Health and economic burden of sugar-sweetened beverages consumption in Brazil

Sugar-sweetened beverages (SSBs) are a major source of added sugar and are associated with noncommunicable diseases (NCDs) such as obesity and diabetes. This study assessed the impact of SSBs consumption on disease burden in Brazil, including deaths, disability-adjusted life years (DALYs), and healthcare costs. A 3-stage methodology was used to assess the direct effects of SSBs on diabetes, cardiovascular diseases, and body mass index (BMI), along with the influence of BMI on disease incidence. These assessments were then used to estimate the economic and health burden using population-attributable factors. Results showed that 2.7% and 11% of adult and children overweight/obesity cases were attributable to SSBs, respectively. SSBs consumption in Brazil led to 1,814,486 cases, 12,942 deaths, 362,088 DALYs, and USD 2,915.91 million in medical costs related to diabetes, cardiovascular diseases, oncological diseases, and other NCDs. Urgent implementation of public policies is crucial to address the consumption of SSBs, recognized as a key risk factor for NCDs.

What is the burden of tinnitus?

Introduction

Tinnitus is a complex experience that often occurs alongside other health conditions, including hearing loss. In the UK, as in other western countries, patterns of health are changing with a rise in multi-morbidity and complexity of health conditions. As we age, we can expect to live with multiple health conditions. Burden of illness has long been recognised. Less well recognised is the burden that accumulates from the treatment of health conditions.

Methods

This qualitative thematic analysis of patient accounts described the cumulative burdens of tinnitus, both the experience of hearing the tinnitus and from the treatments undertaken. Between 2017-8 we conducted interviews with 38 participants who were help-seekers in a range of contrasting UK clinical services (Physician led, Audiology led and Hearing Therapy led). We examined these interview data using reflexive thematic analysis methods to identify and explore the cumulative burdens for those who live with and seek help for their tinnitus. Specifically, we used six phased approach to determine and group themes.

Results

The themes provide a coherent description of the nature of the burden that people with tinnitus experience.

Discussion

In tinnitus, as with most chronic health conditions, the largest treatment workload is devolved to the patient. Patients are required to implement treatments, learn about tinnitus and find new ways of coping. Yet this work happens invisibly, without recognition from clinicians who measure outcomes but not the efforts made to achieve outcomes. Patient-centred care depends upon the recognition of the cumulative burdens that patients experience.

The Economic Burden of Chronic Kidney Disease in Vietnam

Our objective is to analyze the economic burden of chronic kidney disease (CKD) in Vietnam, particularly in District 2 Hospital at Ho Chi Minh City in 2019. This is a descriptive cross-sectional study. The data source is the medical records of the patients. Encoding the data, analyzing treatment cost, regression modeling, and verification were performed using Stata 15 software. Patients with stage 3 CKD account for the highest proportion of the CKD patient population. CKD comorbidities include hypertension, diabetes, cardiovascular disease, and anemia, which increase the treatment fees of patients. Approximately half of the patients with CKD have diabetes or cardiovascular disease. Treatment costs increase as the condition of the patient worsens (except for stage 1 and 2 CKD). The total expenses of all CKD patients in District 2 Hospital were USD 916 423 988.60. Five main factors that affect the treatment fee of a patient: CKD stage, age, gender, and the presence of diabetes, cardiovascular disease, and anemia. The regression model correctly predicts 96% of cases and can explain 64.15% of the fluctuations in costs. The cost of CKD treatment was higher than Vietnam's per capita GDP in 2019, and the primary factors affecting costs are comorbidities and dialysis.

Multimorbidity and Opioid Prescribing in Hospitalized Older Adults

Background: Multimorbidity and pain are both common among older adults, yet pain treatment strategies for older patients with multimorbidity have not been well characterized. Objectives: To assess the prevalence and relationship between multimorbidity and opioid prescribing in hospitalized older medical patients with pain. Methods: We collected demographic, morbidity, pain, and analgesic treatment data through structured review of the electronic medical records of a consecutive sample of 238 medical patients, aged ≥65 years admitted between November 2014 and May 2015 with moderate-to-severe pain by numerical pain rating scale (range 4-10). We used the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) to assess multimorbidity and cumulative illness burden. We examined the relationship between morbidity measures and opioid prescribing at hospital discharge using multivariate regression analysis. Results: The mean age was 75 ± 8 years, 57% were female and 50% were non-White. Mean CIRS-G total score was 17 ± 6, indicating high cumulative illness burden. Ninety-nine percent of patients had multimorbidity, defined as moderate-to-extremely severe morbidity in ≥2 organ systems. Sixty percent of patients received an opioid prescription at discharge. In multivariate analyses adjusted for age, race, and gender, patients with a discharge opioid prescription were significantly more likely to have higher cumulative illness burden and chronic pain. Conclusion: Among older medical inpatients, multimorbidity was nearly universal, and patients with higher cumulative illness burden were more likely to receive a discharge opioid prescription. More studies of benefits and harms of analgesic treatments in older adults with multimorbidity are needed to guide clinical practice.

