Download Depression in Teens - Comprehensive Behavioral Health Assessment

Depression: Lifestyle and Complementary
Therapies to Promote Healthy Moods in
Teens CME/CE
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Release Date: November 27, 2007; Valid for credit through November 27, 2008
Target Audience
This activity is intended for pediatricians, primary care clinicians and other healthcare
professionals who provide services to children and adolescents.
Goal
The goal of this activity is to provide a review of current research findings and clinical strategies
for the prevention, diagnosis, and management of pediatric conditions and diseases.
Learning Objectives
Upon completion of this activity, participants will be able to:
1.
2.
3.
Appropriately counsel parents on complementary therapies and lifestyle modification
to promote healthy moods in teens.
Review key studies that examine the safety and efficacy of complementary therapies
and lifestyle modification to promote healthy moods in teens.
List acceptable strategies for alternative treatment or lifestyle treatment to promote
healthy moods in teens.
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Contents of This
o
CME/CE
Activity
Depression: Lifestyle and Complementary Therapies to Promote Healthy Moods in
TeensKathi J. Kemper, MD, MPH
Depression: Lifestyle and Complementary Therapies to Promote Healthy Moods in Teens
Case
Kelly is a 17-year-old teenager who expresses a chief concern about trouble sleeping. On further questioning, she
says has troubling falling asleep. In addition, she has lost about 5 pounds because she's "just not hungry," and just
doesn't enjoy shopping any more. She has stopped hanging out with her friends, and prefers to just stay in her
room, resting because she's so tired all the time.
She has no significant medical history, no surgeries, hospitalizations, or allergies. Her immunizations are up to
date. She takes oral contraceptive pills, and has not seen any other healthcare professionals. Her family is not
concerned that Kelly is drinking or using drugs, but she has recently started smoking cigarettes. She had a
boyfriend, but they broke up about a month ago.
Her review of systems is otherwise negative.
She has a normal diet for a teenager; she does not do much exercise. She has no diagnosed learning disabilities,
but her grades have dropped and she is failing in 2 classes in which she previously had Cs.
Her height, weight, and vital signs are normal. Her physical examination is normal.
Kelly and her mother believe she may be depressed, but they are not ready to consider psychotherapy or
medications. What kinds of lifestyle advice can the primary clinician offer to help improve Kelly's mood? And what
kinds of dietary supplements or other complementary therapies are safe and effective in promoting a healthy
mood?
Clinical Commentary
Pediatric depression is a serious, common, persistent and recurrent medical condition. The World Health
Organization (WHO) estimates that depression is the 2nd leading contributor to the global burden of disease for
persons 15-44 years old worldwide. Depression recurs in 70% of those affected. Therefore, even patients who
have improved should actively pursue activities to promote positive moods and prevent recurrences.
Mood disorders have several nonmodifiable risk factors including family history, gender, and race. Before puberty,
the prevalence of depression is higher in boys than girls; after puberty, the rates in girls are about twice those in
boys. Native Americans have higher rates, while Asians report lower rates of depression than whites.
Mood disorders have a high rate of comorbidity with both mental health and medical problems. Comorbid mental
health conditions include attention deficit-hyperactivity disorder, anxiety, and substance abuse (particularly
cigarette smoking). Comorbid medical problems include chronic pain, obesity, endocrine disorders, inflammatory
disorders, cancer, anemia, viral infections, and brain injury. Depression can also be caused by medications
including antihypertensive medications and oral contraceptives.
Cognitive therapy is the first-line treatment, but may not be readily available. Given limited mental health resources
and the side effects and stigmatization of standard antidepressant medications, many families turn to
complementary therapies. Therefore, the focuses of this review are safe lifestyle approaches and complementary
therapies that enhance mental health, particularly those that may help achieve and maintain healthy moods.
A holistic approach to health addresses physical and spiritual as well as mental health (Table 1). We will consider
the safety and effectiveness of therapeutic options to enhance mental health specifically in 5 major categories:

Lifestyle (nutrition, exercise/rest, environment);

Mind-body (meditation);

Biochemical (dietary supplements);

