My blog has moved!

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

Wednesday, May 28, 2008

Encephalon 46th edtion on The Neurocritic

Welcome to the Forty-Sixth Edition of Encephalon, a neuroscience blog carnival.

The best neuroscience posts of recent on The Neurocritic

Tuesday, May 27, 2008

Grand Round 4.36 on Parallel Universes

This is my 5th time to host (Thanks, Nick!) and I have not stopped enjoying the privilege of hosting this wonderful weekly anthology of the best posts of the medical blogosphere. Since FIVE is the lucky number for me today, I am opening this round with five of the best posts submitted to me this week...

A lot of excellents posts from the medblog sphere, go read them on Parallel Universes

Monday, May 26, 2008

Grand Round: Gene Genie #32 - Googling the Genie

Welcome to the 32nd edition of Gene Genie, a blog carnival devoted to genes and genetic conditions. This edition includes some excellent articles on genes and gene-related diseases, genetics, genomics and personalized genetics.

Dr Shock is in this excellent grand round with genes and gene related diseases. Go read these excellent articles about the newest research on genes: the 32nd edition of Gene Genie

Saturday, May 24, 2008

Blog Addicted or Internet Addicted

The next three weeks Dr Shock is on vacation. This blog has been updated daily for more then a year. Since blogging is fun I will probably keep on blogging during these three weeks but maybe not daily and the long posts your used to.

No cold turkey to prevent withdrawal symptoms from blog addiction or is it Internet addiction? Won't need shocktherapy for this I hope. But blogging is good for your health, at Living the Scientific Life

By the way there another stupid thing people believe you can get addicted to. Here is a good one: internet dating. Thanks Pure Pedantry

After these three weeks I will probably start with a new design, maybe I will need your help with that, looking forward to all this.

Cognitive Safety of Deep Brain Stimulation for Treatment Resistant Depression

Apart from a transient mild decline in manual motor speed, there seems to be no
adverse cognitive effects associated with chronic Deep Brain Stimulation (DBS) in Cg25 for Treatment Resistant Depression (TRD) in this sample of 6 patients with a follow-up of 12 months.

Another important conclusion from this research:

Several areas of cognition that were below average or impaired at baseline improved over follow-up, and these changes were not correlated with improvements in mood.

Broadman Area 25 as target for deep brain stimulation in treatment resistant depression. This area in the brain is from the most important publication about DBS and depression in Neuron march 2005 by Helen Mayberg. This is the location used in the largest trial with DBS in TRD. Other locations for DBS in TRD appear as well but these publications concern individual cases.

Functional neuroimaging as well as antidepressant treatment effects suggest that this area plays an important role in modulating negative mood states. Clinical response was demonstrated in 4 of 6 patients using standardized psychiatric end points. These results suggest that modulation of pathological activity in specific limbic-cortical circuits by electrical stimulation of Cg25 can effectively reverse symptoms in previously TRD patients.

Comparison to ECT
Moreover, in contrast to the memory deficits consistently reported with
ECT, no consistent declines in memory for either verbal or visual material were noted after onset or maintenance of DBS over baseline.


  • small sample size (n=6)

  • the lack of a matched control group

  • the lack of control (on-off) conditions for stimulation

  • impact of repeat testing or regression toward the mean may have nonetheless affected the results

  • patients were not free of psychopharmacological drugs

Other indications for DBS:
McNeely, H.E., Mayberg, H.S., Lozano, A.M., Kennedy, S.H. (2008). Neuropsychological Impact of Cg25 Deep Brain Stimulation for Treatment-Resistant Depression. The Journal of Nervous and Mental Disease, 196(5), 405-410. DOI: 10.1097/NMD.0b013e3181710927

Friday, May 23, 2008

3 Health Portals

Other blog such as clinical cases and Medgadget also discovered the news around Google Health. For some screen shots see Dr Shock. Eye on FDA also reviews Google Health:

It is a pretty neat concept and, as a big fan of Google myself, I can say that it maintains Google standards for easy maneuverability and is extremely friendly for the user. If you use a Google Reader as an aggregator - this is far easier to negotiate. You put in a few details about yourself, including your medications and already can gain access to a good deal of interesting information.

