My blog has moved!

You should be automatically redirected in 6 seconds. If not, visit
and update your bookmarks.

Friday, November 30, 2007

Can Pilots fly When Using Antidepressants?

Had a patient once who was a airline pilot. He had to be admitted because of severe depression and started an antidepressant. Soon he wanted to get out of the hospital as fast as possible. Within one week he was back home. He was afraid the medical service of his airline would find out. That would cost him his job.

Most airlines don't allow their pilots flying when on antidepressants. In Australia they have a better attitude to this problem, because to my opinion it is better to have a pilot on antidepressants than a depressed pilot.

A study presented at a conference of the World Psychiatric Association in Melbourne on Friday found no statistical difference between medicated and non-medicated pilots in terms of their safety record.

This article in Yahoo News: Depressed pilots no risk -- as long as they're on their meds: study. agrees with my point of view.

"But importantly, there was a tendency for more accidents in the period prior to pilots going on to anti-depressants, but not once they were on them."

10 points for Australia.

Thursday, November 29, 2007

Therapists having sex with their "clients"

ONE in every ten male therapists will have sex or develop an intimate link with a female client, according to Australian research.

In the article from One in ten shrinks 'intimate' with patients, the shrinks that let this happen can be identified as coming from three groups:
She said professionals most likely to let this happen fitted into three groups - depressed men who were going through difficult times and were more likely respond to an adoring client, the bad eggs who "prey" on vulnerable clients and the "ego maniacs".

There is very little detail about the research from which these conclusions were drawn, so lets be careful out there.

Depression doesn't exist

Bruce E. Levine thinks that depression is a normal, albeit painful, human reaction. Because no biological markers for depression have been discovered, scanning techniques delivers conflicting results and the serotonin hypothesis of depression can't be proved we shouldn't consider depression being a disease. According to his post Why I Don't Disease Depression in the Huffington Post.

Don't know the man but is he a left over from the seventies of the previous century? Where has he been? Following his line of reasoning all other psychiatric diseases would also be a painful reaction. PTSD? Sorry but that are the consequences when you go to war, shit happens. Schizophrenia well bad luck either. Back to the Anti psychiatry? Again questioning the existence of psychiatric diseases.

Even most somatic illnesses lack biological markers nor signs on CT scans.

An insulting post to all of them suffering from depression

Discussions such as these around over diagnosing depression in the British Medical Journal are far more informative and based on intellectual arguments

Wednesday, November 28, 2007

Best Gifts for the Depressed

From Depression

This is a list of items that our forum members said they would find especially helpful when they are going through a rough time during the holiday season. It includes thoughtful gifts in every price range.

And here is the Top 10 Gift Ideas for the Depressed

I am not so sure about the last suggestion: A Pet?

What do you think about these gift ideas?

Is Electroconvulsive Therapy The Right Choice?

A very short but accurate list of 5 questions to ask yourself when faced by this decision. From Johns Hopkins Health Alert.

Answers to other three important questions on the site of The Royal College of Psychiatrists
1. How is ECT given
2. The Pros and Cons of ECT
3. Controversies in ECT

Thanks to There are black dogs and black dogs
Take special notice of the Further Information Section on this site

Tuesday, November 27, 2007

What kind of Chocolate do you like? A poll

Sinterklaas and Saint Nicolas in French, is a holiday tradition in the Netherlands and Belgium, celebrated every year on Saint Nicholas' eve (December 5) or, in Belgium, on the morning of December 6. The feast celebrates the name day of Saint Nicholas, patron saint of, among other things, children.

Special candy is made for this event such as chocolate characters and pepernoten.
These chocolate characters come in all varieties and all kinds of chocolate. Dr Shock prefers the dark chocolate type. What kind of chocolate do you like? My hypothesis is that medbloggers like dark chocolate. If you want to participate in this observational study please vote on the top right of this blog.

On Saint Nicholas Eve gifts are given to mostly the children but also other invited parties. These gifts are usually ingeniously wrapped, and are therefore called surprises. They are also mostly accompanied by a poem. This poem is usually an occasion to have a laugh.

Pepernoten (Spice nuts?) are a cookie-like kind of candy, traditionally associated with the Sinterklaas holiday in the Netherlands and Belgium. You will see the pepernoot in two varieties, one light brown, randomly shaped and made from the same ingredients as taai-taai, but is very hard like a nutshell, where the name originated from (nut = noot). The other variety is nowadays more common and uses the ingredients that are used for speculaas. That one is not as hard as the first one. Peper, means spiced in this case.

Sinterklaas is the basis for the North American figure of Santa Claus; the Dutch colonial town of New Amsterdam maintained a Sinterklaas tradition, long after it was occupied by the English and renamed New York City. The name Santa Claus is derived from older Dutch Sinte Klaas.

Dual Action not Better Than Mono Action Antidepressants

24 patients would need to be treated with a dual-action antidepressant drug instead of SSRIs in order to obtain one additional responder. This is called a Number Needed to Treat (NNT) of 24. A number of 10 or lower is considered relevant, so 24 is way above it and not relevant although the authors of this review do their out most to let us believe otherwise.

This is the conclusion of a large meta-analysis published in Biological Psychiatry. The assumption is that antidepressants that simultaniously enhance noradrenergic and serotonergic neurotransmission might benefit depressed patients more than antidepressants working on just one neurotransmittor: serotonin.

