Dr Shock MD PhD

Electrical stimulation of areas deep within the brain could improve memory, early research suggests. A team of doctors in Canada were attempting to treat a morbidly obese man through deep brain stimulation (DBS) for his obesitas. Their long-standing interest in functional neurosurgery and DBS made them consider the possibility of a neurosurgical treatment. They wanted to stimulate the hypothalamus for appetite control. Hypothalamic lesion surgery had been used previously to treat obesity. Hypothalamic stimulation was proposed based on experimental studies of appetite control in rodents, dogs, and nonhuman primates.

DBS electrodes were implanted bilaterally in the ventral hypothalamus with the patient receiving local anesthesia without sedation.
During stimulation the patient vividly remembered a situation from the past:

being in a park with friends, a familiar scene to him. He felt he was younger, around 20 years old. He recognized his epoch-appropriate girlfriend among the people. He did not see himself in the scene, but instead was an observer. The scene was in color; people were wearing identifiable clothes and were talking, but he could not decipher what they were saying. As the stimulation intensity was increased from 3.0 to 5.0 volts, he reported that the details in the scene became more vivid.

These recollections were tested under double blind conditions.

The effects of stimulation on memory were further characterized using recognition tasks with high sensitivity and specificity for hippocampus-dependent retrieval processes. Each task was performed twice, with the stimulator on or off in a double-blinded fashion.

Shortly after recovery of the operation as well as after a year the patient performed better in memory tests than he had previously done.

The patient performed well in memory tests when the electrodes were stimulated, but less well when they were switched off.

The results suggest it might be possible to use deep brain stimulation directly to boost memory.

Maybe a new treatment for Alzheimer? Sounds to good to be true. I remember ECT and Morbus Parkinson. ECT can help but as the disease progresses the results diminishes.

The conclusion of the authors:

Electrical stimulation in this high-density area could be affecting a number of neural elements. We cannot be sure how much of the effect is related to stimulation of nuclei versus axons coursing in the hypothalamus. At this time, we believe that the results are consistent with driving the activity of the hippocampal memory circuit through stimulation of the fornix. The effects of hypothalamic stimulation on memory shown here represent an unanticipated collateral effect in the context of a putative treatment for morbid obesity.

Thanks to BBC News Health


Hamani, C., McAndrews, M.P., Cohn, M., Oh, M., Zumsteg, D., Shapiro, C.M., Wennberg, R.A., Lozano, A.M. (2008). Memory enhancement induced by hypothalamic/fornix deep brain stimulation. Annals of Neurology, 63(1), 119-123. DOI: 10.1002/ana.21295

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Elderly residents in a care home are being given Nintendo Wiis to help keep them physically and mentally active.

They hope it will especially help those with dementia.

On BBC NEWS

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Dr Shock is a Google adept. Fortunately Firefox and Google match well together. For blogging I solely rely on Google reader, Google notes and Blogger, all integrated in Firefox. Off line so now and then I use Marsedit and Devonthink for blogging.

What do you use, let me know in the comments

Mozilla just announced that they are planning on having the first Release Candidate build of Firefox 3 Beta 3 coming next Monday.
Two new features:

• new Windows themes


• Add-ons manager for finding extensions without ever going to the add-ons site

For screen shots see Cybernet

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On Vicarious Therapy there was an important question raised: Early Medical Intervention for Major Depression. I kept thinking about it, the answer is: I don't know.
Here is the problem:

Now, six plus years into this MDE I'm still searching for something that will help me, but I believe I at least FINALLY, in the psychiatrist I see, have the knowledgeable and completely supportive help I needed all along.

I often wonder, had I received help at 18 or 19, instead of 36, would I be better today? Would I be struggling so hard to find something to help me?

That is why I got interested in a long article in Clinical Psychology Research about Risk of Recurrence in Depression.

Some facts about Recurrent Depression:

• 50% of patients who recover from their first episode will have one or more additional episodes in their lifetime.


• 80% of patients with a history of two episodes will have another recurrence during their life


• On average , patients with a history of depression will have five to nine separate depressive episodes in their lifetime


• 90% of those with recurrent depression report "very much" impairment, limiting work productivity and social interactions.

This review article considered studies that were identified through literature searches. The focus is on psychological and clinical risk factors not on biological measures.
Depression in this review can be a diagnosis by DSM or ICD criteria but also a score above a cutt-off on the BDI or Hamilton. Especially this last method of defining depression is very controversial, a high score on one of these severity scales doesn't always imply the existence of a depression.
They studied risk factors for recurrence these are different from risk factors for first episode depression.

Causes of recurrence

• Female gender is not a significant risk factor for recurrence


• Age at first onset (younger age) and lifetime number of depressive episodes (more numbers of episodes) appear to be related to increased risk of recurrence , although further research disentangling these variables is necessary


• A severe first episode as indicated by a severe symptom picture is also a risk factor


• Longer duration of first depressive episode is not a risk factor


• In adults co morbidity is also associated with higher risk of recurrence. Co morbidity such as dysthymia, alcohol or drug abuse, anxiety disorders


• Transmission of genetic risk from parents to children is a risk factor of recurrence.


• Negative cognitive styles is a risk factor for recurrence.


• High levels of neuroticism are a risk for recurrence


• Stressful life events are risk factors for recurrence


• In women social support is a protective factor against recurrent episodes of depression


• Studies on psychosocial scarring and personality scarring due to depressive episode have largely been negative

The Scar Hypothesis of Depression

People who have recovered from an episode of clinical depression have an elevated risk for developing a new episode of depression compared with those not previously depressed. One possible explanation for this finding is that depression may leave ‘scars’—enduring psychological changes resulting from depression.

