Dr. Keith Roach

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The vast majority of people have had the measles vaccine. One group that has recently generated public attention are the people who were deliberately not immunized as children, because of misplaced parental concerns over the safety or effectiveness of the vaccine. Those who are now becoming adults-and those who are already adults-have the opportunity to make up their own minds about whether to get themselves vaccinated.

Vaccination is generally a requirement for students planning to attend college, unless there is a legitimate medical reason not to vaccinate (such as a severe immune system disease). This is part of the social contract: you need to protect not only yourself but others who may not be able to take the vaccine. Depending on the state, some teens may be able to get vaccinated without parental consent before age 18: in all states, all may get vaccinated at age 18. Vaccines can be obtained from ones own doctor, many local pharmacies, and state and local health departments.

<h1> But if youve had it, youre fine, right? </h1>

Maybe. Two groups of people should check just how protected they are:

<ol><li> People who are risk of exposure to measles . This could be healthcare workers or childcare workers. These groups should consider getting tested for immunity-its a simple blood test your doctor can do. Healthcare workers are usually tested at hiring to be sure their blood contains protective levels of antibodies. Lack of antibodies might be due to a poorly stored vaccine, or someone may be one of the few people who didnt respond. If not, they are required to get two doses of vaccine before starting to work. </li><li> People planning international travel to a place with ongoing measles outbreaks. Madagascar is having a massive outbreak now: information for travelers can be found at <a href="https://www.cdc.gov/measles/travelers.html">https://www.cdc.gov/measles/travelers.html</a> . Those who do not have protective antibodies will need two doses before travel, separated by at least 28 days, so this requires advance planning. </li><li> People born between 1963 and 1967 . Many who were born doing that time period were vaccinated using a killed vaccine, and they are at risk for a syndrome called atypical measles. The vaccine record should say whether you received a killed vaccine or a live vaccine (the Schwarz, Edmonston B, and Moraten strains are all live strains). If it doesnt say, you cant find your records, or received a killed vaccine, then you are at risk, and if you are in an area of an outbreak in the US or planning international travel to an area with an outbreak, you should see your doctor about getting revaccinated with 2 doses of the current MMR vaccine. (Since there is no measles vaccine apart from MMR, you get additional protection to mumps and rubella, and mumps has had several outbreaks lately.) </li></ol>

The measles vaccine is generally safe and effective, but there is no treatment in medicine that is perfect. Common side effects after the vaccine include joint pain, fever, and a short-lived rash. Two doses of the vaccine provides protection for more than 99% of the population, and this protection is thought to be lifelong.

Protection against measles is important, because measles is a serious disease. Many people mistakenly feel measles is no big deal, but it's not always a harmless disease. People over age 20 are more likely to have complications. Best case is two weeks off from work. Worst case goes from ear damage (can be permanent hearing loss) to pneumonia or encephalitis (swelling of the brain, which may cause permanent brain damage), both of which can be fatal. One out of 1,000 people with measles will die; 5 percent will require the ICU. One in 2,000 will later develop another problem, subacute sclerosing panencephalitis, which is uniformly fatal.

And even among those who have a straightforward course, measles leaves a "hole" in the immune system that predisposes people to other kinds of infections for years. There is no effective treatment for measles (although vitamin A is given to people with vitamin A deficiency), so prevention is important.

It's Never Too Late to Get Measles-Or the Vaccine

If you didnt get the measles vaccine (MMR) as a child-or don't know whether you did-should you get it as an adult? The answer is, unsurprisingly, a resounding yes. From January 1 to March 14, 2019, 268 cases of measles have been confirmed in 15 states. Even if you did get the vaccine, certain people who fit some specific criteria might need it again.

Daily Expert: It's Never Too Late to Get Measles—Or the Vaccine

It turns out that there are already pretty good ways to test for diabetes, and although different authorities have different recommendations about who would benefit from screening, all agree that screening is important, as a huge number of people are at risk.

Diabetes may not have symptoms early in its course-which is why docs screen to catch it early. Unchecked, it can leave you fatigued and with vision problems, kidney failure, an increased risk of heart disease, and ED.

To avoid this kind of damage, its best to try to prevent diabetes if possible, or at least find it in its earliest stages (called prediabetes) so that a person can be more aggressive in preventing overt diabetes. People with prediabetes are likely to develop overt diabetes within ten years unless they take steps to prevent it. Its estimated that there are 86 million(!) people in the US with prediabetes, 90 percent of whom are unaware of it.

