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Wednesday, April 30, 2008

Alzheimer Severity and Prevalence of Depression Not Associated

Comorbid depressive symptomatology or diagnosed depression is not more prevalent in early, mild or severe Alzheimer's disease. This is an important conclusion from a recent systematic review. Before theories existed about the relationship between Alzheimer's and depression. These theories said that the prevalence of depression either decreases or increases with the increasing severity of Alzheimer's disease.

This is comparable to the relationship between depression and personality, does personality predispose to depression or is personality affected by going through depression.

Previous reviews stated that no conclusions could be drawn due to large differences between studies. This review tried to overcome this problem.
They made sure all studies consisted of patients with Alzheimer, valid assessments of depression and severity of Alzheimer were performed.

Instead of a linear correlation between Alzheimer's disease and depression this result could be explained by a theory that neurological and psychosocial factors can reinforce or diminish each other, depending on the specific situation of a patient.

The real answer can only come from a longitudinal study with Alzheimer patients.

Some news about the relation between depression and Alzheimer on NYT:

A history of depression is associated with an increased risk for Alzheimer’s disease, a new study has found, especially when the depression develops before age 60.
Verkaik, R., Nuyen, J., Schellevis, F., Francke, A. (2007). The relationship between severity of Alzheimer's disease and prevalence of comorbid depressive symptoms and depression: a systematic review. International Journal of Geriatric Psychiatry, 22(11), 1063-1086. DOI: 10.1002/gps.1809

Tuesday, April 29, 2008

Personality of Online Game Players

Online game players score higher in openness, conscientiousness and extraversion compared to non players. They are eager to learn and master new challenges, they are motivated by competition and they enjoy social activities which can all be provided by online game playing.

The online game playing provides them with initial experiences of success and then provide them with more complex challenges creating a flow of immersed experience further satisfying their needs. This creates a positive spiral enhancing their online game experience.

Chin-I Teng the author of this articles says:"I also believe that skill of players matters in player intention to continuously play online games." Not only personality but also skills such as visuospatial memory,speed of reaction, problem solving skills play an important role.

Participants played various online games, including international popular games such as Warcraft3, Lineage2,Crazyracing, Rich Online, and Nostale.

Eight hundred three Taiwanese students were approached in high schools and universities, and 591 questionnaires were collected, producing an effective return ratio of 74%. The matched sample comprised 130 pairs of students, which was used for analysis. The two students in each pair were matched by gender and age because players and nonplayers were found significantly different in gender and age. A matched sample was used to minimize the confounding effects of gender and age. Seventy-one percent of participants were male, and all were between 12 and 22 years of age (Mean 16.06). Of the participants, 89% had a monthly income below U.S. $180,while 98% had access to a computer at home, reflecting the Taiwanese student population.

I wasn't sure about the design so I emailed the author and he confirmed that from the 591 students 130 pairs were formed matched for age and sexe consisting of an online gamer and someone not playing online games. The author:"Yes, each pair consist of a online game player and a non online game player."

The researchers used a scale to measure openness, conscientiousness and extracersion, the so called Mini-Marker scale of Saucier
This scale determines varying levels of introversion and extraversion. Along with introversion and extraversion the inventory also measures openness, conscientiousness, agreeableness, and neuroticism. The mini-marker asks participants to rate themselves according to 40 different measures (e.g. creative, extraverted, philosophical, and sloppy) using a Likert scale from 1 to 9, with 1 being extremely inaccurate and 9being extremely accurate. Although the mini-marker is a shortened version (about half the personality measures) of the NEO-5 factor, Saucier (1994) determined that it was representative of the full 100 trait NEO-5 factor inventory. The mini-marker was developed on behalf of many people who appreciated the fact that it was shorter and more efficient; however, Saucier (1994) stresses that because of the smaller version it may create lower reliabilities.

Online game players and non players didn't differ in agreeableness and neuroticism.

According to the authors this research shed some light on online game playing and personality, their suggestion for further research is to investigate personality to different online games.

The limitation of this study is the selection of personality traits, the change of finding what you are looking for is relatively large with this design. The selection of participants is relatively selective, students just aren't the average kid in the Internet cafe around the corner. These results can not be generalized to larger populations.So this research has some limitations nevertheless I like the outcome it counter balances all the negative publicity around internet addiction and game addiction.To my opinion these are just other disguises of the same problem and not a reason to hamper new developments such as Internet and gaming since this would lead to throw the baby out with the bath water.
Teng, C. (2008). Personality Differences between Online Game Players and Nonplayers in a Student Sample. CyberPsychology & Behavior, 11(2), 232-234. DOI: 10.1089/cpb.2007.0064

Monday, April 28, 2008

Computer Based Psychotherapy

Patients often improve more with computer based cognitive-behavioral psychotherapy than with conditions such as waiting list control or care as usual, says a recent review. This is coupled with an over 50% cut in usual therapist time. This review is published in a book: Hands-on Help Computer-aided Psychotherapy. A book review in the Am. J. Psychiatry

Hands-on Help is a narrative review of the mushrooming field of computer-aided psychotherapy for mental health problems as a whole, from the time it began in the 1960's through to the present day. The many types of computer-aided psychotherapy and how each might be accessed are detailed together with the pros and cons of such help and the functions it can serve. The authors review prevention as well as treatment.

Such a therapy for depression in the UK is called: Beating the Blues
Beating the Blues® is a computerised cognitive behavioural therapy (CCBT) program for depression and anxiety that is available via CD-ROM and the Internet. It has been shown to be a cost effective and time efficient way of helping people suffering from these conditions to get better and stay better. In Feb 2006 the National Institute of Health and Clinical Excellence (NICE) recommended Beating the Blues® as a treatment option for all people seen with mild or moderate depression.