This hypothesis has been refuted several times.The role of personality in depression [of moderate duration and severity] is more consistent with the vulnerability model than with the scar hypothesis. See also Depression fails to scar personality - introversion, neurotism and dependency tend to predispose individuals to depression rather than result from depression - Brief Article

This is the conclusion of the authors in their abstract:

Our review suggests that recurrent depression reflects an underlying vulnerability that is largely genetic in nature and that may predispose those high in the vulnerability not only to recurrent depressive episodes, but also to the significant psychosocial risk factors that often accompany recurrent depression.

The problem with risk factors is the casual relationship with the depression. Is the depression the cause for these risk factors having an effect or are these risk factors of significant influence on the course of the disease. The only solution to this question is a large prospective study with adolescents at risk followed over a long period of time compared to adolescents without risk (genetic risk).
Nevertheless the authors did a large and comprehensive review of the subject, their conclusions are well-founded by the data. This review doesn't answer the question posed by the author of Vicarious Therapy. To my knowledge there is no evidence of early intervention and course of recurrent of depression. Anyone else?

Related post on this blog:
Risk Factors for Psychiatric Disorders

BURCUSA, S., IACONO, W. (2007). Risk for recurrence in depression. Clinical Psychology Review, 27(8), 959-985. DOI: 10.1016/j.cpr.2007.02.005

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Some tech talk now. The web has very useful information about health, medication, and illness to name a few.
Problem:Del icio.us is ideal for storing all the links for these websites. Nevertheless the web is also rapidly evolving, links can vanish, so clicking the link in del.icio.us delivers a blank page, link gone.
Solution: Diigo: a social bookmarking service that caches a full version of each bookmarked page with all the graphics and formatting intact. No more lost links. Moreover it is much faster than del.icio.us according to the comments on this post about Diigo at LifeClever. Also some suggested uses from Diigo: in research, a want list, recipes and yes Blogging:

Blogging. One of the big advantages of a social bookmarking service is the social part. Diigo makes it easy to share your links, post them to your blog, or even do an automatic daily post of links to your site.

Problem: Wrting a book online has several advantages: work from anywhere, quick use of the internet for links or texts.
Solution: Google Docs. On Google Blogoscoped there is a whole article about using google docs for writing a book online. With the outline, naming documents, workflow, you name it it's there.
Maybe I will switch from using wikis or word to using google docs with this article as instruction

There are many other differences between the two programs. Google Docs is free, for instance, whereas Word isn't. There may be smaller differences in start-up times (Google documents could really use a speed boost in this regards). One other thing I like about Google docs, or most web applications, is that I can switch to the English interface; this makes it much easier to, for instance, communicate about the application in help groups, or search for certain things in regards to the application.

OK not everyone is into using online applications for their notes. In comes Livescribe with the pulse smartpen. A pen that can record what you are writing as well as record and sync audio with whatever you write, so you never miss a word. With Paper Replay, users can tap on their notes written on paper to hear exactly what was said. They can also fast forward, rewind, jump ahead, pause, and even speed up or slow down their audio recordings using controls printed on the bottom of each page. Yes your notes on the computer screen as well as on paper. You will have to see it to believe it Have a look at the demo video's at livescribe.com
You can't buy it yet, takes a couple of months.

From Gizmodo.com

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Curious about these addictions? Is chocolate in them? These addictions account for a large share of addictions-related online searches.

The most common substances found in online searches for addictions on clearhavencenter.com

While many of these searches may spring from harmless situations, the pattern of abusing substances to cope with stress is a more common social issue than addiction to one specific substance.

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For a while now the New England Journal is testing a new website with all kinds of widgets and many Web 2.0 and interactive features.

I liked the specialised RRS feeds: NEJM Online Feeds. You can select: Current Issue Feed, Four Most Recent Issues Feed and Image of the Week Feed.

The “Image of the Week” feed contains information about, and a link to the most recent Image in Clinical Medicine. Four times a year, this feed will also contain information about a current “Medical Mystery.”

Another thing I liked is the: Drag and Drop Images to Create a PowerPoint Slideshow

Search NEJM Online for medical images, then drag and drop to create a PowerPoint slide set you can save to your desktop.

And yes I did put RSS feeds of the major medical journals -- NEJM, JAMA, BMJ, Lancet and Annals on my iGoogle Home Page on a Separate Tab

Thanks Clinical Cases and Images

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In an Editorial in the American Journal of Psychiatry the author recommends the use of five psychological symptoms of depression as sufficient for the diagnosis of Major Depression. Diagnosing Major Depression on the basis of a restricted symptom set.

Moreover, the justification for this restriction according to the author, is based on studies that showed that psychiatry and primary care trainees could not remember the nine symptoms.

That's why they are trainees

He replicated the findings of Zimmerman et al, using the 12 month version of the Composite International Diagnostic Interview (CIDI), famous for the inclusion of false positivies.

In the process this also means loosing classifications such as atypical or psychotic or melancholic depression. Diagnosing major depression has serious consequences, not a trifle matter. It could mean prescribing antidepressants for months, admittance or even other major interventions.

Dr Shock is not very keen on this development, what do you think?

Symptoms proposed, three or more of these five should be enough according to the author:
1. Depressed mood
2. Lack of interest
3. Worthlessness
4. Poor concentration
5. Thoughts of Death

They used data from the 10,641 respondents to the Australian National Survey of Mental Health and Well-Being (free full text), which used the 12-month version of the Composite International Diagnostic Interview, Version 2.1. Nineteen percent of respondents reported 2 weeks of either depressed mood or loss of interest in the past 12 months, and all of these respondents were asked questions about every DSM-IV symptom for criterion A of major depressive disorder. Six percent met criteria for major depressive disorder during the year; one-half were current cases. The first replication included all respondents and showed 99.6% agreement between the full and restricted definitions. The large number without major depressive disorder could have inflated the measures of agreement. In order to recreate the clinical characteristics of the Zimmerman et al. sample, we focused on the 1,013 people from the Australian survey who met criteria for current mood, anxiety, or substance use disorders. This second replication (Table 1) showed 96.8% agreement between the full and restricted definitions. Substantially the same people were diagnosed by the full and restricted definitions in both replications.

