Screening for Depression in Adolescents

Earlier this month, the United States Preventive Services Task Force (USPSTF) published their most recent recommendations regarding screening for depression in adolescents (aged 12 to 18 years).  This recommendation seems particularly timely in view of reports of "clusters" of teen suicide recently reported in California and other locations in the U.S. The USPSTF is an independent panel of experts, who do not have affiliation with the Federal government or other special interest groups.  Following careful study of high quality research pertaining to a particular clinical area, they offer recommendations to guide medical professionals in providing preventive services in their practices.

Summary of the USPSTF Recommendation:  "The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up."

Symptoms of MDD in adolescents:  According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a major depressive episode is defined as: "A period of two weeks or longer during which there is either depressed mood or loss of interest or pleasure, and at least four other symptoms that reflect a change in functioning."  Other symptoms could include:

1. Disturbed or altered sleep habits.
    
2. Weight change or appetite disturbance
    
3. Impaired ability to concentrate or make decisions.
    
4. Suicidal thoughts.
    
5. Fatigue or loss of energy
    
6. Feelings of worthlessness or inappropriate guilt

Scope of the problem:  In surveys of U.S. adolescents, approximately 8% were thought to have experienced major depression during the year prior to being surveyed. Those at particular risk for developing depression included adolescents with a family history of depression, a prior episode of depression, females, older adolescents, overweight or obese individuals and adolescents with a chronic medical illness.  Abuse or neglect, low socioeconomic status, family conflict, loss of a loved one and conflict regarding sexual orientation also appears to increase the risk of adolescent MDD.

Screening tests for MDD in adolescents:  The USPSTF is unlikely to endorse screening for any medical condition unless an effective screening tool is available. In the case of adolescent MDD, the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI) were both found to be acceptable for screening for depression in this population. These tools can be quickly administered by health professionals in primary care practices.

Treatments Options: Treatment options for MDD in adolescents include psychotherapy, medications, collaborative care, and alternative medicine approaches.  Of these, the most effective in producing a reduction in depression symptoms appears to be treatment with antidepressant medications, psychotherapy, or a combination of these two approaches.  The FDA has approved fluoxetine (Prozac) for treatment of MDD in children aged 8 years or older and escitalopram (Lexapro) in adolescents aged 12 to 17 years. Clearly, there are concerns regarding the use of medications in treating young people, so the USPSTF strongly advises that "patients of all ages who start antidepressant therapy be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior".

Outcome of screening:  Overall, the USPSTF gave a "B" rating to screening for MDD in adolescents.  This means that they believe that the net benefit of screening is moderate to substantial.  They found adequate evidence that screening and treatment of MDD was associated with reduction in depression symptoms and improved general functioning.  They went on to say that the potential harms of treatment with approved antidepressant medications or psychotherapy were far less than the anticipated benefits. Hopefully, screening for depression in adolescents will become standard practice in primary care offices.

Texting Injuries

Text messaging has become a preferred method of communication for a large number of Americans, particularly teens and young adults. According to market research performed by the Nielsen Company in 2010, the average teenager sends more than 3,000 texts per month!  Amazingly, this number appears to be on the rise, especially among teenagers age 13 to 17. The second highest frequency of texting occurs in young adults, age 18 to 24.  This group exchanged approximately 1,630 texts per month, an average of almost 3 texts per hour.  Along with its popularity, however, have come a number of health hazards. Foremost of these are repetitive stress injuries, motor vehicle accidents, and walking-while-texting injuries.

Texting tendonitis:  Also called “texting thumb”, this is a repetitive stress injury affecting the tendons of the thumbs, since texting relies almost exclusively on the use of the thumbs for typing.  Features of this condition include aching and throbbing pain in the thumb or sometimes other fingers and wrist. As with other repetitive stress injuries, such as carpal tunnel syndrome, treatment usually involves avoidance of the aggravating activity, splinting, application of ice, and anti-inflammatory medications.

