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V. Gambal, M.B. B.CH., M.B.B.Ch., Ph.D.

Co-Director, University of Nevada, Reno School of Medicine

There are no real predictors of response to individual antidepressants, yet in the absence of other information clinicians sometimes rely on family history of therapeutic benefit to select a specific medication for a family member. Although it does not have specific support in the literature, this practice appears reasonable. Due to the interrelationship between depression and medical illness, it is very important to recognize and treat depressive symptoms in medically ill patients, and vice versa. The psychiatrist should also attend to the potential for interactions between antidepressants and the co-occurring medical conditions as well as any nonpsychiatric medications that the patient may be taking. Hypertension the presence of treated or untreated hypertension may influence the choice of an antidepressant, as a few antidepressant medications have been associated with increases in blood pressure. However, another study found no increase in hypertension with duloxetine dosed up to 80 mg/day (798). Alternatively, for a patient with well-controlled depressive symptoms, it may be preferable to add an antihypertensive agent rather than risk a depressive relapse or recurrence with medication tapering. Antihypertensive agents and antidepressant medications may interact to either intensify or counteract the effect of the antihypertensive therapy (799). Tricyclic antidepressants may antagonize the therapeutic actions of guanethidine, clonidine, or alpha-methyldopa. Side effects of antihypertensive agents, such as fatigue or sexual dysfunction, may also confound the evaluation and interpretation of depressive symptoms. It has also been thought that beta-blockers, especially propranolol, may account for depressive symptoms in some patients, but this association has been questioned (700, 701). Furthermore, co-occurring medical conditions in patients with major depressive disorder are associated with poorer outcome (794, 795). A number of medical conditions are known to cause mood symptoms, such as stroke, hypothyroidism, carcinoma of the pancreas, and many others. Apart from directly causing depressive symptoms, debilitating, painful, and chronic medical conditions often constitute an ongoing stressor that predisposes patients to depressive episodes. Nevertheless, a depressive episode, in any context, is never a "normal" response to illness and consequently warrants treatment. In addition to the increased risk of major depressive disorder with general medical conditions, depressive episodes increase the risk of certain general medical conditions, 2. Following an acute myocardial infarction, the decreased survival rates of depressed patients may in part be due to Copyright 2010, American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition lower heart rate variability in these patients, compared with nondepressed patients (804). Particularly in patients with a history of major depressive disorder (805), there is evidence that the depressive symptoms associated with cardiac illness respond to antidepressants (717, 806, 807). Monamine oxidase inhibitors do not adversely affect cardiac conduction, rhythm, or contraction but may induce orthostatic hypotension and have risks relating to drug-food and drug-drug interactions. When depression develops after a stroke, it has detrimental effects on quality of life (823). In addition, the presence of depression 1 month following a stroke has been associated with an increase in subsequent mortality (828). Psychotherapies have not been well studied as treatments for poststroke depression; however, a meta-analysis of randomized trials that have been conducted did not show efficacy (825). Findings on the therapeutic effects of antidepressants in post-stroke depression have been mixed, perhaps due to the substantial heterogeneity of study populations and designs (831, 832). Although a meta-analysis did not show any difference in the rate of depressive remission with antidepressant treatments compared with placebo (832), patients receiving an antidepressant did show more improvement in depressive symptoms (831, 832) and a greater proportion were classified as treatment responders (831). However, in individuals who are receiving concomitant treatment with anticoagulant.