The other contester looking for your medical history is Microsoft with HealthVault. A screen shot is on the top of this post. You will need a LiveID or create one. Tried to create a LiveID, very difficult, it kept complaining about the strength of my password. Even medium strength was not enough, doesn't sound hopeful if they even don't trust their own system.

The website of the Canadian Medical Association has it's own system for patient information and medical history: Health Portal
The new portal, created by Practice Solutions, a CMA company, allows physicians to register their patients with any or all of the online tools the portal offers - asthma tracker, blood pressure tool and weight tracker and a personal health record. Designed by physicians, the portal also provides secure messaging, ensuring a private channel of communication between patient and doctor.
"This service really shows the role of technological innovation in raising the standards of health care delivery in Canada," said Dr. Brian Day, President of the CMA. "The Health Portal provides a new way for physicians to give each patient the care and attention they deserve while also empowering patients to become active participants in their care."

Here is a screen shot of the patient's dashboard.

You can read the Press release about

Thursday, May 22, 2008

Peer Review Is Sacred

Peer review means reviewing the research of other scientists in your field for publication in a scientific journal. This procedure is confidential. Reviewers should abstain from peer review if there is a conflict of interest not only financial but also scientifically.

Pfizer subpoenaed the New England Journal demanding that the Journal produce peer-review and other editorial documents on all manuscripts concerning Pfizer's cyclooxygenase-2 (COX-2) inhibitors, valdecoxib (Bextra) and celecoxib (Celebrex) specific articles that they had published and any others that we had rejected for publication. Pfizer wanted the peer-review documents, including the critiques prepared by reviewers for the authors, to help defend itself in product-liability litigation, the company was not looking for specific information. Pfizer was hoping to use the Journal's expert reviewers and their critical commentary in an attempt to challenge scientific aspects of the articles, adding what Pfizer's attorneys called the "significant imprimatur" of the Journal to their case.


the judge decided that while the materials Pfizer sought were relevant, their probative value was limited. As Sorokin concluded, even though the information sought was relevant, "the NEJM's interest in maintaining the confidentiality of the peer-review process is a very significant one, especially in light of its non-party status, and tips the scales in favor of the NEJM."

Yoiu can read the whole editorial: Peer Review in the Balance

Screening Adolescents for Depression on the Internet

Screening for depression through the Internet is feasible and is acceptable to large groups of adolescents. Furthermore, the Major Depression Inventory (MDI) and the Center for Epidemiological Studies-Depression scale for Children (pdf, small) (CES-D) are reliable and valid instruments that can be used for this screening.

By the age of 18 about one in every four adolescents has had at least one
depressive episode, and most adults with recurrent depression have their initial depressive episodes as teenagers

Teen depression or depression during adolescence can be hard to discover. There is even a website about depression for children and parents: KidsHealth. It is a doctor-approved website with health information about children from before birth through adolescence. KidsHealth provides families with accurate, up-to-date, and jargon-free health information they can use.

Treatments for depression in adolescents are available. Usually treatment is started with cognitive therapy. The combination with antidepressants is also very effective in treating depressed adolescents.

Despite the availability of effective treatments, however, undertreatment is considerable in depressed adolescents because:

  • adolescents tend to consider help-seeking as a sign of weakness

  • they do not consider their problems to be mental health problems that can be treated

  • they prefer to solve their problems on their own

  • both parents and health professionals consider mental health problems a normal part of adolescence

The Internet may be an acceptable medium for adolescents to receive help.

In this research two screening instruments for depression in adolescents the Center forEpidemiological Studies-depression scale(pdf, small)(CES-D); and the major depression inventory, MDI) were validated for the use through the Internet.

What was done in this research?
A total of 1,392 adolescents, recruited through high schools and the
Internet, filled in the online questionnaires. Of these, 243 (17%) were interviewed with the MINI diagnostic interview to assess the presence of a mood disorder.

So not only were these screening instruments used they were also validated against the the International Neuropsychiatric Interview (MINI). Not the best diagnostic instrument but a good one.

From the two screening instruments the MDI has the advantage that it is considerably shorter than the CES-D (12 compared to 20 items), and requires less time input from the adolescents.

