Dr Shock MD PhD

Light therapy might be a promising augmentation strategy for treatment-resistant depression and three other nonseasonal depressive disorders. The evolving applications of light therapy are discussed in a recent article.

Beside seasonal affective disorder light therapy can be of use or subject of study for:
1. This articles suggests that light therapy might also be useful for nonseasonal depression. Evidence is based on an inconclusive meta analysis and a recent study which showed good result for light therapy compared to placebo treatment (low-output negative air ionizer placebo).This was done with patients suffering from chronic depression (at least 2 years) and without seasonal modulation.

2. Also the use of light therapy with treatment-resistant depression is substantiated with 4 cases. All cases were unresponsive to conventional drug treatment, electroconvulsive therapy or both. Patients were first treated with tranylcypromine (monoamine oxidase inhibitor) to which 40% responded. The four remaining patients received light therapy as an add-on to the tranylcyromine. Three of four showed positive response to light augmentation of tranylcypromine.

3. Light therapy for Bipolar depression is more complicated. Usually in those cases the antidepressants failed. Most cases described used a mood stabilizer and light was added to this treatment. The time of administration of the light therapy is crucial and variable per patient as well as dosing of the light.

4. Research with light therapy for antepartum depression has had it's drawbacks. Fear for the effect of light on the fetus stopped a few trials before their start. Recently large trials are underway after promising results in an open trial.

Especially the strategy with treatment-resistant depression looks very promising to me.

Other interesting fields of research with light therapy are:
1. ADHD
2. Dementia
3. Parkinson's disease
These indications were mostly studied in open studies and case series.


The trouble with research for efficacy of light therapy is the placebo condition. Other drawbacks are the conceptual affront to mainline antidepressant pharmacotherapy and the lack of industry support.

A recent meta analysis by American Psychiatric Association from 8 out of 45 potential studies concluded that there was a "significant reduction in depression symptoms severity following bright light therapy" for seasonal affective disorder.

Related blog posts:
8 Articles about SAD

Articles discussed:
The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence.
PMID: 15800134Related Articles
Authors: Golden RN, Gaynes BN, Ekstrom RD, Hamer RM, Jacobsen FM, Suppes T, Wisner KL, Nemeroff CB
Journal: Am J Psychiatry, 162 (4): 656-62, 2005


Evolving applications of light therapy.
Terman M.
Sleep Med Rev. 2007 Oct 24; [Epub ahead of print]

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Excellent lecture on ECT with his own experience with the treatment.

Sherwin Nuland, the surgeon and author, talks about the development of electroshock therapy as a cure for severe, life-threatening depression. Midway through, his story turns personal. It's a moving and deeply felt talk about relief, redemption, second chances.

About Sherwin Nuland

A practicing surgeon for three decades, Sherwin Nuland witnessed life and death in every variety. Then he turned to writing, exploring what there is to people beyond just anatomy. Read full bio »

Original video on TED Talks

Thanks to There are black dogs and black dogs

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This is a comment in a blog post on Trusted.MD about this years conference. Get a taste and check the prices before you sign up for next years conference in Sydney

I've been thinking about happiness more than usual for a few days, ever since receiving a brochure describing a grand conference in Sydney, Australia on Happiness And Its Causes. The event, sponsored by the Vajrayana Institute, a Buddhist think tank, took place in early June. It attracted a sellout audience of over 3,000 delegates. The featured speaker was The Dalai Lama. A conference report at the event website noted that his Holiness the 14th Dalai Lama spoke about 'Happiness in a Material World in 2007.' Other speakers included noted American happiness experts Richard J. Davidson (University of Wisconsin-Madison), Stephen Post (Case University), Alan Wallace (Santa Barbara Institute for Consciousness Studies) and Tal Ben-Shahar and Daniel Gilbert (Harvard) and Martin Seligmann (University of Pennsylvania).

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This video shows the preparations before ECT.

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I mainly write about depression, electroconvulsive therapy, psychiatry, neuroscience, education and other medical topics. And in this order. Mostly I try to write articles, sometimes links to interesting news related to health and health care. Today I have some interesting links for you, a summary of recent news related to health care and health. Hope you like them. Happy reading.

1. Do you know what a hospitalist is? Well I didn't until I read these posts on Clinical Cases and Images: definition of hospitalists and blogs from hospitalists

2.Bush is sending government officials to The Netherlands to learn from their health insurance.

The Netherlands, which has shifted insurance from employers to individuals and subsidized insurance for the poor, is a particularly appealing model for many in the U.S.

On Wall Street Journal Health Blog.

3. Participants Left Uninformed in Some Halted Medical Trials from The New York Times

When Congress passed a bill last month requiring makers of drugs and medical devices to disclose the results of clinical trials for all approved products, advocates of greater study disclosure applauded the move.But a provision that would have mandated disclosures for another group of products never made it into the final version of the bill. It would have covered products tested on patients, but dropped before marketing.

This way patients and professionals can be kept unaware of outcome of trials with devices that will not reach the market.
Thanks Pharmalot.com

4. The Quit Smoking Counter.
This site counts the time since you quit smoking and the amount of money you saved by not smoking since then. It also clarifies the physical benefits of quiting.

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For about $25, students and employees can buy excuse notes that appear to come from doctors or hospitals. Other options include a fake jury summons or an authentic-looking funeral service program complete with comforting poems and a list of pallbearers.

