Mood and Anxiety Disorders: Major Depressive Disorder.

Major depressive disorder (MDD) is defined as five or more of the following symptoms in the past 2 weeks, during which at least one is depressed mood or loss of interest or pleasure: depressed mood; diminished interest or pleasure in activities; significant weight loss or gain, or decreased or increased appetite; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; poor concentration or indecisiveness; or recurrent thoughts of death or suicidal ideation, plan, or attempt. Screening for MDD is recommended in the general adult population when resources are available for diagnosis, management, and follow-up. Several screening tools are available, including the Patient Health Questionnaire-9 (PHQ-9) and Beck Depression Inventory for Primary Care (BDI-PC). Laboratory tests may be considered to assess for significant comorbidities, differential diagnoses, or contraindications to treatment. Management of MDD depends on its severity and may include psychotherapy, pharmacotherapy, or both. The drugs most commonly used are selective serotonin reuptake inhibitors. Treatment should be continued for at least 16 to 24 weeks to prevent recurrence. Referral to a psychiatrist or other mental health clinician should be considered when the diagnosis is in question or when symptoms do not improve with standard treatment.

Mood and Anxiety Disorders: Bipolar Disorder.

Bipolar I disorder affects approximately 0.4% to 1% of the global population. In the United States, bipolar-related disorders are associated with a significant economic burden because of the functional impairment they cause. Due to long wait times for access to specialist physicians and insurance issues, primary care physicians frequently manage this condition. Up to 4% of patients in primary care have bipolar disorder (BD). The diagnostic criteria for bipolar-related disorders are complex, and screening tools alone are insufficient for identification. Diagnosis involves a comprehensive clinical assessment that often requires multiple visits. Lithium continues to be the gold-standard mood-stabilizing drug for BD management and maintenance therapy in adults. Some anticonvulsants and atypical antipsychotics also have been shown to be effective for maintenance therapy. Ketamine is being studied as a possible future treatment option, but current research does not support its use. Psychotherapy, such as cognitive behavioral therapy and psychoeducation on management strategies, can be a useful adjunct therapy. Mental health clinicians can support primary care physicians in the evaluation and treatment of patients with BD.

Mood and Anxiety Disorders: Suicide.

In the United States, suicide was the cause of more than 47,500 deaths in 2019. Females attempt suicide 1.5 times more frequently than males. However, rates of completed suicide are higher in males than in females. In the US population, the suicide rate is highest in adults older than 75 years. Factors associated with an increased risk of suicide include geographic and social isolation, low access to clinical resources, unemployment, and poverty. Patients with mental disorders, including schizophrenia, major depressive disorder (MDD), bipolar disorder, and substance use disorder, are at increased risk. Directly questioning a patient about suicide has not been shown to increase the patient's risk of completing suicide. Physicians should ask patients about any suicide plans and details of timing, location, means, and any preparation for the act. The goal of pharmacotherapy in patients with suicidality is management of comorbid mood disorders, most often MDD. Esketamine nasal spray is a pharmacotherapy option for MDD management in patients with acute suicidal ideation or behavior. It is approved for use in conjunction with an oral antidepressant. Use of "no harm contracts" or "safety contracts," in which patients attest that they will not commit suicide, should not be relied on to the exclusion of a formal suicide risk assessment and thorough clinical evaluation.

Mood and Anxiety Disorders: Generalized Anxiety and Panic Disorders.