Biomechanical (massage); and

Bioenergetic (acupuncture).
Table 1. Holistic Health -- Physical, Mental, and Spiritual
Characteristics
Physical
Fitness
Mental Health
Spiritual Health
Strength
Confidence and courage
Faith
Flexibility
Adaptability
Forgiveness
Endurance
Cheerfulness
Hope
Focus
Focus/ Attention
Love
Coordination
Harmony
Kindness
Resilience
Resilience
Charity/generosity
Teamwork
Social Network/communication skills/connected to
community
Connection with a higher
power
Lifestyle Essentials: the Fundamentals for Healthy
Moods
In a 4-year prospective cohort German study, intensive lifestyle therapy was as effective as counseling and
medication in improving depressive symptoms. [1]
Nutrition
Healthy nutrition means taking in optimal amounts of essential nutrients while avoiding or minimizing intake of toxic
substances. Genetic variability, lifestyle, medical illnesses, medications, allergies, or environmental exposures may
increase the need for specific nutrients in the form of supplements (see section on Biochemical Therapies).
Nutrients are essential for optimal production of neurotransmitters affecting mood such as serotonin (made from
tryptophan with B vitamins and zinc as cofactors). Table 2 provides a listing of food sources for nutrients essential
for mental health.
Table 2. Selected Nutrients Essential for Mental Health and
their Food Sources
Nutrient
Food Sources
Vitamin B6
Beans, nuts, legumes
Eggs, meats, fish
Whole grains, and fortified breads and cereals
Folate
Beans and legumes
Citrus fruits and juices
Wheat bran and other whole grains
Dark green leafy vegetables
Poultry, pork, shellfish
Liver
Vitamin D
Fish, fish oils, oysters
Fortified foods such as cow milk, soy milk, rice milk, and some
cereals
Calcium
Milk, yogurt, buttermilk, cheese
Calcium-fortified orange juice
Green leafy vegetables (broccoli, collards, kale, mustard greens,
turnip greens, and bok choy or Chinese cabbage)
Canned salmon and sardines canned with their soft bones,
shellfish
Almonds, Brazil nuts
Dried beans
Zinc
Beef, pork, lamb, oysters; dark meat of poultry
Peanuts, peanut butter, nuts, and legumes (beans)
Fortified cereals
Essential fatty acids (omega-3 fatty
acids such as linolenic acid)
Fish (tuna, salmon, and mackerel oil) fish oil, flax seeds, flax oil,
canola oil, walnut oil, dark green leafy vegetables
Tryptophan
Turkey, chicken, fish
Milk, cheese
Eggs
Soy, tofu
Sesame seeds
Pumpkin seeds
Tree nuts, peanuts, peanut butter
Failure to eat breakfast is associated with depressed mood. Encourage patients to eat a healthy breakfast,
including some protein to promote stable blood sugar throughout the day. Foods with a low glycemic index such as
proteins, healthy (unsaturated, non-trans) fats, and complex carbohydrates help minimize mood swings associated
with variations in blood sugar.[2] Minimize the use of processed foods that contain low levels of the nutrients
essential to maintaining a positive mood. Avoid sweetened beverages, processed foods, high fat foods, fried foods,
and junk food.
Food sensitivities can cause mood problems as well as rashes, asthma, and rhinorrhea. Approximately 6% of
children and adolescents have allergies or sensitivities to foods, including 1% who cannot tolerate gluten. The
most common food sensitivities are to wheat, corn, soy, dairy, eggs, tree nuts (such as pecans, walnuts and
almonds), shellfish, and peanuts. Eliminating the triggering food(s) from the diet can improve mood as well as
other symptoms such as chronic headaches, rashes, and gastrointestinal upset.
Healthcare professionals can also urge patients to avoid toxic ingestions. Some teens try to manage their moods
by smoking, drinking alcohol, or taking other drugs. While these may improve mood in the short term, over the
longer term, they do not. In some rare cases, people are sensitive to petrochemicals, artificial flavors, artificial
colors, and artificial sweeteners; these food additives are not essential nutrients and might well be avoided by most
people. Choosing organic or unprocessed foods may be a way to reduce exposure to artificial chemical residues.
Exercise
For many people, vigorous physical exercise is as or more effective than cognitive-behavioral therapy in promoting
positive moods.[3] Children who are sedentary report higher levels of depression. [4] Depressed mood and fatigue are
common in individuals deprived of usual exercise activities (whether from an injury or acute illness) and may be
influenced by reduced fitness levels. Minimizing sedentary activities associated with television, computer, and
electronic games in favor of vigorous activity can improve mood. Side effects of exercise include overuse injuries,
decreased obesity, lower risk of heart disease, improved sleep, less chronic fatigue, improved academic
performance, and decreased pain.
Few studies have evaluated specific sports or compared one form of exercise with another. However, in a metaanalysis of five randomized controlled trials of yoga therapy in adults suffering from depression, all reported
positive effects of this particular exercise. [5] No adverse effects were reported with the exception of fatigue and
breathlessness, as might be expected from physical exertion. Clinicians should consider advising patients to
exercise to improve mood.
Sleep/Rest
Sleep deprivation can lead to poor mood; insomnia is a common symptom of depression. Many teenagers do not
get sufficient sleep. Improving sleep hygiene can help improve mood and set the tone for a restful sleep. Methods
for improving sleep hygiene include:

