The New Old Age Blog: Grief Over New Depression Diagnosis

When the American Psychiatric Association unveils a proposed new version of its Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric diagnoses, it expects controversy. Illnesses get added or deleted, acquire new definitions or lists of symptoms. Everyone from advocacy groups to insurance companies to litigators — all have an interest in what’s defined as mental illness — pays close attention. Invariably, complaints ensue.

“We asked for commentary,” said David Kupfer, the University of Pittsburgh psychiatrist who has spent six years as chairman of the task force that is updating the handbook. He sounded unruffled. “We asked for it and we got it. This was not going to be done in a dark room somewhere.”

But the D.S.M. 5, to be published in May, has generated an unusual amount of heat. Two changes, in particular, could have considerable impact on older people and their families.

First, the new volume revises some of the criteria for major depressive disorder. The D.S.M. IV (among other changes, the new manual swaps Roman numerals for Arabic ones) set out a list of symptoms that over a two-week period would trigger a diagnosis of major depression: either feelings of sadness or emptiness, or a loss of interest or pleasure in most daily activities, plus sleep disturbances, weight loss, fatigue, distraction or other problems, to the extent that they impair someone’s functioning.

Traditionally, depression has been underdiagnosed in older adults. When people’s health suffers and they lose friends and loved ones, the sentiment went, why wouldn’t they be depressed? A few decades back, Dr. Kupfer said, “what was striking to me was the lack of anyone getting a depression diagnosis, because that was ‘normal aging.’” We don’t find depression in old age normal any longer.

But critics of the D.S.M. 5 now argue that depression may become overdiagnosed, because this version removes the so-called “bereavement exclusion.” That was a paragraph that cautioned against diagnosing depression in someone for at least two months after loss of a loved one, unless that patient had severe symptoms like suicidal thoughts.

Without that exception, you could be diagnosed with this disorder if you are feeling empty, listless or distracted, a month after your parent or spouse dies.

“D.S.M. 5 is medicalizing the expected and probably necessary process of mourning that people go through,” said Allen Frances, a professor emeritus at Duke who chaired the D.S.M. IV task force and has denounced several of the changes in the new edition. “Most people get better with time and natural healing and resilience.”

If they are diagnosed with major depression before that can happen, he fears, they will be given antidepressants they may not need. “It gives the drug companies the right to peddle pills for grief,” he said.

An advisory committee to the Association for Death Education and Counseling also argued that bereaved people “will receive antidepressant medication because it is cheaper and ‘easier’ to medicate than to be involved therapeutically,” and noted that antidepressants, like all medications, have side effects.

“I can’t help but see this as a broad overreach by the APA,” Eric Widera, a geriatrician at the University of California, San Francisco, wrote on the GeriPal blog. “Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.”

But Dr. Kupfer said the panel worried that with the exclusion, too many cases of depression could be overlooked and go untreated. “If these things go on and get worse over time and begin to impair someone’s day to day function, we don’t want to use the excuse, ‘It’s bereavement — they’ll get over it,’” he said.

The new entry for major depressive disorder will include a note — the wording isn’t final — pointing out that while grief may be “understandable or appropriate” after a loss, professionals should also consider the possibility of a major depressive episode. Making that distinction, Dr. Kupfer said, will require “good solid clinical judgment.”

Initial field trials testing the reliability of D.S.M. 5 diagnoses, recently published in The American Journal of Psychiatry, don’t bolster confidence, however. An editorial remarked that “the end results are mixed, with both positive and disappointing findings.” Major depressive disorder, for instance, showed “questionable reliability.”

In an upcoming post, I’ll talk more about how patients might respond to the D.S.M. 5, and to a new diagnosis that might also affect a lot of older people — mild neurocognitive disorder.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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This post has been revised to reflect the following correction:

Correction: January 24, 2013

An earlier version of this post misspelled the surname of a professor emeritus at Duke who chaired the D.S.M. IV task force. He is Allen Frances, not Francis.

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Starbucks Earnings Increased 13% in Latest Quarter

The company’s results were helped by a 6 percent increase in global sales at cafes open at least a year.

The performance reflects the turnaround Starbucks has made since its struggles during the recession. After bringing back its founder, Howard Schultz, as chief executive in 2008, the company embarked on a reorganization that included closing underperforming stores in the United States.

Mr. Schultz has said that the company has the ability to keep growing even through a turbulent economy because most people see Starbucks as an “affordable luxury.”