Related posts on this blog:
Depression doesn't exist
In the BMJ
Is Depression overdiagnosed?




Andrews, G., Slade, T., Sunderland, M., Anderson, T. (2007). Issues for DSM-V: Simplifying DSM-IV to Enhance Utility: The Case of Major Depressive Disorder. American Journal of Psychiatry, 164(12), 1784-1785. DOI: 10.1176/appi.ajp.2007.07060928

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Which human behaviors are unique compared to other primates such as monkeys and apes?

• Advanced planning. We humans are able to plan ahead. Planting crops for harvests later on. Humans have a ability to trade immediate gratification for long term rewards.


• Culture innovation and teaching through language. Apes show some signs of rudimentary culture, such as different traditions in the use of tools to crack nuts. But the complex cultures produced by humans societies are unique to our species.Humans are good imitators, they accumulate culture and knowledge over generations.


• Altruism. Humans can a lend a helping hand to another without expecting anything in return.Chimps, although remarkably cooperative most of the time, do not spontaneously help fellow apes.For what reason do humans engage in spontaneous altruism? Most probably due to the fact that humans are cooperative breeders. Off-spring is also taken care of by other adults such as grandparents, siblings and friends.


• Social organization and cooperation

This is a very short version of a enjoyable read of an article in Science: Why We're Different: Probing the Gap Between Apes and Humans.
My interest in Apes and Monkeys besides their valuable contributions to a better understanding of Neuroscience? I was born in the year of the ape according to Chinese Astrology.

Related post on this blog:
What distinguishes us from the chimpanzee? The Ultimate Game.


Balter, M. (2008). HUMAN EVOLUTION: Why We're Different: Probing the Gap Between Apes and Humans. Science, 319(5862), 404-405. DOI: 10.1126/science.319.5862.404

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In pictures in the 2 largest medical journals in Sweden over a period of 1 year the majority (64%) of women doctors were dressed in white coats. The majority of male doctors (59%) appeared in civil dress.

The author of the letter to the editor in Medical Education asks herself if women still need to wear a white coat to be recognized as doctors and not be mistaken for nurses. Such images may maintain and reinforce gender inequalities. High-prestige specialties such as cardiology and neurosurgery are dominated by men, whereas psychiatry, dermatology and geriatrics are dominated by women.

The role of media representations as cause for this segregation has been studied by the author and her team in a research project at the Medical School in Umea, Sweden.

They investigated how female and male doctors were presented in the 2 largest medical journals in Sweden. All picture during a period of 1 year were counted and their relevant details gathered and analyzed.

1. Of all pictures 66% presented men, the actual percentage in the workforce in that year was 60%.
2. 85% of pictures in editorials were from men, in debates 77% and 70% in marks of honor featured men.
3. Women featured more often in chronicles (53%), columns and personal diaries.
4. Men were more often pictured in leading, demonstrating or speaking positions
5. Women were more often depicted in consultations or in bedside activities.

Eva E Johansson, Hanna Röjlar, Bodil Eriksson, Kristina Frisk (2008)
Gender differences in media portrayals of doctors: a challenge in the socialisation of next-generation doctors
Medical Education 42 (2), 226–226.
doi:10.1111/j.1365-2923.2007.02983.x

.

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I am a great fan of Sigmund Freud and psychoanalysis. Weird for a clinician with interest in neuroscience? No, Freud was probably the first biological psychiatrist. Freud started out as an anatomist in 1887. He started studying single nerve cells. It was only later, after he began treating mentally ill patients that Freud got interested in the unconscious mental processes. As the Nazi influence increased in Austria he fled to London. He arrived in England in June 1938 and was shown the beautiful house on the outskirts of London that he was to live in. On seeing the tranquility and civility that his forced emigration had brought him to, he was moved to whisper with typical Viennese irony: "Heil Hitler".

The New England Journal has a review on the book: The Death of Sigmund Freud: The Legacy of His Last Days by Mark Edmundson. 276 pp. New York, Bloomsbury, 2007. $25.95. ISBN 978-1-58234-537-6.

You are warned, may be not on my list

Edmundson, a professor of literature at the University of Virginia, interacts with Freud on a literary level in a sort of prolonged literary reflection on Freud's later work. His presentation of Freud's thought is laced with comparisons to the thought of a host of literary lights: William Blake, Sylvia Plath, Charles Dickens, Mark Twain, John Milton, Salman Rushdie, Saul Bellow, and others. Despite the historical appearance of the book, though, Edmundson decontextualizes and idealizes Freud. He takes Freud out of his medical context almost entirely, minimizing the reality that although psychoanalysis has become something of a fixture in Western culture, its status as a scientific theory is in decline. The book contains a fairly lengthy bibliography and 234 brief endnotes, but it skims across the surface of relevant scholarship on Freud, plucking out what strikes the author's fancy and ignoring the rest. Edmundson writes about Freud's views of America without referring to the two volumes on Freud and Freudianism in the United States by Nathan G. Hale, Jr., and he ignores Frank Sulloway's influential biography, Freud, Biologist of the Mind: Beyond the Psychoanalytic Legend (first published in 1979).

Edmundson's Freud is a postreligion thinker who can serve as a guide for life in the current world situation and whose concepts have a practical use and a political application. Although Freud's ideas about religion are central to this book, Edmundson accepts these ideas uncritically and does not engage the thoughts of many other writers on Freud's religion who have taken different and more historically nuanced approaches. Edmundson writes as though major works on Freud's view of God by Hans Küng, William W. Meissner, Gregory Zilboorg, and others did not exist.

