Dr Shock MD PhD

OrganizedWisdom has excellent information on depression. The information delivered is divided in:
1. 5 great resources
2. what is depression
3. what are the symptoms and complications of depression
4. what are the types of depression
5. what are the treatments of depression
6. what Are The Holistic and Alternative Treatments for Depression
7. how do you prevent depression?
8. wisdom, stories and blogs about depression
9. foundations and support groups on depression
10. message boards, chat and discussions about depression
11. scientific and medical journal articles on depression
12. clinical trials on depression
13. related searches

There is no WisdomCard for electroconvulsive therapy yet.

About OrganizedWisdom:

It shouldn't be a time consuming process to quickly find links to the very best resources when searching for health information. So, we are solving this problem by adding the wisdom of trained expert search guides and physician reviewers to the power of algorithmic-only search tools and social bookmarking sites. This human-powered model helps us deliver far superior health search results by eliminating search index spam from low-quality websites, links to duplicative libraries of licensed health content or potentially dangerous web sites.

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Chocolate reduces irritability and rejection sensitivity in patients with atypical depression. The question about chocolate craving succesfully allocates two third of particpants with three or four symptoms of atypical depression.

How?
3000 participants reporting clinical depression completed a web-based questionnaire when visiting a website (http://www.blackdoginstitute.org.au). Respondents were required to have experienced depressive episodes lasting at least 2 weeks and requiring treatment. The questionnaire was used to investigate self-reported benefits of chocolate during a depressive episode and examine for any specificity of personality style to such chocolate craving.

More results
When depressed 1465 (54,4%) reported food cravings, with 1210 (44,9) specifically being chocolate cravers (50,7% of the women, 30,9% of men).
Of the chocolate craver group, the 736 (60,8%) who rated chocolate's capacity to improve their depressed mood as moderately to very important were more likely to rate it as making them feel significantly less anxious and less irritated.



What is atypical depression?
Criteria for atypical depression (DSM IV):

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)

B. At least two of the following:

1. Significant weight gain or increase in appetite
2. Hypersomnia (sleeping too much, as opposed to the insomnia present in melancholic depression)
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
4. long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

C. Criteria are not met for Melancholic Depression or Catatonic Depression during the same episode.


In general, atypical depression tends to cause greater functional impairment than other forms of depression. Atypical depression is a chronic syndrome that tends to begin earlier in life than other forms of depression — usually beginning in teenage years.
Atypical depression is more common in females — nearly 70% of the atypical population are women

Good to know
The author Gordon Parker is an excellent researcher from Australia. In his work he states that mood reactivity as the main criteria for atypical depression should be abandoned. He pleads for another feature as the main criterion: personality style with emotional dysregulation.

Article discussed:
Gordon Parker Joanna Crwford
Chocolate craving when depressed: a personality marker
British Journal of Psychiatry (2007) 191: 351-352

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Dr Shock is skeptical about the possibilities of Transcranial Magnetic Stimulation (TMS) influencing the neural networks involved with depression. TMS can influence the cortex on the surface and probably a few centimeters beyond. In research TMS has been used to disrupt neural activity experimentally in studies of human cognition but relatively little is known about how TMS works.

Effects of TMS on brain functions:

1.Single burst TMS instead of repetitive TMS applied to the visual cortex interferes with visual imaging (repeated stimulation=rTMS has a longer lasting effect than a sinle burst)

2. Stimulation of the right spot in the motor cortex causes the tumb to twitch (intensity calibration of the TMS stimulus, this is used before repetitive stimulation to other parts of the scalp (rTMS))

3. Low frequency stimulation (1-5 pulses per second) depress brain activity, higher frequency stimulation (25 or more pulses per second) increases excitability.

4. Stimulation of the left prefrontal cortex with rTMS relieves depression in some patients who haven't responded to other antidepressant treatments

5. Low frequency rTMS to the temporoparietal cortex (above the ear) reduces auditory hallucinations in Schizophrenia

6. rTMS treatment on speech areas of the brain can make people name picture at a faster rate

7. rTMS applied to motor regions of the brain facilitates lightening fast movements

8. rTMS applied to the prefrontal cortex compared to sham rTMS enhances solving of analogy puzzles, rTMS might facilitate thinking. (Try rTMS before an exam). rTMS may raise baseline level of neural activity just enough so that neurons don't have to work hard to retrieve memory or problem solving strategies.

What is TMS?
rTMS influences neurons indirectly. It is a non invasive technique to stimulate brain tissue. Anesthesia is not required. Repeated pulses of electric current are sent through a metal wire, which is usually round or figure eight shaped. This electric current generates a perpendicular magnetic field. This magnetic field in return, generates another electric current in nearby material, in this case the current runs through brain tissue just below where the coil is placed on the scalp

How is it applied in Depression?
A depressed patients receives rTMS over the left prefrontal cortex for 20-30 minutes once a day for 2-4 weeks. It is unknowm if this is the right and effective combination of stimulation frequency, intensity, timing, and location.

In a recent article in Science: TMS elicits coupled neural and hemodynamic consequences, a more detailed look on how TMS might affect the neurons is presented.

TMS was applied to the cat visual cortex and the neural and hemodynamic consequences were evaluated.
Short TMS pulse train elicited initial activation (to 1 minute) and prolonged suppression (5-10 minutes). Oxygen concentration and hemoglobin levels were tracked simultaneously with the stimulation and the recordings. Oxygen consumption and hemoglobin are metabolic markers. Both mirrored the pattern of increase in firing (about 1 minute) by the neurons followed by a decrease in firing for several minutes after a stimulation by a TMS pulse train of a few seconds.