Prescription Patterns and Burden of Pediatric Asthma in Korea

Purpose

This study aimed to estimate the prevalence, prescription pattern and burden of pediatric asthma in Korea by analyzing the National Health Insurance (NHI) claims data.

Methods

We retrospectively analyzed the insurance claim records from the Korean NHI claims database from January 2010 to December 2014. Asthmatic patients were defined as children younger than 18 years, with appropriate 10th Revision of the International Classification of Diseases codes (J45 or J46) and a prescription for 1 or more asthma maintenance medications at the same date. Hospitalization and emergency department visits for asthma were defined as use of short-acting beta₂-agonists during hospital visits among asthmatic patients.

Results

There were 1,172,807 asthmatic children in 2010, which increased steadily to 1,590,228 in 2014 in Korea. The prevalence showed an increasing trend annually for all ages. The mean prevalence by age in those older than 2 years decreased during the study period (from 39.4% in the 2–3 year age group to 2.6% in the 15–18 year age group). In an outpatient prescription, leukotriene receptor antagonists were the most commonly prescribed medication for all ages. Patients older than 6 years for whom inhaled corticosteroids were prescribed comprised less than 15% of asthmatic patients. The total direct medical cost for asthma between 2010 and 2014 ranged from $376 to $483 million. Asthma-related medical cost per person reached its peak in $366 in 2011 and decreased to $275 in 2014.

Conclusions

The prevalence of pediatric asthma increased annually and decreased with age. Individual cost of asthma showed a decreasing trend in Korean children.

One-Year Linear Trajectories of Symptoms, Physical Functioning, Cognitive Functioning, Emotional Well-being, and Spiritual Well-being Among Patients Receiving Dialysis

BACKGROUND

This study evaluated 1-year linear trajectories of patient-reported dimensions of quality of life among patients receiving dialysis.

STUDY DESIGN

Longitudinal observational study.

SETTING & PARTICIPANTS

227 patients recruited from 12 dialysis centers.

FACTORS

Sociodemographic and clinical characteristics.

MEASUREMENTS/OUTCOMES

Participants completed an hour-long interview monthly for 12 months. Each interview included patient-reported outcome measures of overall symptoms (Edmonton Symptom Assessment System), physical functioning (Activities of Daily Living/Instrumental Activities of Daily Living), cognitive functioning (Patient's Assessment of Own Functioning Inventory), emotional well-being (Center for Epidemiologic Studies Depression Scale, State Anxiety Inventory, and Positive and Negative Affect Schedule), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale). For each dimension, linear and generalized linear mixed-effects models were used. Linear trajectories of the 5 dimensions were jointly modeled as a multivariate outcome over time.

RESULTS

Although dimension scores fluctuated greatly from month to month, overall symptoms, cognitive functioning, emotional well-being, and spiritual well-being improved over time. Older compared with younger participants reported higher scores across all dimensions (all P<0.05). Higher comorbidity scores were associated with worse scores in most dimensions (all P<0.01). Nonwhite participants reported better spiritual well-being compared with their white counterparts (P<0.01). Clustering analysis of dimension scores revealed 2 distinctive clusters. Cluster 1 was characterized by better scores than those of cluster 2 in nearly all dimensions at baseline and by gradual improvement over time.

LIMITATIONS

Study was conducted in a single region of the United States and included mostly patients with high levels of function across the dimensions of quality of life studied.

CONCLUSIONS

Multidimensional patient-reported quality of life varies widely from month to month regardless of whether overall trajectories improve or worsen over time. Additional research is needed to identify the best approaches to incorporate patient-reported outcome measures into dialysis care.