Starbucks said it earned $432.2 million, or 57 cents a share, in the quarter, up from $382.1 million, or 50 cents a share, a year earlier. Revenue in the period ending Dec. 30, the first quarter of Starbucks’s fiscal year, rose 11 percent, to $3.8 billion. Analysts had expected a profit of 57 cents a share and revenue of $3.85 billion, according to FactSet.

Shares rose 11 cents on Thursday, to $54.57 a share.

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The Making of Yair Lapid, Israel’s New Power Broker

Oliver Weiken/European Pressphoto Agency

Yair Lapid spoke to reporters in Tel Aviv on Wednesday, a day after his centrist party became the second-largest faction in Parliament.

TEL AVIV — They pitched tents along Rothschild Boulevard and took to the streets in unprecedented numbers, hundreds of thousands demonstrating against the rising costs of gas, apartments, even cottage cheese.

Back on the genteel boulevard on Wednesday, many of those middle-class protesters from 2011 said they had taken their grievances to the ballot box the day before, helping to catapult Yair Lapid, a suave, handsome journalist-turned-populist-politician, into Israel’s newest power broker.

“He spoke out the strongest about how everything in this country is upside down,” said Elad Shoshan, 28, who works with computers and rents an apartment on a cheaper street off the boulevard.

Echoing his candidate’s mantra, Roni Klein, 52, an accountant, said, “My wife and I work, and still it is very hard for us to finish the month.”

Mr. Lapid’s new, centrist Yesh Atid party shocked the political establishment by winning 19 of Parliament’s 120 seats, becoming Israel’s second-largest faction and a crucial partner for Prime Minister Benjamin Netanyahu, whose relatively poor showing left him scrambling to form a stable coalition.

While Mr. Netanyahu remains all but assured of serving a third term — Mr. Lapid said Wednesday that he would not unite with Arab lawmakers to stop him — Yesh Atid’s ascendance promises to shift the government’s focus to pocketbook concerns despite the pressing foreign policy issues Israel faces.

Mr. Lapid’s campaign hardly challenged Mr. Netanyahu’s policies on the Iranian nuclear threat, the tumult in the Arab world or the Israeli-Palestinian conflict. This was the first election in memory in which such existential security issues were not emphasized, as a growing majority of Israelis see them as too tough to tackle. Even Mr. Netanyahu barely spoke about Iran, his raison d’être.

Instead, voters and analysts alike said Mr. Lapid had captured the hearts of Israel’s silent majority with his personal charm and a positive, inclusive message that harnessed the everyday frustrations that fueled the huge social justice protests in 2011.

One pollster found that about 40 percent of Mr. Lapid’s supporters defined themselves as right-leaning, and in Israel’s coalition system, many saw his success as a tactical move by voters not to oust Mr. Netanyahu but to nudge him to broaden the agenda.

On Wednesday, the prime minister embraced Mr. Lapid’s platform, promising a government “as broad as possible” that would bring change on three fronts: affordable housing, government reform and forcing ultra-Orthodox Jews to “share the burden” of military service and taxes.

Some saw the results as a victory for secular Jews at a time of conflict with the ultra-Orthodox over resources and religious pluralism. Mr. Lapid’s stronghold was here in coastal Tel Aviv and its bourgeois suburbs, where he won about 1 in 4 votes cast, and Modiin, a fast-growing bedroom community halfway between here and Jerusalem.

Tamar Hermann, a political scientist and vice president of Israel’s Open University, called Mr. Lapid “the epitome of the Israeli dream” and described his voters as “the mainstream of the mainstream.”

“This is the kind of voting you can take your kids to and teach them a lesson in civic fulfillment without taking any risks,” Professor Hermann said. “They are complaining, but this is a kind of the zeitgeist, not real agony, not real suffering, not real dissatisfaction with the basic cornerstone of the system. It’s just polishing here and there.”

The election results were widely seen as a rebuke to the status quo, but not necessarily a call for change in approach to contentious questions like what to do about the Palestinians. While Mr. Lapid has called for a return to negotiations, he shares Mr. Netanyahu’s skepticism about the lack of a partner, saying this week, “I don’t think the Arabs want peace.” He opposes division of Jerusalem and made his foreign policy speech in Ariel, a sprawling Jewish settlement 12 miles into the West Bank that the Palestinians see as problematic for the viability of their state.

“The majority of Israelis came to the conclusion that there will be no new Middle East,” Mr. Lapid said over cappuccino here last month. “What we want is not a happy marriage, but a decent divorce.”

Instead, the change voters were seeking was more about the nature of politics itself.