Neural activity elicited by flashes of white and black bars on a computer screen which can influence even anesthetized animals, had an altering effect on neural activation by TMS. Neural firing dipped sharply after TMS on the visual cortex and remained suppressed for several minutes during this challenge.
These findings can have important implications for the use of TMS in depressed patients:

The findings have implications for designing TMS therapies, says George. For depression therapy, for example, "we may need people to become sad in the chair while stimulating [them]," George says (Mark George, a psychiatrist at the Medical University of South Carolina in Charleston). "Alternatively, we might have them engage in formal cognitive therapy, thinking positive thoughts." Such considerations are important, he adds, as the Food and Drug Administration is considering approval for daily TMS of the prefrontal cortex to treat depression.

The new findings also suggest why the effects of TMS often vary, says Alvaro Pascual-Leone, a neurologist at Harvard Medical School in Boston. Pascual-Leone suggests that TMS results could be made more consistent by monitoring the physiological state of the brain using electroencephalography or functional magnetic resonance imaging.

Picture used:
The picture at the top of this article is from a website about neurostimulation in all it's forms
Articles used:
Boosting Brain Activity From the Outside In
Laura Helmuth
Science 18 May 2001:
Vol. 292. no. 5520, pp. 1284 - 1286
DOI: 10.1126/science.292.5520.1284

Uncovering the Magic in Magnetic Brain Stimulation
Greg Miller
Science 28 September 2007:
Vol. 317. no. 5846, p. 1846
DOI: 10.1126/science.317.5846.1846a


Transcranial Magnetic Stimulation Elicits Coupled Neural and Hemodynamic Consequences
Elena A. Allen,* Brian N. Pasley,* Thang Duong, Ralph D. Freeman
Science 28 September 2007:
Vol. 317. no. 5846, pp. 1918 - 1921
DOI: 10.1126/science.1146426

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Interesting question in relation to Electroconvulsive therapy (ECT). Retrograde amnesia and anterograde amnesia can occur during an ECT course. The memory of some recent events can be lost due to ECT, some patients complain of forgetting recent events. This retrograde amnesia extends from shortly before ECT to events that occured during the illness episode.
That is why this is an interesting question. How is it possible that some memories are not consolidated. It takes time for a short-term memory to become long-term memory. The passage of time allows it to become resistant to interference from competing stimuli or disrupting factors such as a ECT treatment. Consolidation is the time-dependent process of stabilization, whereby our experiences achieve a permanent record in our memory.
This consolidation is explained on ask the expert from ScientificAmerican.com

Just a tip of veil:

Memory consolidation can occur at many organizational levels in the brain. Cellular and molecular changes typically take place within the first minutes or hours of learning and result in structural and functional changes to neurons (nerve cells) or sets of neurons. Systems-level consolidation, involving the reorganization of brain networks that handle the processing of individual memories, may then happen, but on a much slower time frame that can take several days or years.

More in dept information about changes on a molecular and neuron level can be found on the site of Chemical and Engineering News.

Forgetting is also discussed. Where did you park your car? Were are your keys?

BUT WHAT happens to memories that last for a while but aren't permanently retained?

Understanding of the process of forgetting is murky, and the proposed mechanisms are controversial. Some researchers believe certain parts of the brain employ "long-term depression" to clean the slate, so to speak. In the hippocampus, for example, long-term depression weakens connections between synapses that are only rarely stimulated. Under these conditions, glutamate binding to NMDA receptors on the postsynaptic membrane brings only a small number of calcium ions into the neuron. This small amount of calcium activates enzymes that dephosphorylate the receptors, making them less responsive to glutamate.

Long-term depression also reduces the number of AMPA receptors in the postsynaptic membrane. It also might alter the structure of synaptic connections between the neurons. The net result of these steps is to return the neuron to a state in which it's ready to receive new information.

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What is the difference? Dr Shock forgot. He received a review of a manuscript. Fortunately it will be accepted if...... And one of the mistakes Dr Shock made was confusing the two, using them both for efficacy. After a search on the web Dr Shock will remember the difference, once and for all. He found a clear explanation on medicinescomplete.com. Mind you English is not his native tongue.

Efficacy is: Whether or not an intervention can work under ideal conditions relates to efficacy.1 If the conditions of a trial are optimised, the measurement of the outcome variable may detect even relatively small effects of the treatment. In such a trial, bias is excluded as far as possible, for example by including only patients who are likely to cooperate fully with the medical advice.2 In such a trial, patients should not be treated with concomitant medication and other co-interventions should be avoided. A treatment is efficacious when it proves to be superior to (usually) placebo or another treatment of known efficacy.

Effectiveness is: The pragmatic question of whether an intervention works in routine clinical care relates to effectiveness.1 In this setting, the inclusion criteria for patients are more relaxed. In such a trial, the question is whether the treatment does more good than harm among those to whom it is offered and patients are allowed to accept or reject the treatment, much as would be the case in real-life situations.

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Gearlive has it. Scientists developed a translucent frog so they can see the organs and blood vessels during experiments with diseases.

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No Dr Shock is not going into herbal remedies nor acupuncture or any other expensive crap. Papayas are used to introduce Year 3 medical students to uterine anatomy, endometrial biopsies, intrauterine contraception, and uterine aspiration. They sure learn a lot more than we did in the "Old Days".

During the second week of the Year 3 obstretics and gynaecological clerkship students participate in a "Papaya Workshop". The Gynaecologists pokes holes in the stem ends to mimic the cervix. On these papayas the students practice intrauterine contraception (IUC) placement with two different IUC's. They learn to dilate and aspirate and curette their papayas, mimicking the case of a women with a missed abortion.

During 1 year the students were surveyed before and after the workshop and at the end of the rotation. 90% of those asked rated the workshop as highly valuable. Before the workshop a score of 75% correct answers was achieved by 48% of the students, after the workshop this had increased to 98% and it remained fairly steady to the end of the rotation (91%).

The papaya workshop is a fun, inexpensive and easily replicable model for teaching intrauterine procedures.