Anxiety disorders are characterized by excessive fear and worry. Generalized anxiety disorder (GAD) and panic disorder (PD) are two of the most common anxiety disorders in the United States. GAD is defined as excessive worry and anxiety that occur on most days for at least 6 months that affect daily functioning. PD is defined by recurrent unexpected panic attacks. Patients with symptoms of GAD or PD should be assessed for conditions such as hyperthyroidism, hyperparathyroidism, and cardiac arrhythmia before confirmation of an anxiety disorder diagnosis. A U.S. Preventive Services Task Force (USPSTF) draft statement recommends screening for anxiety in adults 64 years and younger, including pregnant and postpartum women. A final statement recommends screening for anxiety in children and adolescents ages 8 to 18 years. Multiple self-report tools have been validated for GAD and PD screening. The 7-item Generalized Anxiety Disorder (GAD-7) scale is an option for screening for GAD. The Panic Disorder Severity Scale (PDSS) is a 7-item tool with excellent sensitivity and specificity in screening for PD. Management with selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors in combination with psychotherapy has been shown to be effective for GAD and PD. Research on alternative treatments, such as psychedelic-assisted psychotherapy, is ongoing.

Ubrogepant: An Oral Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist for Abortive Migraine Treatment.

OBJECTIVE: To review the pharmacology, efficacy, and safety of ubrogepant as an abortive migraine treatment. DATA SOURCES: A literature search of MEDLINE and PubMed was performed (January 2006 through May 2021) using the following search terms: ubrogepant, calcitonin gene related peptide, and abortive migraine therapy. STUDY SELECTION AND DATA EXTRACTION: Relevant studies evaluating ubrogepant's pharmacology, efficacy, and safety in humans for the treatment of migraine were considered. DATA SYNTHESIS: Ubrogepant is a calcitonin gene-related peptide receptor antagonist approved by the Food and Drug Administration for the acute treatment of migraine via data from ACHIEVE I and II. From ACHIEVE I, ubrogepant demonstrated superiority to placebo in freedom from migraine pain at 2 hours postdose (50-mg dose: odds ratio [OR] = 1.83, 95% CI = 1.25-2.66; 100-mg dose: OR = 2.04, 95% CI = 1.41-2.95) and freedom from most bothersome symptom (MBS; 50-mg dose: OR = 1.70, 95% CI = 1.27-2.28; 100-mg dose: OR = 1.63, 95% CI = 1.22-2.17). ACHIEVE II trial demonstrated efficacy of ubrogepant 50 mg compared with placebo (2-hour pain freedom: OR = 1.62, 95% CI = 1.14-2.29; 2-hour MBS freedom: OR = 1.65, 95% CI = 1.25-2.20). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Ubrogepant is a viable option for patients who are unable to tolerate nonsteroidal anti-inflammatory drug or triptan therapy because of ineffective relief or contraindications that limit use. CONCLUSIONS: Ubrogepant is a well-tolerated effective abortive migraine treatment that bridges a gap in therapy for many patients who previously could not tolerate other first-line treatments.

Less Common Respiratory Conditions: Occupational Lung Diseases.

Occupational lung diseases are caused by workplace inhalation of chemicals, dusts, or fumes. They include asbestosis, silicosis, coal workers' pneumoconiosis (CWP), and occupational asthma. These diseases have nonspecific respiratory symptoms and are only identified if an occupational history is taken. Asbestosis typically is diagnosed 20 to 30 years after peak exposure, often when pleural plaques are noted on chest x-ray (CXR). Asbestosis is associated with an increased cancer risk, which is higher in smokers. Silicosis results from exposure to silica dust from sand, stone, and quartz. It is a fibrotic lung disease with acute, chronic, or accelerated presentations; CXR findings show interstitial fibrosis or nodular opacities. Silicosis increases risk of mycobacterial and fungal infections. In CWP, patients may present with mild symptoms and CXR findings showing small fibrous nodules; progressive massive fibrosis may develop, and there is a risk of mycobacterial and fungal infections. Occupational asthma (OA) can occur de novo from inhaling sensitizers that induce immunoglobulin E-mediated airway reactions, or from inhaling irritants such as smoke, dust, and fumes. OA also can be due to sensitizers/irritants aggravating preexisting asthma. There are no cures for these occupational lung diseases, so prevention, including elimination/control of workplace exposures, and early diagnosis are key.

Less Common Respiratory Conditions: Sarcoidosis.