Using the bed only for sleep;

Removing TV from the bedroom;

Ensuring that the bedroom is dark and cool;

Taking a hot bath before bed, listening to relaxing music;

Reading positive or inspiring books;

Receiving a brief back, foot, or hand rub from a trusted family member; and

Writing in a journal before bed.
Environment
A healthy environment is of critical importance in promoting, maintaining, and restoring healthy mood. Discussions
of the known impact of abuse, neglect, racism, sexism, poverty, and social isolation will not be included here
despite their obvious effects on mood. Instead, we will focus on light and toxins in the physical environment.
Songs, poems, and stories as well as folk wisdom support the association between sunshine and happiness and
lack of sunshine with sadness (the blues). Seasonal affective disorder (SAD) has been well-described. Modern
children and adolescents receive far less sunshine than our ancestors.
A 2005 meta-analysis concluded that bright light treatment for nonseasonal depression is effective, with effect
sizes equivalent to those in most antidepressant pharmacotherapy trials. [6] In a randomized controlled trial
published in 2006, bright light was as effective as fluoxetine in improving symptoms of SAD (67% response rate for
both).[7] Light therapy can be an effective adjunctive therapy, enhancing the effectiveness of other treatments and
is safe during pregnancy.[8]
Bright light early in the morning seems to be most effective. In most trials of light therapy, the patient receives
2000-10,000 lux for 30-120 minutes daily.
Heavy metals such as lead and mercury are also associated with depressive symptoms. [9] Carbon monoxide
poisoning is also associated with depression. [10,11] Alerting parents and caregivers to check for and eliminate
environmental toxins may help improve mood.
Mind-Body Therapies
Meditation
Meditation practice, particularly mindfulness meditation (moment-to-moment nonjudgmental awareness of
breathing, physical sensations, emotions, and thoughts), can contribute to enhanced mood, and change brain
activation patterns in ways likely to support ongoing benefits. Specifically, meditation training leads to significant
increases in left-sided anterior activation, a pattern associated with positive affect.[12] Long-term meditators
compared with age-matched controls exhibit increased cortical thickness in brain regions associated with attention
and sensory processing, including the prefrontal cortex. [13] Side effects of meditation may include improved ability
to cope with stress, reduced pain, reduced anxiety, and enhanced immune function.
Biochemical Therapies
Because of our individual uniqueness (genomic variability), diet, and environment, some individuals require
additional nutrients or benefit from specific biochemical therapies to achieve healthy moods. We will consider
vitamins and minerals, fatty acids, amino acids, and herbs. Given the fact that fewer than 1% of American children
meet their recommended daily allowance of all essential nutrients through diet alone,[14] it is likely that many
children would benefit from supplementation with 1 or more nutrients in addition to striving to improve their overall
diet. This is especially important for children who eat a restricted diet due to suspected food allergies or
sensitivities.
B Vitamins, Including Folate
Vitamin B6 is essential in metabolizing tryptophan to serotonin. Folate and vitamin B12 are major determinants of