Several recent studies have shown that Internet-based interventions are as effective in the treatment of depression as more traditional types of psychological treatment, although most of these studies have been conducted with adults. But Cognitive Therapy through Internet might be an acceptable treatment and medium for depressed adolescents.
Cuijpers, P., Boluijt, P., Straten, A. (2008). Screening of depression in adolescents through the Internet. European Child & Adolescent Psychiatry, 17(1), 32-38. DOI: 10.1007/s00787-007-0631-2

Wednesday, May 21, 2008

New Grand Round

The New Grand Round of this week is up on Musing of a Dinosaur.

Grand Rounds has become the contemporary weekly portrait of medicine through the eyes of the medical bloggers.

Life Hacks for Doctors

Dr Shock is a fan of Life hacks. He even reviewed some books about it on this blog: Getting Things Done, and Upgrade Your Life.

But now he discovered a slide show with Life Hacks for Doctors. There is even a blog dedicated to efficiency for doctors: The Efficient MD and a WIKI.

The Efficient MD Wiki is designed to help healthcare professionals and medical students discover clinical pearls, useful resources, life hacks, and strategies to improve the practice of medicine.

Thanks clinical cases and images, who is also a collaborator on this new project, The Efficient MD Wiki.

Facts about Chocolate and Health

  • Cocoa is rich in polyphenols, similar to those found in green tea, and as polyphenols have been shown to have beneficial effects on cardiovascular disease such as hypertension, stroke, myocardial infarction but also diabetes

  • For cocoa, the terms that are used to describe the particular compounds of interest are flavanols. Flavanols are a subclass of flavonoids which are, in turn, a subclass of polyphenols

  • Cocoa is the non-fat component of cocoa liquor (finely ground cocoa beans) which is used in chocolate making or as cocoa powder (commonly 12 % fat) for cooking and drinks

  • Chocolate refers to the combination of cocoa, cocoa butter, sugar, etc. into a solid food product

  • In Europe, 58 % of people ate milk chocolate, closely followed by dark chocolate (43 %)

  • Cocoa taken as a beverage is popular in Spain

  • There were two human trials with interventions using cocoa published in 2001, three in 2002, five in 2003, three in 2004, six in 2005 and five in 2006 (one so far in 2007). More often than not, the studies yield at least one positive and significant result

  • The research is predominantly focused on effects on the vascular system, however, there are other areas of research on man in vivo which are not so extensively investigated, such as those concerned with cognition, cancer and diabetes

  • The mechanism of action of cocoa polyphenols including clinical, pre-clinical and in vitro studies consistently show changes in biomarkers related to oxidative status and/or vascular function

  • High cocoa content dark chocolate tends to be richest in polyphenols, although each chocolate is different in polyphenol content

  • For future research:

    • Where possible, conduct randomised, controlled, cross-over, multi-dose trials

    • Use well-defined cocoa or chocolate

    • Use an appropriate control of no-polyphenol chocolate

    • Recruit volunteers with at least one non-optimal biomarker or disease risk factor
Cooper, K.A., Donovan, J.L., Waterhouse, A.L., Williamson, G. (2008). Cocoa and health: a decade of research. British Journal of Nutrition, 99(01) DOI: 10.1017/S0007114507795296

Tuesday, May 20, 2008

Psychiatry in Bagdad

But Dr. Hussain, who entered his profession at a time when Iraqi doctors were among the most sophisticated and highly trained in the Middle East, is caught in a time warp in a war-torn land where knowledge and sophistication have been largely overwhelmed by third-world decay, and ancient equipment has plunged some treatments into a “One Flew Over the Cuckoo’s Nest” barbarism, despite the best intentions.

Article in The New York Times, shocking news

Google Health, One More Step

In Google Health you can now add your health information. You can add your diseases and medication use. The systems alarms when dangerous interactions appear with your different medications. You can also add allergies.

You can even add medical records from sources of which a few of are shown in the next figure

When you link a website to your profile, you may authorize that website to read your Google Health profile or to automatically send and update information in your profile (such as medical records or prescription histories). You decide which permissions to grant when you sign up with each website.

All you need is a google account.


If you're willing to hand over your medical profile to the big G in the name of convenient info, Google Health is for you. The more privacy-minded, of course, may refrain.

Monday, May 19, 2008

Supportive Psychotherapy mostly Novice Pilots Flying In The Dark Without Maps

Supportive therapy in psychiatry is mostly done by unexperienced psychiatric residents during their training. Most residents as well as psychiatrists think that supportive therapy is just providing a sense of safety, support self esteem and hope, alternated by advice how patients should live their life, structure their day, get to work and behave. Psychiatrist the least qualified usually apply for the supervision of residents doing these therapies based on these premises.