Motor vehicle accidents: As if talking on a cell phone while driving wasn't bad enough, the impact of texting while driving appears to be even worse. The Centers for Disease Control found that 31% of U.S. drivers ages 18-64 reported that they had read or sent text messages or email messages while driving at least once within the 30 days before they were surveyed.  In a study pre
sented to the Pediatric Academic Societies, teens using a driving simulator were noted to drive erratically and in some cases even ran over simulated pedestrians while texting or operating a MP3 player. The specific act of texting while driving was cited to raise the risk of a crash by 23 times in a report from the American Academy of Pediatrics. The actual number of texting-related automobile accidents may never be known, however, since it would be unlikely that the perpetrator of the accident would admit that they were texting while driving.

Walking-while-texting injuries: There appears to be a growing trend of injuries and even deaths occurring when people are texting while walking.  Many instances of facial and eye injuries have been reported when distracted walkers strike a signpost or parked car.  Researchers from Ohio State University estimated that in 2010, over 1,500 emergency rooms visits from pedestrians who tripped, fell, or ran into something after becoming distracted while using a cell phone to talk or text. If repeated today, this figure would almost certainly be higher. Distracted walking has also resulted in injuries to others through collisions with other pedestrians, bicyclists, or people on roller blades.

The following are suggestions to help prevent injuries related to texting:

1. Vary the hand or digits used to text. Don’t text for more than an few minutes without a break.
    
2. Stop texting if it produces pain or tingling in your thumbs or hands. You may need to make changes in your work, play, or texting habits.
    
3. Never text while driving or operating machinery.
    
4. Be alert when walking, particularly in cities. People have been injured or killed by walking into traffic while texting or talking on a cell phone.
    
5. Don’t text while engaging in physical activities such as bicycling, rollerblading, or running.
    
6. Be careful if texting in settings where attention to your surrounding is required, such as waiting for a bus or sitting alone at night. 

The 7 minute workout

The American College of Sports Medicine (ACSM) recommends that healthy adults get 150 minutes of moderately intense cardiovascular exercise per week. Considering the amount of time that many people have available for exercising, however, this is often an unrealistic goal. An alternate way of reaching the ACSM goal for cardiovascular exercise is based on working out at a higher intensity. When this route is chosen, between 20 to 60 minutes of vigorous-intensity exercise is recommended on three days each week.
   
An exercise program that is popularly referred to as the "Seven Minute Workout" falls into the vigorous-intensity category. This program was described in an article from the American College of Sports Medicine's Health and Fitness journal., "HIGH-INTENSITY CIRCUIT TRAINING USING BODY WEIGHT:  Maximum Results With Minimal Investment".  In this article, authors Brett Klika and Chris Jordan describe an exercise program that is highly efficient in regard to its time requirement, but may not be appropriate for everyone due to the vigorous nature of the workout. The program is designed to combine both aerobic (cardiovascular) training along with weight (resistance) training, with the only equipment required being a chair and a wall to lean against.
 
The program is also referred to as the "scientific" 7 minute workout because there is research-based evidence that short, intense exercise can produce similar fitness benefits as those produced through longer, less intense workouts. The workout involves 12 different exercises, such as squats, running in place and jumping jacks. Each exercise is performed for 30 seconds with 10 seconds for rest and transition in between.  The time required for performing the 12 exercises is approximately 7 minutes, although as fitness improves, the authors suggest that the circuit be repeated 2 to 3 times.

The method of performing each individual exercise is well described in the previously mentioned link.  Additionally, the New York Times has developed an app for smart phone, tablet or computer to assist with timing the workout.

It cannot be overstated that this type of workout is not for everyone.  Because of the vigorous nature of the program, it could be harmful for someone with certain health problems, such as heart disease, not to mention being uncomfortable for most.  Furthermore, there are fitness experts who are critical of this method, suggesting that the physiologic benefits of exercise may not be achieved in such a short period of time. Nevertheless, a program such as this could be of great benefit to many people including those that have a limited amount of time to exercise, whose resources may not allow gym membership, or someone who needs a way to exercise while travelling.