At about page 150, this book becomes a lengthy critique of fundamentalism and "patriarchal religion," both of which Edmundson associates with fascism. He apparently believes that psychoanalysis offers a way forward for humanity, explaining that, "To Freud, the self-aware person is continually in the process of deconstructing various god replacements. . . . He feels, on balance, more than fortunate to be alive. Such people can be quite formidable when they're pushed to the wall. (Fundamentalists and fascists should be warned.)" In truth, to offer up a postmodern literary interpretation of Freud's sociological and anthropologic works as a solution to the political ills of the world is naive.

Psychoanalytic "enlightenment" comes with extensive psychotherapy and reflection, and it is a luxury that few can afford even in the West. Although this book is postmodern in outlook, it takes a rather old-fashioned Whig approach to history that portrays Freud as a man ahead of his time whose thought can be isolated from historical context and universalized. For those who have more than a passing acquaintance with Freud, there is little new in this book and much to take issue with.

Related post on this blog:
15 Common Defense Mechanisms

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The book Psychotic Depression by Conrad M. Swartz and Edward Shorter (New York, Cambridge University Press 2007, 344 pages, $85) is reviewed in the most recent item of the New England Journal of Medicine. Since it is not freely accessible here the most important part of a short review:

Psychotic Depression is not an arcane diagnostic polemic, and much of the information in it is of interest to the general medical reader. On the other hand, the final chapters and appendixes that try to give a practical outline of treatment seem tacked on and are not authoritative or clearly referenced. The most interesting parts of the book are the discussions of historical cases, such as that of the poet Sylvia Plath and that of Andrea Yates, who drowned her five children in a bathtub in her Texas home in 2001 while in a psychotic depression.

The book lacks a central thesis other than a desire to make general medical practitioners aware that this subtyping of depression may be useful. But the authors did not succeed in truly convincing me. Instead they raised in me a subliminal anxiety because in the past, the introduction of new diagnostic systems in psychiatry was often seen as progress, when in fact these new systems diverted attention from empirical psychiatric research.

An easy accessible review online is from Dr. Block, clinical associate professor, Department of Psychiatry, University of Medicine and Dentistry of New Jersey, Newark.
Read her review of Psychotic Depression on Psychiatric Services

I know I should do it myself, it is on my list.

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Both increase the exercise regulated gene for producing VGF a neuropeptide precursor. The administration of synthetic VGF-derived peptide produces a robust antidepressant effect in mice. Blocking the gene for VGF inhibited the effect of exercise and induced depressive-like behavior in the mice.

This information further supports the benefit of exercise and provides a novel target for the development of new antidepressants with a different mode of action than the ones now being used.

From Science Daily

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Shrink Rap and I share an interest in Neuroanatomy. In a recent post 8 links to different interactive sites on neuroanatomy: Interactive Brains. Check it out.

Here are some sites discussed in posts on this blog:
The Brain from Top to Bottom
Do you have some more please let me know in a comment.

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Read the book. Liked it a lot. It is not about how to use PowerPoint. It doesn't provide step by step instructions to make slides. It is more of an approach, a road, a direction, a frame of mind, a philosophy.
The book is divided in three sections: Preparation, Design, and Delivery. I liked the design part the best.
Preparation is about ditching "dead by PowerPoint", "bullet points driven slides". From his point of view he explains clearly why bullet points and the hampered use of graphics can only confuse the audience. The emphasize is on beautiful designed slides with pictures or graphics that illustrates the point your making in your presentation.
During preparations he encourages you not to start with the computer and PowerPoint but he explains "analog techniques" to develop your presentations by using sticky notes, whiteboards, and post-its. Especially useful for academics is the use of hand out instead of cluttered slides with to much information.

Yes I hear you think, can academics use this approach? Yes they can. Even data can be presented in a more fashionable way. More understandable. Slide design can make the difference in understanding more clearly what point your trying to make. Here is an example:



The Design section is filled with examples of slides and tips on how to design slides. Not in a step by step approach but by explaining basic design principles such as Signal vs Noise Ratio, Picture Superiority Effect, Empty Space, Contrast, Repetition, Alignment, and Proximity.
This section has a lot of examples.
You can see presentations based on this approach on slideshare.net:
Lecture by Jeff Brenamn, CEO Apollo Ideas, with a medical topic, excellent example
Lecture by Chris Landry Director of Food Development & Communications
Lecture by G Kawasaki, Co-founder of Truemors

The last section is about actually giving the presentation.

As mentioned before I liked the book, it is a new approach to doing presentations, more visual, more focus. I read this book after I had read Beyond Bullet Points (BBP). This book is more of a step by step approach. It explains how you build a presentation on a storyboard. These two books complement each other because in Beyond Bullet Points emphasize is also placed on visuals and design next to the build up of the story. BBP has examples on how to use the approach also for academic presentations.
I read the first and second edition of BBP. Both depend a lot on Microsoft Office especially PowerPoint. The second edition focuses on Office 2007 which is not very compatible with older versions of Office and is not widely present on computers in the Academia.



I tried BBP twice giving lectures to students and colleagues. I liked it. It is not faster it takes more time to prepare the lecture and the slides but the results are very satisfactory. If you are in to something new read BBP first and than PresentationZen, enjoy.

The author of presentationzen has a blog all about presentations on presentationzen.com also with slide examples

Also an example of the recent presentation of Steve Jobs: 6 Presentation tips from a Steve Jobs keynote, according to the book a amster in the art of presentationzen. With a comprehensive video of the keynote presentation (60 sec).

More presentations tips:
Creating Impressive PowerPoint presentations
PowerPoint Presentations: Tips To Avoid Last Minute Surprises
5 ways to screw up your talk from GTD in Academia

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This is what Scientology can do to you.

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Blue Snow... When life is a suffering, when thoughts are torture, and pleasure is a long-gone memory - Depressed? Burned out? Anxious? Cyclothymic? This page is for you...

Blue Snow a site with some advice. But also very nice is clicking the door on the bottom right to the Blue Snow Experience.
Make some time to watch it.