To my opinion these kind of therapies are the hardest to do, need the most experienced and psychotherapeutic best qualified psychiatrists. Yes psychiatrists because this kind of therapy is mostly done with the most vulnerable patients with sever psychopathology and usually with several diagnoses. Sure residents can be trained in supportive therapy and they should be.

What makes supportive psychotherapy besides the patients in need for it so difficult?

  • It is not just common sense, interpersonal skills, and a capacity for empathy.To my opinion it is a psychotherapy as dimension of dynamic psychotherapy, to a greater or lesser extent depending on the particular context, problems, and needs of the person. Interpretive approaches and transference work must also be used with the so-called less suitable patients who have a history of immature object relations in this kind of treatment. But it has to be used wisely.

  • Supportive psychotherapy relies heavily on psychoanalysis in describing characteristic techniques, such as “improving ego functions,” “minimizing the focus on transferential material,” and “confronting maladaptive defenses,” thus assuming some familiarity with ego-psychological psychodynamic theory. For beginning psychotherapists it can hardly be expected to understand what it means to “manage” or “manipulate” the transference in supportive therapy and how this differs from “interpreting” the transference in a more exploratory treatment, let alone which patients under what circumstances require such “management” and why.

  • Without a good working hypotheses about the unconscious motives, feelings,
    and conflicts underlying a person’s distress, it is also difficult to see how they would have any basis for predicting what would be supportive or nonsupportive for the individual patient at any given moment in the treatment.

  • You also need to understand the differences between thinking psychoanalytically in providing support and acting like a psychoanalyst.One of the most important rules is: “Do not say everything you know, only what will be helpful.”

  • The supportive therapist helps the patient see things more clearly by supporting
    reality testing, tactfully challenging unrealistic ideas, and demonstrating more effective, less costly ways of defending while supporting adaptive have to understand these different aspects in your patient before you can even work on it.

  • The main priority in supportive psychotherapy is to build a “holding environment”
    and to foster the therapeutic alliance. This is hard to dose, most unexperienced therapist remain to silent, distant.

  • It is hard to know about how responsive and self-revealing you should be, about what, and why. The best way to learn this is in supervision. Supervisors should feel free to share their own learning process, including any gaffes, confusion, and embarrassing moments they may have experienced along the way.

  • You should realize that small improvements can lead to bigger changes and that setting overly ambitious goals will only increase the likelihood of failure. Doing “just enough” is good enough—just enough to reduce anxiety,build self-esteem, instill hope, support deficient psychological functions, and improve overall functioning.

The biggest problem with this effective and satisfying kind of treatment is the lack of a clear definition, consensus about training and guidelines for supportive therapy.

This post is based on Teaching Supportive Psychotherapy to Psychiatric Residents by Carolyn J. Douglas, M.D. and published in the American Journal of Psychiatry 165:4, April 2008, but holds the views of the author of this post: Dr Shock
By the way it is an excellent account of supportive therapy

Sunday, May 18, 2008

Iceland has the Happiest People in the World

This blog is mostly about depression and it's treatment. Today some happy news.

Iceland, the block of sub-Arctic lava to which these statistics apply, tops the latest table of the United Nations Development Programme's (UNDP) Human Development Index rankings, meaning that as a society and as an economy - in terms of wealth, health and education - they are champions of the world.

And why is that?

  • It is the country with the sixth highest GDP per capita in the world

  • Where people buy the most books

  • Where life expectancy for men is the highest in the world, and not far behind for women

  • It's the only country in NATO with no armed forces (they were banned 700 years ago)

  • The highest ratio of mobile telephones to population

  • The fastest-expanding banking system in the world

  • Rocketing export business

  • Crystal-pure air

  • Hot water delivered to all Icelandic households straight from the earth's volcanic bowels

  • and so on and so forth...

Want to know how this came about, read the excellent article John Carlin on The Guardian: No wonder Iceland has the happiest people on earth.
It has something to do with them Vikings.

