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In This Issue

In this issue Pesa et al examine the total direct costs incurred by child and adult migraineurs relative to nonmigraineurs and the impact on those costs of co-existing anxiety, depression, or both. While in their study simply having migraine was associated with greater expense, blending affective disorder into the migrainous stew led to a significant multiplication of direct medical costs. These findings are highly relevant to one of our most vexing public health issues: while migraine is comorbid with a number of common psychiatric disorders, those who treat migraine-primary care providers and, to a much lesser extent, neurologists-too often are deficient in diagnosing and managing those disorders, and the American health care system is at present not structured financially to allow patients easy access to specialists who are more proficient. My own formal education in psychiatry has been limited to 2 months long ago in medical school and a month during my residency training in neurology; anything else has been gleaned on the run, snatched from dinner lectures, an occasional article and from the daily trial-and-error experience afforded by my work with patients. This seems a bit irrational. With a migraine patient, I often spend more time discussing the individual’s mood disorder than the headache syndrome, attempting to gauge the depth and character of any depression present and discussing the various treatment options available, along with the pros and cons associated with each. Psychiatric issues have high relevance to my clinical practice, and I am sure the same is true for many among the readership. When is antidepressant therapy indicated? Which antidepressant is most appropriate for a given patient? How can one identify the borderline patient early in therapy, and how can one minimize the chaos associated with the attempted management of such patients? All good questions . . . questions with which we wrestle on a daily basis. For those among us who must function at times as clinical psychiatrists and whose skills in that regard clearly could use some polishing, some assistance is called for. While this journal alone will not serve to make a psychotherapeutic silk purse out of a sow’s ear, upcoming issues will contain special features addressing the questions raised here, and a supplement examining migraine’s psychiatric comorbidities and their management is in the works. With efforts such as these and our renewed determination to treat “the whole patient,” a similar investigation by Pesa et al in the future hopefully would yield a very different result.