They indcluded as much data as possible. The did not only search medline/pubmed and EMBase but also clinical trial registries, program syllabi from major psychiatric meetings held since 1995, and documents from relevant pharmaceutical companies. These last options means also including non peer reviewed work in their search and analysis.

They included 93 trials (n= 17036 patients)for analysis. All comparing a SSRI and a dual action antidepressant: venlafaxine, duloxetine, milnacipran, mirtazepine, mianserin, or moclobemide. Even these so called dual action antidepressant vary much in mechanism of action, their action is not solely based on the inhibition of reuptake of serotonin and noradrenalin.

Duloxetine was apparently less efficacious compared to the others and SSRIs.

Especially important in a meta-analysis is a test for heterogeneity of trials. From the article it is not clear which test they used for heterogeneity, their conclusion was that there existed no heterogeneity. All trials were comparable.

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.

Article Discussed
Biol Psychiatry. 2007 Dec 1;62(11):1217-27. Epub 2007 Jun 22.

Are Antidepressant Drugs That Combine Serotonergic and Noradrenergic Mechanisms
of Action More Effective Than the Selective Serotonin Reuptake Inhibitors in
Treating Major Depressive Disorder? A Meta-analysis of Studies of Newer Agents.
Blogging on Peer-Reviewed Research

Papakostas GI, Thase ME, Fava M, Nelson JC, Shelton RC.
PMID: 17588546

Monday, November 26, 2007

Super Scan makes Incredible 3D Pictures of the Body

Very detailed pictures of the human body in 3D. These pictures can be rotated and viewed from different directions - giving doctors the greatest possible help in looking for signs of abnormalities or disease. You can see animated images from this super scanner on BBC health.

A new scanner has been unveiled which can produce 3D body images of unprecedented clarity while reducing radiation by as much as 80%.

The new 256-slice CT machine takes large numbers of X-ray pictures, and combines them using computer technology to produce the final detailed images.

It also generates images in a fraction of the time of other scanners: a full body scan takes less than a minute.

Create Fake Magazine Covers

Create Fake Magazine Covers with your own picture at

I just couldn't resist it, uploaded a photo and tried it.

Sunday, November 25, 2007

Italian Quack Treats Breast Cancer with Sodium Bicarbonate

Horrifying story from a Dutch Medblog written in English. Dr Lutser who has a famous Dutch Medblog reports about an Italian Doctor Simoncini. This Doctor Simoncini is well known for his assumption that cancer is a fungus and should therefore be treated with sodium bicarbonate.

By the beginning of October 2007 Dr. Simoncini flew to the Netherlands and started treating Sylvia with intratumoral bicarbonate injections. He was supported by an Italian male assistant who is a doctor as well. She received up to 20 injections in her breast tumor. Shortly thereafter she became sick and contacted the general practitioner who prescribed something for diarrhea. While getting worse every day, her friend contacted Simoncini’s assistant who diagnosed ordinary flu over the telephone.

Read the whole article by Dr Lutser

Found a website about this quackery:

What is the Best Evidence in Evidence Based Medicine?

The popular belief that only randomized, controlled trials (RCTs) produce trustworthy results and that all observational studies are misleading has been a subject for debate for a while.

Two studies in the New England Journal of Medicine did not confirm this rule of thumb for Evidence Based Medicine.
A comparison between randomized controlled trials with observational studies in 19 therapeutic areas and meta analyses of RCT's with meta-analyses of cohort and case control studies in 5 therapeutic areas did not find a difference in treatment effect.

What is the difference between RCT and an Observational study?
RCTs involve the random allocation of different interventions (or treatments) to subjects. This ensures that confounding factors are evenly distributed between treatment groups.
The goal of an observational study is to draw inferences about the possible effect of a treatment on subjects, where the assignment of subjects into a treated group versus a control group is outside the control of the investigator. This is in contrast with controlled experiments, such as randomized controlled trials, where each subject is randomly assigned to a treated group or a control group before the start of the treatment.

Explanations for the lack of differences in outcome between RCTs and observational studies emerged in the BMJ: Which clinical studies provide the best evidence?:

  • Observational studies have improved

  • Selection of publications limited to well known journals

  • One observational study did not involve treatment but risk factors in the general population

  • Some of the results of the meta-analyses and RCT's were falsified in more recent trials, e.g.screening for breast cancer was not found to be of benefit and hormone replacement therapy in menopausal women did not prevent coronary risk nor fracture risk

Objections to the use of observational studies:

  • Observational studies are mostly performed in institutions with better quality of care for that specific group

  • Selection of patients with a larger capacity to benefit

  • Publication bias against negative results

Now what is the best evidence?
Randomized Controlled Trials when well conducted are the golden standard. However small inadequate RCT's are not better than a well conducted conflicting observational study.
Well done observational studies are preferred above lousy RCT's.

But what is a well-done observational study?

A good observational study adheres the STROBE statement.

What is STROBE?

