Today I read in the newspaper that another important film director had died: Michelangelo Antnioni. His movies Identificazione di una Donna and Blow Up made an ever lasting impression on me, more than any other movie by Ingmar Bergman. Not that those two film makers could easily be compared, their style and themes differed remarkably. Reading about Ingmar Bergman I was surprised to learn that he suffered from depression and even had to be hospitalised for his depression. I wondered whether Antonioni also suffered from depression during his life. In an obituary in the Herald Tribune I learned that In 1954 the 12-year marriage of M. Antonioni to Letizia Balboni fell apart. Antonioni sank into a deep depression. His insomnia worsened. Often he spent the early morning hours writing screenplays.
This is the only reference to a probable depression I could find. Does anyone know more about Antonioni suffering from depression?
The movie "The Passenger" made by Antonioni is about a melancholic, depressed, and jaded television reporter (Jack Nicholson) assuming the identity of a dead man while at a hotel in a north African country, not knowing that the man was a renowned arms smuggler.
Have to have a look at this movie.
Tuesday, July 31, 2007
Michelangelo Antonioni, depressed?
Shock, the healing power of electroconvulsive therapy
Recently read a review about this book in the Journal of ECT by Prof Max Fink and one by Dr Geller for Psychiatric services from the American Psychiatric association. The first review is only accessible for subscribers to the journal of ECT, the second review can be read online.
This quote from the online review sums up the conclusions from both authors:
Shock is recommended to all professionals not only to inform themselves about the history and current state of ECT but also so they can recommend it to patients. Any patient considering ECT would do well to read Dukakis and Tye's take on this intervention. There is no better material currently available that would allow a patient to provide true informed consent for ECT than reading Shock cover to cover.
Monday, July 30, 2007
Don't send your soldier longer than 13 months to battle
In a recent article in British Medical Journal it is concluded that an association was found between deployment for more than a year in the past three years and mental health that might be explained by exposure to combat. In other words: Personnel who were deployed for 13 months or more in the past three years were more likely to fulfil the criteria for post-traumatic stress disorder, scored worse on the general health questionnaire, and have multiple physical symptoms.
Ingmar Bergman depressed?
The death yesterday of Swedish cinema legend Ingmar Bergman drew stirring tributes in his homeland as well as other countries form all over the world. An article on news.com.au. drew my attention to the fact that Ingmar Bergman suffered form depression. He was hospitalised for depression. According to a biography it was in the year 1976 which was a traumatic one in the life of Ingmar Bergman. On January 30, while rehearsing Strindberg's "Dance of Death" at Stockholm's Royal Dramatic Theatre, he was arrest by two plainclothes policeman, booked like a common criminal, and charged with income-tax fraud. The impact of the event on Bergman was devastating. He suffered a nervous breakdown as a result of the humiliation and was hospitalized in a state of deep depression. Even though the charges were later dropped, Bergman was for a while inconsolate, fearing he would never again return to directing. He eventually recovered from the shock, but despite pleas by the Swedish prime minister, high public figures, and leaders of the film industry, he vowed never to work again in Sweden. This is confirmed on another website about film directors.
Never knew this before.
“I think it's difficult to understand and to fully comprehend the enormous contribution Bergman made to cinema and theatre, not only in Sweden but also abroad.”
Sunday, July 29, 2007
Rule the Web, book review
This book by Mark Frauenfelder, the founding editor of BoingBoing.net holds a treasure of useful information on the WEB. It's a guide to getting things done with the web. It has a companion website which to my opinion doesn't ad much to all the information in this book. The book is divided in 11 chapters. The first chapter is about creating and sharing, it has a lot of information on building websites, blogs, wikis and what have you, on the web. Chapter 2 holds information about browsing and searching the web. Mainly about Google, but then this is the best search engine. Next chapter is about selling and shopping: how to find promo codes and ebay tricks are some of the discussed topics. Chapter 4 is about health, exercise, and sports and chapter 5 about media and entertainment. This last chapter is full of information about movies, how can I play movies on ipod, how do I play old msdos games on my computer and so on. The chapter about travel and sightseeing not only suggest sites to plan your trip or to make a travelblog but also practical information about finding cheap hotels, the best seats on a particular plane. The chapters work, organisation productivity and communication have tips for email, skype, projects, bookmarks. The chapters Toolbox and Protecting and maintaining have a lot of information about how to keep your computer healthy and protect and improve your hardware. In conclusion the best information on getting things done with the web. The book is not for continuous reading although it is written accessibly, it is an excellent dictionary for the web.
My favorite tips from Rule the Web:
1. How can I get promo codes when shopping online
2. How can I search for a book on more than one site at once?
3. How can I plan a vacation with my friends
Saturday, July 28, 2007
Counting is done in the parietal part of the brain
A new study has found that there is a set of cells in the top rear of the brain that apparently keeps score. A team of Duke University researchers report in PLoS Biology that they discovered a pocket of "accumulator neurons" in the region of a monkey brain called the parietal cortex that appears to integrate and sum up the total quantity of individual items. Researchers focused on this region of the brain because previous human studies indicated that damage to the intraparietal portion of the brain impairs numerical processing. The researchers speculate that the information in these intraparietal neurons is then passed to another population of cells in the prefrontal cortex, which then fine-tunes the calculation into an exact value.