I hope that the University of California San Francisco, San Francisco General Hospital will keep including this workshop in the ob-gyn clerkship and may they come up with more fun workshops with educational profits.

Article discussed:
Steinauer J, Preskill F, Robertson P.
Med Educ. 2007 Sep 20; [Epub ahead of print]
Training medical students in intrauterine procedures using papayas.

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How commonly prescribed medications and medical conditions affect ECT is written in a recent article in Cleveland Clinic Journal of Medicine. This article: Electroconvulsive Therapy: What the Internist needs to know, can be downloaded for free. It is an excellent clearly understandable written article. Even patients can benefit from the presentation of all this knowledge and discuss some points made in this article with their psychaitrist and consulting internists.


It starts with an accurate description of the history of ECT, indications, but more important which medical assessments are needed and when. Comprehensively the authors divided the medical conditions that may require more extensive workup in three categories:
1. Patients with autonomic sensitivity
2. Patients with anesthesia sensitivity
3. Patients with cognitive sensitivity

These conditions that require special considerations are summarized in a table



Another important topic for extra workup and considerations before ECT are medication use. These medications are also summarized in a clear table.




Article discussed:
MAYUR PANDYA, DO LEOPOLDO POZUELO, MD DONALD MALONE, MD Electroconvulsive therapy: What the Internist needs to know
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 9 679-685 SEPTEMBER 2007

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Part-time work and office hours are important factors for recent graduated medical students. These factors influence their choice for becoming a general practitioner and public or occupational health specialist. So not long from now 60-80 working hours per week as in the "Old Days" will be history. A larger percentage women choosing medical education enhances this trend.



Enthusing medical students for your specialism also works. The main factor for medical students for choosing a medical specialism is enthusiasm for that particular specialism. The second important factor is their experiences during their education and third their experiences working in that specialism e.g. as an intern.

1091 physicians who graduated between July 1999 and June 2002 from the (Vrije Universiteit) VU university in Amsterdam or the University Utrecht were sent a questionnaire in 2002. Among other information they were asked about the extent to which certain factors have influenced their career choice. Respondents were divided in three groups: clinical specialists, general practitioners and public or occupational health professionals.

The response was 70%, 68% were working in a specialty, 23% in general practice, 9% in public or occupational health, and 2% in another occupation. Of the respondents 64% was female and 36% male.

There were some differences between the three groups. For clinical specialist training the three most important factors influencing their choice was enthusiasm and interest in the specific field (98%), experiences during education (68%) and work experience after graduation (mostly internship)(46%).

For general practitioners also interest in the specific field was the main criterion (97%) and experiences during education (79%) second, but the third factor was the possibility for part-time work (64%).

For public and occupational health professionals the most important facor was working in office hours (88%) followed by possibility to work part-time (68%) and interest in the specific field (59%) was the third factor.

These factors influence career choices. Most important working during office hours and the possibility to work part-time. This will probably increase the coming years, something to consider for Universities and medical specialists and educators.

Article discussed:
Nederlands Tijdschrift voor Geneeskunde
Carrièrewensen en beroepskeuze van recent afgestudeerde artsen
Soethout, M.B.M., Wal, G. van der en Cate, Th.J. ten
2007; 151(38); 2118-23

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Blogging addiction is a serious condition. Dr Shock is 64% addicted to blogging which is very high according to his wife. Before looking for marital counseling fortunately Dr Shock found a blog with 23 health tips for bloggers. If you're not a blogger you may try them as well.

Two tips:

If you're in a healthy relationship, have sex at least once every 3 days. I'm dead serious about this. It can be critical to both mental and physical stability.

If you're addicted to IMing, porn, RSS reading, movie watching, shoe shopping, music searching or whatever else dominates your time.... TAKE BACK CONTROL OF YOURSELF and YOUR TIME ... addictions of any kind are not healthy - a healthy person has full control over him or herself.

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Adultery, a child from another man, HIV infection, abused as a child, suicidal ideation, all secrets often revealed to Dr Shock by patients during their depressive episode. Depression is often accompanied by pessimistic thoughts, guilty thought, self-blame and ideas of personal failures. That's why Dr Shock usually tries to comfort these patients and advises them to express these secrets only to him or other members of the treatment team not the ones they were hiding their secrets from. Wait until you're depressive episode has gone and then reconsider what to do. Not that they listen. Paternalistic? Maybe. There is no evidence how to handle secrets in depressed patients, no evidence based medicine on this topic yet.

Questions about Secrets and Depression
1. Is keeping a secret because of shame or anxiety harmful?

2. Can a secret become a leaden weight resulting in depression?

3. Might revealing this secret prevent becoming depressed, improve you're mental health?

Gopubmed doesn't help, only 9 articles, not one relevant.
While searching a little bit further the search with "secrets" revealed several articles not very relevant except a recent article in the Dutch Tijdschrift voor Psychiatrie on the second result page of his search. Dr Shock reads this journal every month but hadn't noticed this article. Secrets going bad is explained by the paradox that the attempt to suppress a secret thought leads to thinking more about this secret amplifying the thought to an obsession.

Disadvantages of Secrets:
1. secrets can lead to obsessive thinking and to psychiatric complaints and diseases
2. secrets can lead to somatic illness. An example is the study off HIV positive homosexuals. Those who had to keep their homosexuality as a secret progressed faster to AIDS than those who didn't have to keep it secret. The difference was 1 to 2 years. Another proof was published with non HIV infected homosexuals. Those who had to keep their homosexuality a secret were significantly more prone to infections.
3. Keeping a secret because anxiety for being excluded from their social environment


Advantages of Secrets:
1. Having secrets and sharing them with others requires social skills
2. Prevention from exclusion of social environment

Secrets
So secrets or having a secret has disadvantages and only a few advantages. Dr Shock found the search term: secrecy and disclosure the best for this topic on gopubmed. Scientific interest in this subject is increasing as can be seen on this graph:


Good instructions for revealing secrets during a depressive episode are lacking so Dr Shock will stick with his regimen until instructed otherwise.