If you are feeling like you need a day of work you can contact this company: The Excused Absence Network. Customers receive templates so they can print the notes after typing the name and address of a local doctor or emergency room. Those who choose jury duty as an excuse to miss work enter their county courthouse information on the form.
There are downsides as well:

If bosses find out the notes are not authentic, they might think the medical provider helped in the scam, said Dr. John Z. Sadler, a psychiatry and clinical sciences professor at the University of Texas Southwestern Medical Center at Dallas. Reputations could be unfairly damaged, and accreditation or license problems could arise, he said.

From CNN

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42.5% of psychiatrist working in Michigan would consider self-medicating or would self-medicate if afflicted with mild to moderate depression.
46% would treat a friend and/or a relative for mild to moderate depression.
These numbers decrease dramatically when afflicted with a severe depression with suicidal ideation: 7% and 18.2%.

Nevertheless this practice is against the Code of Medical Ethics:

....physician generally should not treat themselves or members of their immediate family. Professional objectivity may be compromised when ...the physician is the patient

The reason why psychiatrists treat themselves would more likely be influenced by the presence of a permanent insurance record (40.4%) than the stigma of mental illness (25.7%).

These data are from a questionnaire which were mailed to 830 psychiatrists listed in the Michigan Psychiatric Society directory. It consisted of 11 questions regarding self-treatment for depression and 7 demographic questions. The author of the article received 567 responses ( response rate of 68.3%).




These numbers are comparable to Finnish physicians reporting self-treatment for mental disorders: 66%.
In a survey of Norwegian physicians, 75% of responders had performed self-treatment during the 3 years prior to the survey.

These figures emphasize a difficult problem among physicians and in this case psychiatrists. In spite of the Code of Medical Ethics self-treatment is common among psychiatrists.

Limitations of the study:
1. Sampling bias:those who self-medicate may be less likely to respond
2. Generalizability: how representative was this population for psychiatrists in general
3. a difference between what one thinks he will do and what one actually does when depressed


Desitigmatize mental illness, start with the psychiatrists

Article discussed:
Psychiatrist Attitudes toward Self-Treatment of Their Own Depression.
PMID: 17700051
Author: Balon R
Journal: Psychother Psychosom, 76 (5): 306-10, 2007

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Whether it is all those articles you still have to read, or all those blog post you have to write, or all those feeds you have to check, read these 7 tips how to deal with all that information

Loved this one:

Don't train your brain to become a visual, unreflective, passive recipient of information. If you are the average American, stop watching TV 5 hours a day. You may have heard the expression "Cells that fire together wire together." Our brains are composed of billions of neurons, each of which can have thousand of connections to other neurons. Any thing you do in life is going to activate a specific constellation of neurons. Visualize one million neurons firing at the same time when you watch a TV program. Now, the more TV you watch, the more those neurons will fire together, and therefore the more they will wire together (meaning that the connections between them become, literally, stronger), which then creates automatic-like behaviors. You are making yourself more passive, unreflective, person, the more TV you watch. Exactly the opposite of what you need to prioritize and process the growing amount of information we have available these days.

Via lifehacker.com

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Read here to understand the difference between an article and a blog post.

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Dr Shock frequently discusses peer reviewed articles from different journals. BPR3 or bloggers for Peer-Reviewed Research Reporting has developed an icon for identification of such articles on blogs. 9 Guidelines for using the icon were published in a recent post on the BPR3 blog

1. The "Blogging on Peer-Reviewed Research" icons are to be used solely to denote individual blog posts about peer-reviewed research.
2. While there is no hard-and-fast definition of "peer-review," peer reviewed research should meet the following guidelines:
* Reviewed by experts in field
* Edited
* Archived
* Published with clearly stated publication standards
* Viewed as trustworthy by experts in field
3. The post should offer a complete formal citation of the work(s) being discussed.
4. The post author should have read and understood the entire work cited.
5. The blog post should report accurately and thoughtfully on the research it presents.
6. Where possible, the post should link to the original source and / or provide a DOI or other universal reference number.
7. The post should contain original work by the post author -- while some quoting of others is acceptable, the majority of the post should be the author's own work.
8. Users and readers may report potential abuse of the icons by emailing the site administrator, Dave Munger (remove dashes). Reported abuses may be brought to the attention of readers and discussed publicly online.
9. Repeated abuse of the icons will result in removal of the privilege of using them.

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1. Cochrane Adverse Effects Methods Group: had their first workshop on Friday 26 October 2007 during the XV Cochrane Colloquium in Sao Paulo, Brazil.
This workgroup was formally registered with The Cochrane Collaboration on the 14th June 2007.

The main purposes of the group are;
• to raise awareness of the adverse effects of interventions, and to promote the inclusion of adverse effects data in Cochrane reviews;
• to provide educational help to reviewers and users of reviews to spread and deepen understanding of the principles involved in assessing adverse effects;
• to provide methodological guidance on specific aspects of evaluating adverse effects;
• to identify areas of methodological uncertainty, and to develop a toolbox for the assessment of adverse effects.

They welcome your active (or passive) involvement. Fill in the form to join their group.

2. Pharmalot, News Comment and Conversation.
This blog is writen by Ed Silverman.

Ed Silverman is a prize-winning journalist who has covered the pharmaceutical industry for The Star-Ledger of New Jersey, one of the nation’s largest daily newspapers, for the past 12 years. During that time, he has closely followed a variety of topics of concern to those who work for, and with, pharmaceutical manufacturers — drug development; mergers and acquisitions; regulatory oversight; safety and pricing controversies, and marketing issues.