Myth: Depression is a Normal Part of Aging
This myth about depression in old age is one of many. If you know another myth about aging please tell me in a comment.
When people get older a lot can happen, you can loose your spouse, have to take medication for all kinds of ilnesses, you loose friends etc. Feeling blue is a normal part of life at any age. When this turns into depression it is something completely different. Depression increases the risk of suicide, it is not self limiting, and can be treated. The best advice is to consult your family doctor and visit the website from consumeraffairs.com with some more information.
Myth: Treating a depressed elderly won't work. Fact: Antidepressants, ECT, and cognitive therapy are all effective in the elderly
Friday, July 27, 2007
Why are there so many great unmarried women and no great unmarried men?
The answer is because alfa males spreads smells that attracts female. At least in rodents this is proven by a study with a nice design. They first exposed female mice to soiled bedding from male mice as a source of pheromones. They proofed that a 7-day exposure of female mice to soiled male bedding increased the production and survival of new neurons in the hippocampus. The authors also exposed female mice to the bedding of castrated males. Castration removes pheromones from the urine by eliminating circulating testosterone. Bedding from castrated males did not stimulate neurogenesis. This pheromone-induced neurogenesis appears to ultimately determine female mating preference for dominant males. The preference of female mice for dominant males is explained by pheromone-induced neurogenesis in the olfactory system and hippocampus.
From the articles:
Nature Neuroscience - 10, 938 - 940 (2007)
Alpha males win again, by Derek P DiRocco & Zhengui Xia
Nature Neuroscience - 10, 1003 - 1011 (2007)
Male pheromone–stimulated neurogenesis in the adult female brain: possible role in mating behavior. By Gloria K Mak, Emeka K Enwere, Christopher Gregg, Tomi Pakarainen, Matti Poutanen, Ilpo Huhtaniemi & Samuel Weiss
Thursday, July 26, 2007
Assertive Community Treatment, helps when hospital use is high
In clinical trials of intensive case management for people with severe mental illness inconsistent effects on the use of hospital care are reported. In a systematic review published in the British Medical Journal this seems to be related to high hospital use by the participants. Intensive case management works best when participants tend to use a lot of hospital care and less well when they do not. It might not be necessary to apply the full model of assertive community treatment to achieve reductions in inpatient care, but focus on the patients that get hospitalised frequently.
Teen depression, nobody is immune
Teen depression or depression during adolescence can be hard to discover. Even young good looking kids can suffer from it. In an article called: Depression has many faces, the author Jessica Lopez describes the "faces of depression" in teens and the troubles these teens can experience. Besides mentioning the symptoms of depression there is also a myth versus fact part in this article.
Myth: Telling an adult that a friend might be depressed is betraying a trust. If someone wants help, he or she will get it.
Fact: Depression, which saps energy and self-esteem, interferes with a person's ability or wish to get help. It is an act of true friendship to share your concerns with an adult who can help.
Reading this nice article I came across an excellent website called KidsHealth.org.
KidsHealth is the largest and most-visited site on the Web providing doctor-approved health information about children from before birth through adolescence. Created by The Nemours Foundation's Center for Children's Health Media, the award-winning KidsHealth provides families with accurate, up-to-date, and jargon-free health information they can use.
It also has information about teen depression for parents, and teens.
Tuesday, July 24, 2007
Adolescents brain and Depression
Symptoms of depression in adolescents look like those of depression in adults. Before the late 1970s the existence of depression in adolescents was controversial. The last two decades research has shown that adolescents are capable of experiencing episodes of depression comparable to adults. As a beginning psychiatrist I wouldn't believe that adolescents could be depressed, all other diseases starting in young life such as ADHD, Autism I did accept. Depression such as adults can experience, no.
Epidemiological studies estimate the prevalence of depression in adolescents is 5-8%. Despite similarities there are also notable differences in treatment response of depressed adolescents compared to adults.In contrast to adults TCA do not appear effective for the treatment of depression in children and adolescents.
Recently I discussed the brain changes during adolescence.
There are notable neurobiological differences between depressed adolescents and adults:
1. Adolescents do not have subtle thyroid alterations as in adults with depression
2. Growth hormone probes in adolescents donot differ between depressed adolescents and healthy adolescents in contrast with most adult depressed patients. Adolescents do not differ in growth hormone secretion after administration of clonidine, L-Dopa and dextroamphetamine.
3. Cortisol hyper-secretion is rare in adolescent depressed patients in contrast to depressed adults.
4. There is no blunted corticotrophin secretion after CRH infusion with depressed adolescents compared to a not depressed groups. In adults 50% of depressed patients have a blunted corticotrophin release.
5. Depressed adults have changes in cellular immunity such as changes in lymphocytes or lymphocyte subset number. In adolescents no studies reported changes in lymphocyte or lymphocyte subset number.
Depressed adolescents share another similarity with depressed adults, EEG changes during sleep are comparable between these groups:
1. prolonged sleep latency
2. sleep continuity disorders
3. reduced time until rapid eye movement (REM) period
4. increased REM density
5. decreased alfa (stage 3 and 4) sleep (this last one not with adolescents)
Neuroanatomical differences between adults with depression and adolescents has hardly been a subject for research. In adults the most important findings in MRI research are abnormal amygdala volumes, although the direction of this abnormality varies across studies. Volumes of the hippocampus have been found to be reduced in most, though not all, studies of chronic or recurrent adult depressives.
