Nancy H. Nielsen

Awareness, diagnosis, and treatment of depression.

OBJECTIVES: To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers.DESIGN: Medline serches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized.CONCLUSIONS: Depression occurs commonly, causing suffering, functional impairment, increased risk of suicide, added health care costs, and productivity losses. Effective treatments are available both when depression occurs alone and when it co-occurs with general medical illnesses. Many cases of depression seen in general medical settings are suitable for treatment within those settings. About half of all cases of depression in primary care settings are recognized, although subsequent treatments often fall short of existing practice guidelines. When treatments of documented efficacy are used, short-term patient outcomes are generally good. Barriers to diagnosing and treating depression include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of providers and treatments; limitations of third-party coverage; and restrictions on specialist, drug, and psychotherapeutic care. Public and professional education efforts, destigmatization, and improvement in access to mental health care are all needed to reduce these barriers.

Drug interactions between oral contraceptives and antibiotics

OBJECTIVE To evaluate the evidence on possible drug interactions between antibiotics and oral contraceptives (OCs) that may lead to OC failure. DATA SOURCES MEDLINE and Lexis/Nexis Medical Library searches for 1966–1999 using the key word “oral contraceptives,” cross‐indexed with the terms “antibiotics,” “adverse effects,” and “pregnancy,” and MEDLINE search using the additional MeSH term “drug interactions.” No language restrictions were used. METHODS OF STUDY SELECTION A total of 167 articles were retrieved for analysis. Another 32 articles were identified by review of the references cited in these publications. Articles were selected based on their ability to provide information on the relationship between antibiotic therapy and OC efficacy in otherwise compliant users (defined as women with unplanned pregnancies who reported compliance with their OC regimen). Additionally, studies that either directly measured the effects of antibiotics on the pharmacokinetics of OC components, or that analyzed the effects of antibiotics on measures of ovulation in OC users were accepted. TABULATION, INTEGRATION, AND RESULTS At least 30 cases have been reported of pregnancies occurring in women taking OCs and antibiotics, particularly rifampin. Approximately 20% of pregnant women reporting to family planning or abortion clinics reported concomitant OC and antibiotic use. Information from adverse event reporting databases generally mirrors the types of information gleaned from these case reports and clinical surveys and accounts for approximately one‐third of reported cases. Retrospective surveys, primarily from dermatology‐based practices, also have reported 24 pregnancies in OC users who concomitantly received therapy with antibiotics, most commonly tetracyclines and penicillins. Apparent OC failure rates in clinical surveys were within the usual range expected for patterns of typical use. In pooled results obtained from relatively small populations, oral antibiotics, with the exception of rifampin, have not significantly affected the pharmacokinetics of ethinyl estradiol, levonorgestrel, and norethindrone or reduced the serum concentrations of gonadotropins. However, individual patients have been identified who experienced significant decreases in the plasma concentration of these components of OCs and who appeared to ovulate. CONCLUSION Rifampin impairs the effectiveness of OCs. Pharmacokinetic studies of other antibiotics have not shown any systematic interaction between antibiotics and OC steroids. However, individual patients do show large decreases in the plasma concentrations of ethinyl estradiol when they take certain other antibiotics, notably tetracycline and penicillin derivatives. Because it is not possible to identify these women in advance, a cautious approach is advised.

Report of the Council on Scientific Affairs*: Unlabeled Indications of Food and Drug Administration-Approved Drugs

Unlabeled (also called off-label) uses are defined as the use of a drug product for indications or in patient populations, doses, or routes of administration that are not included in Food and Drug Administration (FDA)-approved labeling. The prevalence and clinical importance of prescribing FDA-approved drugs for unlabeled uses is substantial. In this report, the American Medical Associations (AMA) Council on Scientific Affairs reviews and makes recommendations on four important subjects related to unlabeled uses: clinical significance and prescribing; coverage and reimbursement; dissemination of information by pharmaceutical manufacturers; and improving the Supplemental New-Drug Application (SNDA) process. The recommendations in this report have been adopted as official policy of the AMA.