Especially check out this article about the FDA approving a new med guide for antidepressants that dilute the power and clarity of the warnings contained in the old med guides, and as such, deny parents information that is vital to the safety of their children.

3. Eye on FDA
Eye on FDA is published by Mark Senak of Fleishman-Hillard's Washington, D.C. office.

Frequent speaker on various aspects of same - drug development, promotion, reimbursement and new media in a highly regulated environment. Author of books, newspaper and magazine pieces related to drug marketing and promotion as well as HIV specialty pieces. And of course... blogger!

4. Hooked: Ethics, Medicine, and Pharma.
A recently started blog by Howard Brody, MD, PhD (Rowman and Littlefield, January, 2007).
A lot of articles with critical commentary related to the medical profession and pharmaceutical industry.


5. peRX.

The peRx Project is an educational program funded by the Attorney General Consumer and Prescriber Education Grant Program. The program was developed to improve awareness of drug development and pharmaceutical marketing practices and to positively impact prescribing behaviors, specifically among advanced practice nurses. An innovative, multi-media, interactive web-based pharmaceutical curriculum has been developed that targets advance practice nurse students and other clinician audiences.

On their website there is a series of 4 web based modules. The modules are presented in an informative, engaging and entertaining format that cover topic areas of:
1. FDA drug approval process
2. Pharmaceutical marketing strategies commonly found in health care practice i.e., gifts, free meals, continuing education programs
3. Ethical dimensions of pharmaceutical industry influence on prescribing practices of health care providers
4. Strategies to improve prescribing based on scientific evidence rather than market based information and promotions

I especially enjoyed their second module: There’s no such thing as a free lunch…or dinner, a nice few in the trick box of drug companies

From ISDB: International Society of Drug Bulletins

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A recent meta-analysis suggest that rTMS treatment for depression might have improved compared to a meta-analysis with studies published up until January 2002. Active treatment was significantly better than sham rTMS, there was no significant heterogeneity between trials. Clinical relevance of the significant difference is not discussed in this meta analysis.



Improvement could be due to:
1. better study design: better randomization in 3 of 5 publications, intention to treat analysis inm 3 of 5 publications, blinding comparable to the prior meta-analysis: single blind with external raters, the technician applying the stimulus is not blind, larger sample sizes.
2. more effective parameters of stimulation: more session



Future research questions
1. Is efficacy in patients ho are not refractory to antidepressants better?
2. Efficacy in children and adolescents?
3. Efficacy in the long term?
4. Efficacy when treatment duration is longer than 10 weeks?

Pubmed search-terms: “major depression”, “depression”, “transcranial
magnetic stimulation”, “rTMS”, “TMS”&
Period: Dez/2005-Nov/2006 (12 months)

70 studies of which 65 were exluded

Inclusion criteria:
1) Manuscript written in English
2) Use of rTMS given at any frequency (low and high frequency) and any
localization (left or right dorsolateral prefrontal cortex (DLPFC)
3) Mood effects assessed by a continuous mood scale-Hamilton Depression Rating
Scale, Beck Depression Inventory or Montgomery-Åsberg Depression Rating Scale
4) Randomized, double-blind studies with a sham rTMS group
5) Reporting of mean and standard deviation of the mood scores before and after
the treatment
6) Studies published in the past 12 months (from December/2005 to
November/2006)

5 studies included
3 studies included patients who were refractory to antidepressants.

Article discussed:

Acta Psychiatr Scand. 2007 Sep;116(3):165-73.

Has repetitive transcranial magnetic stimulation (rTMS) treatment for depression
improved? A systematic review and meta-analysis comparing the recent vs. the
earlier rTMS studies.

Gross M, Nakamura L, Pascual-Leone A, Fregni F.

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Jan of Medblog.nl is busy visiting a congres. You can read a report about this symposium on Frankwatching (in Dutch). But this didn't stop Jan from writing on his blog. He discusses a recent article in NEJM about how to deal with medical errors.

Confabula has three articles about Bariatric Surgery.
One of the articles she discusses in her first blog article is from the Archives of Surgery.

Martijn Hulst writes about the Global Health Hub: Singapore. On Zorglog.nl: What about Grandma?. It is about selling posters on ebay and the money goes to the Alzheimer foundation, a worthy cause. On 100%Mike you can pick your clip: ABBA or Tina Turner. Or go to vrouwmenszorg for works of Joan Armatrading.

Medical students on the oldest university of The Netherlands in Leiden have lousy scores on a their annual test compared to other Dutch universities. Aria Rad has some thoughts about that.

On Huize Sonnendaal is one of the authors trying to quit smoking with SuperSmoker (in English). Good Luck. On hotline to home it is about smoking again.

Dr Lutser has a nice video of jetfighter passenger having a "good time", excellent narrative from the pilot. Fight shortage of nurses by extending part-time work with 2 hours extra each parttimer. Is it that simple.
Recipe of quesadillas with ham and gourgette on manindezorg.
Managerzorg has managed to put a slide show on her blog, nice pictures of nurses in white uniforms.

Are the ambulances going on strike somewhere next month? See the paramedics blog.
5 Causes for exceeding the budget for employees on C3log.nl.

Dr Shock likes games but so does Zr Nitro.