MRI findings in 20 children and adolescents with depression:
1. smaller amygdalas in depressed children compared to healthy subjects, reduction of left and right amygdala volumes
2. Hippocampus volumes did not differ between the groups
3. No significant correlation were found between amygdala volumes and depressive symptom severity, age at onset, or illness duration
How can these differences between early onset depression and adult depression be explained? There are three kinds of factors that me contribute to these different findings.
1. Development factors
Many of the neurobiological systems implicated in the pathophysiology of adult depression are not fully devloped until adulthood. For instance serotonin content and synthetic activity matures relatively early, the serotonergic innervation of the prefrontal cortex is achieved at age 5-6 years. In contrast the development of norepinephrine and dopamine content and synthetic activity continues through puberty with dopamine innervation of the prefrontal cortex not finalised until to early adulthood. Corresponding with these changes there are developmental differences in sensitivity to various pharmacological agents.
2. Stages of illness
Biological correlates and treatment response of patients with recurrent episodes of depression may differ from a single episode. Most adolescents experience their first depression in this life-phase. There is also some evidence that HPA axis disturbances differ between recurrent illness and patients experiencing their first episode. Differences in the neurobiological correlates of depression across the life cycle may reflect course-of-illness factors and not fundamental differences in the pathophysiology of the disorder.
3. Heterogeneity in clinical outcome
Several studies have reported that as many as 20 to 40% of children and adolescents with depression experience a manic episode within 5 years of their initial episode of depression. Adolescents in normal control may also switch group status over time In a longitudinal study 23 % of the normal control subjects had an episode of depression during the 7 year interval follow-up. Studies that failed to use normal controls subjects at low familial risk for affective disorder may have obscured group differences in neurobiological studies with child and adolescent probands.
These findings highlight the need for careful characterization of normal control subjects and the importance of longitudinal follow-up data
Conclusion
There are many differences in the neurobiological correlates and treatment response of depressed adolescents and adults. We currently do not know if adolescent- and adult onset depression are one and the same disorder. Systematic longitudinal research is needed that accounts for:
1. developmental stage
2. stage of illness (number of episodes, total duration)
3. familial factors
The results suggest that early onset depression shares some but not all of the neuroanatomical features of adult onset depression. This raises the possibility that the pathophysiology of early onset depression may differ from adult onset depression, despite similarities in phenomenology. This in turn may have implications for the treatment of childhood depression.
Signs of brain shrinkage seen in soccer players
Using high-resolution MRI brain scans, researchers found evidence of reduced gray matter in the brains of 10 male college soccer players, compared with 10 young men who had never played the sport.
Gray matter refers to the brain tissue that controls thinking and memory. The significance of the relatively smaller gray matter volume and density seen in these players is not yet clear, the researchers say.
This may be due to repeated knocks on the front of the head called "heading". More research is needed to flesh out the potential long-term brain injury risks associated with soccer.
The brief report can be found in: Clinical Journal of Sport Medicine. 17(4):304-306, July 2007.
Title: Evidence of Anterior Temporal Atrophy in College-Level Soccer Players.
Shock value
This is the title of an article in the Washington Post online. Another with opinions from different professionals, psychiatrists and psychologists alike as well as patients view. This article put's ECT in a historic perspective and also discusses a recent article in the JAMA which is described in this blog a few day ago.
Monday, July 23, 2007
Discover your learning style
Discovered my learning style in a modern outfit online. From Lifehacker I did a survey on DVC learning Style Survey.
These are my results from the survey:
You learn best when information is presented visually and in a written language format. In a classroom setting, you benefit from instructors who use the blackboard (or overhead projector) to list the essential points of a lecture, or who provide you with an outline to follow along with during lecture. You benefit from information obtained from textbooks and class notes. You tend to like to study by yourself in a quiet room. You often see information "in your mind's eye" when you are trying to remember something.
Learning Strategies for the Visual/ Verbal Learner:
To aid recall, make use of "color coding" when studying new information in your textbook or notes. Using highlighter pens, highlight different kinds of information in contrasting colors.
Write out sentences and phrases that summarize key information obtained from your textbook and lecture.
Make flashcards of vocabulary words and concepts that need to be memorized. Use highlighter pens to emphasize key points on the cards. Limit the amount of information per card so your mind can take a mental "picture" of the information.
When learning information presented in diagrams or illustrations, write out explanations for the information.
When learning mathematical or technical information, write out in sentences and key phrases your understanding of the material. When a problem involves a sequence of steps, write out in detail how to do each step.
Make use of computer word processing. Copy key information from your notes and textbook into a computer. Use the print-outs for visual review.
Before an exam, make yourself visual reminders of information that must be memorized. Make "stick it" notes containing key words and concepts and place them in highly visible places --on your mirror, notebook, car dashboard, etc..
What I like about this survey is the practical and modern advice you get. I suggest all students in particular medical students should do the survey. It will deliver some new tricks and this survey is better than the surveys I did when being trained as a teacher.
These result probably also explain my interest in websites and good design as well as gadgets.