1-carbon metabolism, in which S-adenosylmethionine (SAM-E) is formed. SAM-E donates methyl groups that are
crucial for neurologic function.
A systematic review suggested that 100-200 mg daily supplementation with vitamin B6 significantly benefits
premenstrual depression.[15] Folate and vitamin B12 levels are lower in depressed than nondepressed persons, and
replacing deficiencies can lead to remarkable improvements in mood. [17,18] The side effects of excessive doses of
vitamin B6 include nausea, vomiting, abdominal pain, anorexia, headache, somnolence, lower vitamin B12 levels,
and sensory neuropathy. The latter typically occurs with doses over 1000 mg daily, but can occur lower with lower
doses.
Folate deficiency is common and contributes to a variety of psychiatric symptoms: depression, psychosis,
irritability, dementia, and impaired memory. One review concluded that folate supplementation is beneficial in
treating depression whether used alone or to complement conventional medications. [16] Adding 500 micrograms of
folate to 20 mg of fluoxetine significantly improved the response rate in another study of patients with major
depression.[19] Primary care clinicians should ensure that children prone to mood disorders have an adequate
intake of folate, and vitamins B6 and B12 and consider recommending a multivitamin or a B-vitamin complex
containing folate.
Vitamin D
Low levels of vitamin D are associated with depressive symptoms, and treatment with vitamin D supplements is
associated with improved mood. A growing body of research suggests that American youth are vitamin D deficient,
even in older pediatric and adolescent populations that do not have classic rickets. [20] Many adolescents have
relatively low levels of vitamin D due to indoor lifestyle and inadequate intake of vitamin D fortified foods. [26] This
may be exacerbated in children taking anticonvulsant medications,[21] those with inflammatory bowel disease[22] or
arthritis,[23] those with chronic renal disease,[24] those living in the inner city,[25] and those who are veiled.
In a randomized controlled trial of vitamin D given to 44 Australian patients (none, 400 IU vs 800 IU vitamin D)
vitamin D significantly enhanced mood in a dose-dependent fashion.[27]
It may be worthwhile for adolescents to take vitamin D supplements, particularly during winter months to ensure
adequate vitamin D levels; supplementation is also worthwhile for patients with renal, inflammatory bowel disease
or juvenile arthritis and those patients on anticonvulsant drugs that lower vitamin D levels.
Minerals
Calcium. Lower levels of calcium and higher levels of parathyroid hormone have been observed in depressed
persons. Likewise, depression is commonly noted among patients suffering from hyperparathyroidism [28]; quality of
life and depressive symptoms improve when these patients receive appropriate treatment. [29] Epidemiologically,
normal to high intakes of calcium and vitamin D are associated with lower risks depressive mood in patients with
premenstrual syndrome; conversely, lower intakes of calcium and vitamin D are associated with increased risk of
premenstrual syndrome (PMS).[30] Small studies suggest that calcium supplementation may benefit women with
PMS-related depression.[31,32]
Most adolescent girls do not meet their minimum daily requirement for calcium through diet alone. According to the
Continuing Survey of Food Intakes of Individuals (1994-1996), the following percentages of Americans do notmeet
their recommended intake for calcium:

44% boys and 58% girls ages 6-11; and

64% boys and 87% girls ages 12-19.
It is important for clinicians counseling adolescent girls about mood to address adequate calcium intake (optimally
1200-1500 mg daily) to ensure bone health and promote a healthy mood throughout the menstrual cycle.
Chromium. Chromium, a dietary trace mineral, has a crucial role in glucose and fat metabolism and
neurotransmitter synthesis. Chromium increases free brain levels of serotonin, norepinephrine, and melatonin. A
randomized controlled trial of chromium picolinate (600 micrograms daily) in patients whose depression was
characterized by carbohydrate craving showed significant improvement in craving and depressive symptoms. [33]
Chromium is well tolerated, but it can have a stimulating effect. The RDA for chromium is 120 micrograms. The
daily dietary intake of chromium for a typical American is approximately 25-50 micrograms per day. The dose
range in studies of its effects on mood is typically 200-600 micrograms per day. Dietary sources rich in chromium
include fresh vegetables, meats, fish, and brewer's yeast.
Iron. Iron deficiency anemia is often accompanied by depression. It is important to check adolescents (particularly
females who may not be meeting their needs for iron to replace menstrual losses) for iron sufficiency. [34] Primary
care clinicians should ensure that their patients consume adequate amounts of iron either through diet or
supplementation.
Fatty Acids
Linolenic, Eicosapentanoic (EPA), and Docosahexanoic (DHA) Acids. There is strong epidemiologic
correlation between fish consumption, levels of omega-3 fatty acids and protection from depression and suicide.[3537]
Furthermore, clinical trials suggest that supplemental essential fatty acids (EPA and DHA) can improve mood
and decrease hostility and violence, even in patients hospitalized for severe depression or suicidality. [38,39] The
doses in positive studies range from 1 to 9.6 g per day.
Product testing has revealed no significant contamination with mercury, dioxins, or other contaminants in
molecularly distilled fish oil products. More potent and palatable forms of fish oils make these dietary
recommendations easier to swallow. Small children can take one of the liquid forms easily hidden in food.
However, as always, clinicians should use caution when recommending this product.
Amino Acids
L-Tryptophan. 5-Hydroxytryptophan (5-HTP) is the immediate precursor of serotonin in its metabolism from
dietary L-tryptophan (L-trp). Tryptophan depletion leads to depressive symptoms in rats and humans. A Cochrane
meta-analysis suggested 5-HTP and L-trp are better than placebo in treating depression.[40] The typical dosing for
an adult or fully grown adolescent is 50 mg slowly increasing to 150 mg 2 or 3 times daily on an empty stomach. A
large single dose of 200-400 mg can be used by slowly increasing the dose. The maximum recommended dose is
1200 mg daily.
Side effects of 5-HTP and L-trp include nausea, drowsiness (which may make it useful at bedtime); they may
cause serotonergic syndrome if used in combination with selective serotonin reuptake inhibitor medications; they
may also be associated with decreased carbohydrate intake and weight loss. Eosinophilia-myalgia syndrome was
reported in numerous people taking L-trp, which led to its removal from the American market; however,
investigations revealed that the problem was related to contaminated lot from 1 manufacturer, and L-trp is again
available.
S-Adenosylmethionine (SAM-E). S-adenosyl-L-methionine (SAM-E, pronounced Sam-ee) plays a crucial role in
the production of monoamine neurotransmitters, nucleotides and neuronal membrane phospholipids. A 2002
review by the Agency for Healthcare Quality and Research (AHRQ) concluded that compared to placebo, 3 weeks
of treatment with SAMe was associated with a significant improvement in depression. [41] Several studies published
since the AHRQ report confirm its effectiveness in improving mood and suggest it has similar potency to tricyclic
antidepressants.[42-45] It may also be helpful in patients for whom antidepressant medications have been
ineffective.[46] Furthermore, it can also be a useful adjunctive treatment along with conventional antidepressant
medications.[46]
Typical doses are 800-1600 mg of SAM-E daily. Benefits typically appear within 4 weeks of starting the medication.
SAM-E has fewer side effects than conventional antidepressant medications. Side effects include triggering mania
and increasing the risk of serotonergic syndrome in patients taking SSRI medications. It should not be used by
patients with bipolar disorder. It is expensive and not usually covered by insurance.
A review of SAM-E products by ConsumerLabs revealed that only 1/11 products tested failed their standards.
However, as always, clinicians should use caution when recommending this product.
Herbs for Mood
St John's Wort. The herb most commonly used for depression is St. John's wort. Studies on its effectiveness
have had mixed results, with most of the positive studies coming from European trials using standard extracts. [47]
See Table 3 for a listing of the compounds used in the studies with positive results and the US imports containing
these compounds.
Table 3. St. John's Wort Products Used in Studies Reporting
Positive Effects
Products With Positive Results in
Clinical Studies
LI 160 and LI 160S
Brand Name (Manufacturer)
Quanterra Emotional Balance (Warner-Lambert) Kira (Lichtwer
Pharma US/Germany)
WS 5570 and WS 5572
Neuroplant (Schwabe Pharmaceuticals)
Perika (Schwabe Pharmaceuticals, imported by Nature's Way
Products, Inc)
Ze 117
Remotiv (Bayer Vital GmbH and Zeller AG)
Table courtesy of Dr. Paula Gardiner