STROBE stands for an international, collaborative initiative of epidemiologists, methodologists, statisticians, researchers and journal editors involved in the conduct and dissemination of observational studies, with the common aim of

STrengthening the Reporting of OBservational studies in Epidemiology.
Observational research comprises several study designs and many topic areas. We aimed to establish a checklist of items that should be included in articles reporting such research - the STROBE Statement. We considered it reasonable to initially restrict the recommendations to the three main analytical designs that are used in observational research: cohort, case-control, and cross-sectional studies. We want to provide guidance on how to report observational research well. Our recommendations are not prescriptions for designing or conducting studies. Also, the checklist is not an instrument to evaluate the quality of observational research.

Guidelines for reporting observational studies were recently published in PLoS Medicine

With thses guidelines and the website of Strobe, observational studies can be of importance to clinicians and patients. We shouldn't forget that observational studies laid the foundations for important clinical achievements such as the discovery of AIDs, the relationship between smoking and lung cancer, and the relationship between flying and thrombosis.

Article Discussed:
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, et al.
PLoS Medicine Vol. 4, No. 10, e296 doi:10.1371/journal.pmed.0040296
Blogging on Peer-Reviewed Research

A Psychiatrists Experiences with Lectures for Drug Companies

A year after starting my educational talks for drug companies (I had also given two talks for Forest Pharmaceuticals, pushing the antidepressant Lexapro), I quit. I had made about $30,000 in supplemental income from these talks, a significant addition to the $140,000 or so I made from my private practice.

A well written honest story of a psychiatrist joining the lecture circuit for drug companies, Dr Drug Rep

Saturday, November 24, 2007

Antipsychotic as Antidepressants?

Recent publications about the use of antipsychotics for depression arise. The Carlat Psychiatry Blog has an excellent article about the most recent antipsychotic: Abilify . I fully agree with his statement:

What is abundantly clear is that drug companies are going to be pushing both psychiatrists and primary care doctors to think of "antipsychotics" as "antidepressants." Look closely at the data before you buy the message!

Recently on this blog I also discussed a publication with negative results of an antipsychotics for depression. This was a case series with clozapine. The study was stopped because of "severely disrupting side effects".

We also discussed the use of antipsychotics for depression without psychotic features.
If there is really an effect it is very small and clinically irrelevant. Moreover it means loosing time before using a more evidence based strategy such as lithium addition. Were looking forward for a comparison between risperidone, lithium and placebo.

Even the use of antipsychotics for psychotic depression has it drawbacks.
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

I will certainly keep an eye on this development.

Friday, November 23, 2007

Everything you always wanted to know about hemorrhoids

A 24 year student at the University of Cambridge, Department of Medicine has a website about hemorrhoids. He has dealt with it many times in his life.

My father and my grandfather also suffered from this disease, as well as many other friends of mine. There where times when I was trying to find out more about hemorrhoids, but the sites that I found on internet were full with commercials and ads. I decided to build this site as a complete hemorrhoid resource on internet, so that people like me to find what they need.

A site well done, technically as well as content:

A Dutchman Invented Chocolate

Did you know that Coenraad Johannes van Houten invented a hydraulic press to improve the quality of chocolate drink?

Van Houten's press gave him a solid mass which could be ground to powder, from which he made easily soluble, easily digestible and - relatively - easily affordable cocoa.

The press left him with a lot of cocoa butter. It was this by-product which became the basis for the solid chocolate developed some 20 years later by Englishman Joseph Fry, who mixed it back into the cocoa paste.

Thanks to Nutrition and Wellness

Thursday, November 22, 2007

5 Features of Pseudoresistant Depression

Pseudoresistant depression means not having received adequate treatment for major depression.

5 Features of inadequate treatment for Depression are:

  • The most common source of lack of response in depression is the administration of inadequate dosage. With some antidepressants, the tricyclic antidepressants (TCAs), there is evidence for a relationship between plasma levels and therapeutic outcome

  • Treatment duration with antidepressants. There is some evidence that elderly patients may require longer exposure to medication. At least adequate dosage during 4 weeks is the absolute minimum.

  • Adherence with treatment. Improvement is unlikely if patients do not adhere to treatment. Side-effects are a common cause.

  • It is important to evaluate treatment outcome. The greater the level of depressive symptomatology following antidepressant treatment the higher the probability of relapse. The goal in treating the acute episode is to achieve remission

  • Wrong diagnosis. If the antidepressant doesn't work this option should be considered. Several somatic illnesses and medication can present with depressive symptoms.

Nevertheless it is estimated that 20-40% of patients with a major depressive episode do not show substantial clinical improvement to their first antidepressant treatment.

Staging methods to assess levels of treatment resistance in depression are being developed:

  • The Antidepressant Treatment History form. A clinician rated instrument. This form is empirically validated via prospective treatment outcome reports. This form is mostly used with electroconvulsive therapy (ECT) outcome. There is debate about the influence of treatment resistance and efficacy of ECT. Some studies show a negative influence on ECT outcome of medication resistance other studies can't find such an influence.

  • Harvard Antidepressant Treatment History. Clinician rated instrument.

  • Massachusetts General Hospital Treatment Response Questionnaire. Patient rated instrument. Advantage of this instrument is the absence of clinicians' biases, particularly when treatment resistance is required for inclusion in a study.