Sunday, July 22, 2007
For Adolescents no additional benefit of cognitive behavioural therapy with an antidepressant
There was no evidence of a protective effect on suicidal thinking or action with the addition of CBT to an antidepressant in depressed adolescents. In contrast to an earlier study in the United States cognitive behavioural therapy (CBT) does not improve outcome of treatment with a selective serotonin reuptake inhibitor (SSRI). On second look the US study also did not show additional benefit of CBT added to a SSRI (fluoxetine). Moreover the results of the US trial limits generalisability since it excluded adolescents with active suicidal intent, self harm, severe conduct disorder, and active substance abuse. Certainly suicidality is a core feature of severe depression. More than half of the participants were recruited from advertisement.
This trial in Great Britain is of more importance since it includes moderate to severely depressed adolescents and this randomised controlled trial had a follow-up of 28 weeks and it did not exclude suicidal adolescents nor psychotic depressed patients. They were all outpatients. CBT was offered weekly for 12 weeks, then fortnightly for 12 weeks with a final session at 28 weeks (total 19 sessions). The focus of usual care was an explanation of depression and attention to recent family or peer group conflicts. Comorbidity problems were also attended to when required, including liaison with schools and other agencies.
Overall outcome on the long term (28 weeks) was not bad at all: 7/94 (61%) of those in the SSRI alone group and 52/98 (53%) of the CBT plus SSRI group were much or very much improved. Again no significant difference but a good response for adolescents with a severe depression.
One weakness is the absence of a placebo arm, which we considered to be unethical in such ill patients, so we cannot draw any conclusions regarding overall effectiveness of treatment.Now this is the most regrettable remark in this article about this excellent trial. Since there is such difficulty in deciding what is the best treatment for adolescents with depression as well as so much uncertainty about the benefit or harm from the use of antidepressants it is most unethical not to include a placebo arm in this kind of randomised controlled trials. If we want to get any further in the treatment of a sever illness we shouldn't choose for the easy way out.
Saturday, July 21, 2007
Depression as side effect of drug against obesity or overweight
Acomplia (rimonabant) from sanofi-aventis has serious psychiatric side effects, namely depression. The European Medicines Agency (EMEA) recommends not prescribing this drug to patients with a depression or on antidepressants.
More information medicalnewstoday.
Electroshock (ECT) Round Up
This blog about depression and it's treatment especially with ECT is in the air for a while. I hope a lot of readers benefit from these scribbles. The truth be told, I learn a lot from writing these articles. Mostly I gather a lot of information for my work as a psychiatrist which end somewhere in a drawer or the "round archive" without being read at all. Since writing this blog I actually read them and when appropriate post the information on my blog. Surfing on the net nowadays is always accompanied by the question: Is this information relevant, blogable?
Now I take the privilege today to look back on my posts and make a round up of the most important sites with information about ECT relevant for interested readers in this subject, hope you like it.
1. About ECT for bipolar disorder from healthyplace.com, also more general information about ECT, the procedure, side effects.
2. Take it easy on ECT. Opinion of a patient treated with ECT about the side effects and the discussions about this topic in the media.
3. Another patient's opinion about ECT and it's side effects adding to the discussion in the media.
4. Electroconvulsive therapy (ECT): Treating severe depression and mental illness. Information by the Mayo Clinic. Very informative for patients facing the choice.
5. ECT get's a makeover. On ABC News, the opinion of patients and doctors.
Friday, July 20, 2007
ECT gets a makeover
New article with proponents and antagonists of ECT, objectively written by Sibile Morency at ABC news.
Thursday, July 19, 2007
The placebo effect, dopamine and reward
"If you have the capacity to respond to reward, then you have the placebo effect," says neuroscientist and radiologist Jon-Kar Zubieta, senior author of the new study published this week in Neuron.
In this study they used brain imaging techniques. The 14 volunteers were told they would receive painful injections of saltwater in their jaw muscles. This shot would be followed by a painkiller. Half of the volunteers would receive the painkiller and the other half would be injected a fake painkiller, so they were told. However all volunteers were injected with the fake painkiller (placebo). During this procedure they were monitored with brain imaging techniques (positron emission tomography (PET) scans).
The scans showed that half of the participants who believed they were receiving painkillers reported feeling significantly less pain than did other volunteers. Their dopamine levels were noticeably higher (than that of the others) from the moment they were told they were receiving authentic painkillers.
On another day these fourteen with 16 new volunteers were brain scanned with functional magnetic resonance imaging (fMRI) during a card gambling game. They were told they could win or lose a certain amount of money each round; they would then push a button to determine the real take.Several of the participants showed a flurry of activity involving dopamine release in the nucleus accumbens while awaiting the outcome, indicating that they were expecting a reward. These participants were also the people reporting pain relief from the fake painkiller. So there is a strong link between the reward system (dopamine, nucleus accumbens) and the placebo effect. With this result you can predict the placebo response or even develop techniques targeting the dopamine system to increase the placebo effect.
Wednesday, July 18, 2007
Electroconvulsive therapy, evidence and challenges
A commentary in the JAMA by Prof Max Fink. In this commentayr he sumarizes the most important recent topics in ECT.
1. Remission for depressive illness with ECT: 55%-86%, these results compare favorably to the response rates in the STAR*D trial.