Cognitive-behavioral psychotherapy is a form of psychotherapy that lends it self well for a computer based program. Computer based forms of Psychoanalytic Psychotherapy are far more complicated to my opinion. We recently discussed using a blog during psychodynamic psychotherapy, blogtherapy. Based on this review you can conclude that at least some patients may benefit from this kind of therapy. Nevertheless despite a lot of research questions about computer based psychotherapy remain.

  • As with other new developments healthcare companies are reluctant to pay for this kind of therapy. What should be the price and who do you have to pay. The developer of the program, the therapist working with patient and computer?

  • How much human contact with the therapist is best? No human contact at all in these programs are associated with large drop out rates.When should human contact be necessary, with intake or followup or during the program for monitoring progress?

  • How should human contact take place, by telephone, email, face to face?

  • What should be the background of the therapists? Psychologists trained in cognitive behavioral therapy, trained nurses, general practitioners, trained volunteers?

  • Most trials with CBT were with care as usual and waiting lists conditions. These trials suffer from a large placebo effect and high expectancy of the participants of the new treatment. Trials with comparison to other therapies are necessary. Knowledge of what works in this kind of psychotherapy is still fragmentary.

  • Some patients prefer live to computer-guided help. Not all depressions can be treated by computer psychotherapy. Mostly mild to moderate depression can benefit, more severe forms of depression will still need other forms of therapy of which medication is one.

Overall computer aided psychotherapy as an early option in the treatment of depression is opening up new possibilities. It can be a cost-effective treatment that can reduce chronicity and perhaps even prevalence of depression. Will computer-aided psychotherapy integrate smoothly into the palette of therapeutic options? A lot of research and time will tell.

Computer based cognitive-behavioral therapy is not only used in depression but also in other psychiatric conditions such as anxiety disorders, obsessive-compulsive disorders and problem drinking to name a few.

Advantages are:

  • No lengthy clinician contacts

  • Reduce waiting lists

  • No travel to a therapist

  • No stigma

  • Self-empowerment

What is Computer aided cognitive-behavioral therapy?
Computer-aided cognitive–behavioural therapy (CCBT) is any computing system that aids cognitive–behavioural therapy by using patient input to make at least some computations and treatment decisions. This definition excludes video conferencing and ordinary telephone and electronic mail consultations, chat rooms and support groups, which expedite communication and overcome the tyranny of distance but do not delegate any treatment tasks to a computer or other electronic device. It excludes, too, the electronic delivery of educational materials and electronic recording of clinical state or behaviour where those allow no more interaction than do paper leaflets and workbooks.

Computer-aided therapy may be delivered on a range of computing devices, such as stand-alone personal computers, internet-linked computers, palmtops and personal digital assistants, telephone interactive voice response systems, gaming machines, CD–ROMs, DVDs, cellphones and virtual reality devices.

This post was inspired by a recent editorial in the British Journal of Psychiatry.
Marks, I.M., Cavanagh, K., Gega, L. (2007). Computer-aided psychotherapy: revolution or bubble?. The British Journal of Psychiatry, 191(6), 471-473. DOI: 10.1192/bjp.bp.107.041152

Sunday, April 27, 2008

6 Sleep Aids Without Pills

  • Relaxation techniques such as deep breathing, progressive relaxation, and guided imagery help in improving the quality of sleep.

  • Behavior therapy includes cognitive therapy, stimulus control, and sleep hygiene, which helps in improving sleep.Of these I think sleep hygiene is the most important:Maintaining sleep routine, that is sleep and wake up times should be same every day, engaging in regular exercise workout, avoiding naps in daytime, preventing nicotine and caffeine 3 to 4 hours before bed time and keeping worries out of your bedroom before going to sleep are necessary for getting quality sleep.

  • Exercise, a sleep aid, not only helps you to sleep better but it also helps you to be alert and effective during day. You shouldn't exercise before you go to sleep. Before going to sleep do relaxation techniques

  • Hot bath is one of the sleep aids that relax your body. It raises your body temperature, which helps in getting sleep. It is another way to relax. The water shouldn't be to hot.

  • Diet to promote sleep. No caffeine of alcohol before bed time. Sleep inducing foods are: milk, oatmeal, bananas, almonds and turkey, most of them rich in trypthophan. Don't eat to much, this will keep you awake.

  • Bright light in the morning to set your internalclock.

From an excellent website about Sleep Disorders

Related posts on this blog:
Better sleep without pills

Saturday, April 26, 2008

Med School is Hell

Regularly I write posts about medical education.Medical education is not alway fun. Female students suffer sexual harassment, during clerkship they sometimes have to stay late, which isn't always such a good idea.
In my time most students dropped out at the first years. Don't know if that is still the case. But how do you prepare your self for choosing med school?
MedSchool Hell has: 101 Things You Wish You Knew Before Starting Medical School.

Some examples:

  • You won’t be a medical student on the surgery service. You’ll be the retractor bitch.

  • Residents will probably ask you to retrieve some type of nourishment for them.

  • Most of your time on rotations will be wasted. Thrown away. Down the drain.

  • You’ll look forward to the weekend, not so you can relax and have a good time but so you can catch up on studying for the week.

  • You’ll meet a lot of cool people, many new friends, and maybe your husband or wife.

  • # If you piss off your intern, he or she can make your life hell. If your intern pisses you off, you can make his or her life hell.

  • You’ll probably change your specialty of choice at least 4 times.

Very typical but sometimes true.