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• Evaluating Internet Resources from National Network of Libraries of Medicine


• How to Evaluate Health Information on the Internet from the FDA


• How To Evaluate Health Information on the Internet: Questions and Answers from the National Cancer Institute

I warned you

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At work I get a lot of request to explain RSS feeds. Told the residents about them a few months ago, well here is a link with everything and I mean everything about RSS feeds and their use: Favorite RSS Resources and Tools at davidrothman.net.

From explaining RSS feeds to how to use them with PubMed.

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The strongest evidence exists for Broadman Area 25 as target for deep brain stimulation in treatment resistant depression. This area in the brain is depicted in te figure above and is from the most important publication about DBS and depression in Neuron march 2005 by Helen Mayberg. Functional neuroimaging as well as antidepressant treatment effects suggest that this area plays an important role in modulating negative mood states. A decrease in activity is reported with clinical response to antidepressants and electroconvulsive therapy (ECT).

But depression is not a disease of a single brain region nor neurotransmitter system. It is now generally viewed as a systems-level disorder affecting integrated pathways linking select cortical, subcortical, and limbic brain regions with their related neurotransmitter systems.

Suggestions of other brain localizations for treatment with DBS for depression comes from case reports with DBS for other indications than depression. In a case report of a 56 year old patient with obsessive compulsive disorder and major depression suggests that deep brain stimulation of the ventral caudate nucleus could be a promising strategy for treatment of refractory cases of both OCD and major depression. The caudate nucleus is depicted in the figure below.



In another case report DBS was used to treat severe tardive dyskinesia in a patient suffering from major depression. DBS was performed bilaterally in the globus pallidus. The dyskinesia as well as the depression improved substantially.



In another case report deep brain stimulation was used for treatment resistant depression in a patient with borderline personality disorder and bulimia. Stimulation was targeted bilateral with eight-contact electrodes of areas at and around the inferior thalamic peduncle. The inferior thalamic peduncle is depicted in the figure below with a light blue circle. There was a good effect on depression. Depression improved progressively over a period of eight months to normal level. On an Off period of stimulation the depression took a fluctuating course. Therefore the authors were not able to prove that the electrical current induced the beneficial effects. Complete return of depression in an Off period would have. Bulimia did not subside with DBS.



Since these are case reports possible influences by placebo effect or other explanations for success can not be ruled out and these results should be interpreted with caution. Nevertheless since the authors usually select the targets based on hypothesis of function and relationships with depression further research on these techniques should be used in an extended study with treatment resistant depression.

Two other area's are suggested in two publications in Medical Hypotheses in 2006 and 2007. Broadman area 24a and the lateral habenula are suggested in these articles as targets for deep brain stimulation for treatment refractory depression. The habenula is depicted with number 5 in the figure below. Both hypotheses are based on findings of clinical imaging studies, animal models, SPECT and PET scans.


Articles Discussed:
Sartorius A, Henn FA.
1 Deep brain stimulation of the lateral habenula in treatment resistant major
depression.
Med Hypotheses. 2007;69(6):1305-8. Epub 2007 May 10.
PMID: 17498883 [PubMed - indexed for MEDLINE]

2: Kosel M, Sturm V, Frick C, Lenartz D, Zeidler G, Brodesser D, Schlaepfer TE.
Mood improvement after deep brain stimulation of the internal globus pallidus for
tardive dyskinesia in a patient suffering from major depression.
J Psychiatr Res. 2007 Nov;41(9):801-3. Epub 2006 Sep 8.
PMID: 16962613 [PubMed - indexed for MEDLINE]

3: Aouizerate B, Martin-Guehl C, Cuny E, Guehl D, Amieva H, Benazzouz A,
Fabrigoule C, Bioulac B, Tignol J, Burbaud P.
Deep brain stimulation for OCD and major depression.
Am J Psychiatry. 2005 Nov;162(11):2192. No abstract available.
PMID: 16263870 [PubMed - indexed for MEDLINE]

4: Schlaepfer TE, Lieb K.
Deep brain stimulation for treatment of refractory depression.
Lancet. 2005 Oct 22-28;366(9495):1420-2. No abstract available.
PMID: 16243078 [PubMed - indexed for MEDLINE]

5: Jiménez F, Velasco F, Salin-Pascual R, Hernández JA, Velasco M, Criales JL,
Nicolini H.
A patient with a resistant major depression disorder treated with deep brain
stimulation in the inferior thalamic peduncle.
Neurosurgery. 2005 Sep;57(3):585-93; discussion 585-93.
PMID: 16145540 [PubMed - indexed for MEDLINE]

6: Mayberg HS, Lozano AM, Voon V, McNeely HE, Seminowicz D, Hamani C, Schwalb JM,
Kennedy SH.
Deep brain stimulation for treatment-resistant depression.
Neuron. 2005 Mar 3;45(5):651-60.
PMID: 15748841 [PubMed - indexed for MEDLINE]


Related posts on this blog:

The Switch That Lifts Depression

DBS resolves coma

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Recently we are the proud owners of a digital patient record form in our department. This means putting all your notes, lab results and other patient data down in to the computer.

During staff meetings it also meant sitting down around a table with at least 10 expensive professionals watching a secretary walking through at least nine steps on screen before relevant information could be typed down into the patient record form and hoping the program won't freeze.

Getting tired of loosing a lot of valuable time we decided to skip the digital patient record form and instead type the conclusions and treatment plan in a word file. Afterwards this file is sent to the secretary who copies and pastes our efforts into the patient record form. Saves a lot of time.

Beside this practical solution to a meeting getting out of hand and becoming inefficient there are other solutions to boring and often redundant meetings. Especially the Dutch are famous for their meetings. No wonder the "poldermodel" was invented by the Dutch, it meant endless discussions in to many meetings.
We even have specialized companies dealing with insufficient meeting cultures in companies: In Company Services of Vergaderkundig Bureau Van Vree

Our approach of meeting-problems consists of a sophisticated combination of benchmarking meeting-cultures, coaching, and tailor-made presentations, seminars and workshops. Employees will be jointly equipped with adequate skills and tools, and adhere to actually make use of them.