Irit Pazner Garshowitz contributed reporting.

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Seau's family sues NFL over brain injuries

Add Junior Seau's family to the thousands of people who are suing the NFL over the long-term damage caused by concussions.

Seau's ex-wife and four children sued the league Wednesday, saying the former linebacker's suicide was the result of brain disease caused by violent hits he sustained while playing football.

The wrongful death lawsuit, filed in California Superior Court in San Diego, blames the NFL for its "acts or omissions" that hid the dangers of repetitive blows to the head. It says Seau developed chronic traumatic encephalopathy (CTE) from those hits, and accuses the NFL of deliberately ignoring and concealing evidence of the risks associated with traumatic brain injuries.

Seau died at age 43 of a self-inflicted gunshot in May. He was diagnosed with CTE, based on posthumous tests, earlier this month.

An Associated Press review in November found that more than 3,800 players have sued the NFL over head injuries in at least 175 cases as the concussion issue has gained attention in recent years. The total number of plaintiffs is 6,000 when spouses, relatives and other representatives are included.

Scores of the concussion lawsuits have been brought together before U.S. District Judge Anita B. Brody in Philadelphia.

"Our attorneys will review it and respond to the claims appropriately through the court," the NFL said in a statement Wednesday.

Helmet manufacturer Riddell Inc., also is a defendant, with the Seau family saying Riddell was "negligent in their design, testing, assembly, manufacture, marketing, and engineering of the helmets" used by NFL players. The suit says the helmets were unreasonably dangerous and unsafe.

Riddell issued a statement saying it is, "confident in the integrity of our products and our ability to successfully defend our products against challenges."

Seau was one of the best linebackers during his 20 seasons in the NFL, retiring in 2009.

"We were saddened to learn that Junior, a loving father and teammate, suffered from CTE," the family said in a statement released to the AP. "While Junior always expected to have aches and pains from his playing days, none of us ever fathomed that he would suffer a debilitating brain disease that would cause him to leave us too soon.

"We know this lawsuit will not bring back Junior. But it will send a message that the NFL needs to care for its former players, acknowledge its decades of deception on the issue of head injuries and player safety, and make the game safer for future generations."

Plaintiffs are listed as Gina Seau, Junior's ex-wife; Junior's children Tyler, Sydney, Jake and Hunter, and Bette Hoffman, trustee of Seau's estate.

The lawsuit accuses the league of glorifying the violence in pro football, and creating the impression that delivering big hits "is a badge of courage which does not seriously threaten one's health."

It singles out NFL Films and some of its videos for promoting the brutality of the game.

"In 1993's 'NFL Rocks,' Junior Seau offered his opinion on the measure of a punishing hit: 'If I can feel some dizziness, I know that guy is feeling double (that)," the suit says.

The NFL consistently has denied allegations similar to those in the lawsuit.

"The NFL, both directly and in partnership with the NIH, Centers for Disease Control and other leading organizations, is committed to supporting a wide range of independent medical and scientific research that will both address CTE and promote the long-term health and safety of athletes at all levels," the league told the AP after it was revealed Seau had CTE.

The lawsuit claims money was behind the NFL's actions.

"The NFL knew or suspected that any rule changes that sought to recognize that link (to brain disease) and the health risk to NFL players would impose an economic cost that would significantly and adversely change the profit margins enjoyed by the NFL and its teams," the Seaus said in the suit.

The National Institutes of Health, based in Bethesda, Md., studied three unidentified brains, one of which was Seau's, and said the findings on Seau were similar to autopsies of people "with exposure to repetitive head injuries."

"It was important to us to get to the bottom of this, the truth," Gina Seau told the AP then. "And now that it has been conclusively determined from every expert that he had obviously had CTE, we just hope it is taken more seriously. You can't deny it exists, and it is hard to deny there is a link between head trauma and CTE. There's such strong evidence correlating head trauma and collisions and CTE."

In the final years of his life, Seau went through wild behavior swings, according to Gina and to 23-year-old son, Tyler. There also were signs of irrationality, forgetfulness, insomnia and depression.

"He emotionally detached himself and would kind of 'go away' for a little bit," Tyler Seau said. "And then the depression and things like that. It started to progressively get worse."

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Well: Long Term Effects on Life Expectancy From Smoking

It is often said that smoking takes years off your life, and now a new study shows just how many: Longtime smokers can expect to lose about 10 years of life expectancy.

But amid those grim findings was some good news for former smokers. Those who quit before they turn 35 can gain most if not all of that decade back, and even those who wait until middle age to kick the habit can add about five years back to their life expectancies.