This is a serious blog but so is soccer. Man United draws 0-0 at Barcelona. Barcelona, looking for its second Champions League title in three seasons both Lionel Messi and Samuel Eto’o had good chances. This is a video of Lionel Messi, one of the best players today according to Dr Shock. An artist.This rush is often compared with the rush by Maradonna.

Friday, April 25, 2008

Where does creativity come from?

Novelist Amy Tan digs deep into the creative process, journeying through her childhood and family history and into the worlds of physics and chance, looking for hints of where her own creativity comes from. It's a wild ride with a surprise ending.

There is even some neuroscience in this excellent talk.

Thursday, April 24, 2008

Shocking Lightning reaction Handheld

This new portable device brings a shocking experience to your playfull-life. Enjoy this game with your friends, be quick and you won’t be the one who suffers from a tiny electric shock wave.

Each of the four players keep their hands on the base of the device. You push the center button and the music starts to play accompanied with red light flashes. Suddenly, the music stops and the light turns green, and if you’re not quick enough to hit your button you’ll be the one that will receive the electric shock.

Thanks Gizmodo
For English please read here

Cocaine addiction, web based information useless

The quality of information on cocaine addiction on the web is generally poor, confirming previous studies on other health issues. Furthermore, universities seem to be poorly active in proposing websites (8.2%), while commercial organizations hold 55.7% of the studied websites.

This seems a little of topic but for depression the quality of websites for information about depression and it's treatment is also poor. Wouldn't it be nice to have a quality scale for health websites?

The authors used quality indicators. They looked at: quality of content, design and aesthetics of the site, readability, dating of information, authority of source, ease of use, accessibility and disclosure of authors and sponsors.

Health on the Net foundation (HON) has issued a code of conduct for medical sites covering much of the above mentioned and attributes a quality label taking into account the following points: disclosure of authorship, sources, updating of information, disclosure of editorial and publicity policy, as well as confidentiality.

Sites having the HON label scored higher.

The global score seems to be a direct content quality indicator. It could be helpful for people to be informed by this quality indicator. It remains however a complex measure.
Further larger studies on websites, including more sites with the HON label may help to conclude about its usefulness as a content quality indicator.

Another quality measure used was the Silberg measure. This measure used accountability standards (disclosure of authorship, ownership and currency of information). They may be useful indicators of the quality of web health information. These accountability criteria have been widely assumed to reflect web site quality. But it doesn't account for website content.

The third measure used was DISCERN.
DISCERN is a brief questionnaire which provides users with a valid and reliable way of assessing the quality of written information on treatment choices for a health problem. DISCERN can also be used by authors and publishers of information on treatment choices as a guide to the standard which users are entitled to expect.

There is also a quick reference guide to DISCERN

The biggest problem is how to evaluate content. In this study they used the following criteria:
Content quality was examined around the following five points: frequency of cocaine addiction and cocaine abuse; possible somatic, social and psychological complications of cocaine addiction and abuse; cocaine withdrawal; pharmacological treatment options and limitations; motivational and psychotherapeutic treatments. Comparison of information found was done in consensus with field experts (American Psychiatric Association, 2006: Practice guidelines for the treatment of substance use disorders). Coverage and correctness of medical information were evaluated. The coverage of a topic was characterized as “none”, “minimal” and “sufficient” (0–2 points). Correctness of information was characterized as “mostly not”, “mostly” and “completely right” (0–2 points)

They reviewed 120 websites. There was a sensible overlap in the sites identified by the two search engines (Google, Yahoo) and the three keywords: cocaine, cocaine addiction and cocaine dependence (35/120). This left 85 websites. Of these, 24 were excluded for the following reasons: 6 contained no information on cocaine addiction; 3 were inaccessible, 2 required an access fee; 13 were not websites (only external links or books). They included 61 sites in our study.

In the article on depression they used the following content assessment:
Concordance between site information and best practice was assessed using a 43-item rating scale based on the evidence-based AHCPR clinical practice guidelines for treating depression

Does anyone know a better way to score the quality of content of health websites, please let me know in the comments.
KHAZAAL, Y., CHATTON, A., COCHAND, S., ZULLINO, D. (2008). Quality of web-based information on cocaine addiction. Patient Education and Counseling DOI: 10.1016/j.pec.2008.03.002

Tuesday, April 22, 2008

9 Email Tips

Email has it's advantages. It is a fast way to communicate. Writing a good clear email message is something you will have to learn. Pushing the send button to quick can lead to embarrassing situations.
But don't get stuck to much to email. Sometimes it is better to talk to someone about something. Not all topics lend themselves for email. Besides the number of emails in your inbox can be overwhelming. It can ruin your life. So use email right and appropriate.
An important reason email is plaguing so much of your time is the amount of unnecessary or badly written email being sent.

From the book: Upgrade Your Life some suggestions for proper email writing:

  • Write descriptive subject lines. Descriptive subject lines are essential to being able to process email quickly. It saves time from having to open each email just to figure out what it’s about, you can’t prioritize their responses as efficiently. E.g. subject:IMPORTANT isn't very descriptive but Subject: Questions about Monday's presentation is.

  • Don't write long emails. If your message is longer than one page trim it down. Only when explaining complicated concepts or providing detailed instructions make it longer than one page if absolutely necessary

  • Make it easy to read by using line breaks and bullet points. Reading from a computer monitor is more tiring than from paper.

  • Don't CC if it is not necessary. Only do it when the recipient has to act on something don't do it just to keep him informed. While there are sometimes cases where this is a good idea, for the most part you shouldn’t send someone an email unless you want them to take action on it. If you do CC make it clear why everybody received the message.

  • Reply all is not always necessary. Use it only for a good reason.