2. Relapse prevention after ECT, nortriptyline with lithium is first choice, continuation ECT for patients who relapse despite this treatment and for those who may not tolerate medication.
3. ECT is a primary treatment for psychotic depression.
4. ECT reduces the acute risk for suicide.
5. Medication resistance does not bare relation to treatment efficacy with ECT.
6. He still favours bilateral electrode placement.
7. Important side effects are anterograde-, retrograde amnesia.
8. Vagus Nerve Stimulation and Deep Brain Stimulation are not comparable in efficacy to ECT.
This is in short his few about the recent achievements in ECT treatment and it's research. His preference for bilateral ECT is a topic for debate. Unilateral electrode placement is technically more complex but comparable in efficacy when done the right way. That is with supratreshold stimulus dosage after stimulus titration during the first session. Research with side effects should be done for the long term and focussed on individual differences
The Secret of Wisdom
These are the words of a wise old man. George W. Comstock, an epidemiologist renowned for proving both what worked and what didn’t in the prevention and treatment of tuberculosis. He died last sunday of prostate cancer on the age of 92 and he had never retired:
Comstock said of his career: “I never really thought too much of it in terms of achievement. It’s been fun. While there are people in science, of course, who are shooting for the Nobel Prize, who are shooting to be the top dog in this field, but I think most of us are just interested in learning something that will push the knowledge a little bit further ahead. And, you know, that’s gratifying.”
For his achievements you can read an article at WSJ.com Health Blog by Jacob Goldstein.
For me these words are an example of wisdom that struck me.
Tuesday, July 17, 2007
Take it easy on ECT
This is the title of an article from a patient treated with ECT and a nuanced opinion about this treatment, wish a lot of patients would read it.
A voice from the silent majority
Monday, July 16, 2007
Adolescents, they are brain damaged people
The way adolescents act and react such as poor decision making, recklessness, and emotional outbursts makes many parents hopeless. At least that's what I remember from my parents although I was a very agreeable adolescents. The title of this post is by Dr. Huxtable, Bill Cosby in The Cosby Show who has the same opinion as many parents.
As a psychiatrist I am also a consultant for a adolescent unit in our hospital. The consults are very few but mostly about depressed adolescents. I find it very hard to diagnose depression in this category of patients, they do have symptoms comparable to adults but they can also differ in their symptoms.
Can adolescents be depressed, is it the same as with adults? I wonder. So I have chosen to explore this topic from a more scientific, biological view point. Are the brains of adolescents different than those from adults, can these brains become depressed or are their differences explaining a different symptom pattern and treatment needs?
Brain maturation continues into the teen years and continues even into the 20's. During the teen you get an overproduction of gray-matter. Gray matter is distributed at the surface of the cerebral hemispheres (cerebral cortex) and of the cerebellum (cerebellar cortex) mostly, but also in the deeper centres of the brain.
After the overproduction of gray matter the brain undergoes a proces called "pruning". Pruning is a neurological regulatory process, which facilitates a productive change in neural structure by reducing the overall number of overproduced or "weak" neurons into more efficient synaptic configurations. It is often a synonym used to describe the maturation of behavior and cognitive intelligence in children by "weeding out" the weaker synapses. Connections among neurons in the brain that are not used wither away. This is also called: the use it or lose it principle.
This pruning proces makes the brain more efficient by strengthening the connections that are used most often, and eliminating the clutter of those that are not used at all.
Functional magnetic resonance imaging (fMRI) research found that compared to adults teens' frontal lobes are less active during the showing of pictures of people with fearful expressions and their amygdala is more active. The frontal lobe is the seat of goal oriented rational thinking and the amygdala is involved in discriminating fear and other emotions.
Teens often misread facial expressions, the judgement insight and reasoning power of the frontal cortex is not up up to the task yet as it is in adults. Adolescents process information differently from adults.
What does this mean?
1 Adolescents are "hard wiring" their brains during this period in life, that's probably why this is the period for education
2 This explains why adolescents fail to to heed adults' warnings, they may simply not be able to understand and accept logical arguments
3 It is also possible that adolescents misperceive or misunderstand the emotions of adults, leading to miscommunication
4 Adolescence seems not to be the right time to experiment with alcohol and drugs
The question about depression and adolescence in view of brain development remains for a next article, to be continued
Cyberonics and Vagus Nerve Stimulation Back in the Race?
Cyberonics Inc. on Monday said the United States Food and Drug Administration has approved its Demipulse and Demipulse Duo generators for commercial release. The products are used for vagus nerve stimulation, which is used in the treatment of epilepsy and certain types of depression.
In August 2006 Cyberonics saw the FDA reject the company's application to use its implantable generator to treat depression in patients who do not respond to medications. Mainly due to disappointing results of clinical trials. In the only randomized controlled trial VNS failed to perform any better when turned on than in otherwise similar implanted patients whose device was not turned on. For summary of safety and effectiveness data see this FDA rapport.
The pacemaker-like device, which is surgically implanted into a patient, has been available in the U.S. since 1997 as a treatment for epilepsy.