Articles used:
Wismeijer AA, Vingerhoets AJ. Tijdschr Psychiatr. 2007;49(6):383-9. The emotional burden of secrets. Consequences for somatic health and implications for health care
[Article in Dutch] PDF
Departement Psychologie en Gezondheid, Prisma-gebouw, Kamer, AB Tilburg.

NRC W&O 23-9-2007

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64%How Addicted to Blogging Are You?

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An unusual story but it seems that the old stethoscope could be replaced in the future by the ipod. Unusual subject for Dr Shock as well but he has an iPod and loves gadgets to.

Gearlive has an article about this new development although unclear.

iPod are already in use to teach medical students all kinds of heart murmurs and sounds:

Barrett produced a CD that mimicked the sounds of six abnormal heart conditions and gave it to a group of medical students, who promptly uploaded the recordings to their iPods.

Found an earlier article of the use of ipod as a stethoscope on turbogadgets

Anyway the iPod Stethoscope package combines a diagnostic stethoscope with compatible software that is able to record and playback sounds, the stethoscope has a fifty times amplification, which enables it to be used under many difficult circumstances, yet can still get excellent readings from faint heart beats to obese patients and in a very noisy environments, this makes the package a useful tool for other professions which would require the use of recording and amplification.

Anyone with more information on this development?

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This grand round for Dutch Medblogs was started by Jan at medblog.nl. He is on my blogroll.
On his blog there is an extensive article about evidence based medicine. He also links in his article to several other recent medblog articles in english.

Dr Lutser worries about the Dutch health care system. He fears that due to more market orienting health care a clear division between haves and have nots will evolve.

A funny English song explains what anesthetists do when their patients are a sleep on Martijnhulst.nl .

Admitted patients are more severely ill in comparison with say about 10 years ago, hospital stay is shortened since then, turn-over increased, medical technology and regulations increased as well as "paper work", all explanations for the increased safety risks for patients. Especially since the number of nurses and nursing staff has not increased proportionally. This was established in a recent research by a non-profit research institution in The Netherlands. Nurses have less time to take care for their patients. Writes 100% Mike.

Nurse Klivia is in Iceland, with nice pictures. Another funny travel story with pictures from Greece on manager zorg verteld

On Hotline to Home their is a interesting discussion on anonymous blogging by physicians.

Wireless LAN harmless in Hospitals on MedLog.nl.

Are patients more often depressed after myocardial infarction and is this a reason not to prescribe beta-blocking agents? Two important questions raised in an article on ecgreetje

If you want an automatic translation of e.g. for a blog please see DigiCMB. This blog is written in English, unfortunately there is no Dutch translation.

And last but not least Psych-Leiden***Club-Confabula with a couple of interesting articles from which it is hard to choose. In one of them the dangers of internet are discussed: internet-stress, infomania, and internet addiction. Luckily some tips to treat them or prevent them are also given. Loneliness is in your genes and is accompanied by lower immunity and higher risk of infections. By the way her RSS feed is working again.

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Another new form of Neurostimulation for the treatment of depression came to my attention: transcranial direct current stimulation (tDCS).

What is transcranial direct current stimulation?
With tDCS a weak electrical current of 1 or 2 m Ampere is applied to the head with an electrode. The electrode is a non-metalic conductive rubber electrode, covered completely by saline soaked sponges.It is a noninvasive brain stimulation technique that utilizes low amplitude direct currents applied via scalp electrodes to inject currents in the brain and thus modulates the level of excitability. It doesn't elicit seizures and it doesn't require anesthesia. For comparison in ECT current of 9 m Ampere is used to elicit seizures during narcosis.


A recent article about this "treatment" was published: A randomized, double-blind clinical trial on the efficacy of cortical direct current stimulation for the treatment of major depression.
The abstract describes a double blind parallel placebo controlled trial. In other words, depressed patients were divided in three groups, one that received the actual treatment, one group that received an active control treatment and a group that received a placebo treatment. Active control was stimulation of the occipital cortex which is assumed to be without antidepressant potential. The placebo group received the treatment without the actual stimulation, active treatment was anodal tDCS of the left dorsolateral prefrontal cortex.

Mood was evaluated by a blinded rater using the Hamilton Depression Rating Scale (HDRS) and by a self evaluation scale the Beck Depression Inventory (BDI).

The reduction in severity score on the HDRS was significantly larger for the active treatment compared to occipital and sham tDCS. Again although significant the question remains how clinical relevant. More clinical outcome such as response ( 50% or more reduction on HDRS compared to baseline) and remission (absolute HDRS score below 7) are not provided. This makes the clinical relevance of the data hard to compare. The beneficial effects of tDCS in the DLPFC group persisted at least for 1 month after the end of treatment.


On ClinicalTrials.gov 17 studies with tDCS are recorded. Two of them are recruiting depressed patients for efficacy and safety of tDCS. One study in New York State Psychiatric Institute USA the other in The University of New South Wales, Australia.

A PubMed search for tDCS and depression results in 19 publications.

A website of The Center for Noninvasive Brain Stimulation has more information about tDCS and also rTMS.
This picture is from tmslab.org:



Dr Shock's opinion
This treatment has something magical about it. This increases the placebo effect. Moreover side-effects were minimal. It is hard to understand how local excitation of the cortex could influence serious alterations of the hypothalamic-pituitary-adrenal axis (HPA axis) present in some depressed patients or other neurobiological alterations for that matter.