Related posts:
9 Steps for Treatment Resistant Depression
Deep Brain Stimulation
Vagus Nerve Stimulation
rTMS, Transcranial Magnetic Stimulation for Depression

Bizarre Diseases: Trichobezoar

A patient with the habit of eating her hair for many years — a condition called trichophagia. Leading to a large bezoar occluding nearly the entire stomach.
Go see the pictures of the bezoar in the New England Journal of Medicine.

Wednesday, November 21, 2007

8 Ways to prevent an early Death

On the Pacific Prime Blog 8 ways to prevent early death.
I approve most of them such as stop smoking and chill out.

Dark Chocolate is Good for The Heart

A publication in Circulation, the journal of the American Heart Association, is discussed on

First, this is a small study, but it’s a randomized controlled trial. That’s a good thing. It looked at 22 heart transplant patients, assigned to receive two different kinds of chocolate, one with particular flavinoids, one without. Various parameters important to cardiac physiology were measured. A significant difference was found between the groups. Those receiving flavinol-rich chocolate had more beneficial effects on the heart as measured in this study.

Well if it is not an antidepressant it might be good for the heart, whatever reason be sure to have the dark chocolate, my favorite, what is yours?

Related posts on this blog:
Chocolate and craving and brain centers

Chocolate and atypical depression

Bacteria responsible for chocolate craving?

Biased Medical Education

It is all about the influence of drug companies on doctors' compulsory education in the US. Fat change that the material is biased by the funding drug company.
Two small studies have attempted the first objective measurements of bias in doctors' education, they are discussed on

Dr Carlat is busy validating a instrument, called the Commercial Bias Inventory (CBI). He is going to blindly rate a number of CME articles and report his findings.
From The Carlat Psychiatry Blog:

A few months ago, Jim Giles, a science writer for the New Scientist and Nature, called me out of the blue to ask about my opinions on drug industry-funded CME. I gave him my usual earful, and mentioned a preliminary study on CME bias that I presented at the American Psychiatric Association meeting two years ago. He asked to see the raw data, meaning the ghost-written CME articles, and it impressed me that he took this level of interest.

Can't wait for their findings.

Tuesday, November 20, 2007

Violent Video Game Playing Does Not Lead to Aggressive Behavior

Results from a recent meta-analysis did not support the conclusion that violent video game playing leads to aggressive behavior. However it was associated with higher visuospatial cognition such as visual rotation, visual memory, visual attention and selection or related abilities.

These findings are valuable since it is not hard to link video game playing to aggression because the prevalence of video game playing in adolescents is 98.7%. In contrast excess violent behavior such as a school shooting has a very low base rate.
Can an almost universal behavior truly predict a rare behavior? According to this excellent meta-analysis: No.

Shortcomings of previous trials and reviews:
1. In one study the confidence interval crosses zero, so instead of proof of a relationship this publication questions such a relationship.
2. Violent activity may simply be a byproduct of family violence.
3. Use of unstandardized measures of aggression
4. The assumption that these games have only negative consequences could be wrong, positive aspects are neglected.
5. Publication bias

When correcting for this publication bias the result of the meta-analysis does not support a relationship between violent video game playing and aggressive behavior.

A total of 17 published studies comprising of 21 independent observations were found that met the above criteria including a total sample size of 3,602.

When correcting for the publication bias, violent video game playing does improve visuospatial cognition.
A total of seven published studies comprising of 14 independent observations were found that met the above criteria including a total sample size of 384.

The author suggests to look into the effect of violent video games on individuals already at risk for violent behavior. He also suggests to look at adopting these games for more positive goals e.g. educational purposes.

Article discussed:
Psychiatr Q. 2007 Dec;78(4):309-16.

The Good, The Bad and the Ugly: A Meta-analytic Review of Positive and Negative Effects of Violent Video Games.

Ferguson CJ.
PMID: 17914672

Blogging on Peer-Reviewed Research

Related posts:
Games for Health
Medical Vest Improved to Game Vest
16 Medical Games
Video Game Addiction
50 Brain Games
Gaming is good for you

Professional Medical Search With SearchMedica

A new medical search engine: SearchMedica. You can search three specialties: Psychiatry, Primary Care and Oncology/Hematology, who needs more? Well you can vote for other specialties. You can search in three languages: English (both US and GB), French and Spanish.

They keep track of the search terms used and they bring out a quarterly report with the most used search term in the different specialties

For psychiatry the top 5 of the third quarter of 2007 were:
1. mood stabilizer
2. unipolar vs. bipolar depression
3. asperger's
4. hypomania
5. bipolar

"The 'Clinical Search Terms' quarterly reports list the disorders, diseases, conditions and treatments that are top of mind with medical professionals," said Cyndy Finnie, senior product manager for SearchMedica. "We have compiled all of the oncology, primary care and psychiatry searches that took place in the third quarter to help other medical professionals stay informed of the latest patient care trends impacting their peers and clarify the online behavior of medical professionals for those that can apply these findings to improve communication efforts aimed at medical doctors and other healthcare professionals."

I tried electroconvulsive therapy. It delivers results by category such as:
1. Reviews
2. Practical artiles and news
3. Evidence-based Articles and Meta-analysis
4. Practice Guidelines
5. Patient Education Materials
6. Clinical Trials for Patients
7. Alternative-Complementary Medicine
8. Practice Management

There is also Related concepts such as depression memory etc for electroconvulsive therapy.
There were some good results, e.g. patient material.