VNS uses a stimulator that sends electric impulses to the left vagus nerve in the neck via a lead implanted under the skin. The left vagus nerve is stimulated rather than the right because the right plays a role in cardiac function such that stimulating it could have negative cardiac effects. The exact method of therapeutic action is unknown, but VNS has been shown to affect blood flow to different parts of the brain, and affect neurotransmitters including Serotonin and Norepinephrine which are implicated in depression. Some patients experience an alteration of voice quality and loudness during the time that the pulse is being delivered to the vagus nerve. Other common side effects include hoarseness, throat pain, cough, shortness of breath.
For further eading on VNS please see Wikipedia.
For more explanations about the differences between VNS, Magnetic Brain Stimulation and Deep Brain Stimulation, please see this website from Biotele.
For more information about VNS see this page from the Mayo Clinic. And this one for Deep Brain Stimulation.
My opinion is that efficacy is not proven for these treatments for depression although there are patients that can benefit. Before you try one of these methods be sure they have been treated with all regular options including ECT or electroshock.
Sunday, July 15, 2007
Psychiatrists Top List in Drug Maker Gifts
The New York Times reveals that among specialists the psychiatrists are the one's that get payed the most by pharmaceutical industries in the USA. In the USA drug companies are required to disclose their payments to doctors for lectures and other services. Endocrinologists received the second largest amount.
Efforts to require disclosure of payments to doctors began almost by happenstance in 1993. Compliance with the law seems to be "spotty". In The Netherlands such laws do not exist. To my opinion it would be time to make them. Even with disclosures in abstracts, articles and lectures it is still hard to evaluate the objectiveness of some psychiatrists.
Well that's to posts on money and health today.
United kingdom corrects myths on mental illness
In the biggest attempt yet to change the public perception of conditions such as depression and schizophrenia, three major charities are to run a TV campaign showing that many conditions thought of as incurable are treatable.
The amount of money involved in this campaign is about 16 million pounds, according to the Guardian.
Saturday, July 14, 2007
Side effects of ECT how do they work out?
Side effects of ECT, the possible memory loss is a topic for debate. Not only between psychiatrists but also between patients. Here is another story of how these side effects ruined the life of a patient. Made a comment to this post but it was not published on the blog as a comment. Here is another more positive opinion about ECT from a patient.
Side effects will be a topic for discussion for a long time. On this blog two other views are described in 2 posts. First a view from Prof Max Fink and here a post about an ongoing discussion with Prof Sackeim.
I will post your comment anyway.
Friday, July 13, 2007
Side effects from Chocolate
An unfortunate 46 years old man had a strange side effect with a selective serotonin re uptake inhibitor (SSRI). SSRIs are antidepressants. In continuation of yesterdays post about chocolate here is another strange story. After approximately two weeks of treatment with the SSRI he noted an intense itching sensation in his scalp after eating a piece of chocolate cake.
The itch spread to the arms, abdomen and legs and the patient treated himself with clemastine and the itch disappeared. He now realised that he had eaten a chocolate cake before this episode and remembered that before the first episode he had had a chocolate mousse dessert. He had never had any reaction from eating chocolate before and therefore reported this observation to his doctor.
The skin contains a system for producing serotonin as well as serotonin receptors. Serotonin can also cause itching when injected into the skin. SSRI-drugs increase serotonin concentrations and are known to have itching and other dermal side effects.
This case report suggests that there may be individuals that are very sensitive to increases in serotonin concentrations.
"Life is a box of chocolates, you'll never know what you'll get" (Forrest Gump)
Thursday, July 12, 2007
Is Chocolate an Antidepressant?
It is claimed that chocolate has the capacity to improve mood, and make people feel good. Chocolate is made from cocoa, butter and sugar. Milk chocolate contains extra milk solids and fats, white chocolate is akin to milk chocolate without the cocoa. That's why white chocolate to my opinion is not chocolate. Attempts have been made to identify any psychoactive substance in chocolate. Several candidates were identified but their concentrations are too low to have a significant psychoactive effect and they are also present in higher concentrations in non-craved foods. Milk chocolate is the most preferred but if psychoactive substances were involved dark chocolate should be the most preferred. At least I prefer the dark chocolate.
Interaction between chocolate and neurotransmitter systems that contribute to appetite, reward and mood regulation were studied but no antidepressant mechanism of chocolate was found.
Chocolate can be the quality of chocolate graving, only chocolate will satisfy that craving. When experiencing an aversive mood state any carbohydrate will suffice in an attempt to achieve relief. This last form of behavior is also called emotional eating, food preference can be altered across a range of mood states. It is useful to distinguish between these two separate phenomena: chocolate craving and carbohydrate craving. The two phenomena can, however, co-exist in the same individual by virtue of the dual status of chocolate as being specifically desired and being more generally craved as a carbohydrate at times of emotional eating.
For most people chocolate is a substance of pleasure and extravagance. When taken in response to a dysphoric state as an emotional eating strategy it may provide a transient comforting role but it is more likely prolonging this state. It is not an antidepressant.
For an excellent review please read: Mood state effects of chocolate.
Parker G, Parker I, Brotchie H. J Affect Disord. 2006 Jun;92(2-3):149-59.
Wednesday, July 11, 2007
On the Antidepressant-Suicide link
In the last couple of years antidepressants were accused of causing suicide in patients using them. More recently a subgroup of patients, adolescents were assumed to be of increased risk for suicide when using antidepressants. This is a reference to an article on The Corpus Callosum, a scienceblog.