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Electroconvulsive therapy (ECT) has a negative effect on word fluency shortly after a course of ECT. This improves during follow-up. Elderly have a greater improvement compared to younger patients. More precise the scores on word fluency tests were significantly influenced by age. The effect of age changed from a negative influence directly after ECT to a positive effect during follow-up. The negative effect for older patients is what you expect. The change to a more positive effect is unexpected.

What is word fluency
Word fluency is tested by a simple test, the word fluency test, right. In this research , patients were tested before ECT, shortly after ECT and at 3 months and 12 months after discharge. The word fluency tests consist of naming as much animals and professions as possible during 1 minute.

What is Semantic Memory
Semantic memory is tested with the word fluency tests. Semantic memory are all those acquired facts, concepts and skill you gather during your life. We can learn new facts or concepts from our experiences with semantic memory. Episodic memory represents our memory of events and experiences in a serial form from which we can reconstruct events that took place at a given point in our lives.

Long-term memory
Semantic memory and episodic memory are both part of long term memory.

Why do elderly regain their vocabulary, their semantic memory better than younger patients?
We don't know. This effect could be due to more life experiences or more mental reserve. Another possible explanation could be that stimulation of the neural system results in restorative plasticity, especially in the elderly. Because elderly are at a disadvantage for disturbances of other kinds of memory (such as short-term memory), restorative plasticity may adhere to specific brain regions.

Article discussed:
Changes in Everyday and Semantic Memory Function After Electroconvulsive Therapy for Unipolar Depression.
PMID: 17804988
Authors: Schat A, van den Broek WW, Mulder PG, Birkenhäger TK, van Tuijl R, Murre JM
Journal: J ECT, 23 (3): 153-157, 2007

You can read the whole article on my PBWIKI

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Now Dr Shock had the feeling that this association between prescription drop for SSRIs and an increase in suicide rates amongst children, wasn't that simple. He feared that it was all jumping to conclusions. But he didn't feel like going at it. Fortunately a lot of critical bloggers had the same hunge and had a closer look. All were astonished.

Here are some excellent critical minds at work:

1.The Last Psychiatrist
2. Clinical Psychology and Psychiatry: a closer look
3. Furious Seasons

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I have written an earlier article about BPR3.

They have asked for the creation of icons for their initiative.

Design the icon that bloggers will use to identify peer-reviewed research and win subscriptions to Nature, Seed, and more!

I have tried to place the javascript on the left sidebar so you could vote, but alas the script doesn't work so here is an image of three designs and a link for voting, go do it, I voted for Kevin Z’s entry but he is not winning yet.

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I am a Midlife Urban Professional and I should worry. According to a Dutch newspaper (NRC) the babyboomers look down on me because we were to young to battle against the establishment in the sixties and seventies, I am to old to start a new career and to old for a retraining, government measures for retirement don't apply to me, and it remains to be seen whether the younger generation will still be prepared to pay for my care in about 20 years from now.

MUPs are not limited to the Netherlands. In the US the MUPs have to live on less money

The phenomenon can be traced to the recession of the early 90s and the downsizing of American companies. Eager to trim costs, corporations are cutting the middle--mid-managers, most of them middle-aged. According to a 1992 report in Business Week, "some two million middle-management positions have been permanently eliminated." And the prospects for reemployment are not good. According to The Wall Street Journal, most of these laid-off, white-collar professionals are reentering the workforce at one-half their previous salaries. Business Week says it succinctly, "The newly dispossessed are increasingly aware that they often have nowhere to look but down."

According to Mike Bellah

Well don't worry, I still love my job, and I have a lot of interests that keep me going besides my job. But that is also characteristic for the MUP. He or she values work above income.

Characteristics of a MUP:
1. Born between 1955-1963
2. High education
3. Idealistic instead of materialistic


Does anyone recognize him- or herself in this picture and do you worry?

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In an article on ScienceNews a placebo controlled trial with tamoxifen in 16 manic patients is described.
Tamoxifen is a Breast cancer drug.

Over a 3-week period, each individual was given either tamoxifen or a placebo. In a paper appearing online today in the journal Bipolar Disorders, the team reports that the tamoxifen-treated patients started improving by the 5th day, and five of the eight showed a 50% or more reduction of symptoms on a mania-rating scale--compared with only one of the eight in the placebo group.

In this article side-effects are not mentioned.

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Because Vagus Nerve Stimulation (VNS) is still considered investigational the Centers for Medicare and Medicaid Services in the US will not cover costs for VNS treatment. In spite of approval by the FDA.


When Dr Shock returned home from Germany this evening he found the newest Journal of ECT on his doormat.Because of his recent articles on his blog about VNS he read the editorial of this journal with great interest and amazement.

Pros for VNS as a reimbursable treatment
Patients have been implanted the device, some with good effect but continuation of this treatment is uncertain. Some patients won't be able to replace their devices when the battery dies. Some patients can afford replacement with their own money.
The most important question still remains: can we predict which patients might benefit from VNS. Another point to the matter is that with clear definition of treatment resistant depression and all other options failing wouldn't VNS be an option. Treatments that work for a minority of patients are readily excepted in other field of medicine such as oncology.



Cons with VNS
The company that manufactures the VNS device has enlisted the help of psychiatrists. A letter-writing campaign was started. Where is the line between advocacy for patients versus advocacy for industry?
Results from trials are disappointing. Recent trials were used collecting safety data and effectiveness. Their quality varies, efficacy at least for the short term disappointing.

For Dr Shock this all is hard to apprehend. The Netherlands until now has a very different health care system than the US although differences are getting smaller.
If a treatment is approved it should at least have a the opportunity to prove it self. Continuation for those who clearly benefit from the treatment should be guaranteed.

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Dr Shock found an even better website with links for brain anatomy and pathology. The ultimate brainmap site.