Saturday, May 17, 2008

I knew it, Tetris can make you Smarter

Bass-Krueger wanted to test how large this effect was. He had some of his several dozen subjects play Tetris for 15 minutes. Then he gave everyone a spatial reasoning test similar to those used in IQ assessments. The results were staggering: Tetris players scored more than 55% higher than the control group. “Even in 15 minutes it can still have an effect,” Bass-Krueger told us here in Atlanta at the Intel International Science & Engineering Fair, where he presented his results.

In Scientific American

More healthy games

Friday, May 16, 2008

US Citizens have a Distorted World View

Watch this video and you will know why.

Alisa Miller, head of Public Radio International, talks about why -- though we want to know more about the world than ever -- the US media is actually showing less. Eye-opening stats and graphs.

How can Genes and Stress cause Depression?

The answer is: in the stress system. Stress reactivity might be an important link between a genetic variant of the serotonin transporter gene, stressful life events in early years and depression.

There is evidence of interaction between a functional genetic variant of the serotonin transporter gene and life events. Depression is not based on a simple gene or a cluster of genes. But on a gene and environment interaction. So the risk of getting a depression is higher when a certain genetic variant of the serotonin transporter gene is present in the presence of life stress, especially in early life. But how does this genetic predisposition and life stress lead to depression?

Cortisol, a reliable indicator of hypothalamic pituitary-adrenocortical (HPA) axis functioning and stress reactivity has a hereditary component and is also elevated in 40%–60% of adults diagnosed with depression.

How was this research done?
Girls at high (n=25) and low (n=42) risk for depression by virtue of the presence or absence of a family history of this disorder were genotyped and exposed to a standardized laboratory stress task. Forty-two girls had biological mothers with no current or past Axis I disorder (low-risk daughters), and 25 girls had biological mothers with a history of recurrent episodes of depression during their daughter’s lifetime (high-risk daughters). Cortisol levels were assessed before the stressor, after the stressor,and during an extended recovery period.
The two groups of daughters did not differ significantly in their genotype distribution.

And the results?

Daughters who are homozygous for the s allele showed a marked increase in cortisol production during and following exposure to the stressor. In contrast, daughters with at least one copy of the l allele exhibited a slight decrease in cortisol production over the course of the stress session.
See the figure.

These results explain in part why stress in some people can lead to depression and not in others. This is not a black and white outcome. Some people without the s allele can also get a depression but usually with a lot more stress compared to those with a s allele. Probably these findings can't explain everything about the origins of depression but these findings sound plausible. They probably only apply to certain depressions such as melancholic depression and they probably differ based on ethnicity but nevertheless these results are encouraging to my opinion.

Research into how the serotonin system plays a role in regulating HPA axis activity might shed some light on further mechanisms.
Biological stress reactivity is a plausible mechanism underlying the association between genotype and exposure to life stress in predicting the onset of depression.

In the future it might be possible to discover high risk individuals and develop treatment or prevention programs.

Serotonin and the transporter gene
Serotonin is an important neurotransmitter believed to play an important role in depression. The transport of serotonin during reuptake in the neuron from the synaps is done by a protein. The production of this protein is dependent on certain genes. The variant of this gene affects how much serotonin transporter protein is produced. Individuals with the short allelic form of this variant showed an increased risk of depression compared to those carrying the long allele but only when exposed to adverse life events or maltreatment. There have been some nonreplications, but these have been outnumbered by the number of replicated findings. The original science abstract of the article on influence of life stress on depression is freely available
GOTLIB, I., JOORMANN, J., MINOR, K., HALLMAYER, J. (2007). HPA Axis Reactivity: A Mechanism Underlying the Associations Among 5-HTTLPR, Stress, and Depression. Biological Psychiatry DOI: 10.1016/j.biopsych.2007.10.008

Thursday, May 15, 2008

Are we in need of a cases journal?

This is a call for cases to be submitted to this new journal. Not only the extraordinary exciting cases but all cases. The intention is to form a database with thousands of cases and a search function so that physicians as well as patients can look for e.g. male 52 years with COPD and non smoking. The focus is on outcome of these cases, that is what they want to know from the authors

Are we in need of this new journal? Don't think so.
Let me know in the comments

Wednesday, May 14, 2008

Speciality Choice of Medical Students, Impact of Clerkship

I wanted to be a psychiatrist before I went to Med School. Fascinated by the work of Jung and especially Freud, psychiatry seemed the ultimate goal for Med School. Encountered these pioneers while reading literature and a new goal was formulated. Before that my hart was set on social geography, thank god I changed my mind.Other factors such as the encounter with people out of the ordinary during my earlier years most certainly did help my career choice but I found out after finishing Med School during residency in psychiatry.