“There’s the old saw that everyone knows smoking is bad for you,” said Dr. Tim McAfee of the Centers for Disease Control and Prevention. “But this paints a much more dramatic picture of the horror of smoking. These are real people that are getting 10 years of life expectancy hacked off — and that’s just on average.”

The findings were part of research, published on Wednesday in The New England Journal of Medicine, that looked at government data on more than 200,000 Americans who were followed starting in 1997. Similar studies that were done in the 1980s and the decades prior had allowed scientists to predict the impact of smoking on mortality. But since then many population trends have changed, and it was unclear whether smokers today fared differently from smokers decades ago.

Since the 1960s, the prevalence of smoking over all has declined, falling from about 40 percent to 20 percent. Today more than half of people that ever smoked have quit, allowing researchers to compare the effects of stopping at various ages.

Modern cigarettes contain less tar and medical advances have cut the rates of death from vascular disease drastically. But have smokers benefited from these advances?

Women in the 1960s, ’70s and ’80s had lower rates of mortality from smoking than men. But it was largely unknown whether this was a biological difference or merely a matter of different habits: earlier generations of women smoked fewer cigarettes and tended to take up smoking at a later age than men.

Now that smoking habits among women today are similar to those of men, would mortality rates be the same as well?

“There was a big gap in our knowledge,” said Dr. McAfee, an author of the study and the director of the C.D.C.’s Office on Smoking and Public Health.

The new research showed that in fact women are no more protected from the consequences of smoking than men. The female smokers in the study represented the first generation of American women that generally began smoking early in life and continued the habit for decades, and the impact on life span was clear. The risk of death from smoking for these women was 50 percent higher than the risk reported for women in similar studies carried out in the 1980s.

“This sort of puts the nail in the coffin around the idea that women might somehow be different or that they suffer fewer effects of smoking,” Dr. McAfee said.

It also showed that differences between smokers and the population in general are becoming more and more stark. Over the last 20 years, advances in medicine and public health have improved life expectancy for the general public, but smokers have not benefited in the same way.

“If anything, this is accentuating the difference between being a smoker and a nonsmoker,” Dr. McAfee said.

The researchers had information about the participants’ smoking histories and other details about their health and backgrounds, including diet, alcohol consumption, education levels and weight and body fat. Using records from the National Death Index, they calculated their mortality rates over time.

People who had smoked fewer than 100 cigarettes in their lifetimes were not classified as smokers. Those who had smoked at least 100 cigarettes but had not had one within five years of the time the data was collected were classified as former smokers.

Not surprisingly, the study showed that the earlier a person quit smoking, the greater the impact. People who quit between 25 and 34 years of age gained about 10 years of life compared to those who continued to smoke. But there were benefits at many ages. People who quit between 35 and 44 gained about nine years, and those who stopped between 45 and 59 gained about four to six years of life expectancy.

From a public health perspective, those numbers are striking, particularly when juxtaposed with preventive measures like blood pressure screenings, colorectal screenings and mammography, the effects of which on life expectancy are more often viewed in terms of days or months, Dr. McAfee said.

“These things are very important, but the size of the benefit pales in comparison to what you can get from stopping smoking,” he said. “The notion that you could add 10 years to your life by something as straightforward as quitting smoking is just mind boggling.”

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Edging From Europe, Britain Adds to Continent’s Unease

Oli Scarff/Getty Images

Prime Minister David Cameron of Britain speaking in London on Wednesday.

BRUSSELS — The French are engaged in a lonely military adventure in Africa. The Germans are preoccupied with domestic elections rather than regional affairs. Unemployment in some countries is at historic highs and economies across Europe are still mired in recession.

Now Prime Minister David Cameron of Britain has added to Europe’s malaise, vowing to reduce British entanglement with the European Union — or allow his people to vote in a referendum to leave the bloc altogether.

The pledge from the British prompted swift retorts from France and Germany, which said no member has the option of “cherry picking” whatever European rules it wants to enforce. But it reflected a growing sense of unease, not only in Britain but across the Continent, that while the acute phase of the financial crisis has passed, the challenge to Europe’s mission and even its membership has not.

Even the United States has injected itself into the matter, with an unusually public insistence that Britain, a close ally, stay in the union, fearing that its departure would heighten centrifugal forces that would weaken Europe as a diplomatic, military and financial partner.