Other practical original and creative solutions for prevention of to many or to long meetings are:

• Hold the meeting while standing. This makes meetings shorter. Participants need to be more active during the meeting, they can't simply sit back and watch. There are even special meeting tables which can vary in height so you can sit as well as stand at the table.


• Start with the important topics. Don't start with the minutes. Save them till the end. Otherwise a lot of valuable time is lost discussing the minutes while most of the topics in the minutes should be discussed in the meeting.


• Stick to the time the meeting should begin and end. Don't allow waiting for late comers or holding the meeting to long. Quit when it is time, people have other appointments. If you plan longer they will certainly fill the time with talking to long about details or they will talk about this, that and the other. Meetings should take to long it is better to hold two meetings than one long meeting. Concentration decreases over time.


• Don't let everybody sit in the same seat every meeting. Let them take seats in alphabetical order, this increases the interaction.


• Be absolutely clear about the meaning and status of a meeting. Lack of clarity leads to irritation, the meeting will feel like a waist of time.


• Be aware of the costs of a meeting. Illustrate this by a calculation of the total sum of labor costs for all professionals attending the meeting and the costs of the room and equipment needed. You'll be surprised how much a meeting of one hour with all those expensive professionals will cost. Now and then screen all your meetings. Are they still needed?


• Meet only when needed. Not because they were planned or scheduled. Use meetings for important topics not just to chat away.

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A joint team from both the Mayo Clinic and IBM is working to find ways to use the Cell chip, mostly known for running inside the PlayStation 3 videogame console, in a medical imaging system.

"This is focusing on the quality of the medicine," said Erickson. "We might take an image of someone's brain tumor to see if it's getting better or worse or staying the same. We're looking for really subtle changes. You might find out after two months of radiation that it's not working, and you want to switch their treatment. If you have a human interpret that image, they may not see any difference, and the doctor will have them keep on with that same treatment, which in reality is not helping. ... We can have a computer take that image and focus more quickly on what areas need attention."

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Who remembers the Eagleton affaire. Neither did I until I read this article: History, power and electricity: american popular magazine accounts of electroconvulsive therapy, 1940-2005. Senator Thomas Francis Eagleton of Missouri was the running mate for George McGovern, the Democratic candidate for the election for the Presidency of the United States in 1972. He had to step back because of his disclosure having had ECT in the mid 60's.

The drama began early in the week when Eagleton was forced to reveal that on three occasions, in 1960, 1964 and 1966, he had been hospitalized in St. Louis or at the Mayo Clinic for nervous exhaustion. When the McGovern camp learned that the Knight newspapers were ready to break a story on Eagleton's medical history (see THE PRESS), McGovern and his running mate decided to break the news themselves at a press conference in Sylvan Lake, S. Dak. Eagleton described himself as "an intense and hard-fighting person," and added: "I sometimes push myself too far." After his successful 1960 campaign for attorney general of Missouri, he was hospitalized in St. Louis "on my own volition" for about four weeks for "exhaustion and fatigue." He spent four days at the Mayo Clinic in 1964, and about three weeks in 1966. On two of those occasions, in 1960 and 1966, he underwent electric-shock therapy for depression. Now, he said, "I have every confidence that I've learned how to pace myself and know the limits of my own endurance."

Was he the only one with a psychiatric history in those days?

Past U.S. Presidents have had their emotional problems: John Adams had several nervous breakdowns, Franklin Pierce was an alcoholic, Abraham Lincoln had recurring periods of near-suicidal depression, Rutherford Hayes as a young man wandered about the streets of Sandusky, Ohio, weeping uncontrollably. Lesser officials have also been afflicted. Secretary of Defense James Forrestal committed suicide in 1949 while hospitalized for involutional melancholia. Alabama Governor George Wallace, who announced last week that he would not seek a third-party nomination this year, still receives a 10% disability check from the Veterans Administration because of "psychoneurosis" incurred during World War II. As for Eagleton's illness, medical experts know neither what causes depression nor why electric-shock therapy is effective against it, but most of them insist that it is a relatively common ailment and by no means a permanent disability

The Time coverage of the Eagleton affaire was generally negative especially about having had ECT. It portrayed ECT as a relic from the past. The accompanying photograph used was made in 1949. They even compared the stimulus characteristics to those used for the electric chair. This publication came in a time that the anti psychiatry movement was at it's peak.

The coverage in Newsweek was of a completely different nature. The Newsweek article emphasised the ways in which modern ECT was a significant improvement over the past practice. The Newsweek coverage was more balanced and sympathetic toward Eagleton. Newsweek doesn't have a large archive such as Times so I couldn't verify it.

The article in Time ends with:

While recurrence of depression cannot be ruled out, the fact that Eagleton has gone six years without treatment and has performed effectively in office makes it less likely. Lebensohn says he treated high political figures as long as 20 years ago without noting any later ineffectiveness among them. Some psychiatrists even say that Eagleton may be less likely to break under pressure than those who have never undergone such therapy. A period of depression, the A.P.A. panel insists, does not permanently impair a person's judgment.

How did he do after his resignation? You can read it on Countenance Blog The Eagleton Affair

How did the press find out about the medical history of Eagleton? DailyKos has an explanation:

However, it was discovered during the Watergate trial that John Ehrlichman, a whitehouse aide, had a safe that contained copies of hospital records of Democratic Senator Thomas Eagleton's treatment for mental illness.

What do you think, is prior psychiatric history of influence in elections in our days?