Specialized Emergency Nurses on ER departments are very capable of handling strained ankles on their own.
Ever wondered what a GEA bypass was? ECGreetje has it in Dutch, but also a terrific link to an English explanation with pictures

What are the consequences of growing up as a child of a parent with Huntington's disease. A recent study:Van der Meer L, Timman R, Trijsburg W, Duisterhof M, Erdman R, Van Elderen T, Tibben A.
Attachment in families with Huntington's disease: A paradigm in clinical genetics.
Patient Education and Counseling 2006; 63(1-2):246-254. This study is discussed on Huntington daily
Want to know more about medical libaries and second life start here at digicmb
in English. Critique on HealthVault from Microsoft on zorggemak in English.

Barcamp.org is an ad-hoc gathering born from the desire for people to share and learn in an open environment according to zo-communicatie. Go have a look at barcamp.org in pbwiki style.

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A quote from ririan project 8 Little-Known Ways to Think More Effectively

Thrashing the kids at FIFA or dishing out the carnage on Halo may not seem like the highest of intellectual pursuits, but playing computer games will not only help you de-stress, it’ll improve your digital dexterity and mental reaction.

And this is just one of eight tips.

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Use of antipsychotics for psychotic depression especially on the long term is not evidence based. It obscures diagnoses and treatment outcome leading to omission of other effective treatments in order to obtain remission for psychotic depression.

Diagnosis and treatment of psychotic depression is surrounded by controversies and a matter of debate in science and psychiatry. The controversy around classification boils down to the question whether it is a severe form of depression or a separate form of depression. The controversy about treatment is whether antipsychotics are efficacious in the treatment of psychotic depression or antidepressants alone are sufficient. The disadvantage of antipsychotic treatment is side-effects and efficacy.

Two different articles on two blogs fortify these differences. On this blog a recent article discussed the differences between psychotic and non psychotic depression based on a recent article in Schizophrenia Bulletin.

Another opinion especially about treatment is discussed on Corpus Callosum. Mainly in the comments so don't forget to read them. In a recent systematic review of the Cochrane Database no conclusive evidence was found that the combination of an antidepressant with an antipsychotic was better than the antidepressant alone.

A recent publication examined the patterns and predictors of medication use and two year course/outcome in first admission patients with psychotic depression (n=87). This was done in hospitals serving a county of 1.3 million people (Suffolk County Mental Health Project, US).

At discharge from their first admission 44.8% (39) used an antidepressant with an antipsychotic and only 8.1% (7) used antidepressant monotherapy. Overall 77% of patients used an antipsychotic at discharge and 58% an antidepressant. After 6 months 23% still used the combination, after 24 months 21.8% still used the combination. Antidepressant monotherapy did not change very much during follow up: 16% and 12%.
After 2 years 32% of patients still used antipsychotics and 39% antidepressants.

Only 29% achieved functional recovery by 24 months (GAF score).Only 40% had sustained remission for at least 19 months.

What this shows is that patients with psychotic depression have a risk of being prescribed antipsychotics for a long while without sufficient evidence of its efficacy. What is more alarming is that very effective treatments for psychotic depression such as ECT or lithium addition were not tried with partial remission.

Use of antipsychotics especially on the long term is not evidence based. It obscures diagnoses and treatment outcome leading to omission of other effective treatments in order to obtain remission for psychotic depression. There are several effective alternatives for nonresponse or partial response to antidepressants with or without antipsychotics, as can be read in this post with the title: 9 steps for treatment resistant depression

Article discussed
Compr Psychiatry. 2007 Nov-Dec;48(6):497-503. Epub 2007 Aug 20.

Medication use patterns and two-year outcome in first-admission patients with
major depressive disorder with psychotic features.

Craig TJ, Grossman S, Bromet EJ, Fochtmann LJ, Carlson GA.

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In the New York Times Health blog an excellent article about stealing hope from patients by their doctor.

I’m often surprised how often doctors are willing to put forth the worst-case scenario without offering the possibility of a best-case scenario.

Why do doctors do it, what possible explanation is offered in this article:

“When the physician feels that he or she really can’t do anything active, they tend to take the most negative scenario as the likely one,'’ said Dr. Groopman.

And well-meaning doctors often see less harm in having been wrong when a person recovers than wrongly predicting a recovery that doesn’t happen, he explained. “In some ways it’s easier to give people the worst news, and then if something good comes about everyone is overjoyed,'’ he said.

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A single Intramuscular administration of haloperidol (10mg) plus promethazine (50 mg)is the ideal combination for sedating and tranquilizing violent psychotic patients.
In the recent BMJ two randomised controlled trials assess the effectiveness of two antipsychotics: haloperidol and olanzapine.

One trial in Brasil (n= 311) compared 5-10 mg haloperidol intramuscular to the combination of haloperidol (5-10 mg) plus up to 50 mg of promethazine. After 20 minutes significant more patients on the combination were tranquil or asleep compared to haloperidol alone. Moreover, 10 cases of acute dystonia occurred in the haloperidol group. None in the combination group had this side-effect.

One trial in India compared intramuscular olanzapine (10 mg) with haloperidol (10 mg) plus promethazine. This latter combination not only resulted in rapid and effective tranquilisation but also resulted in fewer additional medical interventions within four hours of intervention. No patient experienced dystonia.

intramuscular olanzapine is as good as intramuscular haloperidol plus promethazine if the doctor is willing to take a 20% chance of being called back an hour later to give another dose.

Conclusions about rapid tranquillisation.
Rapid tranquillisation can prevent patients from longer periods of aggression than necessary. These measures can also prevent distressing situations.

From the patient's perspective, being asleep is also less traumatic than being physically restrained. These considerations, and the lower cost, favour the combination of haloperidol-promethazine over olanzapine for the emergency management of violent patients in the developing world.

