I wish I could vanish, ” and often involving ideas of suicide.

In its most severe forms, depression causes major abnormalities in the way sufferers see the world around them. They may become psychotic, believing things that are not true or seeing and hearing imaginary people or objects.

Ann H. was forty years old when her husband took her to the family physician after she began crying daily and begging her husband to take good care of their teenage daughters after her death. Despite a normal medical assessment, Ann remained convinced that she was dying of metastatic cancer as had her mother years before. She “felt” the cancer cells destroying her liver and kidneys and pointed to her twenty-pound weight loss in six months as proof of terminal illness. Ann’s appetite was poor, yet she remained constantly, unproductively active throughout the day. At night she lay awake crying about leaving her daughters without a mother, while during the day she worried constantly about becoming an emotional and financial burden on her family in the late stages of her “terminal” illness. Ann decided she must kill herself to protect her family and took a lethal overdose of an antidepressant medication that had been prescribed by her family physician.

Psychosis in depression is not rare. Between 10 and 25 percent of patients hospitalized for serious depression, especially elderly patients, develop psychotic symptoms. Symptoms of psychosis may include delusions (irrational beliefs that cannot be resolved with rational explanations) and hallucinations (seeing, hearing, feeling, tasting, or smelling things or people that are not present).
People with psychoses may develop paranoia, believing that they are being manipulated by known or unknown people or forces, that there is a conspiracy against them, or that they are in danger. No amount of rational explanation changes the delusional belief. Others may be convinced that they have committed an unpardonable sin against loved ones or against their God and deserve severe punishment, even death. Some sufferers become so firmly convinced of their own worthlessness that they begin to view themselves as a burden to their families and choose to kill themselves. Occasionally, severe depression may result in hallucinations in which the depressed person hears or sees things or people that are not present; other types of hallucinations, such as smelling or feeling things that are not present, are less common in severe depression than in some other brain disorders.

The changes occurring with depression understandably result in alterations in behavior. Most individuals with moderate-to-severe depression will experience decreased activity levels and appear withdrawn and less talkative, although some severely depressed individuals show agitation and restless behavior, such as pacing the floor, wringing their hands, and gripping and massaging their foreheads. Given a choice, most begin to avoid people and activities, yet others will be most uncomfortable when alone or not distracted. In general, the severely depressed become less productive, although they may successfully mask the decline in performance if they have been highly productive in the past. In the workplace, depression may result in morale problems, absenteeism, decreased productivity, increased accidents, frequent complaints of fatigue, references to unexplained aches and pains, and alcohol and drug abuse. Severely depressed individuals have been known to work their regular schedule during the day, interact with their coworkers in a routine way, and then go home and kill themselves.

Depression is more than a mental illness. It is a total body illness. People suffering from moderate-to-severe depression experience changes in their body functions. Their energy levels fall, and they fatigue more easily. Insomnia is common and takes many forms; depressed individuals may have difficulty going to sleep or experience early morning awakenings. A subgroup of depressed patients feel an excessive need for sleep. Depressives consistently complain that their sleep is not restful and that they feel just as tired in the morning when they awake as they did when they went to bed the evening before. Some may be troubled by dreams that carry the depressive tone into sleeping hours, causing abrupt awakenings due to distress.

Appetite changes are common. Most depressives experience decreased or total loss of appetite, with associated weight loss resulting in lower energy levels. The same individuals who oversleep when depressed also tend to overeat. They gain weight from a combination of increased caloric intake and decreased activity level, which compounds their problems through increased frustration and lowered self-esteem. Whether the appetite increases or decreases, the end result is a vicious cycle of physical symptoms aggravating the depression.

Physical complaints are common and may or may not have a physical basis. Many seriously depressed people, in fact, first go to their physicians with physical complaints. The depressed mood may not be recognized initially by these patients, especially if they are men. Men, in general, are less apt to look inward when they “feel bad, ” attempting instead to locate the problem in their environment.

Physical symptoms associated with depression can occur in any part of the body and can include pain (headache, backache), gastrointestinal problems (nausea, stomach pain, diarrhea, constipation), neurologic complaints (dizziness, numbness, memory problems), sexual disorders (lack of desire, failure of orgasm), and general complaints of feeling unwell and heavy, as if one’s feet are stuck in mud. The physical complaints of depressed patients cannot be overlooked, because many studies indicate an increased risk of real physical illness in people who have severe forms of depression.

Costs of Depression

Approximately one in five adults in the United States will suffer from depression at some time. Depression affects more than 17 million Americans each year. Mood disorders, including mania and various forms of depression, account for as many as 70 percent of psychiatric hospitalizations.

Sufferers of depression include some of the most creative and productive members of society, which means that the direct and indirect costs of this common illness are very high. The latest National Institutes of Health (U.S.) study on the cost of depression, reported for 1990, estimated the cost of depressive illness in the United States at between $33 billion and $44 billion annually (fig. 1.1), including direct treatment costs ($12.4 billion), absenteeism ($11.7 billion), lost productivity ($12.1 billion), and mortality costs ($7.5 billion). The number of lost work days due to depression may be as high as 200 million days per year.

On a more personal level, patients treated in psychiatric hospitals for serious depression may find themselves billed $1,000 to $1,500 a day or more for a hospitalization that may exceed five to seven days and occasionally last several weeks. Those charges may not even include the costs of physician visits, consultants, or special studies such as antidepressant medication blood levels or brain scans.

Most people, even solid middle-class individuals with good health insurance, will find themselves psychiatrically indigent if they require hospitalization for the treatment of depression. Health insurance policies, even good ones, commonly discriminate against psychiatric illness. Many policies have a poorer reimbursement rate for mental disorders, impose a lifetime maximum reimbursement limit (sometimes as little as $50,000), and require larger copayments for psychiatric treatment. The length-of-stay allowances for inpatient care of seriously depressed patients may also place the patient at significant risk. For example, a psychiatrist recently hospitalized a severely depressed woman on an emergency basis following her suicide attempt by overdose of prescribed medications. The insurance company ruled that the patient had to be discharged the day she no longer reported suicidal intent. The fragility of severely depressed patients in early recovery, including their increased risk for suicide, was apparently not a cost-efficient consideration.

Another problem is the stigma associated with mental illness, which can make treatment for depression and other brain disorders that are labeled as mental illnesses costly in personal ways. Traditionally, people with mental illnesses such as depression have been required to report their disorders on applications for a driver’s license, for employment, for security clearance, and for other routine purposes, while people with other medical conditions generally have not. Although the recent federal Americans with Disabilities Act attempted to correct that form of discrimination, the problem remains. When a physician recently changed her medical liability insurance policy, the application asked whether the applicant had ever been treated for mental illness. Nowhere on the policy was there another question about any other medical illness or treatment. Fearing discrimination in hiring, promotion, and other occupational and educational opportunities, many people who recognize their own depression will not seek treatment because of concerns that they may have to report it later.

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