More on email etiquette see also

Coping with email overload can be a challenge. I am a fan of the method described in Getting Things Done. But there are some tools available to read and send emails. There are filtering and processing methods and software tweaks that make email less stressful and time-consuming. Some email productivity tips:

  • Filter the emails that are not directly addressed to you. You can use filters in outlook and thunderbird. You can differentiate between need-to-see-it direct mail and emails not directly for you but mostly the ones "to keep you informed".

  • Use Gmail, you can keep your messages and use the Gmail's search functionality. You can even set up persistent searches, and you won't have to spend time again digging through scads of messages to find the right one.

  • Use gmail for all your email accounts. You can import mail from nearly any account into a common Gmail. You can even send and reply to mail from those same addresses.
  • Process and organize your email with a system. There are a lot of systems for organizing email, getting things done is one of them. Based on this is the trusted trio system at lifehacker. Or the Zero Email Bounce for Outlook.

More on email productivity on Lifehacker

Monday, April 21, 2008

Light Affects Mood and Performance during Computer Gaming

Game players perform best and fastest in a computer game world lit with a warm (reddish) as compared to a cool (bluish) lighting. Red lightning in a Computer Game also induced the highest level of pleasantness in game users.
It was probably the level of pleasantness induced by the warm lighting that enhanced the players' better performance in that digital game world.

These were the results of a recent article in CyberPsychology & Behavior: Lighting in Digital Game Worlds: Effects on Affect and Play Performance

These results are important for game designers and developers of online communities and visual worlds. Nevertheless maybe in the future also for indoor lighting and even depression considering the effects on mood. Wouldn't it be nice when suffering from depression and being treated with computer games three times a day?

In experimental psychology there is some evidence that indoor lighting can have an effect on mood. The influence of indoor lighting on psychological mechanisms is complex.This study was designed to investigate the impact of warm (reddish) and cool (bluish) simulated illumination in digital game worlds on game users' affect and play performance.

38 people participated in this study (14 women and 24 men), mostly students with a mean age of 22 years. They were payed to participate 15 dollars.

The players navigated through 3 different lighted sequences of Half Life 2.The three different lighting conditions were neutral (grayish), cool (bluish), and warm (reddish). Affect ratings and game performance were outcome measures.

What we do claim is that we have made a first step toward better understanding the contribution of a specific aesthetic quality of game worlds to the patterns of feeling and response that make up the game experience
Knez, I., Niedenthal, S. (2008). Lighting in Digital Game Worlds: Effects on Affect and Play Performance. CyberPsychology & Behavior, 11(2), 129-137. DOI: 10.1089/cpb.2007.0006

Sunday, April 20, 2008

Ideal Workspace

This would be my ideal workspace. Were can you buy these kind of workspaces?

For more crazy workspaces see CyberNotes

Art and Depression

Anyways, the other thing I am going to try to do (on Dr. X's advice) is actually two things: keep painting even if my creativity seems to have disappeared. He says to keep doing the things that make me feel good when well, even if they are hard to do, or I don't feel like it. Secondly, give myself permission to slow down and ride out the low cycle. He expressed that he knows these are both easier said than done. I appreciate that he gets that.

This quote from Vicarious Therapy inspired me on this subject. I have read some articles online about art and depression a while ago. It is about fighting depression and still be creative. Can depression enhance creativity despite depressed mood, loss of interest not to mention a lack of concentration and all other symptoms?
Depression, for me, has a paradoxical upside (one I would gladly trade away for being rid of the disease). It can be, and has been my greatest source of creative motivation. I find an odd sort of comfort by being able to produce images that reflect my sense of mood or the way my depressed mind sees the world. For me then, photography becomes almost therapeutic. It doesn't make it better, but rather gives me a way to step outside of my depression and look back in at it and better understand how it is affecting me.

This quote is from a photographer. She has written a post on art and depression along with some interesting photos

"Art is my recovery. It's my form of medication now and it's what sustains me."

This quote is from another photographer and how it helped her during her depression.
I am glad we have art therapy on out Depression Unit besides running therapy and cognitive therapy. Sometimes we get questions about how evidence based this form of therapy really is. I remain silent mostly and change the subject.

"When I came out of hospital I wasn't working for about six months but the artwork was always something I could get on with. When I was in such a state that I couldn't communicate with people, the one thing that I could talk about was my artwork. I think it was the only time I became coherent really!

From Tamar Whyte, she is a painter

It can be helpful in Schizophrenia as well. More evidence on that
studies have reported patients more likely to complete therapy regimens if art classes played a part. Just as crayons and construction paper allow kindergarteners to further explore what makes them unique, the act of creation, minor as it may seem, can help those with mental illness understand and cope with their conditions.

Thanks Dr Confabula for the video and Aqua.

Saturday, April 19, 2008

The Story of Stuff

If you like this short video go see the whole talk at The Story of Stuff

The Story of Stuff is a 20-minute, fast-paced, fact-filled look at the underside of our production and consumption patterns. The Story of Stuff exposes the connections between a huge number of environmental and social issues, and calls us together to create a more sustainable and just world. It'll teach you something, it'll make you laugh, and it just may change the way you look at all the stuff in your life forever.

According to Presentation Zen:
Here is a good example of a passionate presenter giving a fast-paced overview of an important topic that is greatly enhanced with the integration of simple visuals in harmony with the narration. The visuals are a wonderful example of "amplification through simplification."

New Blog About Electroconvulsive Therapy

Found a new recent blog called Electroconvulsive Therapy, all about.... you guessed it.

It has a recent post on cognitive side-effects with ultrabrief stimulus. The results were presented as a poster at the European congress of psychiatry of the AEP in Nice, France, 4-9 April.

We concluded that bifrontal and unilateral ultra-brief pulse ECT are effective treatment techniques that do not cause measurable cognitive side-effects or cognitive complaints.