The impact of irritable bowel syndrome on daily functioning: Characterizing and understanding daily consequences of IBS

BACKGROUND

Despite the well-documented economic and psychosocial burden of irritable bowel syndrome (IBS), few studies have focused on the impact of IBS on daily activities. This study aims to quantitate impairment in daily activities among IBS patients and to evaluate the relationship between impairment, IBS, quality of life, and psychiatric symptoms.

METHODS

A total of 179 participants meeting ROME-III criteria for IBS completed an online research survey evaluating the following variables: (i) the impact of IBS on daily activities, (ii) comorbid psychiatric diagnoses, (iii) symptom severity, (iv) quality of life, and (v) symptom-specific cognitive affective factors related to IBS.

KEY RESULTS

This sample reported a high degree of impairment due to IBS, with 76% of the sample reporting some degree of IBS-related impairment in at least five different domains of daily life. Rates of impairment were significantly higher for participants who met criteria for anxiety, depression, and/or panic disorder.

CONCLUSIONS & INFERENCES

This study contributes to existing literature by demonstrating a high level of daily impairment among patients with IBS, particularly those who meet criteria for anxiety, depression, and panic disorder. These findings support the importance of integrated psychosocial and medical care for IBS patients, and highlight the utility of evaluation and intervention for behavioral avoidance/impairment especially among those who exhibit signs or symptoms of psychiatric diagnoses.

Classifying diabetes-burden: A factor analysis of the Problem Areas in Diabetes Scale

This study sought to identify salient factors associated with the Problem Areas in Diabetes Scale to facilitate improved assessment and treatment of diabetes-related burden. Exploratory factor analysis assessed the factor structure of the Problem Areas in Diabetes Scale among 224 Veterans with uncontrolled type 2 diabetes and depressive symptoms. A four-factor solution of emotional, diabetes management, treatment, and social support burden subscales was extracted. These factors represent clinically relevant components of diabetes burden that include but go beyond symptoms of depression. The Problem Areas in Diabetes subscales may expand assessments for depression and improve medical and behavioral health interventions for patients with diabetes.

Predicting frequent hospital admission risk in Singapore: a retrospective cohort study to investigate the impact of comorbidities, acute illness burden and social determinants of health

OBJECTIVES

To evaluate the impact of comorbidities, acute illness burden and social determinants of health on predicting the risk of frequent hospital admissions.

DESIGN

Multivariable logistic regression was used to associate the predictive variables extracted from electronic health records and frequent hospital admission risk. The model's performance of our predictive model was evaluated using a 10-fold cross-validation.

SETTING

A single tertiary hospital in Singapore.

PARTICIPANTS

All adult patients admitted to the hospital between 1 January 2013 and 31 May 2014 (n=25 244).

MAIN OUTCOME MEASURE

Frequent hospital admissions, defined as 3 or more inpatient admissions within 12 months of discharge. Area under the receiver operating characteristic curve (AUC) of the predictive model, and the sensitivity, specificity and positive predictive values for various cut-offs.

RESULTS

4322 patients (17.1%) met the primary outcome. 11 variables were observed as significant predictors and included in the final regression model. The strongest independent predictor was treatment with antidepressants in the past 1 year (adjusted OR 2.51, 95% CI 2.26 to 2.78). Other notable predictors include requiring dialysis and treatment with intravenous furosemide during the index admission. The predictive model achieved an AUC of 0.84 (95% CI 0.83 to 0.85) for predicting frequent hospital admission risk, with a sensitivity of 73.9% (95% CI 72.6% to 75.2%), specificity of 79.1% (78.5% to 79.6%) and positive predictive value of 42.2% (95% CI 41.1% to 43.3%) at the cut-off of 0.235.

CONCLUSIONS

We have identified several predictors for assessing the risk of frequent hospital admissions that achieved high discriminative model performance. Further research is necessary using an external validation cohort.

A High-Touch Model of Community-Based Specialist Palliative Care: Latent Class Analysis Identifies Distinct Patient Subgroups

CONTEXT

Community-based palliative care may support seriously ill homebound patients. Programs vary widely, and few studies have described the heterogeneity of the populations served or service delivery models.

OBJECTIVES

To evaluate a diverse population served by an interdisciplinary model of community-based specialist palliative care and the variation in service delivery over time and identify subgroups with distinct illness burden profiles.

