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Sunday, December 23, 2007

4 times Dutch Delight and a Poll

Regularly I discuss recent articles about different subjects related to medicine, psychiatry and education among other subjects. The choice of articles is completely biased. It is because I think the subject is interesting, the research design is elegant or creative, the research question is relevant, or the results are important or any combination of these characteristics. Sometimes, also to my own surprise, these articles are written by Dutch authors.
This blog now exists for 9 months and it is almost the end of the year. Time to look back on these articles written by Dutch authors and to select the best ones. The articles I appreciated the most. This selection is completely arbitrary based on my personal preferences but nevertheless here they are:

1. The use of SSRIs and venlafaxine among children and adolescents in Dutch general practice decreased between 2001 and 2005. A point of concern is the high percentage off-label prescribing of SSRIs and venlafaxine in 2005 as compared to 2001. Not very creative kind of research but very practical with a clear message: Watch out for prescriptions of off lable drugs in children. I hope they will look into this matter in the near future.

2. A disappointing conclusion in this meta analysis: Efficacy of Internet based Cognitive Behavioral Therapy (CBT) for depression and anxiety disappointing. In a recent meta-analysis CBT for depression and anxiety was modestly effective compared to placebo, care as usual, or waiting list conditions. There was also a significant heterogeneity between trials. In short the trials are different and hard to compare.

3. Bold statements mostly done by senior staff members during grand rounds about material that is less well known occurs frequently. Such bold statements are frequently articulated with great conviction and are usually accepted and assimilated by junior staff and the likes of them.
In this article the authors found only 8 (32%) statements to be supported by scientific evidence. In 17 (68%) statements the available literature contradicted (n=13) the statement, or no literature was avalable (n=4). A lot of bull doe ushered during Grand Rounds.

4. 38 of 50 elderly patients refused randomisation beforehand in this trial because of fear of electroconvulsive therapy (ECT). An in depth interview showed that fear of brain damage by ECT played a major role. This recently published study was a feasibility study testing the efficacy and safety of ECT, prescribed in an earlier phase of treatment than last resort. This study would test the efficacy of ECT versus nortrityline among depressed elderly (> 59 years) who had not responded to sertraline, a selective serotonin reuptake inhibitor (SSRI). The wrong assumption that ECT causes brain damage might be a vestige of the seventy's and the dark period of the anti psychiatry in the Netherlands in that same period.

Which of these articles did you like the most, take the poll on the top right,

Regards Dr Shock.


Anonymous said...

Dear Dr. Shock,

“The wrong assumption that ECT causes brain damage might be a vestige of the seventy's and the dark period of the anti psychiatry in the Netherlands in that same period.” --- Dr. Shock

Although I am a proponent of all treatment options that may lend benefit to those suffering from MDD (Major Depressive Disorder) including ECT, the fact still remains that ECT does have the potential for serious memory and cognitive side-effects as evidenced by Dr. Sackeim et al in their study published in Neuropsychopharmacology and therefore these potential side-effects should not be easily dismissed. In my opinion it is a therapy to be considered when the patient is experiencing or acting upon suicidal ideations and nothing else appears to be efficacious. Then again, knowing that which I do today there are also newer neuromodulation modalities I would consider prior to ECT if possible.

Electroconvulsive Therapy Causes Permanent Amnesia and Cognitive Deficits, Prominent Researcher Admits


Dr. Shock said...

Dear Herb,
Patients can have side-effects from ECT. That is why one should carefully indicate ECT. VNS can be of help for some depressed patients. Evidence of efficacy of VNS is weak for treatment resistant depression. It is necessary to find out which patients can benefit from VNS.
Regards Dr Shock

Anonymous said...

Dear Dr. Shock,

Not wanting to be remiss I want to wish you and yours and your readership a very Merry Christmas and a Happy, Healthy, Prosperous and Peaceful New Year.

“Evidence of efficacy of VNS is weak for treatment resistant depression. It is necessary to find out which patients can benefit from VNS.” --- Dr. Shock

The more I read through the Internet and similar professional blog sites as well as my experiences as a support person over some 44 years the more I am convinced of the fact that psychiatry as well as the pharmaceutical industry needs better “Evidence of efficacy…is weak for treatment resistant depression. It is necessary to find out which patients can benefit…” and that my acronym “TEAW” (Trial and Error Approach to Wellness) continues to appropriately apply to this difficult to treat patient population.

Personally I am not advocating for any particular treatment or therapy knowing intimately the TRD patient population as I do and the fact this patient population spends decades often seeking any form of relief, if ever, and that there are no means to determine which patient will or will not benefit from any of these therapies.

Star*D has given some indication that after 4 or more medication attempts that current medication therapies may not be the answer. Until such time as those of your profession obtain some kind of quantitative diagnostic means to evaluate these patients and their illness it shall remain a TEAW for these people and the compassionate, caring and knowledgeable physicians in attendance will have to continue to consider all available treatment options for their patients even when questionable study results may indicate poor percentages.

Let us also not forget the realities of many of the drug studies such as glowing short-term percentages (12 week studies) when in fact many of these difficult to treat patients are excluded from these studies so as not to skew the results and that they also experience refractory long-term results. In the case of ECT I believe we can also both acknowledge its short-term efficacy and the required need for alternative and/or adjunctive follow up therapies.

I certainly wish it could be better for these patients but my knowledge, at this time, tells me TEAW remains a reality and the patients and I have a right to much skepticism.


Dr. Shock said...

TEAW very nice, but first EBM (evidence based medicine). EBMTEAW?
Merry Christmas and good health in 2008 to you and your family and friends.

Regards Dr Shock