This last quote may also be applicable to short staffed ER departments in the Western countries?

Rapid Tranquillisation is not to be confused with rapid neuroleptization. Used in the 70's and 80's of the previous century. This method is now considered obsolete.

literature on the rapid neuroleptization (titration) method with I.M. haloperidol. Most of the approximately 650 predominantly schizophrenic and manic patients represented in the studies calmed down rapidly on medication, and some demonstrated an early reduction in core psychotic symptoms. The initial doses varied widely, ranging from 1 to 30 mg, with a maximum total daily dosage of 100 mg.

There is no evidence that large loading doses of neuroleptics speed or enhance treatment response.

The aim of rapid neuroleptization was reduction of symptoms not tranquillisation which aim is to sedate a violent psychotic patient.



Articles discussed:
Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine

Gisele Huf, associate professor1, E S F Coutinho, professor2, C E Adams, associate professor3, for the TREC Collaborative Group
BMJ, doi:10.1136/bmj.39339.448819.AE (published 22 October 2007)

Rapid tranquillisation in psychiatric emergency settings in India: pragmatic randomised controlled trial of intramuscular olanzapine versus intramuscular haloperidol plus promethazine

Nirmal S Raveendran, lecturer1, Prathap Tharyan, professor2, Jacob Alexander, lecturer1, Clive Elliot Adams, associate professor3, for the TREC-India II Collaborative Group
BMJ, doi:10.1136/bmj.39341.608519.BE (published 22 October 2007)

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This picture is from JimJamZoo
There are more pictures of the use of artificial sky in Hospital, sure looks nice, wonder were that is hospital is, if it is real.

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Dr Shock really likes this one, a tablet pc for taking around, filling in charts, checking lab, jotting down notes. In a dock it works like a PC.

From Engadget

Made by Philips, more information, see also here

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Its a new platform/ service for physicians, researchers, other professionals in the fields of medicine and biological science .
Actually is for the service of every patient and consumers , so its for the benefit of everyone.
What is it about ? :

Its a directory that aggregate applications, platforms and websites that their content are on the fields of medicine and life science and they are based on web 2.0 tools.

Medical 2.0: medical wikis, medical databases, social networks for physicians and nurses, medical search engines etc.

And this is the blog medical 2.0

Thanks to ScienceRoll

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A must have for the ultimate gamer, even with medical games, an improved medical vest for gaming:

A vest designed by doctor Mark Ombrellaro uses air pressure and feedback from computer games to deliver pneumatic thumps to the spots on players' torsos where they would have been struck were they actually on the battlefields.

While it was originally:

The medical version of the vest is more sophisticated, enabling doctors sitting at their computers to prod, poke and press patients' bodies from afar and get feedback on what they are virtually feeling, according to Ombrellaro.

That model is pending approval by the US Food and Drug Administration, which wants to be assured that diagnosis made using the vests are reliable.

Thanks to Engadget

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From my own experience I know that when I adapt articles on Wikipedia to a more neutral or evidence based point of view on a topic as e.g. electroconvulsive therapy it is reversed to the original text in a matter of days to weeks.
To my opinion you must view the information on Wikipedia as opinion based information and not necessarily as evidence based.

In a recent debate on blogs between David Rothman and ScienceRoll this subject gets thorough attention. I agree with the latest statement of David Rothman: Having lots of references does NOT equal accuracy, credibility or authority.

One should be aware that due to fact that Wikipedia is written collaboratively by volunteers from all around the world not so objective subjects might volunteer as well.

Drug companies rewrite their entries on wikipedia as can be read here
and here

Even Dutch Royalty rewrite the article about them on wikipedia

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Sometimes, improbable reports are erroneously assumed to be symptoms of mental illness, due to a failure or inability to verify whether the events have actually taken place, no matter how improbable intuitively they might appear to the busy clinician. They note that typical examples of such situations, may include:
1. Pursuit by practitioners of organized crime
2. Surveillance by law enforcement officers
3. Infidelity by a spouse
Any patient, they explain, can be misdiagnosed by clinicians, even one with a history of paranoid delusions.

Origin:

Psychologist Brendan Maher named the effect after Martha Beall Mitchell.[2] Mrs. Mitchell was the wife of John Mitchell, Attorney-General in the Nixon administration. When she alleged that White House officials were engaged in illegal activities, her claims were attributed to mental illness. Ultimately, however, the relevant facts of the Watergate scandal vindicated her.

Martha Mitchel effect on wikipedia

Thanks 43folders

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8 steps to become optimistic on wikihow

If you've always had a pessimistic worldview, it can be difficult to shift your focus, but it is possible to start seeing the glass as half full.

Some warnings as well:
1. Avoid negative people. If you can't avoid them, learn how to not let them get you down.
2. Don't let your negative feelings control you.
3. Don't confuse pessimism with depression. Depression can make everything look worse than it is.
4. You can only change you. You can't change other people.
5. While it is true that you create your own circumstances, accept that the past is the past. Don't let negative circumstances trigger irrational guilt.
The past is the past. It's over. It's done. Let it go.

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Our area is rapidly being filled with web development, IT, and biotechnology companies. As a doctor in this area over the last few years, I have discovered some unique health problems associated with this population.