METHODS

A retrospective cohort study evaluated longitudinal electronic health record data from 894 patients served during 2010-2013. Illness burden was defined by measures of performance status (Karnofsky Performance Status scale), symptom distress (Condensed Memorial Symptom Assessment Scale), palliative care needs (Palliative Outcome Scale), and quality of life (Spitzer Quality of Life Index). Service utilization included the frequency of visits received and calls made or received by patients. Latent class analysis identified patient subgroups with distinct illness burden profiles, and mixed-effects modeling was used to evaluate associations between patient characteristics and service utilization.

RESULTS

The mean age was 72.3 years (SD = 14.0); 56.2% were women; 67.5% were English speaking; and 22.2% were Spanish speaking. Most had congestive heart failure (36.4%) or cancer (30.4%); 98.0% had a Karnofsky Performance Status score of 40-70. Four patient subgroups were identified: very low illness burden (26.2%); low burden (39.5%); moderate burden (13.5%); and high burden (20.8%). The subgroups differed in both baseline characteristics and palliative care service utilization over time.

CONCLUSION

The population served by a community-based specialist palliative care program manages patients with different levels of illness burden, which are associated with patient characteristics and service utilization.

Predicting CPAP Use and Treatment Outcomes Using Composite Indices of Sleep Apnea Severity

STUDY OBJECTIVES

Measures of baseline sleep apnea disease burden (apnea-hypopnea index, Epworth Sleepiness Scale) predict continuous positive airway pressure (CPAP) adherence, but composite indices of sleep apnea severity (Sleep Apnea Severity Index, Modified Sleep Apnea Severity Index) may be more robust measures of disease burden. We tested the relative prognostic ability of each measure of sleep apnea disease burden to predict subsequent CPAP adherence and subjective sleep outcomes.

METHODS

Prospective cohort study at a tertiary academic sleep center. Patients (n = 323) underwent initial diagnostic polysomnography for suspected obstructive sleep apnea and 6 mo of subsequent CPAP therapy.

RESULTS

Baseline apnea-hypopnea index and both composite indices predicted adherence to CPAP therapy at 6 mo in multivariate analyses (all p ≤ 0.001). Baseline Epworth Sleepiness Scale did not predict CPAP adherence (p = 0.22). Both composite indices were statistically stronger predictors of CPAP adherence at 6 mo than apnea-hypopnea index (p < 0.001). In multivariate analyses, baseline apnea-hypopnea index (p < 0.05) and both composite indices (both p < 0.04) predicted change in Pittsburgh Sleep Quality Index, whereas only the composite indices predicted changes in Sleep Apnea Quality of Life Index (both p < 0.001). Adjustment for treatment adherence did not affect the relationship of the composite indices with change in Sleep Apnea Quality of Life Index (both p ≤ 0.005).

CONCLUSIONS

Composite indices of baseline sleep apnea severity better predict objective CPAP adherence and subjective treatment outcomes than baseline apnea-hypopnea index and baseline Epworth Sleepiness Scale.

Disease burdens from environmental tobacco smoke in Korean adults

In this study, we estimated the disease burdens attributable to environmental tobacco smoke (ETS) exposure in Korean adults in 2010 and analyzed the trend of that from 2005 to 2010. We obtained information on the study population from the 2010 Cause of Death Statistic and estimated the ETS-attributable fraction using data from the Korean Community Health Survey and the Korean National Health and Nutrition Examination Survey. The numbers of ETS-attributable deaths in female and male non-smokers were estimated to be 4.1 and 69.6% of the numbers of deaths attributable to current smoke, respectively. The deaths attributable to ETS were larger in female than in male non-smokers (710 vs. 420). The ETS-attributable deaths increased slightly in 2005-2008 but decreased in 2009-2010. The number of potential years of life lost from ETS was 9077.24 years in 2010. If there were no exposure to ETS in adult non-smokers, we would expect to see 1130 fewer deaths (9.9% of the deaths from current smoke). The results suggest that ETS poses considerable disease burdens for non-smokers, especially women, in Korea.

Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Symptom Severity: Stress Management Skills are Related to Lower Illness Burden

BACKGROUND

The onset of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) typically involves reductions in activities of daily living and social interactions (jointly referred to as "illness burden"). Emotional distress has been linked to increased reported symptoms, and stress management skills have been related to lower fatigue severity in CFS patients. Symptom severity and illness burden are highly correlated. The ability to manage stress may attenuate this relationship, allowing individuals to feel less burdened by the illness independent of the severity of their symptoms.