Via ResearchBuzz

Related posts:
A search engine as PubMed Clone: Gopubmed

Monday, November 19, 2007

The Blog Readability Test

One of the reasons I write this blog is to practice expressing my views and opinions in Engish. It helps a lot. Now there is a site were you can test the readability of your blog

What level of education is required to understand my blog

cash advance

In another readability test my blog got these scores:

On the Fog Index my blog scores at the level of The Times and Guardian.
Go try it

2 Myths that Haunt Me From the Past about Mental Illness and Schizophrenia

When I started to study Medicine to become a psychiatrist, yes I am one of those, at the end of the seventies I still witnessed the remains of the antipsychiatry. I remember how the books by Thomas Sasz were still read by some psychiatrists.

More alarming is the realization that when I started to work in psychiatry the nonsense of double bind relationships between mother and the child with Schizophrenia as a cause of the illness was still at it's peak. I tell this to my students in order to place our modern hypothesis into perspective.

Even I at this young age have witnessed a huge transformation in psychiatry. I look back a little ashamed because I think that looking back at these two "myths", as I would call them now, they were not that harmless.
Other developments of the past are still usable no matter how you think about them, they didn't cause that much harm, such as psychoanalysis.

1. The Myth of Mental Illness. Thomas Szasz, a seminal text from 1960, prior to the publication of his well-known book with the same name.

The notion of mental illness thus serves mainly to obscure the everyday fact that life for most people is a continuous struggle, not for biological survival, but for a "place in the sun," "peace of mind," or some other human value.

This text and his following book The Myth of Mental Illness: Foundations of a Theory of Personal Conduct was highly influential in the anti-psychiatry movement. In it, Szasz argues that mental illness is a social construct created by doctors, and the term can only be used as a metaphor given that an illness must be an objectively demonstrable biological pathology, whereas psychiatric disorders meet none of these criteria.

2. Double Bind as cause for Schizophrenia
In 1967 a team of researchers published the results of their further investigation of the double bind. They proposed that the operational component of the double bind is its pattern of disqualification -- the means by which one person's experience is invalidated as a result of the imposed bind. They cited five methods for disqualifying the previous communication. Evasion or a change of subject is the first method of disqualification. If the previous statement (a) does not clearly end a topic of discussion, and the next statement (b) does not acknowledge the switch in topic, then the second statement disqualifies the first statement:

a. Son: Can we go to the park and play soccer?

b. Father: What a beautiful day for working in the garden.

The second method of disqualification is sleight-of-hand. Sleight-of-hand occurs when the second response (b) answers the first (a) but changes the content of the previous statement:

a. Daughter: We have always gotten along well.

b. Mother: Yes, I've always loved you. . .

In the above example, the mother has responded to her daughter but has switched the issue from getting along well to love.

Literalization, the third type of disqualification, occurs when the content of the previous statement (a) is switched to a literal level in the second statement (b) with no acknowledgment of the change of frame:

a. Son: You treat me like a child.

b. Father: But you are my child.

The fourth method, status disqualification, happens when a person uses either personal status or superior knowledge to imply that the previous message is not valid:

a. Mother: I have observed that he doesn't play very well with the other children.

b. Son: But I do, Mama!

a. Mother: He doesn't realize because he is so little . . .

Redundant questions are used to imply doubt or disagreement without openly stating it:

a. Daughter: I get along well with everybody.

b. Mother: With everybody, Cathy?

Sunday, November 18, 2007

7 Posts about Adolescents and Depression

And what about electroconvulsive therapy?

Cognitive side-effects of ECT in Adolescents

Games for Health

There is a website for Games for Health:

The Serious Games Initiative founded Games for Health to develop a community and best practices platform for the numerous games being built for health care applications. To date the project has brought together researchers, medical professionals, and game developers to share information about the impact games and game technologies can have on health care and policy.

There is even an Annual Conference for Games for Health:
Games for Health Fourth Annual Conference 2008
May 8-9, 2008
Baltimore MD
Dates & Times:
Thursday, May 8 : 8:00am - 7:30pm (Including Breakfast and Reception)
Friday, May 9 : 8:00am - 4:30pm (Including Breakfast)
Baltimore Convention Center
One West Pratt Street
Baltimore, MD 21201

And a research program:
$8.25 Million Research Program to Investigate Design Strategies and
Benefits of Interactive Games to Improve Health and Health Care

Saturday, November 17, 2007

8 Steps how to interact with a person in a wheelchair

People become wheelchair users for many and varied reasons. No one chooses it, but realizes that the wheelchair will allow them both the mobility and the ability to live a productive and happy life. If you're interacting with a wheelchair user for the first time, it can be difficult to know how to act. You don't want to cross any boundaries or accidentally offend someone, but at the same time you want to be helpful and understanding. Here's how to find a good balance.

On WikiHow, the Howto manual that you can edit 8 steps and tips on how to interact with someone in a wheelchair.

Again Antipsychotics for Depression Ineffective

This time I want to discuss a case series: Clozapine in medication- and ECT resistant depressed inpatients.
I usually discuss peer reviewed articles about randomized controlled trials appearing in Core Clinical Journals usually mitigating the positive results of these trials like in a recent RCT with rTMS. This time I want to make an exception.