<h1> Clues youre at risk for diabetes </h1>

So, without knowing your genetic code, how do we know who is at risk? There are many clues you dont need to pay $199 to find out:

<ul><li> Being overweight or obese. This is the biggest risk factor in the population, and the main reason for the epidemic of diabetes. What exactly constitutes the weight cutoff varies by guideline, but a BMI over 25 is commonly used. </li><li> Family history of diabetes-especially if its in a parent or sibling. </li><li> Age over 45, in the presence of other risk factors. </li><li> People who have taken medications which increase risk: glucocorticoids (prednisone and related drugs) or antipsychotic drugs. </li><li> Sedentary people (who dont get the recommended 30 minutes of moderate physical activity a day). </li><li> People with medical conditions indicating risk, including high blood pressure (higher than 140/90 or on medication); low HDL cholesterol (less than 35 mg/dL) or triglycerides (higher than 250 mg/dL); fatty liver; acanthosis nigricans (a skin finding, more common in people with darker skin, of dark, velvety-appearing skin on the back of the neck, groin, or underarms); sleep disorders (in the presence of other risk factors), such as obstructive sleep apnea. </li><li> People in at-risk ethnic groups (black, Native American, Hispanic, Asian-American, Native Hawaiian or Pacific Islander) in the presence of other risk factors. </li><li> Anyone who has already had abnormal blood sugar results. </li><li> The women in your life is also at higher risk if she had a very large baby, had gestational diabetes, or has polycystic ovarian syndrome. </li></ul>

When there are enough risk factors to screen for diabetes, I would recommend a visit with your friendly health care professional to get screened. Screening tests may be a simple blood sugar check; an A1c test (which looks at blood sugar over the last two months); and the most sensitive but least used of all, the oral glucose tolerance test. If you have actual symptoms of diabetes, including blurry vision, feeling thirsty or like you need to urinate all the time, have numbness or pain in the hands or feet or are feeling fatigued, you need to be tested sooner rather than later.

What is not yet clear is how often someone will be identified by 23andMe as being at risk who otherwise wouldnt meet any of the extensive criteria for screening above. And for those who are identified as at-risk by genetic testing but wouldnt otherwise meet the criteria, how often are they found to be diabetic or pre-diabetic? Until I see that information, I cant recommend spending money on the DNA test.

The popular DNA testing company 23andMe just announced that its $199 at-home DNA test would include a report on diabetes, with an explanation about how both a persons genetic test results and their lifestyle influence their risk of getting type 2 diabetes. Is this a good investment?

A New DNA Test Helps You Assess Your Diabetes Risk

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Weeks went by and I continued not to take pleasure in anything. Things that should have made me happy didnt. I didnt look forward to anything. I had a hard time falling asleep at night, and I woke up with a physical pressure sensation on my chest and my beloveds name on my lips. Dying of consumption seemed a romantic notion (I read a LOT of nineteenth century literature). But it wasnt until I had unbidden thoughts of who should get all my stuff when I died that I realized that something was really wrong. It was briefly clear to me that the depth of feeling I had-despair is not too strong a term-was affecting me far more deeply than I thought it could. In a strange way, this gave me a sense of relief. Its not that I felt better, merely that I could identify where my mental and physical symptoms were coming from.

I didnt talk to my parents, to my sister, or to any of my friends about it. It wasnt that I was ashamed, it just didnt occur to me to do so. It certainly didnt cross my mind to see a doctor: I was seventeen years old and in perfect health. The idea I might not be in perfect mental health didnt even cross my mind.

The idea I might not be in perfect mental health didnt even cross my mind.

Six months went by, and as my first winter in Chicago started to turn to Spring, I slowly began to feel myself again. I enjoyed time with friends. I started to do better in school and to take interest in academics again, rather than going through the motions.

It wasnt until years later, in medical school, that I finally realized that I had been through a pretty textbook case of major depressive disorder. It was a bit of a shock reading about it. The diagnosis of depression is clinical, meaning that it comes from an experienced clinician doing a careful interview and exam, and not from blood testing or imaging studies. Experience is essential because interpreting the answers to the questions requires judgment: it isnt always a simple yes or no answer, despite the fact that the official diagnostic criteria (from the psychiatric reference book called the DSM-5) sound like yes or no questions:

<ul><li> Depressed mood most of the day </li><li> Loss of interest or pleasure in most or all activities </li><li> Too much or too little sleep </li><li> Weight loss or weight gain; or increase or decrease in appetite </li><li> Moving and speaking more slowly (or much faster) than normal </li><li> Fatigue or low energy </li><li> Decreased ability to concentrate, think, or make decisions </li><li> Thoughts of worthlessness or inappropriate guilt </li><li> Recurrent thoughts of death, or thinking about or attempting suicide </li></ul>

Five or more of these criteria for almost every day for two or more weeks meet the diagnosis of major depressive disorder (but that has to include one of the first two listed). There are some conditions that exclude the diagnosis: symptoms cannot be due to another medical condition (uncommon); may not be due to drug use or withdrawal (not as uncommon); and if these occur with episodes of mania or hypomania (times of extreme energy, often associated with poor judgment), the diagnosis is not unipolar depression but bipolar disorder. The symptoms have to be severe enough to cause significant distress or psychosocial impairment.

Primary care doctors like me are the ones who most frequently make the diagnosis.