PURPOSE

This study aimed to evaluate if perceived stress management skills affect illness burden via emotional distress, independent of ME/CFS symptom severity.

METHODS

A total of 117 adults with ME/CFS completed measures of perceived stress management skills, emotional distress, ME/CFS symptom severity and illness burden.

RESULTS

Regression analyses revealed that greater perceived stress management skills related to less social and fatigue-related illness burden, via lower emotional distress. This relationship existed independent of the association of symptom severity on illness burden, and was stronger among those not currently employed.

CONCLUSIONS

Ability to manage stress is associated with a lower illness burden for individuals with ME/CFS. Future studies should evaluate the efficacy of psychosocial interventions in lowering illness burden by targeting stress management skills.

Psychological distress in parents of children with advanced cancer

IMPORTANCE

Parent psychological distress can impact the well-being of childhood cancer patients and other children in the home. Recognizing and alleviating factors of parent distress may improve overall family survivorship experiences following childhood cancer.

OBJECTIVES

To describe the prevalence and factors of psychological distress (PD) among parents of children with advanced cancer.

DESIGN

Cohort study embedded within a randomized clinical trial (Pediatric Quality of Life and Evaluation of Symptoms Technology [PediQUEST] study).

SETTING

Multicenter study conducted at 3 children's hospitals (Boston Children's Hospital, Children's Hospital of Philadelphia, and Seattle Children's Hospital).

PARTICIPANTS

Parents of children with advanced (progressive, recurrent, or refractory) cancer.

MAIN OUTCOME MEASURE

Parental PD, as measured by the Kessler-6 Psychological Distress Scale.

RESULTS

Eighty-six of 104 parents completed the Survey About Caring for Children With Cancer (83% participation); 81 parents had complete Kessler-6 Psychological Distress Scale data. More than 50% of parents reported high PD and 16% met criteria for serious PD (compared with US prevalence of 2%-3%). Parent perceptions of prognosis, goals of therapy, child symptoms/suffering, and financial hardship were associated with PD. In multivariate analyses, average parent Kessler-6 Psychological Distress Scale scores were higher among parents who believed their child was suffering highly and who reported great economic hardship. Conversely, PD was significantly lower among parents whose prognostic understanding was aligned with concrete goals of care.

CONCLUSIONS AND RELEVANCE

Parenting a child with advanced cancer is strongly associated with high to severe levels of PD. Interventions aimed at aligning prognostic understanding with concrete care goals and easing child suffering and financial hardship may mitigate parental PD.

Functional impairment, illness burden, and depressive symptoms in older adults: does type of social relationship matter?

OBJECTIVE

The nature of interpersonal relationships, whether supportive or critical, may affect the association between health status and mental health outcomes. We examined the potential moderating effects of social support, as a buffer, and family criticism, as an exacerbating factor, on the association between illness burden, functional impairment and depressive symptoms.

METHODS

Our sample of 735 older adults, 65 years and older, was recruited from internal and family medicine primary care offices. Trained interviewers administered the Hamilton Rating Scale for Depression, Duke Social Support Inventory, and Family Emotional Involvement and Criticism Scale. Physician-rated assessments of health, including the Karnofsky Performance Status Scale and Cumulative Illness Rating Scale, were also completed.

RESULTS

Linear multivariable hierarchical regression results indicate that social interaction was a significant buffer, weakening the association between illness burden and depressive symptoms, whereas perceived social support buffered the relationship between functional impairment and depressive symptoms. Family criticism and instrumental social support were not significant moderators.

CONCLUSIONS

Type of medical dysfunction, whether illness or impairment, may require different therapeutic and supportive approaches. Enhancement of perceived social support, for those who are impaired, and encouragement of social interactions, for those who are ill, may be important intervention targets for treatment of depressive symptoms in older adult primary care patients.

Brain structural signature of familial predisposition for bipolar disorder: replicable evidence for involvement of the right inferior frontal gyrus

BACKGROUND

To translate our knowledge about neuroanatomy of bipolar disorder (BD) into a diagnostic tool, it is necessary to identify the neural signature of predisposition for BD and separate it from effects of long-standing illness and treatment. Thus, we examined the associations among genetic risk, illness burden, lithium treatment, and brain structure in BD.