On tech recipes the health problems mentioned are:
1. Horrible Sleep Hygiene
2. Headaches
3. Back Pain
4. Poor Attention Span

Ad 4. from lifehacker.com:

The typical geek trains their brain to be heavily focused while multitasking day after day. Is it surprising that this same brain does not do well when forced to isolate down to one task? Listening in a meeting is a very isolated, very passive event. Coding, developing, debugging -- these are not passive at all. The geek brain is just not trained to sit quietly and listen.

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50%-80% of depressed patients experience a major life event during 3-6 months prior to the onset of depression. In comparison only 20%-30% of non depressed persons experience a major life event in the preceding 3-6 months. Approximately 20%-25% of persons who experience a stressful life event develop depression.

Stress also influences the clinical course of depression, due to continuing stress:
1. duration increases
2. symptoms can worsen
3. relapse is more likely
4. reduction of positive response.

These are the conclusions presented in a commentary in the JAMA:
Psychological stress and disease.
PMID: 17925521
Authors: Cohen S, Janicki-Deverts D, Miller GE
Journal: JAMA, 298 (14): 1685-7, 2007

This interesting commentary also discusses the relationship between stress and other major diseases: cardiovascular disease, HIV/AIDS and cancer.

In the conclusion the authors rightly emphasize that stress is an important factor in depression. A clear causal relationship between stress and certain diseases is not yet established. The majority of individuals confronted with major life events and chronic stress remain disease-free. Genetic as well as psychological factors contributing to vulnerability to stress are under investigation.

Evidence is derived from prospective observational studies and natural experiments such as natural disasters, economic downsize, or bereavement

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Healthy life spot has some good tips for a healthy sleep.

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Info about deep brain stimulation and research about deep brain stimulation of the Cleveland Clinic

Patients may be appropriate candidates for investigational studies into deep brain stimulation for depression if they meet the following criteria. (They should know that the procedure is invasive and only experimental at this point.)

1) have a diagnosis of major depression (bipolar patients are not currently being enrolled)
2) have had the illness for at least five years and are significantly disabled by it
3) current episode of depression has lasted for at least two years
4) has failed at least four trials of antidepressants (at least two different classes) as well as augmentation with at least two agents known to be effective in this group (lithium, thyroid, antipsychotics, stimulants)
5) no psychotic symptoms outside of an episode of depression (patient cannot currently be psychotic)
6) no severe personality disorder present which would interfere with safety or compliance
7) past treatment with ECT to which the patient has either been refractory or intolerant
8) ability to comply with study demands (monthly visits, prolonged testing visits, etc.)

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Do you want to know if there is a trial with depression performed in your neighbourhood?
Take a look at this clinical trials information page.

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Adding cognitive behavioral therapy enhances the safety of medication with depressed adolescents. Suicide is the major concern when treating depressed adolescents with selective serotonin reuptake inhibitors (SSRIs).

In a large randomized controlled trial (n=327) in the US with unmasked CBT and combination therapy, comparison was made between double blind placebo or fluoxetine for treatment of depressed adolescents. They were monitored during 12 weeks. After the 12 weeks treatment was unblinded.

At 12 weeks the response rate for combination therapy was 73%, for fluoxetine 62% and 48% for CBT.
After 18 weeks 85% for combination therapy, 69 for fluoxetine treatment, 65% for CBT. After 36 weeks 86% for the combination, 81% for fluoxetine and 81% for CBT.

Suicidal events were more common in patients receiving fuoxetine (14.7%) than combination therapy (8.4%) or CBT (6.3%).

Combination therapy in adolescents with moderate to severe depression is superior to medication or CBT alone.

See the related article with an opposite conclusion, Dr Shock is confused but thinking very hard, will be continued.

Related article on this blog:
For Adolescents no additional benefit of cognitive behavioural therapy with an antidepressant

Discussed article
Arch Gen Psychiatry. 2007 Oct;64(10):1132-43.

The Treatment for Adolescents With Depression Study (TADS): long-term
effectiveness and safety outcomes.

March JS, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M,
McNulty S, Vitiello B, Severe J.

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Efficacy of Internet based Cognitive Behavioral Therapy for depression and anxiety disappointing. In a recent meta-analysis CBT for depression and anxiety was modestly effective compared to placebo, care as usual, or waiting list conditions. There was also a significant heterogeneity between trials.

Heterogeneity:
Trials studying the same question are unlikely to have the same outcomes on the basis of sampling error. A difference between trials may be due to chance. It is important to know whether discrepancies between trials are greater than we would expect by chance. With heterogeneity the results of various trials are more different than one would expect by chance alone. In short the trials are different.

The authors next analyzed the trials with CBT for depression and anxiety separately (post hoc analysis). Again the effect size for depression treatment with CBT compared to the control conditions was small. CBT did not make the patients much better. Again there was significant heterogeneity. This heterogeneity could be accounted for by 1 single trial. This trial combined CBT with individual support. Maybe internet based CBT for depression with therapist support is efficacious. This lessens the advantages of Internet based CBT.

Advantages of Internet based CBT
1. anonymity
2. accessibility
3. avoiding the stigma of visiting a psychiatrist
4. treatment at any time and place
5. work at your own pace
6. review the material as often as as desired
7. reduction of therapist time
8. reach people through the Internet who might otherwise not receive treatment

Disadvantages of Internet based CBT:
1. No control on using the intervention
2. treatment sessions can be postponed infinitely
3. really on your own
4. can seem quite impersonal to participants

Levels of therapist involvement:
1. no assistance
2. contact by e-mail or telephone
3. face to face contact between sessions

Further research should focus on the efficacy of the amount of therapist involvement with the Internet based CBT for depression.