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Recovery from depression:

The RID trial (2006-2010) will test whether a set of web-based self-help programmes work for reducing depression in New Zealand. The programmes are designed to help people manage their depression by providing relevant information and/or working through a number of exercises on the internet. The aim of this site is to explain the RID trial and invite people to take part in it.

.

Really a website worth to look at. It eplains the situation in New Zealand, it has some useful links to helplines online and by phone.

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This article on Popsci.com is a compelling story of a depressed patients treated with deep brain stimulation after failing several antidepressants and electroconvulsive therapy.

Besides the story of the patients this article covers a lot of information about DBS and the ongoing trials testing this treatment.

Related articles on this blog:

Deep Brain Stimulation for Depression

Deep Brain Stimulation and Coma

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When Dr Shock left Dresden he got an invitation by e-mail to visit: transinsight.com. The company behind gopubmed, discussed in an earlier article about gopubmed on this blog.
Regretfully he had just left Dresden for der Pfalz, also in Germany, for photos see on flickr.

The were so kind to offer a solution for linking to searches and articles on gopubmed.

Please read their e-mail reply:

you can link to GoPubMed simply using the link:
www.gopubmed.org/search?t=FriendsOfShock&q=query

This is the direct link into our search engine.
This is a link which will remain stable even in future versions.

The parameter q is the query string. For the parameter t please use the name
FriendsOfShock.

Examples:
www.gopubmed.org/search?t=t=FriendsOfShock&q=Schizophrenia

Example using a PubMed article with PMID 15980585:
www.gopubmed.org/search?t=t=FriendsOfShock&q=15980585

A simple link to GoPubMed without query:
www.gopubmed.org/search?t=t=FriendsOfShock

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This doesn't prevent him from blogging.
If you want to see more photo's please follow this link to Flickr

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This is a website written by a psychiatrist with experience with Cognitive Behavioral Therapy. You will need to register but the course is free.

After registration you have acces to your own page. This page has a Forum, Live Chats (now monthly) and tools to monitor your mood.

The course consits of modules. Also modules to monitor your mood. Even your general practitioner can be allowed to view your progress if wanted. Your physician also has acces to a part of the site that provides links to all modules, the forum, live chats and practitioner only modules.

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The author of finding optimism has made a top 5 of blogs about depression. Since I have been reading his blog for a while now I trust his judgement about these matters clompetely.
So have a look at these 5 blogs by visiting this article on his blog.
As you may have noticed he is on my blogroll as well.

This is his disclaimer for the top 5 blogs about depression:

I’ve taken some poetic license here. The blogs aren’t 100% about depression, although they don’t drift far away. And they aren’t in the Top 5 by consensus, since I am the sole judge and arbiter.

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For those of you not having read the comment on the article about Vagus Nerve Stimulation may I recommend the website VNSDepression.com

It has an enormous amount of information about Vagus Nerve Stimulation.

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Need recent evidence based medicine try Curehunter.com. They also have a dictionary. Which actually is a Mesh browser not a real dictionary. Dr Shock tryed Electroconvulsive therapy but no luck. Typing in a disease delivers an extensive report. Not for free. Davidrothman.net has some pictures of it as well.

The engine you are accessing online right now computes: 121,000 drug and biological agent data points X 11,600 diseases X 15,000,000 peer-reviewed research articles X several hundred thousand additional variables of Gene, Protein, Enzyme, Hormone, Growth Factor, Ligand, Kinase, Receptor, Inhibitor and other important small biologically active molecules.

The CureHunter Engine essentially defines the Clinical Outcome in cross-comparable numerical weights for all successful agents and allows discovery clustering and pattern finding that illuminate both pathogeneses and cures.

Tried it for depression. It delivers:

1. Key Drugs and Agents for Major Depressive Disorder

2. Diseases Related to Major Depressive Disorder

3. Key Therapies for Major Depressive Disorder

You can get a report in PDF with updates for a year for 24 dollars. Physicians can use it for free but only US physicians so Dr Shock can't use it. I can't check the information on depression.

CureHunter Patient-Physician Summary Reports collect in 1 single document all the medications ever reported in the US National Library of Medicine—1949 to the present—to be effective against your target disease. After the CureHunter data mining engine extracts the key scientific evidence supporting a drug's usage, a series of statistical analyses are carried out and the clinical performance of all drugs is computed.

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VNS received FDA approval in July 2005 for adjunctive, long-term use in chronic or recurrent major depression in adult patients with an inadequate response to at least four antidepressant treatments. You could say it is an option after other treatments for depression has failed, these options for treatment resistant depression are summarized in another article on this blog: 9 steps for treatment resistant depression.
Time for an update. A review of important articles from a scientific point of view. Not an exhaustive literature search.

Vagus Nerve Stimulation for the long term efficacious?
Two unblinded trials have been published with (n=59) treatment resistant depressed patients. Over 30% were responders after 10 weeks. Response was defined as at least a 50% reduction of the Hamilton Depression Rating Scale, a depression severity scale. In a long term naturalistic follow-up of this study, 30 patients received an additional 9 months of stimulation. Response was sustained, and remission rates were significantly improved (from 17% to 29%). Remission is defined as a score on the HDRS of 10 or less, that is to say these patients were free of depressive symptoms. This suggests that the efficacy of VNS is probably something that takes time. Patients might benefit if VNS is given during a longer period of time.

Analysis of a 1 year follow-up from patients receiving additional VNS in an open label study showed that response increased per month during the 12-month follow-up. Response defined as decrease of the average HDRS score. This response criterion is very sensitive, clinical relevance is difficult to interpret.

The short term results from the placebo controlled study of VNS combined with usual standard of care the antidepressant effect of VNS could not be established. This study was performed before the open label long term study mentioned above.