Sarcoidosis is a systemic condition characterized by formation of granulomas that can involve many organ systems, with the lungs and intrathoracic lymph nodes involved in more than 90% of cases. Sarcoidosis also can involve the cardiac, ocular, hepatic, dermatologic, and central nervous systems. The presentation of pulmonary sarcoidosis is nonspecific. Less than half of patients initially have respiratory symptoms and the disease often is detected as an incidental finding of lymphadenopathy on chest x-ray. However, lymphadenopathy can occur in many other conditions, ranging from tuberculosis to cancer, so sarcoidosis should be diagnosed only after excluding these other conditions. Typical granulomatous findings on lymph node biopsy can increase confidence in sarcoidosis diagnosis after the other conditions are excluded. However, there are three syndromes which, if present, are diagnostic of sarcoidosis: Lofgren syndrome, Heerfordt syndrome, and lupus pernio. The majority of sarcoidosis cases resolve spontaneously, so treatment typically is reserved for patients with progressive pulmonary or extrapulmonary involvement, specifically ocular, cardiac, or central nervous system. Systemic corticosteroids are first-line treatment. Second-line treatment with methotrexate or hydroxychloroquine is used if steroids are ineffective or to enable steroid tapering. Refractory disease should be comanaged with a sarcoidosis subspecialist.

Less Common Respiratory Conditions: Fungal Respiratory Infections.

Coccidioidomycosis, histoplasmosis, and aspergillosis are all caused by inhaling a soil fungus. Most patients with coccidioidomycosis, which is endemic to California and Arizona, are asymptomatic, but 40% have influenzalike symptoms that frequently resolve without treatment. Rarely, coccidioidomycosis can disseminate. It typically is diagnosed with chest x-ray and antibody tests. Antifungal therapy is only needed for severe infections and individuals with extensive comorbidities. Histoplasmosis is endemic to central/eastern United States. Only 10% of cases are symptomatic, and they typically resolve without treatment. Severe illness can occur in immunocompromised individuals. Diagnosis typically is made with chest x-ray and urine/serum antigen tests. Antifungal therapy is indicated for mild infections that do not resolve and for those with more severe disease. Neither histoplasmosis nor coccidioidomycosis is spread from person to person. Aspergillosis also can be acquired in health care settings via person-to-person spread or contaminated medical devices. Aspergillus-related pulmonary disease includes an allergic syndrome, aspergillomas (fungus balls) in the lungs or sinuses, and chronic or invasive forms. The allergic syndrome is initially diagnosed with skin tests or immunoglobulin E levels and managed with steroids and antifungals. Aspergillomas and invasive disease are initially detected with x-rays and managed with antifungals.

Less Common Respiratory Conditions: Pulmonary Tuberculosis.

Tuberculosis (TB) is the leading cause of infectious disease-related mortality worldwide, affecting 1.7 billion individuals with 9,000 new cases annually in the United States. Disease burden in the United States is greatest among immigrants from areas with high TB rates (eg, India, China, Philippines, Vietnam). Active TB infection can be recently acquired or latent TB infection (LTBI) that becomes active long after initial infection. LTBI testing is recommended for health care workers at hire, immigrants from high-burden areas, and those in high-risk environments (eg, homeless shelters, correctional facilities, long-term care). Health care workers can be tested with interferon gamma release assays (IGRA) or tuberculin skin tests (TSTs). For others older than 5 years, IGRA is recommended. For children younger than 5 years, TSTs are recommended. If test results are positive, several new therapeutic regimens have replaced the previously standard 9-month isoniazid regimen. For patients suspected of having active TB, testing involves chest x-ray, sputum for microscopy, cultures, and nucleic acid amplification tests. Active TB is managed with 2-months of intensive 4-drug therapy, followed by a 4-month continuation phase with isoniazid and rifampin. If multidrug-resistant TB is diagnosed, consultation with infectious disease subspecialists and the health department is recommended.