A lack of support from their boss and even their colleagues to take a vacation is often a driving force in deciding to 337 forgo time off. In fact, 80% of the respondents to the survey above said they would take time away if they felt they had support from their boss. Two-thirds reported that they hear nothing, mixed messages, or discouraging remarks about taking their time off. Almost a third (31%) feel they should contact their workplace, even while on vacation. The benefits of taking time away from work: Several studies have noted the benefits of taking time away from work. It reduces job stress burnout (Nimrod, Kleiber, & Berdychevesky, 2012), improves both mental health (Qian, Yarnal, & Almeida, 2013) and physical health (Stern & Konno, 2009), especially if that leisure time also includes moderate physical activity (Lee et al. While people in their early 20s may emphasize how old they are to gain respect or to be viewed as experienced, by the time people reach their 40s they tend to emphasize how young they are. Neugarten (1968) notes that in midlife, people no longer think of their lives in terms of how long they have lived. Levinson (1978) indicated that adults go through stages and have an image of the future that motivates them. This image is called "the dream" and for the men interviewed, it was a dream of how their career paths would progress and where they would be at midlife. According to Levinson the midlife transition (40-45) was a 338 time of reevaluating previous commitments; making dramatic changes if necessary; giving expression to previously ignored talents or aspirations; and feeling more of a sense of urgency about life and its meaning. Levinson believed that a midlife crisis was a normal part of development as the person is more aware of how much time has gone by and how much time is left. The future focus of early adulthood gives way to an emphasis on the present in midlife, and the men interviewed had difficulty reconciling the "dream" they held about the future with the reality they experienced. Consequently, they felt impatient and were no longer willing to postpone the things they had always wanted to do. Although Levinson believed his research demonstrated the existence of a midlife crisis, his study has been criticized for his research methods, including small sample size, similar ages, and concerns about a cohort effect. Vaillant was one of the main researchers in the 75 year-old Harvard Study of Adult Development, and he considered a midlife crisis to be a rare occurrence among the participants (Vaillant, 1977). Additional findings of this longitudinal study will be discussed in the next chapter on late adulthood. Most research suggests that most people in the United States today do not experience a midlife crisis. Results of a 10-year study conducted by the MacArthur Foundation Research Network on Successful Midlife Development, based on telephone interviews with over 3,000 midlife adults, suggest that the years between 40 and 60 are ones marked by a sense of well-being. The crisis tended to occur among the highly educated and was triggered by a major life event rather than out of a fear of aging (Research Network on Successful Midlife Development, 2007). We all know that stress plays a major role in our mental and physical health, but what exactly is stress The term stress is defined as a pattern of physical and psychological responses in an organism after it perceives a threatening event that disturbs its homeostasis and taxes its abilities to cope with the event (Hooker & Pressman, 2016). Stress was originally derived from the field of mechanics where it is used to describe materials under pressure. The word was first used in a psychological manner by researcher Hans Selye, who was examining the effect of an ovarian hormone that he thought caused sickness in a sample of rats. Surprisingly, he noticed that almost any injected 339 Stress hormone produced this same sickness. He smartly realized that it was not the hormone under investigation that was causing these problems, but instead the aversive experience of being handled and injected by researchers led to high physiological arousal, and eventually to health problems like ulcers. He developed a model of the stress response called the General Adaptation Syndrome, which is a three-phase model of stress, which includes a mobilization of physiological resources phase, a coping phase, and an exhaustion phase. Source Psychologists have studied stress in a myriad of ways, and it is not just major life stressor. Even small daily hassles, like getting stuck in traffic or fighting with your friend, can raise your blood pressure, alter your stress hormones, and even suppress your immune system function (DeLongis, Folkman, & Lazarus, 1988; Twisk, Snel, Kemper, & van Machelen, 1999). Stress continues to be one of the most important and well-studied psychological correlates of illness, because excessive stress causes potentially damaging wear and tear on the body and can influence almost any disease process.