What is VNS?
Bipolar electrodes are attached to the left vagus nerve within the neck. These electrodes are connected to a generator. This generator is a small device, it is implanted subcutaneously into the left chest wall. The generator is programmed to deliver mild electric pulses in continuous cycles, typically with 30 seconds of stimulation followed by 5 minutes off. The device can be set non-invasively by the treating physician who uses an external device to change the "dose".
It could be that the antidepressant effect is achieved by influencing the amygdala and other limbic structures via projections from the vagus nerve.

Procedure
The device and the electrodes on the vagus nerve are implanted during surgery by a neurosurgeon, mostly during general anesthesia.

Side-effects of Vagus Nerve Stimulation
During the short stimulation (30 seconds) voice alteration can occur as well as hoarseness, dyspnoe and cough.
There can be a slight cosmetic change in the appearance of the chest after generator implantation.


Conclusions
No clear acute relief of depression shown yet. In treatment resistant depression maybe an option for the longer term.


Literature used

1. Effects of 12 months of vagus nerve stimulation in treatment-resistant
depression: a naturalistic study.
Biol Psychiatry. 2005 Sep 1;58(5):355-63.

Rush AJ, Sackeim HA, Marangell LB, George MS, Brannan SK, Davis SM, Lavori P, Howland R, Kling MA, Rittberg B, Carpenter L, Ninan P, Moreno F, Schwartz T, Conway C, Burke M, Barry JJ.
Comment in:
Biol Psychiatry. 2006 Dec 15;60(12):1382; author reply 1382-3.

2. Vagus nerve stimulation for treatment-resistant depression: a randomized,
controlled acute phase trial.
Biol Psychiatry. 2005 Sep 1;58(5):347-54.
Rush AJ, Marangell LB, Sackeim HA, George MS, Brannan SK, Davis SM, Howland R, Kling MA, Rittberg BR, Burke WJ, Rapaport MH, Zajecka J, Nierenberg AA, Husain MM, Ginsberg D, Cooke RG.
Comment in:
Biol Psychiatry. 2006 Dec 15;60(12):1382; author reply 1382-3.

3. Vagus nerve stimulation (VNS) for major depressive episodes: one year outcomes.Biol Psychiatry. 2002 Feb 15;51(4):280-7.
Marangell LB, Rush AJ, George MS, Sackeim HA, Johnson CR, Husain MM, Nahas Z, Lisanby SH.

4. Vagus nerve stimulation (VNS) for treatment-resistant depression: efficacy, side
effects, and predictors of outcome.
Neuropsychopharmacology. 2001 Nov;25(5):713-28.
Sackeim HA, Rush AJ, George MS, Marangell LB, Husain MM, Nahas Z, Johnson CR, Seidman S, Giller C, Haines S, Simpson RK Jr, Goodman RR.

Other articles about Neurostimulation in treatment resistant depression on this blog:

1. ECT, for information about ECT this blog delivers a lot of articles, one here and the other over here.

2. More about Magnetic Seizure Therapy in a recent post on this blog.

3. About rTMS

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How accurate is a blogger providing comment on a peer reviewed paper? Dr Shock frequently discusses and makes comments on academic papers. Mostly publications about Electroshock and depression but also about medical education and internet.The important question is how to evaluate the accuracy of the blogger providing the commentary on a peer reviwed paper. In comes BPR3, an initiative Dr Shocks supports.

BPR3

Dr Shock is a member of BPR3. About BPR3:

Bloggers for Peer-Reviewed Research Reporting strives to identify serious academic blog posts about peer-reviewed research by developing an icon and an aggregation site where others can look to find the best academic blogging on the Net.

In a recent post on the BPR3 blog some standards for the evaluation of blog authors are proposed. This is not easy since some blog authors post anonymous. Their main solution is a registration of blog authors and a logo. Controling all those blog authors seems a daunting task to Dr Shock

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He is in Germany since 6-9-07 and it doesn't prevent him from posting to his blog. If you want to see more photo's of Dresden, pleas follow this link to Flickr

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Everyday memory was mainly affected by bilateral electrode placement during Electroconvulsive therapy. Unilateral electrode placement had no significant effect on everyday memory. The effect of bilateral electrode placement significantly improved at three months of follow-up. One year after discharge the everyday memory was not significantly different from before treatment. ECT does not affect everyday memory on the longer term.

What is everyday memory?
Everyday memory was assessed with the Rivermead Behavioural Memory Test (RBMT).
This test is useful to predict everyday life task memory problems in patients.

This test includes the following subtests:

1. remembering an appointment
2. remembering a short route, immediately and after a certain period (delayed recall)
3. remembering a belonging
4. remembering to deliver a message
5. picture recognition
6. orientation
7. story recall, immediate and delayed
8. remembering a name
9. face recognition.

All very useful daily tasks.


This test was administered to patients (n=96) with a depressive disorder before, directly after ECT and at 3 and 12 months after discharge from hospital.

Interaction between this test and age, severity of depression, and electrode placement was analysed.

Age had a significant negative effect on the scores of the RBMT at all times.
Unilateral electrode placement had no effect, bilateral electrode placement did have an effect on RBMT scores. The scores improved at three months of follow up and were comparable to baseline at 12 months of follow up.

Limitations
The article: Everyday and semantic memory function in ECT, in the Journal of ECT reporting these results has some limitations. There was no control group involved, the electrode placement and dosage used was based on clinical arguments not on randomisation. This research is done in an actual psychiatric practice.

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Dr Shock still makes mistakes. But he'll never be as naif and stupid as he was during one of his internships. It was after a grand round on a neurolgy ward in an Academic Hopsital. Even in those days we didn't discuss diagnosis and treatment over the heads of the patients while they were surrounded on their beds by numerous white coats. The discussion was done afterwards with the professor and several senior and junior staff members as well as residents. Interns could listen to the discussion on the back benches of the room.