With the threat of a sudden breakup of the euro zone appearing to recede in recent months, Europe has seen a resurgence of narrow national interests that risks swamping always-elusive common goals. The bickering is undercutting hopes in some circles that the struggle to save the euro had laid the groundwork for “more Europe.”

“As pressure from the financial markets recedes and a sense of urgency lifts, the appetite for serious reform is melting away like butter in the sun,” said Thomas Klau, head of the Paris office of the European Council on Foreign Relations. “Now that markets no longer hold a knife under leaders’ throats, they are slipping back into their normal mode, which is to manage their own immediate reality.”

For Mr. Cameron, with elections coming in 2015, that means heading off a challenge from the hard-right, anti-Europe U.K. Independence Party, known as UKIP, while shoring up support for his government, which recently admitted that its unpopular austerity program would have to be extended to 2018, analysts said. He is also anxious to avoid the sort of ruinous intraparty split over Europe that bedeviled the prime ministerships of two of his Conservative predecessors, Margaret Thatcher and John Major.

That comes against a backdrop of declining public support for British membership in Europe — only 45 percent last year, down from 51 percent in 2011, in polls conducted by the Pew Research Global Attitudes Project.

Mr. Cameron’s speech Wednesday in London calling for a referendum had been in the works for some time but, Mr. Klau noted, it was delivered at a moment when the European Union had begun to declare victory over doomsayers who predicted the common currency and even the whole union could crumble. This mood of calm, Mr. Klau said, has given leaders “the political space” to turn their eyes from Europe toward more pressing and, for politicians seeking re-election, far more important domestic concerns.

The decision by President François Hollande of France to send troops to Mali to halt an advance by rebels with ties to Islamist extremists reprises a long tradition of French interventions in its former African colonies — and has bolstered the Socialist president’s previously flagging popularity.

The French move has been supported by the European Union, whose member states share French fears about the spread of radicalism across the Mediterranean. But it has superseded the bloc’s own ambitions to become a serious player in global affairs and still left the French to fight mostly on their own. The union is sending some military trainers.

Europe’s economic troubles, meanwhile, are far from over, with much of the Continent expected to be in recession this year. Even Germany seems to be losing momentum — its economy contracted by 0.5 percent in the final months of last year. Elsewhere, unemployment is soaring to levels that could threaten grave social unrest, with more than a quarter of working-age people in Greece and Spain without jobs.

Alan Cowell contributed reporting from London.

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Exit Polls in Israel Suggest Netanyahu’s Showing Is Weaker Than Expected

Pool photo by Uriel Sinai

Prime Minister Benjamin Netanyahu of Israel touched the Western Wall on Tuesday in Jerusalem.

TEL AVIV — A weakened Prime Minister Benjamin Netanyahu emerged Wednesday from Israel’s national election likely to serve a third term, according to preliminary results and political analysts after voters on Tuesday gave a surprising second place to a new centrist party founded by a television celebrity who emphasized kitchen-table issues like class size and apartment prices.

Baz Ratner/Reuters

A polling station on Tuesday in the West Bank Jewish settlement of Elon Moreh, near Nablus.

For Mr. Netanyahu, who entered the race an overwhelming favorite with no obvious challenger, the outcome was a humbling rebuke as his ticket lost seats in the new Parliament. Overall, the prime minister’s conservative team came in first, but it was the center, led by the political novice Yair Lapid, 49, that emerged newly invigorated, suggesting that at the very least Israel’s rightward tilt may be stalled.

Mr. Lapid, a telegenic celebrity whose father made a splash with his own short-lived centrist party a decade ago, based his campaign on issues that resonated with the middle class, including the need to integrate the ultra-Orthodox into the army and the work force.

Perhaps as important, he also avoided antagonizing the right, having not emphasized traditional issues of the left, like the peace process. Like a large majority of the Israeli public, he supports a two-state solution to the Israeli-Palestinian conflict, but is skeptical of the Palestinian leadership’s willingness to negotiate seriously; he has called for a return to peace talks but has not made it a priority.

On Tuesday, Mr. Netanyahu implored his supporters to turn out, reading signs that voters were not embracing his message of security and his party’s conservative agenda. The day ended with Mr. Netanyahu reaching out again —this time to Mr. Lapid, offering to work with Israel’s newest kingmaker as part of the “broadest coalition possible.”

Israel’s political hierarchy is only partly determined during an election. The next stage, when factions try to build a majority coalition, decides who will rule, how they will rule and for how long. While Mr. Lapid has signaled a willingness to work with Mr. Netanyahu, the ultimate coalition may bring together parties with such different ideologies and agendas that the result is neither a shift to the right nor the left, but paralysis.