During Med School I only once doubted my choice. It was during my clerkship of internal medicine. The head of the department, it was hematology, seemed to appreciate my interest in patients and internal medicine. He asked me to apply for a residency in Internal Medicine. Shortly thereafter he was diagnosed with oat cell tumor, lung cancer and died within 6 months and that was the end of my uncertainty about my specialty after med school.

Factors that are associated with choice of specialty based on earlier research are:

  • Work content and willingness to work with chronically ill patients as important determinants of choosing a career in general practice.

  • Students who sought surgical training attached greater importance to prestige and career opportunities.

  • Increased awareness of a specialty and clinical experiences during clerkships are associated with shifts in preferences and eventual specialty choice.

  • General practice clerkships encourage students to pursue further training in this specialty

  • Women are more likely to prefer part-time work and opportunities to combine work and personal life and they choose a career in community based areas and social medicine

  • Men are typically more attracted by technical challenges, prestige and learning potential and they prefer hospital-based specialties

What did this research do?
They carried out a longitudinal cohort study to collect data on career preferences and attitudes towards future careers among 3 cohorts of students before and after clerkships in surgery (n = 200), internal medicine (n = 277) and general practice (n = 184).

And what did they find?

  • Students were encouraged by the clerkship to consider a future career in the specialty of the rotation. Many students saw their ideas regarding a specialty, whether positive or negative, reinforced during the clerkship and, as a result, did not alter their preferences.

  • Relatively more male than female students preferred a career in surgery, and more female than male students preferred a career in general practice.

  • Men opted more for surgery and women for general practice.

  • Experiences in primary care settings promote an interest in general practice and show it to have advantages that were not considered or known of beforehand.

  • Gender differences regarding career choice appear to be not only based on typical male and female choices but to be a combination of attitudinal factors, such as type of preferred patients and work (technology oriented work and emergency situations versus chronic patients and palliative care) and lifestyle preferences (part-time work or career and income orientation).

Overall what can be learned from this research is that students choose a specialty
on the basis of the work content experienced during a clerkship. The results also show that it is the content of the work that matters. So clinical teachers, the clerkship is the time to promote your specialty.

My clerkship for psychiatry was not representative of psychiatry as I know it today. It was a clerkship at a medium stay care facility in a state hospital. My first encounter with real work in psychiatry was emergency psychiatry and I loved it and stayed for 2 years. Residency in a University Hospital did the rest. Still love my job.
Maiorova, T., Stevens, F., Scherpbier, A., van der Zee, J. (2008). The impact of clerkships on students’ specialty preferences: what do undergraduates learn for their profession?. Medical Education, 42(6), 554-562. DOI: 10.1111/j.1365-2923.2008.03008.x

Tuesday, May 13, 2008

Spider named after Neil Young

I like the music of Neil Young, not everything but this love for his music started way back in the seventies. Heart of Gold got me hooked. A fan of Neil Young discovered a new spider and named it after Neil Young.

A sneaky spider has been named in honor of rock musician Neil Young.

Jason Bond, a biologist at East Carolina University, named a newly discovered arachnid, Myrmekiaphila neilyoungi. It is also known as a trapdoor spider.

"There are rather strict rules about how you name new species," Bond said. "As long as these rules are followed you can give a new species just about any name you please."

He added, "With regards to Neil Young, I really enjoy his music and have had a great appreciation of him as an activist for peace and justice."


Magnet in Your Knickers against Menopause

Dr Crippen is a blogging doctor from the United Kingdom, his posts are of interest even if you don't have to deal with the lousy health care system of the British Empire and full of humor. In a recent post about new treatments for menopause he exposed Jennifer Harper-Deacon who proudly proclaims that she is “Health Journalist of the Year” and who advocates "Hormonal Balance"

includes the plant essences Dioscorea villosa (wild yam), which possesses oestrogen- and progesterone-like properties and acts as a hormonal regulator; Agnus castus, a progesterone-like essence considered to be a master hormone regulator that helps with night sweats, hot flushes, reduced libido, oedema (swelling) and vaginal dryness; and salvia, an essence that helps the body to adjust to hormonal changes, inhibits perspiration and calms the mind, body and spirit. It also contains pulsatilla, known as the remedy of choice for sensitive women, as it impacts on both the psyche and ever-changing hormonal symptoms. Take three drops three times daily for the first month, gradually increasing the dosage up to seven drops, three times daily. Ideally, you should take this remedy for six months.