The author also has a blog called: A day in the life of a shrink. It is in Dutch or should I say Belgian.

Friday, April 18, 2008

Again Open Label Research with rTMS

Another open labeled trial with rTMS. It is a continuation trial after a recent double-blind placebo controlled trial with rTMS.This study is discussed in a recent post on this blog: Finally some good news about rTMS?

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.
The NICE guidelines use a difference of 3 point or more as clinical significant.

Another open trial is unethical to my opinion in this stage of development of rTMS.
Patients that were non responders on the double-blind sham controlled rTMS trial received an additional 6 weeks of active rTMS. The nonreponders on the active rTMS group also were continued on rTMS for 6 weeks. Both patients and investigators remained blind to prior treatment condition. The open label study had 2 phases: a 6 week antidepressant medication free acute phase treatment and a 3 week taper phase during which antidepressant medication was initiated. Patients received 5 rTMS sessions per week during 6 weeks followed by 3 times a week in week 7, 2 times a week in week 8 and once a week in the last week.

Patients who received sham in the preceding randomized controlled trial (N = 85), the mean reduction in MADRS scores after 6 weeks of open-label active TMS was -17.0. Further, at 6 weeks, 36 (42.4%) of these patients achieved response on the MADRS, and 17 patients (20.0%) remitted. Remission was defined as a score under 10 on the MADRS. For those patients who received and did not respond to active TMS in the preceding randomized controlled trial (N = 73), the mean reduction in MADRS scores was -12.5, and response and remission rates were 26.0% and 11.0%, respectively.

A well just to let you know, we will wait for another open label trial.

What is interesting to know is that in in the sham to rTMS treatment group, failure to only one antidepressant trial before rTMS resulted in a greater likelihood of response. If resistant to more antidepressants before rTMS predicted less favorable outcome.

When is there going to be a sham controlled trial without medication resistant depressive patients?

You can read the abstract of this article on Therapeutic Neuromodulation Weblog
Avery, D.H. (2008). Transcranial magnetic stimulation in the acute treatment of major depressive disorder: clinical response in an open-label extension trial.. Journal of Clinical Psychiatry, 69(3), 441-451.

Thursday, April 17, 2008

6 Reasons Not To Trust Medical Publications

who are they, anonomous
Medicine in every aspect is influenced by the pharmaceutical companies and medical device industries. This influence also jeopardizes medical publications in, until recent respected journals.

These are the tricks used to influence the medical publications even in high ranking medical journals:

  • They use Guest authorship. This has been defined as the designation of an individual who does not meet authorship criteria as an author.First authorship is wrongly attributed to academically affiliated investigators who had little or nothing to do with the reported research.

  • They use Ghostwriting. This has been defined as the failure to designate an individual (as an author) who has made a substantial contribution to the research or writing of a manuscript. This means that articles are written by unacknowledged authors who are employees of the pharmaceutical industry.The research is mostly done by the drug company as well as the analysis and the writing

  • Financial support for the authors is not disclosed in the publications.

  • Some journal editors allow articles and supplements to be published without requiring complete disclosure of individual support from the drug companies

  • They use data analysis done by the drug companies instead of an academic statistician with no ties with the drug company.This could lead to data misrepresentation and data manipulation

  • Some peer reviewers in editorials boards of journals have relationship with industries. This could lead to a biased review of an article favoring the drug of the drug company. A peer reviewer sent a confidential manuscript that he was invited to review and that demonstrated an increased mortality risk associated with a drug to the manufacturer of this drug weeks ahead of the publication.

This is a summary from an article in the JAMA: Guest Authorship and Ghostwriting in Publications Related to Rofecoxib(free article)
Their conclusion
often attributed first authorship to academically affiliated investigators who did not always disclose industry financial support. Review manuscripts were often prepared by unacknowledged authors and subsequently attributed authorship to academically affiliated investigators who often did not disclose industry financial support.

This was based on their meticulous research of a database. In the course of the combined trials of Cona vs Merck and Co, Inc and McDarby vs Merck and Co, Inc, millions of documents were made available to and archived in an integrated database maintained by the plaintiff's attorneys. The authors had complete access to all archived documents. One investigator (J.S.R.) searched the database to extract a subset of documents related to authorship. The search was performed using the database keyword search function.Documents used for this article are posted at this site

Not all medical publications use these tricks but it is hard to tell which don't especially with the lack of disclosure of financial support.

What should we do about it?

In a recent editorial in the JAMA these are the proposed 11 measures:

  • All clinical trials must be prospectively listed in registries accepted by the International Committee of Medical Journal Editors (ICMJE) prior to patient enrollment, and the name(s) of the principal investigator(s) should be included as a required data element in the trial registration record.

  • All individuals named as authors on articles must fulfill authorship criteria. Journals should require each author to report his or her specific contributions to the article, and should consider publishing these contributions. All individuals who were involved with the manuscript or study but who do not qualify for authorship (such as those who provided writing assistance) must be named in the acknowledgment section of the article, with reporting of their specific affiliations and contributions and whether they were compensated for those contributions.

  • All journals must disclose all pertinent relationships of all authors with any for-profit companies, and must publish all funding sources for each article.

  • Journal editors must seriously consider funding sources and authors' disclosed financial conflicts of interest and financial relationships when deciding whether to publish a study or review.

  • For-profit companies that sponsor biomedical research studies should not be solely or primarily involved in collecting and monitoring of data, in conducting the data analysis, and in preparing the manuscript reporting study results. These responsibilities should primarily or solely be performed by academic investigators who are not employed by the company sponsoring the research.