METHODS

This is a two-center, replication-design, structural magnetic resonance imaging study. First, we investigated neuroanatomic markers of familial predisposition by comparing 50 unaffected and 36 affected relatives of BD probands as well as 49 control subjects using modulated voxel-based morphometry. Second, we investigated effects of long-standing illness and treatment on the identified markers in 19 young participants early in the course of BD, 29 subjects with substantial burden of long-lasting BD and either minimal lifetime (n = 12), or long-term ongoing (n = 17) lithium treatment.

RESULTS

Five groups, including the unaffected and affected relatives of BD probands from each center as well as participants early in the course of BD showed larger right inferior frontal gyrus (rIFG) volumes than control subjects (corrected p < .001). The rIFG volume correlated negatively with illness duration (corrected p < .01) and, relative to the controls, was smaller among BD individuals with long-term illness burden and minimal lifetime lithium exposure (corrected p < .001). Li-treated subjects had normal rIFG volumes despite substantial illness burden.

CONCLUSIONS

Brain structural changes in BD may result from interplay between illness burden and compensatory processes, which may be enhanced by lithium treatment. The rIFG volume could aid in identification of subjects at risk for BD even before any behavioral manifestations.

Hippocampal volumes in bipolar disorders: opposing effects of illness burden and lithium treatment

OBJECTIVE

Hippocampal volume decrease associated with illness burden is among the most replicated findings in unipolar depression. The absence of hippocampal volume changes in most studies of individuals with bipolar disorder (BD) may reflect neuroprotective effects of lithium (Li).

METHODS

We recruited 17 BD patients from specialized Li clinics, with at least two years of regularly monitored Li treatment (Li group), and compared them to 12 BD participants with < 3 months of lifetime Li exposure and no Li treatment within two years prior to the scanning (non-Li group) and 11 healthy controls. All BD patients had at least 10 years of illness and five episodes. We also recruited 13 Li-naïve, young BD participants (15-30 years of age) and 18 sex- and age-matched healthy controls. We compared hippocampal volumes obtained from 1.5-T magnetic resonance imaging (MRI) scans using optimized voxel-based morphometry with small volume correction.

RESULTS

The non-Li group had smaller left hippocampal volumes than controls (corrected p < 0.05), with a trend for lower volumes than the Li group (corrected p < 0.1), which did not differ from controls. Young, Li-naïve BD patients close to the typical age of onset had comparable hippocampal volumes to controls.

CONCLUSIONS

Whereas patients with limited lifetime Li exposure had significantly lower hippocampal volumes than controls, patients with comparable illness burden, but with over two years of Li treatment, or young Li-naïve BD patients, showed hippocampal volumes comparable to controls. These results provide indirect support for neuroprotective effects of Li and negative effects of illness burden on hippocampal volumes in bipolar disorders.

The costs of depression

The data reported herein show clearly that major depression is a commonly occurring and burdensome disorder. The high prevalence, early age of onset, and high persistence of MDD in the many different countries where epidemiologic surveys have been administered confirm the high worldwide importance of depression. Although evidence is not definitive that MDD plays a causal role in its associations with the many adverse outcomes reviewed here, there is clear evidence that depression has causal effects on a number of important mediators, making it difficult to assume anything other than that depression has strong causal effects on many dimensions of burden. These results have been used to argue for the likely cost -effectiveness of expanded depression treatment from a societal perspective. Two separate, large-scale, randomized, workplace depression treatment effectiveness trials have been carried out in the United States to evaluate the cost effectiveness of expanded treatment from an employer perspective. Both trials had positive returns on investment to employers. A substantial expansion of worksite depression care management programs has occurred in the United States subsequent to the publication of these trials. However, the proportion of people with depression who receive treatment remains low in the United States and even lower in other parts of the world. A recent US study found that only about half of workers with MDD received treatment in the year of interview and that fewer than half of treated workers received treatment consistent with published treatment guidelines. Although the treatment rate was higher for more severe cases, even some with severe MDD often failed to receive treatment. The WMH surveys show that treatment rates are even lower in many other developed countries and consistently much lower in developing countries. Less information is available on rates of depression treatment among patients with chronic physical disorders, but available evidence suggests that expanded treatment could be of considerable value. Randomized, controlled trials are needed to expand our understanding of the effects of detection and treatment of depression among people in treatment for chronic physical disorders. In addition, controlled effectiveness trials with long-term follow-ups are needed to increase our understanding of the effects of early MDD treatment interventions on changes in life course role trajectories, role performance, and onset of secondary physical disorders.