Articles used:
J Hist Behav Sci. 2008 Jan 14;44(1):1-18 [Epub ahead of print]
History, power, and electricity: American popular magazine accounts of
electroconvulsive therapy, 1940-2005.
Hirshbein L, Sarvananda S.
University of Michigan, Lapeer, Michigan.
PMID: 18196545

Time, August 7, 1972

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AMERICA lags behind other wealthy countries in the overall performance of its medical system. A new study by researchers at the London School of Hygiene and Tropical Medicine looks at data from 19 countries for deaths of under 75-year-olds that should have been avoided with proper health care. Preventable deaths declined by 16% on average in these countries between 1997 and 2003. Big improvements were recorded in countries that started with both low levels of avoidable deaths (like France) and those with higher levels (like Britain). But America, where health-care spending per head is highest, is at the bottom of the table.

From The Economist.com

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Review of the book: Out of the Black Hole on About.com: depression.

You can get it amazon.com

The book is extensively reviewed on amazon, 27 reviews. One important note from these reviews:

Mr. Donovan wrote and self-published this book and simultaneously started an informational web site. It's to his credit that he took the initiative to do these things after a lengthy and debilitating depression, but before you pay $34.95 for this publication, you may want to know that of the 173 pages of this book, only 95 contain original material, the author's story. The balance of the book, the appendices, are--although good information-- drawn from other sources, and readily available without charge from those sources.

Anyone some more information about this book?

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Two nice posts about these subjects, only the connection is mine:
9 Great Ways to make Yourself Miserable
How to Cope when Something goes Terribly Wrong

Well written and humorous, so if your in a dump go read them.

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My aunt attended me to this video, I liked it. By the way she is American.
What do you think

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This video is in Dutch but illustrative.

No hassle with treatment-resistant depressed patients, no comparison with Electroconvulsive Therapy or any other treatment for that matter. Just plain Personalized Medicine what ever that may be. And a nice website: Brainclinics Diagnostics & Treatment rTMS results (in English)

In the Brainclinics Treatment clinic in Nijmegen (The Netherlands) rTMS has been applied over the last year in a practical setting and combined with psychotherapy. In this setting any client with depression is treated (so not only treatment resistive patients). The rTMS treatment is personalized for every client using their individual QEEG on the basis of which the stimulation site is chosen. Furthermore, the EEG is used to rule out contra-indications – such as paroxysmal activity and the presence of beta spindles.

Personalized Medicine?

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Vagus Nerve Stimulation or VNS is hampered by insufficient research. After one disappointing publication of the results of a sham controlled multi site double-blind trial in a large sample no scientific important trials are conducted. This one trial did not demonstrate superiority of active VNS treatment over sham treatments after 3 months.

Since then (2005) another trial was conducted in Europe; an open uncontrolled multi-centre study. This trial used the same protocol as the first open, unblinded four centre pilot study of 60 patients in the US.

The authors mention the argument sometimes used that it is unethical to use a controlled design with a sham condition. We are talking about patients treated with 3-7 different antidepressants and/or ECT. Mostly ill for years. I think it unethical to conduct another uncontrolled trial which will help our knowledge about the efficacy of VNS no further. Besides implanting a VNS is not peanuts nor going to a protocol of up to 1 year.


Anyway, this open study also finds that the efficacy of VNS increases over time. The follow-up in this study is up to 12 months. Again efficacy is hard to interpret since it open labeled uncontrolled design.

VNS

VNS received FDA approval in July 2005 for adjunctive, long-term use in chronic or recurrent major depression in adult patients with an inadequate response to at least four antidepressant treatments. You could say it is an option after other treatments for depression has failed

Website with a lot of information on VNS: VNSDepression.com

Related post on this blog:
5 blogposts on Vagus Nerve Stimulation (Round Up)

Article discussed:
Psychol Med. 2008 Jan 4;:1-11 [Epub ahead of print]

Vagus nerve stimulation for depression: efficacy and safety in a European study.

Schlaepfer TE, Frick C, Zobel A, Maier W, Heuser I, Bajbouj M, O'Keane V,
Corcoran C, Adolfsson R, Trimble M, Rau H, Hoff HJ, Padberg F, Müller-Siecheneder
F, Audenaert K, Van den Abbeele D, Matthews K, Christmas D, Stanga Z, Hasdemir M.

Departments of Psychiatry and Mental Health, The Johns Hopkins University,
Baltimore, MD, USA.

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On June 1, 2007 the reality television show in which "Lisa", a supposedly dying woman, had to decide one of three contestants to whom she would donate a kidney was a hoax. Nevertheless it drew attention to the problem that in The Netherlands there is a shortage of donors. This is due to the fact that in the Netherlands you have to explicitly declare they can use organs after your death. A lot of people in the Netherlands never fill in the form, relatives usually will not give permission to use any organs because it was never a topic discussed with the deceased.
The dutch government is to hesitant to make a law that will allow organ donation unless you have explicitly denied the use of your organs after death.

Now almost one year later:

• The number of transplanted patients increased with 28% to 1100 patients in 2007


• The number of patients waiting for a transplant organ has decreased in 2007 from 1441 to 1284


• The waiting list for a transplant organ consists mainly of patients waiting for a kidney. The number of patients on the waiting list has decreased with 13% compared to January 2007

In the UK they have a complete different approach to this problem, on BBC News:PM backs automatic organ donation

Gordon Brown says he wants a national debate on whether to change the system of organ donation.

He believes thousands of lives would be saved if everyone was automatically placed on the donor register.

It would mean that, unless people opted out of the register or family members objected, hospitals would be allowed to use their organs for transplants.

Related post on this blog:
Dutch Kidney Reality Show a Hoax

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A recent study indicates that lifestyle intervention and metformine in combination has the greatest effect on weight loss and increases insulin sensitivity for patients taking atypical antipsychotics. These methods result in a decrease of 1.8 of the BMI, an increase in insulin resistance index of 3.6 and the waist circumference decreases with 2.0 cm. This is important because all antipsychotics but especially the atypical antipsychotics have weight gain as a common side-effect. Clozapine and olanzapine produce the most weight gainfollowed by quetiapine and risperidone. Ziprasidone and aripiprazole produce the least weight gain.
Metformin alone was more effective than lifestyle intervention alone in increasing insulin sensitivity and reversing weight gain.