This blog has already dedicated a number of posts about this subject. This recent post discusses: Suicide Attempts Among Patients Starting Depression Treatment With Medications or Psychotherapy and an editorial Antidepressants and Suicidal Behavior: Cause or Cure? in the latest (July 2007) issue of the American Journal of Psychiatry.
The main finding of the article was this: the temporal pattern of suicide attempts was the same regardless of treatment modality, and it was the same regardless of the age span of patients studied. Note that the pattern was the same, although the rates were different.
The treatment modalities were antidepressants prescribed by a primary physician, antidepressants prescribed by a psychiatrist and individual psychotherapy.
The risk of suicide attempts peaks before the onset of treatment, these data show a pattern that is exactly the opposite of what one might expect if antidepressants were associated with increased suicidal risk.
This and other studies are observational studies and observational studies can never definitively demonstrate causality, prospective studies are needed for that. However, the results of both studies are consistent with a protective role of treatment against emergent suicidal behavior.
Tuesday, July 10, 2007
What You Ought to Know About a Possible New Drug for Bipolar disorder
A new candidate drug for bipolar disorder is being designed by researchers in Chicago and New York. It works as well in mice as do the currently prescribed drugs. They hope that it will ultimately provide relief without the side-effects of present treatments.
Bipolar disorder, which afflicts about 1% of adults, is typically treated with drugs called mood stabilizers, especially lithium is used. Lithium is thought to act by blocking the function of an enzyme called glycogen synthase kinase-3beta (GSK-3beta) in the brain.
Kozikowski and colleagues did two things. First, they looked for a way to improve binding to the enzyme. They also altered the enzyme so that it could get from the blood into the brain, which involves passing through a water-resistant membrane.
They made a whole family of molecules, and tested how well each of these blocked the enzyme's chemical behavior. They identified the best of them and looked at whether it would work in animals. In a mouse model of 'mania', hyperactive mice were calmed and moved around much less when given the new candidate drug. The new compound looks promising, but a lot of work remains to be done before it will be ready for human trials.
References
1. Kozikowski, A. P. et al. J. Am. Chem. Soc. 129 , 8328-8332 (2007).
Monday, July 9, 2007
Here is a method that is helping depressed patients to feel better
Activity scheduling is an attractive treatment for depression because it is relatively uncomplicated, time-efficient and does not require complex skills. Activity scheduling is a behavioral treatment of depression in which patients learn to monitor their mood and daily activities, and how to increase the number of pleasant activities and to increase positive interactions with their environment. This treatment was developed about three decades ago because it was evident that depressed patients find fewer activities pleasant, engage in pleasant activities less frequent and obtain therefore less positive reinforcement than other individuals.
Researcher form the department of clinical psychology of the Vrije Universiteit in Amsterdam, The Netherlands did a meta-analysis to examine the effects of activity scheduling on depression, on the relative effects of activity scheduling compared to other treatments and on the longer term effects. Their literature search produced 16 studies with a total of 780 subjects. In four studies subjects were recruited from clinical settings. In only five studies the participating subjects had to meet diagnostic criteria for depressive disorder, the other studies included subjects who scored high on a severity rating scale for depression or used other definitions. Activity scheduling was compared to other psychological treatments. Activity scheduling was compared to cognitive therapy in 10 studies.
They concluded that activity scheduling is effective in the treatment of depression and equally effective as cognitive therapy also at follow-up periods up to 6 months.
The limitations of this review were:
1. number of studies was small
2. studies used very small sample sizes
3. only one study compared with antidepressants
4. the quality of the studies was not always optimal
5. few studies used clinical samples
It is remarkable that activity scheduling received so little attention. Since activity scheduling is as effective as other psychological treatments for depression it is possible that the effects of treatment are achieved by common factors such as the intensive relationship between patients and therapist, the expectation of the patient of being cured, the ritual of the therapy, and the presentation of a rationale. Advantages of activity scheduling is that it is simple and easy to understand, no need of complex skills, and time efficient.
If you want to know what activity scheduling is and you don't want to waste to much time before starting some exercise or looking for a therapist, please have a look at this excellent blog on Finding Optimism. There is also a recent article in cooperation with zen habits about Top 42 Exercise Hacks. Besides there is much more about fighting depressed mood in different ways on this blog.
Informative links on this subject:
More Evidence for Antidepressant Properties of Exercise
Sunday, July 8, 2007
Understanding Depression in Kidney Disease
Nearly 30 million Americans suffer from some form of depression. Many people with depression do not seek help, even though most of those with severe cases can be helped. Kidney disease patients are at an increased risk of suffering from depression. Understanding Depression in Kidney Disease and When Your Loved One is Depressed, gives readers an understanding of what depression is, what may cause it and how it is treated.
The American Association of Kidney Patients (AAKP)has published a brochure in the AAKP Understanding series. To download an electronic copy of this brochure, please visit the AAKP site.
It is an excellent brochure with an accurate account of what a depression is and how it is treated. Different treatment options are explained.