The bottom line is that a program such as the "Seven Minute Workout" is time efficient, but not necessarily the best way of exercising.  Anyone with concerns regarding their ability to exercise at an intense level should first consult with their doctor.

Canker Sores

Canker sores, also known as aphthous ulcers, are small, shallow lesions that develop on the soft tissues in your mouth, most commonly inside the cheeks or lips and at the base of the gums.  They are very common, affecting up to 20%-40% of the U.S. population at some point in their lives.  Canker sores are most common during adolescence and young adulthood, becoming less frequent as we get older.

What do canker sores look like? Most canker sores are round or oval and less than 10 mm (1/3 inch) in diameter.  A second type, known as "major" aphthous ulcers, can be much larger.  While the smaller sores heal in from 7-10 days, these larger lesions can take up to a month to heal.  A third type of aphthous ulcer, herpetiform ulcers, consists of multiple of small ulcers.
 
What causes aphthous ulcers?  The exact cause of aphthous ulcers is not known, although they often occur following an injury, such as when someone has bitten their tongue or cheek.  Other factors associated with their development include:

• Stress
   
• Viral infections
   
• Certain foods including chocolate, coffee, strawberries, nuts and citrus foods
   
• Toothpastes containing sodium lauryl sulfate
   
• Food allergies
   
• Hormonal changes
   
• A diet deficient in Vitamin B12, folic acid or iron

How are aphthous ulcers diagnosed?  The diagnosis of aphthous ulcers is made based on the characteristic appearance and clinical course.  They can be confused with other mouth ulcers such cold sores or even mouth cancer. Unlike cold sores, which are caused by the herpes simplex virus (HSV), canker sores don't occur on the surface of your lips.  Mouth cancer may be suspected when a mouth lesion does not resolve by a couple of weeks.

How are canker sores best treated?  There are a number of prescription, over-the-counter, as well as "home remedies" available for treating canker sores.  Most minor canker sores heal on their own, however, so in many cases, specific treatment may not be necessary.

Self-care measures for easing the discomfort associated with aphthous ulcers include:

• Rinsing the mouth with either a solution of ½ teaspoon salt dissolved in 8 ounces of water or diluted hydrogen peroxide. Another mixture that may be helpful consists of 1-2 tablespoons of Maalox mixed with ½ tablespoon of liquid diphenhydramine (Benadryl). A teaspoonful of this mixture can swished and then spit out, up to four times a day.
   
• Applying a small amount of milk of magnesia or a paste made of baking soda.
   
• Over-the-counter products that contain a numbing agent, such as Orabase-B, Anbesol and Orajel.

Some of the most commonly prescribed medications for  aphthous ulcers include mouth rinses containing the steroid dexamethasone or the antibiotic tetracycline, topical pastes containing either a steroid (Kenalog in Orabase) or amlesxanox (Aphthasol paste 5%), and topical cauterizing agents such as Debacterol (Sulfuric acid/Phenolic Solution).

Can aphthous ulcers be prevented?  In many cases, the answer is yes, but some detective work may be necessary to determine the factors that are responsible for their development.  If outbreaks follow eating foods such as nuts, chips, pretzels, or acidic fruits, such as oranges, the food that triggered the outbreak may need to be avoided.  Regular brushing after meals and flossing once a day can keep your mouth clean and free of foods that might trigger a sore.  Check out the toothpaste label to see if it contains sodium lauryl sulfate, which has been associated with the development of canker sores.   In some people, dietary supplementation with vitamins B and C, zinc, or iron or taking the probiotic, acidophilus, may prevent recurrences.  Avoiding injury to the mouth, e.g. use of a soft tooth brush, may also help prevent the development of canker sores.

Final word:  Most canker sores go away on their own in a week or two.  Because of the possibility of a more serious problem, such as mouth cancer, check with your doctor or dentist if you have unusually large or painful canker sores or canker sores that don't seem to heal.