  • All journals must require a statistical analysis of clinical trial data conducted by a statistician who is not an employee of a for-profit company.

  • Any author who fails to disclose financial relationships or other conflicts of interest, or who allows his or her name to be used for work that he or she did not actually perform, must be reported to the appropriate authority (ie, medical school dean or department chair) or appropriate oversight body. If an article in which this occurs is published, the offending author must then submit a letter to the editor, in which he or she provides full disclosure and apologizes for the infraction to the readers of the journal. Depending on the nature and severity of the issue, the author may be banned from publishing articles in that journal.

  • Any peer reviewer who provides any confidential information, such as a manuscript under review, to any third parties, such as for-profit companies, or who engages in other similar unethical behavior, also should be reported to the appropriate authority (eg, medical school dean) or oversight body, and should be banned from reviewing and publishing articles in that journal.

  • Any editor who knowingly allows (or is party to allowing) for-profit companies to manipulate his or her journal must be relieved of the editorship.

  • To maintain a healthy distance from industry influence, professional organizations and providers of continuing medical education courses should not condone or tolerate for-profit companies having any input into the content of educational materials or providing funding or sponsorship for medical education programs.

  • Individual physicians must be free of financial influences of pharmaceutical and medical device companies including serving on speaker's bureaus or accepting gifts.
Ross, J.S. (2008). Guest Authorship and Ghostwriting in Publications Related to Rofecoxib. JAMA, 299(15), 1800-1812.

Wednesday, April 16, 2008

Testosterone Boost On the Trade Floor

Traders on a London trading floor had higher testosterone levels when they make more money than on an average day. The winner effect. Their results also suggests that high morning testosterone predicts greater profitability for the rest of that day.

The role of cortisol in these men wasn't that clear. After some fancy brainstorming and analysis they discovered that cortisol was likely responding to uncertainty rather than the other way a round.

We found a significant relationship between testosterone and
financial return and between cortisol and financial uncertainty.

The ups and downs on Wall Street are simply a matter of hormones. maybe we are better off with female traders instead of all these hormonal males.

Cortisol is likely, therefore, to rise in a market crash and, by increasing risk aversion, to exaggerate the market’s downward movement. Testosterone, on the other hand, is likely to rise in a bubble and, by increasing risk taking to exaggerate the market’s upward movement.

What did they do?
They decided to conduct the study on a real trading floor rather than under laboratory conditions. They sampled steroids while traders did their normal jobs.

Tuesday, April 15, 2008

25% of Medical women students experience sexual harassment

  • Most of the incidents referred to flirtations or sexual remarks.

  • The majority experienced 1 incident of sexual harassment, 6.7% reported 3 or more incidents.

  • The offenders were all male except in one case, 66% were patients the others were medical doctors or residents.

  • Three of 10 students reported that the incident had a negative influence on their functioning afterwards.

  • The majority (77.8%) discussed the incident with their peers, usually other medical students

  • Three quarters of the students were satisfied with the way the incident was dealt with

  • 13.3% experienced a lack of special support afterwards

Students from two medical schools in The Netherlands received a semi-structured questionnaire about their experience with sexual harassment during clerkship.
The questions were not only on the incidents but also on their reactions and the consequences for their wellbeing and professional functioning and the way the cases were handled.

The prevalence differed between the two medical schools but that was due to the fact that in one medical school the clerkship was of longer duration. They had longer clinical exposure to potential harassment.

In the international literature reports of sexual harassment fluctuate between 18-60%. The authors state that the incidence is relatively low in The Netherlands.They explain this by the observation that The Netherlands is considered one of the most feminine cultures in the world in which gender equality is more pervasive. I think the women outnumber the male students and soon the male doctors in The Netherlands. Since a lot of the female students nowadays are Muslim women (moslima's) it would be interesting to repeat this questionnaire soon and trace probable confounding factors such as religion.
The authors explanation that Dutch Women are more assertive seems to me speculative. See also this article on: Dutch women don't get depressed

In the commentary on this article it is written that there still seems to be an undercurrent of student harassment in medical schools in different countries and culture.
Individual schools must define their own norms of professionalbehaviour

There should be attention and education about this subject during medical education.
Rademakers, J.J., van den Muijsenbergh, M.E., Slappendel, G., Lagro-Janssen, A.L., Borleffs, J.C. (2008). Sexual harassment during clinical clerkships in Dutch medical schools. Medical Education, 42(5), 452-458. DOI: 10.1111/j.1365-2923.2007.02935.x

Monday, April 14, 2008

A Chocolate Bar A Day Keeps the Doctor Away

Actually it is 2 chocolate bars a day. Dark chocolate containing flavanols and added plant sterols reduces serum cholesterol and LDL cholesterol as well as blood pressure.
Plant sterols are natural compounds found in foods such as vegetable oils, fruit, cereals and vegetables. They can lower the circulating cholesterol levels. The FDA has recognized that the consumption of plant sterols may reduce the risk of cardiovascular disease by lowering the LDL cholesterol.

In a double-blind placebo controlled cross over study the first aim was to examine the effect of the regular consumption of a flavanol containing chocolate bar (CocoaVia) with added plant sterols on serum cholesterol levels in a free-living population. All participants were on a steady AHA diet and their body weight didn't change during this trial. Serum total cholesterol level was reduced with 3% and LDL cholesterol with 4%.

Also regardless of plant sterols content the consumption of the chocolate bars reduced diastolic (8%) and systolic blood pressure (8%) due to the flavanols. The participants were all normotensive (didn't have high blood pressure).
The trial didn't use chocolate bars with low flavanols concentration thus it is possible that the lower blood pressure could be attributed to other factors.