For anxiety the CBT had a large effect size and very low heterogeneity. It is hard to understand why Internet based CBT seems to work better for anxiety disorders compared to depression.

Limitations of this meta-analysis
1. small number of studies: 5 for depression, 7 for anxiety disorders
2. the post hoc analysis with subgroups such as depression and anxiety disorders resulted in in smaller groups and the power declined.
3. Uneven distribution of numbers of subjects across studies, the studies on depression all had large numbers of subjects, the studies on anxiety disorders all had small numbers of subjects
4. studies used different inclusion criteria for participants

Article discussed:
Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis.
PMID: 17112400
Authors: Spek V, Cuijpers P, Nyklícek I, Riper H, Keyzer J, Pop V
Journal: Psychol Med, 37 (3): 319-28, 2007

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Funny picture on Newbrigand

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The January 2007 issue of Cognition reports that episodes from your past are remembered faster and better while in a body position similar to the pose struck during the event.

More of these interesting facts about your body can be found on LiveScience:Health

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I think that computer games can be of benefit. It can serve as a distraction from business, building computer skills and probably has more benefits.
On sharpbrains

It is always good to stimulate our minds and to learn a bit about how our brains work. Here you have a selection of the 50 Brain Teasers that people have enjoyed the most in our blog and speaking engagements.

Go see these games.

Related articles on this blog:

Gaming is good for you

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There are considerable data to indicate that psychotic depression is not just a severe form of depression but a distinct form of depression. Mostly in terms of clinical symptoms, course, biology, treatment response and outcomes. However, not every difference is indisputable, there are inconsistencies among studies and these differences might not be strong enough to be used in diagnosis.

The authors of the article suggest to make a new dimension in the next DSM update, a dimension of psychosis with depression. I think that broadening our concepts makes research not any easier. Psychotic depression should be limited to depressions with mood congruent delusions and hallucinations. The inclusion of bipolar psychotic depression and even schizo-affective disorder or strong feelings of guilt has until now hampered the research in the distinction between psychotic depression and nonpsychotic depression.

Differences in clinical symptoms
1. Unusual thought content, increased feelings of guilt and psychomotor disturbances such as agitation and retardation are the most robust differences compared to non psychotic depression for clinical symptoms.

Clinical Course
2. Early onset psychotic depression has been associated with a likely bipolar course.

Cognitive symptoms
3. The greatest cognitive impairments of psychotic depressed patients compared to nonpsychotic major depression were: verbal memory, executive functioning and psychomotor speed. An issue that remains is the medication use of psychotic depressed patients. Usually they are on more different drugs than the nonpsychotic depressed, especially antipsychotic which can influence the test scores.

Biological features
4. Psychotic depressed patients have higher rates of nonsuppression on the dexamethason suppresion test (64%) compared to nonpsychotic depressed patients (41%). The sensitivity and specificity are not high enough to use these tests routinely for diagnosis.

Treatment response
5. ECT is very effective in the acute phase of the treatment of psychotic depressed patients. The data are unclear regarding the duration of this effect.

Issues involved with the distinction between the two types of depression:
1. What is called psychotic depression, hallucinations and delusions, and what kind of delusions, only mood congruent delusions? In Europe the presence of mood congruent delusions and hallucinations justifies the diagnosis psychotic depression. Should we look at dimensions of psychosis instead of a binary division?

2. In the DSM IV psychotic depression is linked to severity of the depression. The relationship between severity and psychotic features is not that strong. This implies a scale for severity and a separate classification for psychotic features.

3. The authors of the article promote a separate dimension for psychotic features with the loss of the distinction between mood congruent and mood incongruent delusions. A development not encouraged by Dr Shock.

4. Additionally more research is needed for the distinction between psychotic depression and schizoaffective disorder.


Article discussed:
Keller J, Schatzberg AF, Maj M. Schizophr Bull. 2007 Jul;33(4):877-85. Epub 2007 Jun 4. Current issues in the classification of psychotic major depression.

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Dr Shock said it before here with medical games that gaming can be good for you and he doesn't believe in game addiction. He has now some company. Gaming is good for you on Centre for Emotional Well-Being

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In 8 question you can test your knowledge about depression and usual myths about this important disease. The test is on healthcentral.com.
Withe very answer good or bad a clear explanation is given.
There is also a link to: The First 48 Hours: Top 10 Depression Myths Debunked

1. Myth: Depression is not a real medical illness.

Disclaimer: There are some advertisements on the site in relation to the treatment of depression. This site doesn't look as if it is solely made by a pharmaceutical drug company but Dr Shock is not sure, couldn't find an About easily.

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Sermo a Internet-based networking community for physicians to address professional and public health issues is going into partnership with Pfizer, a large pharmaceutical drug company. Wall Street Journal has an article about it:

Of course, Pfizer and Sermo will have to chat with the FDA first “to define guidelines for the use of social media in communications with health-care professionals,” as the companies say in their press release. Maybe the FDA gets Sermo access, too?

A while a go I tried to become a member but memebership is not open for European physicians. Now I am glad, saves me the trouble of withdrawing membership.

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Gopubmed is an search engine based on PubMed with a web 2.0 dress . It delivers the first 1000 results. On the left you can select on Mesh Headings (Medical subject headings)and GO (Gene Ontology).

They have upgraded their search engine. The left part delivers answers to important questions for researcher about the articles retrieved by their search: What, Who, Where and When. Especially When is very useful. You can easily limit your search to the last month, year or even day. If they apply RRS feeds they are making this blogger very happy.