I want to discuss this case series for the following reasons:

  • The topic is the use of antipsychotics for depressed patients for which several trials with antidepressants and ECT failed to deliver a sufficient response.

  • The authors got it published as a letter to the editor in spite of negative results.

  • The editor and reviewers accepted it for publication in spite of the negative results.

  • I like the Journal of Clinical Psychopharmacology because of their excellent guidance and service with publishing important information in their Journal.

  • I am a opponent for the use of antipsychotics for psychotic depression and certainly for nonpsychotic depression

The authors conducted an open trial in ECT-resistant depressed inpatients. The wanted to investigate the effect of clozapine in these patients. Arguments for this trials were:

  • Clozapine is effective in psychotic patients resistant to typical neuroleptics

  • Clozapine is also beneficial as an add on therapy in ECT-resistant schizophrenic and schizoaffective patients.

  • Recent interest in the addition of atypical antipsychotics to treatment options for "difficult to treat unipolar or bipolar depression".

They planned to include 10 patients with pharmacotherapy treatment failure and insufficient response to ECT as measured by Hamilton Rating Scale for Depression.

The study was discontinued after the inclusion of 5 patients (2 men and 3 women, 2 with unipolar and 3 with bipolar disorder).

ECT was continued during the trial accept for 1 patient because of the patients refusal.

The study was stopped because of "severely disrupting side effects". In all cases except 1 the side effects were severely disrupting in 2 of these cases the side-effects were critical due to neutropenia and an influenza like syndrome. There was no significant reduction in severity of the depression after 4 weeks of treatment. After 8 weeks 2 patients could be classified as partial responders, after 12 weeks only one patient could be classified as responder but there was no remission obtained.

I hope this publication will be noticed not only for its results but also for the importance of the publication of negative outcome, and again I express my respect and appreciation for the authors and editor.

Additional treatment with Clozapine to ECT is not a promising strategy in ECT resistant depressed patients, putting it mildly.

Since Clozapine has serious side-effects it is usually reserved for third-line use for patients with therapy resistant positive symptoms. The rare but potentially lethal side effects of clozapine is agranulocytosis and myocarditis. Furthermore it may rarely lower seizure threshold, cause leukopenia, cause hepatic dysfunction, weight gain and be associated with type II diabetes. More common side effects are predominantly anticholinergic in nature, with dry mouth, sedation and constipation.

Safer use of clozapine requires weekly blood monitoring for around five months followed by four weekly testing thereafter. Echocardiograms are recommended every 6 months to exclude cardiac damage.

Blogging on Peer-Reviewed Research

Discussed article:
J Clin Psychopharmacol. 2007 Dec;27(6):715-717.

Clozapine in Medication- and Electroconvulsive Therapy-Resistant, Depressed
Inpatients: A Case Series.

Quante A, Zeugmann S, Bajbouj M, Anghelescu I.

PMID: 18004147

Friday, November 16, 2007

Psychiatric Patients treated too late for their somatic illness

Psychiatric patients are treated relatively late for their somatic illness. Especially patients with Schizophrenia suffer complications from their somatic illness due to late interventions.

This conclusion is based on a research from different universities in Taiwan and the US. The researchers studied all patients admitted to hospitals in Taiwan during a four year period. They looked at acute appendicitis. This method is used earlier to estimate the accessibility of hospitals and hospital care.

The sample consisted of almost 100.000 patients. They looked at the differences in the course of the illness between patients with or without a psychiatric illness such as Schizophrenia and Depression. They also looked at confounding factors such as age, gender, ethnicity, socioeconomic status and kind of hospital.

In patients without a psychiatric illness, about 25% suffered from a burst appendicitis, a severe complication of acute appendicitis. In patients with a psychiatric disorder this percentage was 45%. When taking the confounding factors in account the risk for a burst appendicitis was only significantly higher for patients with Schizophrenia. They had a 3 times higher risk compared to patients without a psychiatric disease.

Besides doctors not always being acquainted with these patients other factors play a role in this problem:

  • Patients with Schizophrenia are often paranoid and anxious.

  • They also have trouble functioning socially.

  • They usually are less able to express their complaints.

  • They notice pain far more less than others.

Patients with Schizophrenia have a shorter life expectancy due to suicide and accidents, but also due to life threatening somatic illnesses.

Of patients with a major mental illness, schizophrenic patients may be the most vulnerable ones for obtaining timely surgical care.

Article discussed:
Research article
Disparities in appendicitis rupture rate among mentally ill patients
Jen-Huoy Tsay, Cheng-Hua Lee, Yea-Jen Hsu, Pen-Jen Wang, Ya-Mei Bai, Yiing-Jenq Chou and Nicole Huang.
BMC Public Health 2007, 7:331doi:10.1186/1471-2458-7-331
Blogging on Peer-Reviewed Research

Thursday, November 15, 2007

Funny Moments for Doctors

1. A man comes into the ER and yells, "My wife's going to have her baby in the cab!" I grabbed my stuff, rushed out to the cab, lifted the lady's dress, and began to take off her underwear. Suddenly I noticed that there were several cabs -and I was in the wrong one.
Submitted by Dr. Mark MacDonald

There are much more where this came from.
From Funny Moments for Doctors

Everything on Aging and Sleep (Disorders)

From the National Institute on Aging a very informative article: aging and sleep, Alzheimer's Disease and Sleep and much more with relevant links for more information.