Still, for the center, it was a time of celebration.

“The citizens of Israel today said no to politics of fear and hatred,” Mr. Lapid told an upscale crowd of supporters that had welcomed him with drums, dancing and popping Champagne corks. “They said no to the possibility that we might splinter off into sectors, and groups and tribes and narrow interest groups. They said no to extremists, and they said no to antidemocratic behavior.”

With three-quarters of the votes counted by 3 a.m. Wednesday, Israel Radio reported that Mr. Netanyahu’s conservative Likud-Beiteinu ticket was poised to take 31 of Parliament’s 120 seats, with Mr. Lapid’s party, There Is a Future, coming in second with 19, far more than polls had predicted. The right wing and religious parties that make up Mr. Netanyahu’s current coalition garnered a thin majority of perhaps 62 seats, pushing him to try to join with Mr. Lapid instead and possibly embrace other center and left-leaning groups. Labor took 15 seats in early returns and Jewish Home, a new religious-nationalist party, 11

The prime minister called Mr. Lapid shortly after the polls closed at 10 p.m. Tuesday and, according to Israeli television reports, told him that they had great things to do together for the country. In his speech to a rowdy crowd of supporters here Wednesday morning, he said, “I see many partners.”

Mr. Lapid said he was open to working with Mr. Netanyahu, saying the only way to face Israel’s challenges was “together.” But he added: “What is good for Israel is not in the possession of the right, and nor is it in the possession of the left. It lies in the possibility of creating here a real and decent center.”

The results were a blow to the prime minister, whose aggressive push to expand Jewish settlements in East Jerusalem and the West Bank has led to international condemnation and strained relations with Washington. The support for Mr. Lapid and the left-leaning Labor Party showed voters responded strongly to an emphasis on domestic, socioeconomic issues that brought 500,000 people to the streets of Tel Aviv in the summer of 2011.

Jodi Rudoren reported from Tel Aviv, and Isabel Kershner from Jerusalem. Myra Noveck contributed reporting from Jerusalem.

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Google’s fourth quarter results shine after ad rate decline slows

SAN FRANCISCO (Reuters) – Revenue from Google Inc’s core Internet business outpaced many analysts’ expectations during the crucial holiday quarter and advertising rates fell less than in previous periods, pushing its shares up more than 4 percent.

The world’s largest Internet search company introduced new product listings during the fourth quarter – typically its strongest – and also benefited from business growth in international markets, analysts said.

Excluding traffic-acquisition costs, the business generated net revenue of $ 9.83 billion, up from $ 8.13 billion a year earlier, Google reported on Tuesday. That surpassed a $ 9.6 billion average forecast from six analysts polled by Reuters.

“Business looked really strong, especially from a profitability perspective. They really grew their margins in the core business,” said Sameet Sinha, an analyst with B. Riley Caris. “Most of that strength seems to be coming from international markets which grew revenues quite substantially: up 23 percent year over year, versus the 15 percent growth in the third quarter.”

Average cost-per-click, a critical metric that denotes the price advertisers pay Google, declined 6 percent from a year ago, the fifth consecutive quarter of decline.

Google executives told analysts on a conference call that the company had focused on improving the metric – shoring up margins – while lowering the overall growth rate of paid clicks in the holiday quarter.

“Click prices are still declining, but it’s better than expected,” said BGC Partners analyst Colin Gillis.

MOTOROLA MOBILITY “STILL LOSING MONEY”

Consolidated net income in the fourth quarter was $ 2.89 billion or $ 8.62 per share, compared with $ 2.71 billion, or $ 8.22 per share, in the year-ago period when Google had not yet acquired Motorola.

Excluding certain items, Google said it earned $ 10.65 per share in the fourth quarter.

“The core business is a great business and the fourth-quarter is always a time for Google to shine. However, Motorola is still losing money and click rates still declined. They only declined 6 percent, but go back four or five quarters and click prices were improving. So mobile is still pressuring click prices,” Gillis said.

The company posted consolidated revenue – which includes its Motorola Mobility mobile phone business but not the television set-top box business it recently agreed to sell – of $ 14.42 billion on Tuesday.

Motorola Mobility had an operating loss of $ 353 million during the quarter.

Shares of Google were up roughly 4.5 percent at $ 734.46 in after-hours trading on Tuesday.

(Reporting By Alexei Oreskovic; Editing by Bernard Orr)

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Djokovic getting the hang of winning in Australia

MELBOURNE, Australia (AP) — Novak Djokovic is really starting to get the hang of how to handle himself at the Australian Open.