Psychiatrists are the experts in making the diagnosis, but primary care doctors like me are the ones who most frequently do make the diagnosis-although they may not catch it every time. Its now recommended for physicians to screen patients for major depression, but there will still be people like me who have symptoms but dont bring themselves to medical attention. Its much easier to treat if you do check in with a doctor. What else to do:

Get one of the leading treatments

There are two major treatment options for major depression: medications and psychotherapy. Some people have strong feelings about these treatments. Each is effective on its own; a combination of the two is even more effective. There are many different types of drug treatments, and a clinician will choose one based on their best guess of effectiveness and side-effects in an individual. There is increasing evidence that testing for genetic variants can help precisely guide the best medication for an individual; however, this is not yet recommended in general, and I have used it only when a patient has not had success in finding an effective treatment.

These Common Signs of Depression Are Easy to Miss

Psychotherapy often makes people think of many sessions undergoing analysis on a couch: this type, called psychodynamic therapy, is not the way therapy is typically done for depression. Interpersonal therapy addresses a persons relationships, and is intended to change behaviors with family and friends and lasts for 3-4 months, typically, as opposed to psychodynamic therapy, which addresses unresolved childhood issues and unconscious feelings, and typically lasts for years. Cognitive behavioral therapy is another short-term treatment which helps people learn how to understand their feelings and beliefs, and gives exercises to improve awareness of these and make changes to improve them. Both of these therapies have been shown to be effective in depression.

Lose the idea that its something to be hidden

Even in 2019, there remains a stigma to mental illness, and many people (especially men) feel that depression is a sign of weakness, and they are loath to admit it, to themselves or to people who might help them. This is a barrier I have had to fight many times. I tell people that they cant control whether they get high blood pressure, but that it can be treated, and treatment reduces the risk of harms. Depression is similar. Untreated, it leads to a higher likelihood of bad outcomes that arent just about continuing to feel depressed; they include effects on other people (family, friends, work); a higher likelihood of drug and alcohol abuse; and the biggest danger of all, suicide. Depression can be a fatal illness.

I tell people they often can\'t control whether they get high blood pressure. Depression is similar.

Beware being number one

Men are at higher risk for suicide. Although men and women are about equal in thinking about suicide and in suicide attempts, men are much more likely to be successful. Were number one, but this is not an area where men want to be leading the way. Treatment of depression in somebody contemplating, or worse, planning, suicide is a little different. Also, a persons age determines not only their risk for suicide (older men are at the highest risk of all), but also how treatment affects suicidal risk. A medicine like Prozac (fluoxetine), for example, increases suicide risk in adolescents and young adults (at least in the short term), but decreases risk in older men.

This is not an area where men want to be leading the way.

Know it will get better-but you may not see that

One barrier to treatment of depression is the depression itself. Some people have an overwhelming fatigue that prevents them from going to see someone about it. If you are suffering, this means you need to make the effort. Get some help from family or friends in making the appointment. If you are the family or friend whos seeing signs of depression in someone, you can help by helping to get them to an appointment. Assist them in finding a therapist in their network, offer to drive them to an appointment, help with child care if appropriate, or find some other way to reduce the barriers to getting there. One common finding in depression is an inability to see that things can ever get better. This sense of hopelessness is a cruel facet of the issue that prevents proper treatment. However, treatment is effective at restoring hope.

Some people have an overwhelming fatigue that prevents them from going to see someone about it.

Stay vigilant to the signs

Once a person has had an episode of depression, future bouts are much more likely than in a person who hasnt: one study found that 13 percent of people had a recurrence within 5 years, 23% within 10 years, and 42% within 20 years. Fortunately, most people have a much easier time recognizing symptoms the second time around and are faster to seek care. Nobody who has had severe depression and who has gotten better wants to feel that way again.

Its been well over 30 years since I have had depression. I know I am at risk in the future, and in times of stress, I have been vigilant about paying attention to my own feelings. Everyone has ups and downs, but feeling down most days for more than 2 weeks would be a red flag. I also recommend being forthright with the people that matter most: if they recognize that I am not myself they can feel safe in letting me know so that I could get treatment sooner. I dont want to feel that way, and my family, coworkers, and friends dont want that for me either.

When I broke up with my first serious girlfriend (well, she did the breaking up), I was nave, egocentric, and convinced I could think my way out of anything. I was also 17 years old, which may explain a large part of that. I was intensely sad, but the sadness didnt go away. I had just moved from California to Chicago, right at the beginning of my senior year in high school, and felt I had a perfect explanation why I felt down all the time. I thought of it as a sign that my relationship was so...

The Daily Expert: Signs of Depression Can Be So Subtle Even Doctors Miss Them

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Dr. Keith Roach

Articles written by the author

Daily Expert: It's Never Too Late to Get Measles—Or the Vaccine

A New DNA Test Helps You Assess Your Diabetes Risk

The Daily Expert: Signs of Depression Can Be So Subtle Even Doctors Miss Them