Dark chocolate has the most flavonoids. This is the substance that improves blood flow and vascular function and diminishes clotting and reduce blood pressure. Alas some confectionery makers often take out the flavanols, stripping the chocolate of its main health-promoting properties because flavonols also makes the chocolate taste bitter.

Short study period (8 weeks) how will these measures hold on the long term?
Allen, R.R. (2008). Daily consumption of a dark chocolate containing flavanols and added sterol ester affects cardiovascular risk factors in a normotensive population with elevated cholesterol. The Journal of Nutrition, 138(4), 725-731.

Sunday, April 13, 2008

Blog like a man or a woman?

The Gender Genie is about pasting a text in a box on The Gender Genie. Choose a genre and click submit for the results. It will predict whether the text is written by a man or a woman. I tried it, you can see the result in the picture above this post.

There is even a video on FoxNews about this software

The Gender Genie uses a simplified version of an algorithm developed by Moshe Koppel, Bar-Ilan University in Israel, and Shlomo Argamon, Illinois Institute of Technology, to predict the gender of an author.

Although I think you really can't figure out whether a writer is male or female based on writing, I still believe that the linguists' algorithm has useful applications. I have received emails from several authors saying that they have used it to help make their female characters come across as being more female and vice versa. Now, Customer Experience Crossroads sees it as another tool for tailoring marketing to target market: "We don't all communicate in the same way. Worth considering when you think about customer experience."

For other gender testing tools read this article on Customer Experience

Do you believe in Angels?

Memorable music and video from YouTube.

Thanks Bright::ToniesTunes

Xbox and the Iphone are killing the internet

Zittrain argues that today's Internet appliances such as the iPhone and Xbox hamper innovation. That's because these locked-down devices prohibit the kind of tinkering by end users that made PCs and the Internet such a force of economic, political and artistic change.

Professor Jonathan Zittrain is Chair in Internet Governance and Regulation at Oxford University.
Zittrain's research includes digital property, privacy, and speech, and the role played by private "middlepeople" in Internet architecture. He has a strong interest in creative, useful, and unobtrusive ways to deploy technology in the classroom.

He has written a new book: The Future of the Internet--And How to Stop It. This book is due for release on April 14. He discusses the future of Internet and it's threats. Since I am a fan of open source software I will order it an probably tell you more about this topic in the recent future. There is some comfort in knowing that iphone's and xboxes get hacked easily and readily, besides most consumers just want a properly working device.

Zittrain doesn't predict that PCs will become extinct any time soon. But he worries that PCs are being locked down and prohibited from running open source code that has driven much of the Internet's new functionality.

Thanks PC World

Saturday, April 12, 2008

7 Reasons for placebo controlled trials in depression

antidepressants placebo
Placebo-controlled trials in depression are scientifically necessary, ethical and feasible. As mentioned in a recent post about antidepressants for adolescents I am a great fan of placebo controlled trials, also in depression.

The best clinical trial is a placebo controlled trial, because:

  • The response to placebo can vary considerably form around 10 to 50%.On average 30% of patients respond to placebo

  • The proportion of patients who respond to placebo has increased with 7% per decade. This effect is mainly caused by the method of patient recruitment and the inclusion of patients with less severe forms of depression

  • According to several studies,no difference in rates of suicide and attempted suicide was found in placebo controlled trials compared to the patients on antidepressants in those trials

  • In a placebo controlled trial it is easier to distinguish between adverse reaction to the drug and disease symptoms

  • Smaller sample sizes are required.They expose fewer patients to ineffective or potentially harmful drugs

  • Studycosts are reduced

  • New drugs become available sooner to patients if efficacious

Only placebo-controlled trials can give unambiguous evidence of efficacy and if future antidepressants were only tested against standard treatment, half of the studies would yield invalid (false positive or false negative)results.

The response of a patient to drug treatment is not only affected by the drug itself but also by:

  • features of the illness.For instance in bulimia most patients also suffer from personality disorder which reponds to the structured visits and attention of the researcher. Not per se to the antidepressant

  • The personality of the patient.

  • The doctor-patient relationship. If you like your doctor you wouldn't want to disappoint him of her.

  • The setting of the treatment. Inpatients are different from outpatients. Depressed inpatients aremore often suicidal and or psychotically depressed

These confounding effects can only be reduced by a controlled trial, preferably a placebo controlled trial.
Adam, D., Kasper, .S., Möller, H., Singer, E.A. (2005). Placebo–controlled trials in major depression
are necessary and ethically justifiable. European Archives of Psychiatry and Clinical Neuroscience, 255(4), 258-260. DOI: 10.1007/s00406-004-0555-5

Friday, April 11, 2008

Demystifying Depression; a WikiBook


"Depression is a mood disorder", so start many descriptions of the illness. That is a gross understatement. Depression does indeed seriously affect your mood, but that is just the tip of the iceberg. A clinical depression can be an incapacitating illness, affecting your ability to perform tasks that require concentration and rendering you unable to work.

By writing this document we hope to provide you with the knowledge everyone should have about their mental well-being. Depression is not an unavoidable fate. It is physical.

The good news is that you can recover and yes, even learn to be happier than you have ever been before.

A wiki about depression also downloadable as pdf.

Thanks David Rothman: List of Medical Wikis

Thursday, April 10, 2008

Blog Psychotherapy

On Vicarious Therapy the author wrote an to my opion already classic post on "blog therapy".

She explains her ideas about using a blog during psychodynamic psychotherapy. She has given the subject a lot of thought and wrote the pros and cons on different approaches for using a blog with therapy. Be sure to check the comments.