An expression often used Down Under — "Keep your shirt on" — is designed to discourage anyone from becoming unnecessarily overexcited.

Djokovic took it literally after his 6-1, 4-6, 6-1, 6-4 win Tuesday night over fifth-seeded Tomas Berdych, advancing to the semifinals at an 11th consecutive Grand Slam tournament.

The 2-hour, 31-minute victory took exactly half the time of his five-set, fourth-round win two nights previously against Stanislas Wawrinka. In the early hours of Monday morning, Djokovic ripped his sweat-drenched shirt off and flexed his muscles, mimicking his victory celebration after the 5:53 victory over Rafael Nadal in the 2012 Australian Open final.

That was acceptable at the time to the Rod Laver Arena crowd, which was still abuzz at 1:40 a.m. following five sets of high-level tennis.

After the Berdych match, however, he realized there was no need to raise the roof. Djokovic calmly pumped his fist once and walked to the net; he later joked about the ice baths he'd taken in between matches on the advice of local hero Lleyton Hewitt.

"It was a great performance. I was hoping to have a shorter match ... just not to go over 5 hours," Djokovic said, in a comparatively subdued mood after a considerably more routine victory. "It's always going to be tough against Tomas; he's an established player. He has a big game, big serve. He can compete against anyone on any surface."

In the semifinals, Djokovic will meet No. 4-seeded David Ferrer.

Ferrer survived a quarterfinal battle with fellow Spaniard Nicolas Almagro. Almagro had three chances to serve for the match, but Ferrer broke each time.

A usually mild-mannered pro, Ferrer showed his aggression at times when he threatened to spike his racket and even smashed his water bottle in the changeover after he'd dropped serve in a frustrating fourth set that featured eight breaks of serve.

He'd never lost to Almagro in 12 previous meetings and, as the No. 1 Spaniard in the draw in the absence of 11-time major winner Rafael Nadal, felt a responsibility to reach the semis.

"It was (a) miracle I won this match," Ferrer said of his comeback 4-6, 4-6, 7-5, 7-6 (4), 6-2 win. "I tried to fight every point; that's my game. I always fight."

Ferrer survived once in the third set and twice in the fourth when Almagro was serving for the match, but held his nerve and finally advanced to his third semifinal in the last four Grand Slam events.

"In the important moments, I played more consistent in my game," Ferrer said. "Of course, in the next round, the semifinals, I need to play my best tennis, better than today."

Djokovic acknowledged Ferrer's work ethic, saying the 30-year-old Spaniard was "one of the most respected guys on the tour because he never gives up."

"He plays every single match of his career with 100 percent," Djokovic said.

"I'm expecting a long one," he added.

Ferrer has never been past a major semifinal.

There are only three men left in the draw who have won Grand Slam titles — Djokovic has won five, including the last two in Australia. He's aiming to be the first man in the Open era to win three consecutive Australian titles.

The other two are in action Wednesday, with 17-time Grand Slam winner Roger Federer against 2008 Australian finalist Jo-Wilfried Tsonga of France. Andy Murray, who broke the 76-year drought for British men at the major tournaments by winning the U.S. Open last year, will play Jeremy Chardy of France.

On the women's side, defending champion Victoria Azarenka faces Svetlana Kuznetsova, who has won the U.S. Open and the French Open, and 15-time major winner Serena Williams is against 19-year-old American Sloane Stephens, who is playing her first quarterfinal at a Grand Slam.

Maria Sharapova completed a career Grand Slam last year by winning the French Open, a few months after losing the Australian Open final to Azarenka. After her 6-2, 6-2 quarterfinal win over Ekatrina Makarova on Tuesday, she has conceded only nine games in five matches — a record in Australia.

"To be honest, those are not the stats you want to be known for," Sharapova said.

After opening with a pair of 6-0, 6-0 wins, Sharapova thrashed seven-time major winner Venus Williams 6-1, 6-3 in the third round and Belgian Kristen Flipkens 6-0, 6-1 in the fourth.

Li Na has reached the semifinals in three of the last four years at Melbourne Park after beating Agnieszka Radwanska 7-5, 6-3. The 30-year-old Chinese player lost the 2011 final in Australia to Kim Clijsters, then won her breakthrough Grand Slam at the French Open a few months later. She hasn't been back to a major final since.

Djokovic won his first major title in Australia in 2008, then didn't make another final in his next 11 Grand Slam events. He's won four since then and is the top-ranked man in tennis, crediting the lessons from his experiences back then.