Why is this important?
Weight gain influences adherence to drug therapy. Overweight is an important risk factor for cardiovascular disease such as hypertension, diabetes and heart disease.
Outpatient mental health clinics should also provide these measures to their patients when they are on atypical antipsychotics

The mechanism underlying weight gain resulting from atypical antipsychotics is not fully understood. It could be caused by influencing brain receptors that can lead to increase in appetite. It can also impair metabolic regulation and alteration of insulin sensitivity.


The Treatment
Metformin inhibits hepatic glucose production. It is well tolerated and prevents continual weight gain while it decreases measures of insulin resistance. Insulin resistance is a risk factor for diabetes type II.
The lifestyle intervention included psycho-education, dietary, and exercise programs.
The psycho-education focused on eating and activity and how these can influence weight management.
The diet prescribed was less than 30% of total calories from fat (<7% satured fat and <200 mg of vcholesterol); 55% from carbohydrates; and more than 15% from protein daily with an increase in fiber intake to at least 15 gr per 1000 kcal. The so called American Hearty Association step 2 diet
Exercise for at least 30 minutes per day. It consisted of walking bicycling, jogging ball games. The therapists and patients collaboratively developed individual programs of gradual assignment of exercise.

BMI=body mass index:
The BMI is one of the most accurate ways to determine whether an adult is overweight. It is a gauge of total body fat, calculated by dividing the person's weight (in kilograms) by his or her height (in square meters). A person with a BMI of 25 or greater is considered to be overweight and with a BMI of 30 or greater is considered to be obese.

Insulin resistance
In a person with normal metabolism, insulin is released from the beta (β) cells of the Islets of Langerhans located in the pancreas after eating ("postprandial"), and it signals insulin-sensitive tissues in the body (e.g., muscle, adipose) to absorb glucose to lower blood glucose to a normal level (approximately 5 mmol/L (mM), or 90 mg/dL). In an insulin-resistant person, normal levels of insulin do not trigger the signal for glucose absorption by muscle and adipose cells. To compensate for this, the pancreas in an insulin-resistant individual releases much more insulin such that the cells are adequately triggered to absorb glucose. On occasion, this can lead to a steep drop in blood sugar and a hypoglycemic reaction several hours after the meal.

Article discussed:
JAMA. 2008 Jan 9;299(2):185-93.
Lifestyle intervention and metformin for treatment of antipsychotic-induced
weight gain: a randomized controlled trial.
Wu RR, Zhao JP, Jin H, Shao P, Fang MS, Guo XF, He YQ, Liu YJ, Chen JD, Li LH.
PMID: 18182600

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• Patients consider their depression due to external sources of stress or conflict. These include: conflict with work colleagues, or family, chronic illness, events in childhood, material disadvantages and racism. Doctors mostly think of depression in terms of presence of symptoms, in terms of illness. Being unable to cope and disturbances in everyday functioning and social roles (e.g. husband or wife, caretaker, breadwinner)is what depressed patients perceive



• Seeking help from general practitioners or other health professionals by depressed patients is problematic. Mostly done as an option of last resort, rather than through a specific expectation. Doctors mostly think patients visit them with a specific expectation that assessing the service will be helpful. Patients visit their GP because inaction was leading to negative consequences for other family members, complicated by feelings of guilt, or shame and lack of legitimacy. Asking for help is probably also perceived as a threat to an already weakened sense of self. There might be fear for treatment options that a patient might find unacceptable. Covert presentation of psychological problems is another obstacle in diagnosing depression.



• Seeking help and treatment is primarily associated with failure of strategies to cope by patients. These failing coping strategies are mostly seeking distraction or the use of particular locations associated with feelings of safety and control. Seeking help is not associated by patients with negative feelings or symptoms of depression. Taking medication e.g. is mostly not a measure for patients to feel in control and recovering a sense of self and social functioning.



• Stigma associated with treatment due to feelings of loss of control, lack of legitimacy in seeking help for a non-physical problem. Lack of control especially due to taking medication (antidepressants). Taking medication is related to a moral discourse about personal responsibility, the fear of loss of function in everyday life and a need to accept help for the sake of others. What to tell others that they were taking antidepressants, taking medication was perceived as somehow deficient, afraid of long term changes to their personality.



• Understanding of self-help is difficult when suffering from low self-esteem and lack of motivation.

How can these insights help guided self-help?

• Patients description of their problems differs from the biomedical model such as used by doctors. The subjective experience of depression with the need to restore social functioning should be prioritized over symptoms. Maximize the resources the patients already bring with them. Be aware of the patients' own constructions of depression and their current coping mechanism.


• Promote primary care as an appropriate place for mental health problems, not only physical symptoms. Primary care as a suitable location for mental health care


• Patients develop individual strategies for controlling feelings. Guided self-help is largely based on cognitive behavioral therapy. It may not be optimal to replace every day strategies with evidence-based strategies. Accept the individual strategies as important and built the self-help on them.


• Provide means of management of depression wider than medication. Make it more acceptable to them and others around them.


• Promote the feelings of strength to overcome negative feelings and depression. The self as mechanism of change of taking control. Support the active role of the patients. Control and social functioning are important to patients.

Now these mutterings are the interpretation by yours truly of a recent article. What do you think? Do these differences and advise regarding self help sound reasonable? Or are they just another misconception by a good willing professional?


Article used:
Br J Psychiatry. 2007 Sep;191:206-11.
Guided self-help in primary care mental health: meta-synthesis of qualitative
studies of patient experience.
Khan N, Bower P, Rogers A.
PMID: 17766759

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