During a discusion after such a ground round one of the senior staff members ended the discussion with the statement that patients X was clearly suffering from disease Y as derived from his symptomps and recently published in the Lancet by Prof Z. Soon the discussion ended, and everybody got back to work, leaving us interns flabbergasted.

Young Dr Shock was so impressed that he decided to search for the literature mentioned, but no matter how long he searched for Porf Z in The Lancet about disease Y he couldn't find it nor any other recent publication on the topic of discussion. Well that's just being naif probably corresponding with has age then, a long time ago. More stupid was that on the next discussion after a grand round he decided to inform the attendees about his bad luck on his search. Obviously the senior staff member was not amused, after a short and brisk remark the meeting was over quickly.

Bold Statements during Grand Rounds
Bold statements mostly done by senior staff members during grand rounds about material that is less well known occurs frequently. Such bold statements are frequently articulated with great conviction and are usually accepted and assimilated by junior staff and the likes of them. Until recently it was unclear whether these exotic statements were substantiated with scientific evidence.



Researching Grand Rounds
In Medical Education, one of Dr Shock's favorite journals, a study about this phenomenon was published. The study aimed to evaluate the degree of scientific proof behind the bold statements made during grand rounds.


What they did was evaluate the level of scientific evidence for all bold statements during grand rounds for a period of 4 months. The study was performed on the Departement of Internal Medicine in a large teaching hospital in Amsterdam, The Netherlands. The evidence was searched on PubMed and discussed in short plenary discussion by the internal medicine residents. Outcome was categorical: supported by evidence based medical knowledge or unfounded exotic statement. Result were statistically analyzed.

The Truth on Grand Rounds
In total 25 cases of bold statements were indentified during these 4 months, of which 22 were made by senior staff and 3 by residents. An exaple of such a statement: "Legionella pneumonia never causes pleuritic pain". Only 8 (32%) statements were found to be supported by scientific evidence. In 17 (68%) statements the available literature contradicted (n=13) the statement, or no literature was avalable (n=4). The difference between confirmed and false or not confirmed statements was significant. Every intern and resident should read this article before they are send into clinical practice.

Article Discussed:
Gabor E Linthorst, Johannes M A Daniels, David J van Westerloo (2007)
The majority of bold statements expressed during grand rounds lack scientific merit
Medical Education 41 (10), 965–967.
doi:10.1111/j.1365-2923.2007.02838.x

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The big thing is that the brain needs a rest every now and then, and apparently, the brain can refresh itself and go on “like with a full tank of gas” with just a short, 20-minute power nap.

On the blog of the ririan project benefits of power naps, how to get the perfect power nap and the different kinds of power naps are explained are explained in a recent article.

About the Ririan Project:

Personal development is hard work, so don’t look for shallow quick fixes. Instead here you will learn practical ideas to make important changes in your life, both big and small, so you can get your life on track and start living up to your true potential.

Dr Shock is convinced of the advantages of a power nap

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They are lowering the frequency of his ECT treatment. Normaly ECT is stopped when the patient is in remission or no further improvement is seen during two weeks after at least 10 bilateral treatments.

When someone relapses after ECT, a new course is started and the frequency lowered as soon as the patient is better again. This last procedure is also called maintenance ECT treatment.

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Dr Shock needs refreshment of his memory when certain brain areas are mentioned in articles. He has found several websites that can help with clear pictures or search boxes.

This site from the BBC has an interactive brain map, you can find structures or brain functions by clicking on them.



On the same site you can rotate a brain, text explains the different regions.



More difficult to use but very interesting and instructive is a site from Harvard University with 3D images from the normal anatomy as well as from particular diseases such as CVA or stroke, brain tumor, dementia and infectious disease. Structures are clearly labelled. You can control the place of the slices yourself

An entertaining refreshing of simple anatomy of the brain is on this video on YouTube


Another interactive brain map. The structures are not named so you need some understanding of brain anatomy. This site also has a quiz. The url of the maps can be copied easily. It has animations, 3D pictures and a lot more.


A simple flash brain map is easy to use. Not very detailed but the main parts and bodies are covered in this map.

Well for Dr Shock this is enough , he regrets that all those pictures and maps are hard or impossible to integrate in a blog post.


Anyone suggestions for other brain maps and pictures for "educational" use?
Thanks Dr Shock

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When discussing Magnetic Seizure Therapy (MST) colleagues confused it with repetetive transcranial magnetic stimulation (rTMS). That's not so strange, both use a magnetic field.

An important difference is that with MST the intensity of the stimulation with the magnetic field is much higher than the intensity of rTMS. The aim of MST is to induce a seizure with the magnetic field. For this patients have to be treated in a hospital and they must receive anaesthesia and muscle paralysis during seizure induction. More about MST in a recent post on this blog.


With rTMS anaesthesia is not needed although Engadget errounously mentioned otherwise. It is not intended to elicit a seizure.
rTMS is not approved in the USA nor Europe as far as Dr Shock knows. The TMS device induces a widespread current distribution due to the magnetic field. This magnetic field is elicited by pulsing high-intensity current through an electromagnetic coil placed near the scalp.
The magnetic field induces electricla currents in the cortex of the brain. Yes, only the cortex, that's why Dr Shock has a hard time beliefing rTMS is an antidepressant. There is some evidence that rTMS causes indirect activation of deeper structures including hippocampus and thalamus.

rTMS has no cognitive side-effects, because of the noise the apparatus makes ear protection needed during therapy.

Drawbacks of rTMS are that coil placement, stimulus frequency and intensity have not yet been determined. A recent published meta-analyses found no diffference between sham rTMS and real rTMS. More large trials are needed to convince Dr Shock and others.

Besides MST and rTMS there are two other neurostimulation treatments for depression:

1. ECT, for information about ECT this blog delivers a lot of articles, one here and the other over here.

2. Vagus nerve stimulation

Have to write another post about VNS another time.

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