It is stated on this website that kidney disease patients are at an increased risk of suffering from depression. Since we did some research about depression and chronic inflammatory liver disease I am a little reluctant about scattering around this diagnoses. Would need to do a thorough literature search before answering this important question. With patients with liver disease a high prevalence of depression was only found by using a depression severity scale. Using severity scales to screen for depressive disorders in chronic somatic patients yields a prevalence that is too high. With a structured psychiatric interview prevalence is usually less and comparable with the prevalence in the general population for patients with a chronic inflammatory liver disease. It is possible that patients with a chronic somatic illness have some features of a depressive disorder, but lack all the features required for the DSM-IV diagnosis.
In conclusion patients with chronic somatic illness can have "psychiatric complaints" sometimes due to a psychiatric disease but most of the times due to their somatic illness.
Saturday, July 7, 2007
Direct To Consumer Advertising of prescription drugs, a threat to Europe?
The European Committee supports the request of the pharmaceutical companies for "direct-to-consumer-advertising". The International Society of Drug Bulletins warns against this legislation. It is wrong to confuse information with advertising.
The dangers of "direct-to-consumer-advertising" are:
1. advertisements from drug companies are mostly limited to those drugs with the highest profit
2. efficacy is often exaggerated
3. risks are usually obscured
4. it confuses patients when suggested another drug by their physicians
5. it forces physicians to use the advertised drug
6. advertisements by drug companies lack comparison with drugs from other companies or other treatments, making it hard for consumers to compare different drugs or other treatment options
Another objection is the impartiality of the Pharmaceutical Forum preparing this proposal. This is done by the Pharmaceutical Forum. This forum is not elected and not less than 5 drug companies are part of this forum. Moreover the patients are represented by The European Patients' Forum sponsored by the Drug Companies.
There are only two countries allowing "direct-to-consumer-advertising": USA and New Zealand.
Thursday, July 5, 2007
Another site with short description of ECT
Another short but concise introduction to ECT for patients can be found on this page of webMD. It is short but on this blog more posts about sites with information on ECT for patients can be found. Use the tags on the right column.
The information is reviewed by the department of psychiatry from the Cleveland Clinic.
Wednesday, July 4, 2007
An example of publication bias in systematic reviews
In a recent systematic review it is suggested that antidepressants, more specific the selective serotonin reuptake inhibitors (SSRIs) begin to have observable beneficial effects in depression during the first week of treatment. This conclusion is debated by the authors of a recent letter in the same Journal: Archives of General Psychiatry.
We argue that the criteria of including only studies reporting outcomes for at least 2 points in the first 4 weeks of treatment might have systematically selected positive trials, that is trials showing significant differences between placebo and active drugs during the early phases of the trial. In other words, it is possible that the authors of primary studies reported more often early outcome data suitable for reanalysis when differences emerged.
They also argue that probably most of these trials with the positive outcome were sponsored by the drug companies. And it is not unusual for these companies to not publish negative trials comparing SSRIs with placebo. The authors plead that scientific journals should require, before accepting reports of clinical trials, a statement in which authors agree that data may be accessed by organizations involved in research synthesis. Reports of clinical trials should not be accepted without such a statement. Only in this way would the damage of publication bias be mitigated.
Tuesday, July 3, 2007
Complaints of loss of personal memories after ECT: evidence of a somatoform disorder?
Memory complaints after ECT a somatoform disorder . This needs some explanation. It is the title of an article by Prof M. Fink. A very distinguished physician with a tremendous amount of experience with ECT. In this article he summarizes the complaints of two patients treated successfully with ECT. They both have expressed their memory loss with great detail in the media and even psychiatric congresses. He also mentions Kitty Dukakis and her new published book and DVD: Shock.
The author doesn't deny memory loss can occur after ECT but not to the extend as noted by the examples he mentions in this article. In his article he makes a case for defining these extraordinary cases with extensive personal memory loss as a somatoform disorder. This is a disorder consisting of unexplained physical complaints, inconsistent with known anatomy, physiology, or biology. According to the author:
The rare complaints of persistent loss of personal memories as a consequence of ECT are well within the family of these syndromes.The demographic features of the complainants according to the author are well educated women, often nurses, with histories of prolonged depressive illness marked by somatic features and suicidal episodes. ECT was the last resort, reluctantly advised and administered, that resulted in relief of depression. The loss of personal memories is a new focus of illness making return to work impossible, however these patients function well in new roles as critics of psychiatry.
I don't know, I can recognize his arguments but the problem is as stated in an earlier article that we do not know enough about the possible causes of memory loss. By that I mean the possibility that some patients are more vulnerable for this side effect. Vulnerable in a biological sense and the patients he describes could well be the ones we are looking for but we need better understanding of the etiology for discovery of high risk groups.
Sunday, July 1, 2007
The Diet Plate, food and depression
I have recently written a post about food and depression and how healthy eating might help. Here is another interesting site for help on healthy eating.
The Diet Plate ® system, invented by Kay Illingworth, centres around a portion control plate that literally takes all the guesswork from maintaining a healthy, balanced diet. That means there's no counting calories, points or fat grams and no denial of essential food groups, so it doesn't rely on having to eat starchy carbohydrate one day and protein the next.
They have studied the use of this plate with patients with type 2 diabetes in clinical trials. The results off this study are promising so they say. The article is being reviewed, but they already mention the effects being very positive. As stated earlier:
Research in this area is still underway so it is not possible to draw any firm conclusions but the evidence does suggest that it is worth trying to follow a healthy diet in order to protect our mental health.