On top of the list are the 5 most important categories for your search. With "electroconvulsive therapy" you can immediately select the Mesh term depression with the results of your search. Next are the top 10 GO and Mesh terms to refine your search.You can also see the last 5 queries you typed in.

With Who you can search for the authors or a specific author. Not only does Where deliver the countries and cities the publications are from, but also the most important journals.You can easily search the most important journals such as the NEJM for your query.

Everything very slick, fast and with a nice lay out.Can't wait for the next improvements (RSS?).

“In GoPubMed the search is sorted; sorting documents into highly organised networks such as GO and MeSH facilitates the finding of relevant documents and the answering of questions with significant ease!” says Michael Schroeder, Professor for Bioinformatics at TU Dresden and CSO and Co‑Founder of Transinsight.

Related articles on this blog:
Gopubmed with a web 2.0 dress
Linking to a search or article with Gopubmed

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Get stuck when making a presentation, or revising your lectures, or writing an article, or treating a patient? Well her are 10 tips for coping with mental blocks on copyblogger.com.

Whether you’re trying to solve a tough problem, start a business, get attention for that business or write an interesting article, creative thinking is crucial. The process boils down to changing your perspective and seeing things differently than you currently do.

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A small study links the type of bacteria living in people's digestive system to a desire for chocolate. Everyone has a vast community of microbes in their guts. But people who crave daily chocolate show signs of having different colonies of bacteria than people who are immune to chocolate's allure.

The study appears Friday in the peer-reviewed Journal of Proteome Research. Dr Shock can't reach this article it is not in the library of the University Hospital, tantalizing.
LiveScience has an article about chocolate craving due to bacteria.

In fact, the study was delayed because it took a year for the researchers to find 11 men who don't eat chocolate.

Kochhar compared the blood and urine of those 11 men, who he jokingly called "weird" for their indifference to chocolate, to 11 similar men who ate chocolate daily. They were all healthy, not obese, and were fed the same food for five days.

The researchers examined the byproducts of metabolism in their blood and urine and found that a dozen substances were significantly different between the two groups. For example, the amino acid glycine was higher in chocolate lovers, while taurine (an active ingredient in energy drinks) was higher in people who didn't eat chocolate. Also chocolate lovers had lower levels of the bad cholesterol, LDL. Still to be determined is if the bacteria cause the craving, or if early in life people's diets changed the bacteria, which then reinforced food choices.

There is also a video on chocolates and platelets.

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Since blogging is so much fun I have been thinking about a blog on my own domain. This article on performancing.com gives me 12 reasons to do so.
Does anyone know of a good hosting service, I live in The Netherlands, maybe not so important. Thanks.

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Yes in the British Medical Journal (full text)

No in the British Medical Journal (full text)

Related article on this blog:
On the antidepressant-suicide link

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A lot of exciting new developments are taken place with treatment resistant depression. A lot of candidate genes are under study to clarify an individual vulnerable to non response to antidepressants. Since most antidepressants exert their effect through functional modification of monoamine neurotransmitters a lot of genetic research has focused on processes accompanying neurotransmission.

Dr Shock's opinion is that we will not find a gene for treatment resistant depression (TRD) as we we will not find a gene for depression. Both terms are to complex, but we will be able to discover genes contributing to TRD. TRD can result from pharmacokinetic factors as well as farmacodynamic factors. Research can unravel different genes for different mechanism for TRD

Dr Francisco Moreno has written an introduction about the role of gene factors in TRD on PsychiatricTimes

The following gene polymorphismen were analyzed with showing a difference between depressed patients responding to antidepressants and those not responding:
1. Serotonin transporter genes (5-HTTLPR and intron (STin2))
2. Norepinephrine transporter gene (NET)

Why did this not lead to genetic testing to predict TRD?
1. Conflicting results for the various racial groups, research from Asia differed from that in Europe for these genes.
2. Other pharmacodynamically related genes (e.g. circadian systems, immunological systems, neurotrophic factors)also showed significant differences but subsequent inconsistent replications have been reported.

Patients with a TRD had a larger number of risk genotypes than treatment responders, who in turn had a greater number of risk genotypes than the healthy controls. This finding supports a model in which the additive small effects of multile risk genes explain depression and treatment resistance

Beside this overview of the research on genes and TRD he suggests the following 4 principles when confronted with TRD:

1. Diagnosis. Establishing an accurate diagnosis is essential, identifying co morbidity and specific features that might predict a specific response can facilitate treatment. In the future hopefully selection of treatment can be based on genetic predictors of efficacy, safety and tolerability.

2. Dosage. What dosage will ensure the greatest likelihood of response. Genotyping of drug-metabolizing genes can help. Pharmacokinetic factors are of importance in antidepressant treatment. Genotyping of metabolizing enzymes are available and more accessible to clinicians.

3. Duration. Take time for the antidepressant to become fully operative. Don't switch every now and then.

4. Drug. What has helped before or a relative with depression, what has been tried, were prior treatments optimal.

Dr Shock enjoyed this article. He recognizes these aspects of the treatment of TRD. On his unit these principles are implemented as follows:

1. Drug free observation on inpatient depression unit for diagnoses.

2. Treatment with tricyclic antidepressants with weekly plasma level control for adequate dosing

3. Average inpatient stay of 40 days

4. Clear extensive treatment algorithm for depression

Related article on this blog:
9 steps for treatment resistant depression

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