But what really made me laugh as well as him probably was the other cure for menopause:
I was however very taken by her second recommendation for menopausal symptoms. Ladycare from Magnopulse is only £19.95

It is a small, discreet static magnet that you attach inside your underwear, which can help alleviate a number of symptoms, including mood swings and hot flushes. Do not use it if you or your partner has a heart pacemaker, defibrillator or insulin syringe driver.

This made me very happy.

Feeling menopausal ladies? Stick a magnet in your knickers. May I just add to the caveats that users of Magnopulse may have some explaining to do at airport security.

I checked with Google if this was also available in The Netherlands but Dutch women can stay at ease, not in the news here.

Please keep on posting about these frauds , make my day

Monday, May 12, 2008

Does Vascular Depression Exist?

Are the recent claims to fame from a SSRI and rTMS correct for treatment of vascular depression or just treatments seeking new markets? I think the latter. rTMS is of dubious efficacy in the treatment of depression and new "me too" SSRI's are struggling for a share.

Vascular depression is in the news, especially due to the latest annual meeting of the American Psychiatric Association in Washington DC. Claim has been made that Several Therapies Show Promise for Vascular Depression meaning a SSRI and rTMS. See also Anxiety Insights.

But does the diagnostic entity of Vascular Depression really exist?

The relationship between vascular disease and depression cannot solely be explained by current established risk factors or the effects of treatment for depression. Other mechanisms must apply, and there is some evidence for common genetic factors.

This is the conclusion of a recent review in the International Journal of Geriatric Psychiatry. The current evidence regarding the relationship between vascular disease such as hypertension, coronary artery disease, and depression cannot be entirely explained by current established risk factors. They think that shared genetic factors between depression and vascular diseases can play some role. This has still to be determined.

What is Vascular Depression (Alexopoulos)
Cerebrovascular disease may predispose, precipitate, or perpetuate some geriatric depressive syndromes. The "vascular depression" hypothesis is supported by the comorbidity of depression, vascular disease, and vascular risk factors and the association of ischemic lesions to distinctive behavioral symptoms. Drugs used for the prevention and treatment of cerebrovascular disease may be shown to reduce the risk for vascular depression or improve its outcomes.

The relationship between cardiovascular disease and depression is a bidirectional relationship.
Just as vascular disease and vascular risk factors are associated with increased rates of depression, so depression has also been shown to be an independent risk factor for cardiovascular and cerebrovascular events.

The relationship between depression and cardiovascular disease is not a simple casual one. The two conditions might also be linked via other mechanisms than risk factors such as genetic factors.

So the notion that cardiovascular disease contributes to the development of depression and vice versa is to simple. The claim that some treatments are more efficacious for vascular depression still remain shaky.

Even a Dutch research group with a strong believe in the concept of vascular depression showed in a recent research for cerebrovascular risk factors and incident of depression in community-dwelling elderly, that only moderate support for the vascular depression hypothesis was found.
Teper, E., O'Brien, J.T. (2008). Vascular factors and depression. International Journal of Geriatric Psychiatry DOI: 10.1002/gps.2020
Luijendijk, H.J., Stricker, B.H., Hofman, A., Witteman, J.C., Tiemeier, H. (2008). Cerebrovascular risk factors and incident depression in community-dwelling elderly. Acta Psychiatrica Scandinavica DOI: 10.1111/j.1600-0447.2008.01189.x

Sunday, May 11, 2008

Dr Shock went Hiking

Went hiking this weekend and encountered some weird creatures as well as beautiful views, go see them on flickr.

Saturday, May 10, 2008

10 Things You can Learn from a Digital Detox Week

Yes Dr Shock is preparing for his yearly holiday, should he keep on blogging or just go "cold turkey"? Can he cope with his blog addiction? What do you think let me know in the comments.