I believe a blog is an incredible way for the patient to clearly layout their defense mechanisms and for the Psychiatrist to have a much more in depth and detailed view of his/her patient's transference. If the blog is two way; one written by both the patient and the pdoc, I could see tremendous value for the therapist to also recognize their countertransference more clearly.

And this is just the beginning of her post.

Minimize Cognitive Side Effects with ECT

Optimizing the technique of ECT can minimize cognitive side effects. These optimizing measures for ECT technique are:

  • Use brief pulse stimulus (0.5 to 2 milliseconds)instead of sine wave stimulus. This has a positive effect on cognitive side effects. It is not yet clear if ultrabrief pulse waveform (pulse width of less than 0.5 milliseconds) will produce even fewer cognitive side effects without sacrificing efficacy.

  • Right Unilateral Electrode placement when performed right has the best benefit/risk ratio concerning cognitive side effects. Performed right means using brief pulse stimulus or better ultrabrief stimulus with a dosage of 6 times seizure threshold. Bilateral brief pulse ECT with a dosage of 2.5 times threshold has comparable efficacy at the risk of more severe cognitive side effects. Bifrontal electrode placement may represent a better benefit/risk ratio compared to bilateral ECT. Statements comparing bifrontal and right unilateral ECT is premature because of lack of sufficient data about comparison of side effects and efficacy

  • Dosing by titration schedule is critical to reducing adverse cognitive side effects. Adverse cognitive side effects of ECT are attributable to the dose above seizure threshold not to absolute electrical dose. Aged based dosing methods cannot be advised because of only modest association of age with seizure threshold.

  • The frequency of twice weekly treatment schedules result in fewer cognitive side effects than higher frequency schedules. Increasing frequency increases the risk of side effects.

  • The number of treatments predicts the extent of cognitive side effects in bilateral ECT not in unilateral ECT. If bilateral ECT is administered, minimizing the number of treatments may offer some protection against the development of persistent cognitive deficits.
Prudic, J. (2008). Strategies to minimize cognitive side effects with ECT: aspects of ECT technique.. Journal of ECT, 24(1), 46-51.

Wednesday, April 9, 2008

Finally some good news about antidepressants and adolescents

Continuation treatment with fluoxetine was superior to placebo in preventing relapse and in increasing time to relapse in children and adolescents with major depression.

This is the conclusion of a randomized placebo controlled trial after a 12-week open-label acute treatment period with 10–40 mg of fluoxetine. Those who responded at the end of 12 weeks of acute treatment were randomly assigned to receive fluoxetine or placebo for an additional 6 months. 102 patients were randomized.Those in the fluoxetine group received the same dose they were receiving in acute treatment. In the placebo group, fluoxetine was not tapered given its long half-life.

Relapse occurred more frequently in participants in the placebo group than in the fluoxetine group (N=36 [69.2%] and N=21 [42.0%], respectively. Even using a stricter definition, relapse was more frequent in the placebo group than in the fluoxetine group (N=25 [48.1%] and N=11 [22.0%], respectively). These differences were statistically significant.

Some practical consequences of these findings:

This suggests that the adult guidelines recommending 6–9 months of overall treatment for major depression would apply equally to children and adolescents. It also reinforces the fact that early-onset depression is associated with high rates of relapse, even though the majority of participants in this sample were in their first episode of major depression.

In another study with adolescents with depression the focus was on the question to what degree do patients not responding to acute anti depressive treatment consisting of fluoxetine, Cognitive Behavioral Therapy or the combination of both subsequently achieve response during continuation and maintenance therapy?

And among those that achieve response during acute anti depressive therapy, how many maintain their response during continuation and maintenance therapy?

Among 95 patients (39.3%) who had not achieved sustained response by week 12 (29.1% combination of fluoxetine and cognitive behavioral therapy, 32.5% fluoxetine alone, and 57.9% Cognitive Behavioral Therapy), sustained response rates during stages 2 and 3 were 80.0% COMB, 61.5% FLX, and 77.3% CBT (difference not significant). Among the remaining 147 patients (60.7%) who achieved sustained response by week 12, CBT patients were more likely than FLX patients to maintain sustained response through week 36 (96.9% vs 74.1%; P = .007; 88.5% of COMB patients maintained sustained response through week 36). Total rates of sustained response by week 36 were 88.4% COMB, 82.5% FLX, and 75.0% CBT.

Thus the majority of adolescents who had not achieved response by week 12 achieved response by week 36: 80% with the combination of fluoxetine and CBT, 61.5% on fluoxetine and 77.3% with CBT alone. These outcomes were not significantly different from each other. Overall adolescents with depression who have not fully responded after 12 weeks of acute treatment three-quarters of them will experience sustained response with further treatment.

Those who had responded by week 12 the majority (82.3% of 147 patients) maintained their sustained response throughout week 36. 15% failed to maintain their acute response with rates differing as a function of treatment modality: 11.5% combination treatment, 25.9% fluoxetine alone and 3.1% CBT alone.

I am jealous, this is excellent research especially the placebo controlled one. These are findings that are easily applicable to practice. We in adult psychiatry have to do with a lot less evidence as far as placebo controlled trials for continuation and maintenance therapy are concerned.
CBT monotherapy in the acute phase has a lower response rate, nevertheless during follow-up only 3.1% failed to sustain that response. A larger proportion of patients respond on fluoxetine but the sustained response is not as enduring as with CBT. Further research could focus on augmenting response on fluoxetine with CBT for enduring this response.

Related articles on this blog about adolescents and depression
Emslie, G.J. (2008). Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents. American Journal of Psychiatry, 165(4), 459-467.
Rohde, P. (2008). Achievement and maintenance of sustained response during the treatment for adolescents with depression study continuation and maintenance therapy. Archives of General Psychiatry, 65(4), 447-455.