At last some good news about rTMS?

A large study to the efficacy and safety of rTMS is recently published. The primary outcome criterion for rTMS for treatment of depression was the difference between the mean MADRS score before minus the score at week 4 of treatment. The difference between rTMS and sham TMS was not significant (p=0.057)at week 4. There was a baseline imbalance between groups. Six patients had a MADRS baseline score between 14 and 19 which is in the mild range. They were unevenly randomized across the two groups (i.e., 4 to the active and 2 to the sham). Excluding these six from the analysis finally resulted in a significant difference between groups (p=0.038), favoring active treatment. At week 6 the baseline to endpoint change on the MADRS was not significant with or without the six afore mentioned patients.

With the Hamilton Ratings Scale for Depression 17 and 24 item version (HAMD-17, HAMD-24), the difference of the mean change at week 4 was significant for both rating scales in favor of the active treatment. This advantage was sustained at week 6.

Mean differences of scores of depression severity scales are very sensitive measures. They easily lead to significant differences but are these differences not only significant but also clinically relevant.

For comparison clinician rated global illness severity showed significant greater improvement with the active treatment already at week 2 continuing to week 6.
Response rates, that is a reduction of 50% or more on the severity scale from baseline until week 4 and 6 was significantly higher for the active treatment compared to the sham treatment for all three rating scales.

Remission rates were not significantly higher for the active treatment except for the MADRS at week 6 and HAMD-24 at week 6. Remission is what you should seek in the treatment of depression. Remission rate at week 6 defined as a score on the HAMD-17 lower than 7 was 15.5%.

Patient reported mood change and global improvement were not significantly higher for the active treatment compared to sham rTMS.

Side effects of rTMS
There was more scalp discomfort and pain with the active treatment. There were no seizures. 16 serious were reported, 9 in the active treatment and 7 in the sham treatment, mostly due to disease related exacerbation.

This is the first large (n=301), multi site (23 US, 2 Australia, 1 Canada), placebo controlled trial on medication free depressed patients. Patients were required to have failed at least one but no more than four adequate antidepressant treatments. Patients with lack of response to ECT were excluded.

Dr Shock's opinion
This is a trial very well done. Due to its design only the scores on time point of week 4 are truly double-blind. They introduced a new method for sham treatment: the sham coil had a embedded magnetic shield. This study also shows that longer treatment with rTMS is well tolerated. The use of pharmacotherapy treatment failure as an inclusion criterion every time amazes Dr Shock. There are far better treatment options e.g. plasma level controlled TCAs, lithium addition and ECT to name a few.

Considering the outcome on the time point at week 4, Dr Shock is not very impressed by the results. For significant difference with the primary outcome 6 patients had to be excluded from the analysis. The mean difference between active and sham on the severity scales is in the range of 2-3 points, significant but hardly clinical relevant. Absolute figures on response and remission at week 4 are not given in this article. Remission rate at 6 weeks on the HAMD-17 was 15.5% increasing to 22.6% at week 9 with open labeled therapy. Not very impressive.

Article discussed:

Biol Psychiatry. 2007 Dec 1;62(11):1208-16. Epub 2007 Jun 14.
Efficacy and safety of transcranial magnetic stimulation in the acute treatment
of major depression: a multisite randomized controlled trial.
O'Reardon JP, Solvason HB, Janicak PG, Sampson S, Isenberg KE, Nahas Z, McDonald
WM, Avery D, Fitzgerald PB, Loo C, Demitrack MA, George MS, Sackeim HA.
PMID: 17573044 [PubMed - in process]
Blogging on Peer-Reviewed Research

Wednesday, November 14, 2007

Chocolate drink older then we thought

The history of chocolate will have to be revised following a new discovery, along with the history of humanity’s troubled relationship with alcohol. Archaeologists working in Honduras detected residues from cacao plants in liquid holding vessels from 500 years earlier than beverages of the chocolate precursor have previously been found. John Henderson and colleagues think the beverages in question were more like beer than a hot chocolate-type drink and could have been as potent at 5% alcohol by volume

On The Great Beyond:‘Chocolate beer’ is older than we thought

2007’s Best of the Web - Blogs for Depression

We’ve been indexing and reviewing online resources since 1991. In 1995, we began awarding Web awards to recognize those online resources that really stood out. Flash forward 12 years later and a lot has changed. We aim to give you the best of the best, so you know where to go when you need information, opinion, and support.

On the 10 best blogs about depression

Nope Dr Shock is not on it, but Finding Optimism is. Finding Optimism has some technical difficulties, but he will be back soon.

I am missing Vicarious Therapy, she writes a damn good blog about depression.

Bizarre Diseases

Ever heard of Jerusalem Syndrome?

Affecting around 100 tourists a year, it is a form of religious psychosis sparked by a visit to Jerusalem and is not confined to any one religion. Sufferers may believe they are prophets or messengers from the Lord and indulge in behaviours such as parading around delivering their own sermons, obsessing about virtue and cleanliness and will often ask sinners to repent their sins. The syndrome invariably disappears after a few weeks or when the tourist leaves the area.

