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Antidepressant Use Goes Up, Psychotherapy Goes Down

Moving Toward AIDS Drugs With Fewer Side Effects

Osteoporosis Remains Underdiagnosed

Antidepressant Use Goes Up, Psychotherapy Goes Down

The proportion of Americans taking antidepressants for the treatment of depression in an outpatient setting increased more than sixfold during the period between 1987 and 1997, according to a study led by Health Sciences researchers. The findings were reported in the Jan. 9, 2002, issue of the Journal of the American Medical Association.

The investigators, led by Dr. Mark Olfson, associate professor of clinical psychiatry, compared trends in outpatient treatment of depressive disorders in the United States in 1987 and 1997. They analyzed data from a sample of 34,459 individuals from the 1987 National Medical Expenditure Panel Survey and from a sample of 32,636 people from the 1997 Medical Expenditure Survey.

They focused on rate of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of health care professional, and source of payment by respondents who had made one or more outpatient visits for the treatment of depression during the calendar year.The proportion of people seeking outpatient treatment for depression and the proportion getting antidepressants for depression in an outpatient setting increased in that time, the researchers found. The rate of outpatient treatment for depression almost tripled from 0.73 per 100 persons in 1987 to 2.33 per 100 persons in 1997, the authors say.

The proportion treated with antidepressants almost doubled, from 37.3 percent to 74.5 percent, while the proportion treated with psychotherapy declined, from 71.1 percent to 60.2 percent.

The authors suggest several factors since 1987 contributed to these trends, including the introduction of fluoxetine, or Prozac, in 1987 followed by other SSRIs and other newer antidepressants.

"These medications have fewer side effects, require less complicated dosing regimens, and pose less danger than older tricyclic medications," the researchers say. The advertising of SSRI drugs and managed care reimbursement encouraging medication over psychotherapy also probably played a part.

Moving Toward AIDS Drugs With Fewer Side Effects

Researchers at P&S are learning why the anti-AIDS drugs known as protease inhibitors cause severe cardiovascular side effects in some patients. The findings could help drug developers develop new medications with fewer side effects.

Protease inhibitors are part of a three-component AIDS drug cocktail that has for the past six years worked well for many patients, slowing viral proliferation and destruction of the immune system. But protease inhibitors also can cause severe fat metabolism problems, including a disfiguring redistribution of fat called lipodystrophy and high blood levels of cholesterol and fat (triglycerides).

The P&S research team along with an Australian researcher found protease inhibitors disrupted the function of cultured liver cells by interfering with their production of particles called apolipo-proteins. Apolipoproteins direct the transport of fat throughout the body by being part of larger particles, lipo-proteins, which carry the fat.

The protease inhibitors, the researchers found, block the proper breakdown of one apolipoprotein, apolipoprotein B, and prevent cells that produce it from exporting it out. This leads to a buildup of apolipoprotein B which, in turn, fosters the creation of LDL cholesterol--the so-called "bad cholesterol" that clogs arteries with fat and causes heart disease.

The researchers say the liver cell assay systems used in their study might help drug developers design protease inhibitors that don't cause apolipoprotein B accumulation. The cell systems also can be used to assess the extent of currently used protease inhibitors' effects on apolipoprotein.

The research, published in the December 2001 issue of Nature Medicine, was performed by Dr. Jun-Shan Liang, a postdoctoral fellow in the laboratory of Dr. Henry Ginsberg, director of the Irving Center for Clinical Research and Irving Professor of Medicine at P&S; and by Oliver Distler, a student working in the laboratory of Dr. Stephen Sturley, assistant professor of human nutrition (in pediatrics and the Institute of Human Nutrition) at P&S. Mr. Distler is on loan from Dr. David Cooper of the University of New South Wales in Sydney, Australia. Dr. Richard Deckelbaum, professor of pediatrics and director of the Institute of Human Nutrition at P&S, also contributed to the study.

Osteoporosis Remains Underdiagnosed

More women should be getting tested for osteoporosis, a devastating bone disease that can lead to debilitating fractures, according to results from the largest U.S. study of osteoporosis risk factors, which was led by a physician from P&S.

The study of more than 200,000 women from 34 states found that almost half of women over age 50 who visit primary care doctors in the United States are at some risk for osteoporosis. Seven percent had osteoporosis and 42 percent had osteopenia, a precursor condition to osteoporosis. The women had been patients of more than 4,000 primary care doctors between Fall 1997 and Spring 1999.

"Despite excellent diagnostic tools and safe therapies, osteoporosis and low bone density remain underdiagnosed," says the study's lead author, Dr. Ethel Siris. Dr. Siris is the Madeline C. Stabile Professor of Clinical Medicine at P&S and director of the Toni Stabile Center for the Prevention and Treatment of Osteoporosis at Columbia-Presbyterian Medical Center.

The findings, which appeared in the Dec. 12, 2001, issue of the Journal of the American Medical Association, should be "meaningful to all women," Dr. Siris says. "As women age, they should work with their doctors to prevent osteoporosis, to get evaluated for it using bone mineral density measurement and to get treated appropriately" if diagnosed.

Although the gold standard to measure bone mineral density is dual X-ray absorptiometry (DXA) of the hip and spine, or the central skeleton, the study found that measurements of bone mineral density at peripheral sites (such as the forearm, finger, and heel) could predict future fracture risk. Among the 163,979 participants who underwent peripheral measurement and provided one year of follow-up information, osteoporosis was associated with a fracture rate four times that expected in normal women; osteopenia had fracture rates nearly twice that of normals. Fractures of the hip, wrist, rib, and spine were included in the rate.

To prevent osteoporosis, women should get ample calcium and vitamin D, stop smoking, and exercise. Medications also exist for osteoporosis prevention and treatment.

The study was sponsored by Merck & Co.