When an excluded service is the primary procedure involved, it is not covered, regardless of its complexity or difficulty. Similarly, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and a frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service. In a like manner, the removal of a torus palatinus (a bony protuberance of the hard palate) may be a covered service. However, with rare exception, this surgery is performed in connection with an excluded service, i. Dental splints used to treat a dental condition are excluded from coverage under 1862(a)(12) of the Act. On the other hand, if the treatment is determined to be a covered medical condition. Whether such services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. Thus, an x-ray taken in connection with the reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x- ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered. Medicare makes payment for a covered dental procedure no matter where the service is performed. The hospitalization or nonhospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure. Payment may also be made for services and supplies furnished incident to covered dental services. For example, the Medicare law excludes from coverage services that are not "reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Certified Nurse-Midwife Defined A certified nurse-midwife is a registered nurse who has successfully completed a program of study and clinical experience in nurse-midwifery, meeting guidelines prescribed by the Secretary, or who has been certified by an organization recognized by the Secretary. The Secretary has recognized certification by the American College of Nurse-Midwives and State qualifying requirements in those States that specify a program of education and clinical experience for nurse-midwives for these purposes. Be legally authorized under State law or regulations to practice as a nursemidwife and have completed a program of study and clinical experience for nurse-midwives, as specified by the State; or 2. If the State does not specify a program of study and clinical experience that nurse-midwives must complete to practice in that State, the nursemidwife must: a. Be currently certified as a nurse-midwife by the American College of Nurse-Midwives; b. Have satisfactorily completed a formal education program (of at least one academic year) that, upon completion, qualifies the nurse to take the certification examination offered by the American College of Nurse-Midwives; or c. Have successfully completed a formal education program for preparing registered nurses to furnish gynecological and obstetrical care to women during pregnancy, delivery, and the postpartum period, and care to normal newborns, and have practiced as a nurse-midwife for a total of 12 months during any 18-month period from August 8, 1976, to July 16, 1982. General - Effective January 1, 1988, through December 31, 1993, the coverage of nurse-midwife services was restricted to the maternity cycle. The maternity cycle is a period that includes pregnancy, labor, and the immediate postpartum period. Beginning with services furnished on or after January 1, 1994, coverage is no longer limited to the maternity cycle. Coverage is available for services furnished by a nursemidwife that he or she is legally authorized to perform in the State in which the services are furnished and that would otherwise be covered if furnished by a physician, including obstetrical and gynecological services. Noncovered Services the services of nurse-midwives are not covered if they are otherwise excluded from Medicare coverage even though a nurse-midwife is authorized by State law to perform them. For example, the Medicare program excludes from coverage routine physical checkups and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

Making materials and training available for those who work with students on the skills and knowledge needed to address bullying: For example, StopBullying. Identify benefits, motivators, barriers, and change strategies Bullying prevention messages needed to address motivators for bullying and behaviors to change. The planners met with students to identify barriers and motivators, and to discuss perceptions of factors that contribute to and prevent bullying behavior. Craft a positioning statement [The Howard County Public School System] has taken a strong stand against bullying with a goal to eradicate bullying. Unfortunately, bullying is a reality that lives within the hallways of our schools and one that we must root out once and for all. We know that those who are bullied may experience depression, anxiety, sadness and loneliness. They can suffer from changes in sleep and eating patterns and loss of interest in activities that they typically enjoy. Children who have suffered through bullying have gone so far as to injure themselves and even take their own life. Price: Although there was a cost involved in developing and implementing the bullying prevention plan, fewer bullying incidents decreased the staff burden related to response, and results in a cost savings. Place: the target market was the community served by the Howard County Public School System. Promotion: One example of a promotional tool was the public service announcement at a school-sponsored prevention event, Bullying prevention message (2017c). The number of forms submitted provides a strategy for measuring change in the incidence of bullying behaviors. Implement the plan During implementation, the planners noted the response of different market segments within the community-students, parents, school staff, community organizations, and the public. Monitor and evaluate plan implementation the evaluation plan initially called for evaluating whether the bullying prevention campaign changed knowledge, behaviors, and attitudes related to bullying. Intermediate measures on community responses were important for refining social marketing messages. Later measures would compare bullying incidence rates to the rate occurring during the 2016-2017 (baseline) school year. Theories supporting social marketing Several theories support social marketing: Exchange theory, the Theory of Planned Behavior, and the health belief model. These theories explain how motivation and incentives lead individuals or groups to adopt healthy behaviors. Identifying social marketing interventions Interventions can be categorized as social marketing if they meet the following criteria: the intervention focuses on actual change of behavior rather than a change in awareness or knowledge. Research is conducted to provide insight into the consumer experience and to drive decision-making. Consumer research analysis provides those planning the intervention with insight into targets of opportunity. The intervention strategy is tailored to targets of opportunity and marketing mix (product, price, place, promotion, exchange, competition). Concepts related to the intervention strategy and the marketing mix are pretested with the intended audience. Effective social marketing Tips for effective social marketing include: Develop a plan that includes attention to all aspects of the marketing mix-product, price, place, and promotion-as well as policy and partnerships. Use research throughout the process-carefully review existing literature, and collect new data through focus groups, surveys, and observation. Involve the target population, including opinion leaders, to actively participate in and co-create the development process. Consider socioeconomic factors, cultural beliefs, values, geographic location, and local norms and values. The target audience must perceive benefits that equal or exceed perceived costs associated with performing the behavior. Employ marketing techniques, including consumer-oriented market research, segmentation and targeting, and marketing mix of strategies. Focus on the end goal of improving individual and societal well-being, rather than focusing on the organization.