Or Alien Hand Syndrome, Jumping Frenchman of Maine Disorder, Alice in Wonderland Syndrome, Capgras Syndrome?

Go have a look at Weird Diseases

In Australia no ECT for involuntary patients, says New Mental Health Bill

Objective: The Mental Health Act in New South Wales (NSW) has recently been revised, resulting in the Mental Health Bill 2007, which has been submitted to the NSW Parliament to be passed as law. The new Bill includes some changes to the sections dealing with electroconvulsive therapy (ECT), particularly for involuntary patients. The implications of these changes for the provision of ECT in these patients are examined in this paper. Conclusions: New limits introduced in the Mental Health Bill 2007 may have potentially detrimental consequences for ECT therapy in involuntary patients and may inadvertently result in the provision of suboptimal ECT to these patients.

The worst ill patients will have difficulty receiving the right treatment with ECT. These involuntary patients are usually the ones that needs ECT the most.

Australas Psychiatry. 2007 Dec;15(6):457-60.
The NSW Mental Health Bill 2007: Implications for the provision of
electroconvulsive therapy.
Loo C.

Beatrice L Selvin, anesthesiologist

Dr. Beatrice L. "Bea" Selvin, former clinical director of the department of anesthesiology at what is now University of Maryland Medical Center and professor of anesthesiology at the University of Maryland School of Medicine, died of a cerebral hemorrhage Nov. 6 at Anne Arundel Medical Center. She was 85.

From the

Not many of you will know who she was.
She was the sole author of a frequent cited paper in articles about electroconvulsive therapy:
Anesthesiology. 1987 Sep;67(3):367-85.
Electroconvulsive therapy--1987.
Selvin BL.

In total she published 5 articles according to PubMed.

Tuesday, November 13, 2007

Cognitive Dissonance or why they stay in Iraq and we in Afghanistan

I was always a great fan off General Colin Powell, read his biography and visited the Pentagon before 9/11. It was a great deception learning that his plea to enter Iraq because of the presence of weapons of mass destruction was a scam. Nevertheless one of his rules of thumb was that you should have an exit strategy before invading a country.

That rule was neglected. A lot of soldiers have died since. Justification of staying besides economic reasons is the already invested cost of lives and effort in the occupied country. This kind of reasoning is called cognitive dissonance.

What is Cognitive Dissonance?
Cognitive dissonance is in simple terms the filtering of information that conflicts with what one already believes, in an effort to ignore that information and reinforce one's beliefs.

From Wikipedia

Social psychologist Leon Festinger first proposed the theory in 1957 after the publication of his book When Prophecy Fails, observing the counterintuitive belief persistence of members of a UFO doomsday cult and their increased proselytization after the leader's prophecy failed. The failed message of earth's destruction, purportedly sent by aliens to a woman in 1956, became a disconfirmed expectancy that increased dissonance between cognitions, thereby causing most members of the impromptu cult to lessen the dissonance by accepting a new prophecy: that the aliens had instead spared the planet for their sake.

In popular usage, it can be associated with the tendency for people to resist information that they don't want to think about, because if they did it would create cognitive dissonance, and perhaps require them to act in ways that depart from their comfortable habits. They usually have at least partial awareness of the information, without having moved to full acceptance of it, and are thus in a state of denial about it.

Until a recent publication in Psychological Science it was assumed that you needed the capability of abstractive thinking as present in adults. This recent publication provided the first evidence of cognitive dissonance in children (30 four-year-olds) and 6 capuchin monkeys.

The procedure
Children's preference for different stickers were rated with a smiley face rating scale, corresponding to 6 levels of liking.

Next they were asked to to match a series of stickers to the faces on it until they became tired of it. Once a the child had rated the stickers the experimenter randomly labeled the sticker in each triad as A,B and C. Next each child participated in the choice or the no-choice experiment.

In the choice condition the child was given one choice between A and B. Next the child was given a similar choice between the unchosen alternative and C. All triads were used.

In the no-choice condition the experimenter displayed A and B of a triad and said: "Now , I am going to give you a sticker to take home". Randomly A or B was given to the child. After receiving the sticker the child was given a choice between the unreceived sticker and the equally preferred alternative C.

In the choice condition the children and monkeys more often chose the alternative C. In the no-choice condition, where the children were not allowed to choose a sticker, the preference for C disappeared.

Both children and capuchins demonstrated a decrease in preference for one of two equally preferred alternatives after they had chosen against it but not when the experimenter had chosen against it. This suggests that children and monkeys change their current preference to fit with their past decisions They changed their preferences to match more closely the choices they made in previous decisions.

Since children and monkeys have little experience with decision making it is unlikely that cognitive dissonance can be attributed solely to past cognitive history. It might be a core-knowledge mechanism, there may be some core aspects of cognition that give rise to cognitive dissonance. Cognitive dissonance reduction may be more automatic than previously suspected.

Were does that leave us concerning the decisions made by Generals, Presidents, and Governments?
Obviously their decisions made on cognitive dissonance reduction doesn't surpass the level of 4 year old and monkeys.

Article discussed:
Psychol Sci. 2007 Nov;18(11):978-83.
The origins of cognitive dissonance: evidence from children and monkeys.
Egan LC, Santos LR, Bloom P.
Blogging on Peer-Reviewed Research