For example, in a German randomized controlled trial, St. John's wort was as effective as sertraline in improving
depressive symptoms.[48] A similar German study showed its comparability to citalopram. [49] Two open label trials in
adolescents also showed significant improvement in depressive symptoms[50,51]; patients who improved in these
studies generally showed improvement within 2 weeks of starting therapy.
St. John's wort is generally safer than most antidepressant medications; however, it can have directed adverse
effects and serious interactions with commonly used medications. A meta-analysis of 16 postmarketing
surveillance studies including 34,804 patients, recorded an incidence of adverse events (AEs) between 0% and
6%; of the 4 large-scale surveillance studies with a total of 14,245 patients the rate of AEs ranged from 0.1% to
2.4% and the drop-out rate due to AEs of 0.1%-0.9%.[52]
The most common direct AEs of St. John's wort are phototoxicity and stomach upset. The most serious AEs are
drug interactions in which St. John's wort reduces the serum levels of other medications including oral
contraceptives. St. John's wort should not be used in conjunction with SSRIs because such use may increase the
risk of serotonergic syndrome.
Clinicians should be aware that there is substantial variability the quality of St. John's wort preparations. Patients
who wish to use it may use a product tested in a large randomized, controlled trial or refer to product testing
conducted by Consumerlabs (Table 4).
Table 4. Resources on Integrative Approaches to Pediatric
Mood Disorders
Resource
URL
American Academy of Pediatrics
Provisional Section for
Complementary, Holistic and
Integrative Medicine
http://www.aap.org/sections/chim/
American Academy of Pediatrics,
Committee on Environmental
Health
http://www.aap.org/visit/cmte16.htm
National Institutes of Health,
Institute on Mental Health,
information on depression in
children and adolescents
http://www.nimh.nih.gov/healthinformation/depchildmenu.cfm
National Library of Medicine,
Medline Plus -- information on
many medications, nutrients and
dietary supplements
http://www.nlm.nih.gov/medlineplus/
Natural Medicines Comprehensive http://www.naturaldatabase.com/
Database
Natural Standard
http://www.naturalstandard.com/
World Health Organization -information on depression
http://www.who.int/mental_health/management/depression/definition/en/
ConsumerLabs
http://www.consumerlabs.com
Biomechanical Therapies
Massage
Massage is widely used to improve mood. Therapeutic massage contributes to increased blood flow and lymphatic
drainage, muscle relaxation, stress reduction, and social support. Physiologically, massage is linked to the
balancing of right and left prefrontal cortex activity in those with right dominance.[53] Furthermore, massage
decreases cortisol levels and increases levels of serotonin and dopamine in patients with depression. [54] In
depressed women, massage, compared with progressive relaxation, led to higher dopamine and serotonin levels
and lower levels of cortisol and norepinephrine. [55]
In the studies showing positive effects, massage has been provided 5 days a week. To achieve this frequency cost
effectively, parents are generally trained to provide the massage. Massage is generally safe if care is taken to
avoid wounds, burns, intravenous lines, pumps, or other subcutaneous devices and vigorous strokes in patients
with low platelet counts. Careful discussion and respect for individual patients is extremely important for patients
with a history of physical or sexual abuse.
Bioenergetic Therapy
Acupuncture
Randomized controlled trials suggest that acupuncture has significant benefits for depressed adults and may be
comparable in effectiveness to prescription antidepressant medications.[56] In a meta-analysis published in 2005,
the authors concluded that "the effect of electroacupuncture may not be significantly different from antidepressant
medication."[57] Acupuncture rarely causes bleeding, bruising, infection; it causes sleepiness in about 5% of
patients. In general, it has fewer side effects than medications. Serious side effects are extremely rare. Pediatric
patients will accept it, but it's not usually their first choice of therapies. Those who receive it generally report that it
is helpful and unlike their expectations, pleasant. [58]
Summary
Depression is the second leading cause of illness and disability among young people worldwide. A healthy lifestyle
(good nutrition, vigorous exercise, restful sleep, sunshine) is the cornerstone for promoting positive moods. In
addition, several complementary therapies, including meditation, supplementation if needed with B vitamins,
vitamin D, calcium, chromium, iron, omega-3 fatty acids, tryptophan and SAM-E, treatment with effective brands of
St. John's wort, massage, and acupuncture may be helpful. Resources are available online to help address
clinicians' ongoing questions on this topic.
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[ CLOSE WINDOW ]
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Authors and Disclosures
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Author
Kathi J. Kemper, MD, MPH
Caryl J. Guth Chair for Holistic and Integrative Medicine, Wake Forest University School of
Medicine, Winston-Salem, North Carolina; Director, Second Opinion Clinic, Brenner Children’s
Hospital, Winston-Salem, North Carolina
Disclosure: Kathi J. Kemper, MD, MPH, has disclosed no relevant financial relationships.
Editor
Mindy Hung
Editor, Medscape, LLC, New York, NY
Disclosure: Mindy Hung has disclosed no relevant financial relationships.
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