"At the start of my career, I went through a lot of different kinds of challenges physically, mentally," he said. "Everybody makes mistakes. I was aware of the fact that I need to improve because I wasn't feeling well, especially in the heat. I had lots of health issues.

"I don't want to go through it again. I am aware of the importance of an everyday practice and recovery basis. So as long as it's like that, I think I'll be all right."

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Medicaid Patients Could Face Higher Fees Under a Proposed Federal Policy

WASHINGTON — Millions of low-income people could be required to pay more for health care under a proposed federal policy that would give states more freedom to impose co-payments and other charges on Medicaid patients.

Hoping to persuade states to expand Medicaid, the Obama administration said state Medicaid officials could charge higher co-payments and premiums for doctors’ services, prescription drugs and certain types of hospital care, including the “nonemergency use” of emergency rooms. State officials have long asked for more leeway to impose such charges.

The 2010 health care law extended Medicaid to many childless adults and others who were previously ineligible. The Supreme Court said the expansion of Medicaid was an option for states, not a requirement as Congress had intended. The administration has been trying to persuade states to take the option, emphasizing that they can reconfigure Medicaid to hold down their costs and “promote the most effective use of services.”

In the proposed rule published Tuesday in the Federal Register, the administration said it was simplifying a complex, confusing array of standards that limit states’ ability to charge Medicaid beneficiaries. Under the proposal, a family of three with annual income of $30,000 could be required to pay $1,500 in premiums and co-payments.

As if to emphasize the latitude given to states, the administration used this heading for part of the new rule: “Higher Cost Sharing Permitted for Individuals With Incomes Above 100 Percent of the Federal Poverty Level” (that is, $19,090 for a family of three).

Barbara K. Tomar, director of federal affairs at the American College of Emergency Physicians, said the administration had not adequately defined the “nonemergency services” for which low-income people could be required to pay. In many cases, she said, patients legitimately believe they need emergency care, but the final diagnosis does not bear that out.

“This is just a way to reduce payments to physicians and hospitals” from the government, Ms. Tomar said.

With patients paying more, the federal government and states would pay less than they otherwise would. Medicaid covers 60 million people, and at least 11 million more are expected to qualify under the 2010 law. The federal government pays more than half of Medicaid costs and will pay a much larger share for those who become eligible under the law.

In the proposed rule, the administration said it had discovered several potential problems in its efforts to carry out the law.

First, it said, it has not found a reliable, comprehensive and up-to-date source of information about whether people have employer-sponsored health insurance. The government needs such information to decide whether low- and middle-income people can obtain federal subsidies for private insurance.

The subsidies can be used to buy coverage in competitive marketplaces known as insurance exchanges. Under the law, people can start enrolling in October for coverage that starts in January 2014, when most Americans will be required to have health insurance. People who have access to affordable coverage from employers will generally be ineligible for subsidies.

In applying for subsidies, people must report any employer-sponsored insurance they have. But the administration said it could be difficult to verify this information because the main sources of data reflect only “whether an individual is employed and with which employer, and not whether the employer provides health insurance.”

Since passage of the health care law, the administration has often said that people seeking insurance would use a single streamlined application for Medicaid and the subsidies for private coverage. Moreover, the state Medicaid agency and the exchange are supposed to share data and issue a “combined eligibility notice” for all types of assistance.

But the administration said this requirement would be delayed to Jan. 1, 2015, because more time was needed to establish electronic links between Medicaid and the exchanges.

Leonardo D. Cuello, who represents Medicaid beneficiaries as a lawyer at the National Health Law Program, expressed concern.

“Under the proposed rule,” Mr. Cuello said, “many people will be funneled into health insurance exchanges even though they have special needs that are better met in Medicaid. And if you asked the right questions, you would find out that they are eligible for Medicaid.”

The federal government will have the primary responsibility for running exchanges in more than half the states. About 20 states are expected to expand Medicaid; governors in other states are opposed or uncommitted.

The proposed rule allows hospitals to decide, “on the basis of preliminary information,” whether a person is eligible for Medicaid. States must provide immediate temporary coverage to people who appear eligible.

Kenneth E. Raske, president of the Greater New York Hospital Association, said this could be a boon to low-income people. “Currently,” he said, “only children and pregnant women are presumed eligible for inpatient admissions under Medicaid in New York.”

The public has until Feb. 13 to comment on the proposed rule. Comments can be submitted at www.regulations.gov.

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