As some of you will know I took part in Adbusters’ Mental Detox Week last week. This meant I stopped doing screen and computer based stuff as much as possible. I was at work so there were obviously times when I had to check email and things. But I did manage to cut it right down to a bare minimum. Outside of work it was a total no computer, no TV, no iPod existence for me. Which is quite a big thing in my ordinary daily life.

  • E-mail can wait

  • Phones are good

  • Screens and Sleep

and so on, and so on......
Read all 10 at

Friday, May 9, 2008

Chronicity in Depression

Major depressive disorder is unremitting in 15% of cases

Major depressive disorder is recurrent in 35%.

About half of those with a first-onset episode recover and have no further episodes.

53% of those with a lifetime episode of depressive disorder either do not recover at all or have at least 1 recurrence.

What is new in this research?

The focus of this analysis is the group of 92 participants who experienced an episode of depression (meeting criteria for DSM-IV) for the first time in their life during the follow-up. Seventy-one first lifetime episodes occurred between the baseline and 1993 follow-up, and 21 occurred between the 1993 and 2004 follow-ups. The comparison group for onset consists of the 1739 participants followed up through the 1993 wave who also had the opportunity for onset but for whom onset did not occur.

This way the Neyman bias and the Berkson bias (A special example of selection bias)are avoided. The first bias is also called the "clinician's illusion. Clinicians only see a subsample of patients with depression, those with chronic or recurrent episodes.

The Berkson Bias occurs when the combination of exposure and disease under study increases the risk of hospital admission, thus leading to a higher exposure rate among the hospital cases than the hospital controls. So the natural history of depression is best studied using a population based sample, in which individuals are selected from the general population without regard to treatment.Both these biases lead to exaggeration of the chronicity of depression. This research avoids these biases.

Besides the above mentioned results, more common findings in this research were:
the 92 participants with first lifetime onset of depressive disorder were:

  • more likely to be women

  • younger of age

  • those with 1 or 2 short 5HTT alleles. This polymorphism has also been shown to be of importance for evidence of interaction between a functional genetic variant in the serotonin transporter gene and life events

  • persons with a history of drug or alcohol disorders and
    panic attacks were at a higher risk.

These factors raised the risk of first lifetime onset of depressive disorder.

That is somewhat different but also show some overlap with the risk factor for recurrence of depression

What is more important is that the data suggest little or no acceleration or amplification of the course through time.

Another important finding in this research was the intriguing result of the paradoxical effects of the 5HTT on the natural history of MDD. Individuals
with 2 long alleles are protected from the occurrence of first lifetime onset of depressive disorder,consistent with other research. However, the same configuration
is related to longer, not shorter, episodes of depression.
Our speculative explanation is based on the notion that depressive disorder has multiple causes which
endure in varying degrees throughout the course of life.Individuals with the protective genetic configuration sometimes are exposed to other causes whose force is sufficient to break through this protective effect, and presumably these other causes are stronger than in individualswith first episodes and a less protective genetic constellation. After the occurrence of the first episode, these causal forces remain
in place, producing longer episodes andmore difficult recovery.

The serotonin transporter gene
There is evidence of interaction between a functional genetic variant in the serotonin transporter gene and life events.

Serotonin is an important neurotransmitter believed to play an important role in depression. The variant of this gene affects how much serotonin transporter protein is produced. This protein is involved in reuptake of serotonin in the synaps. Individuals with the short allelic form of this variant showed an increased risk of depression compared to those carrying the long allele but only when exposed to adverse life events or maltreatment. There have been some nonreplications, but these have been outnumbered by the number of replicated findings.

These results are not very different from the results of patient samples from clinics and studies whose samples include cases late in the course.

Eaton, W.W. (2008). Population-Based Study of First Onset
and Chronicity in Major Depressive Disorder. Archives of GeneralPsychiatry, 65(5), 513-520.

Thursday, May 8, 2008

What makes a Good Clinical Teacher

The authors emphasize these common themes:

1. Medical/clinical knowledge - obviously this is a sine qua non
2. Competence and clinical reasoning
3. Positive relationships with students and supportive learning environment
4. Communication skills
5. Enthusiasm

On DB's Medical Rants

A literature review

rTMS can Improve Working Memory

Columbia University Medical Center has used conventional transcranial magnetic stimulation (TMS) to reduce the deficits in working memory associated with sleep deprivation.

On Brain Stimulant

rTMS can do other things as well, read about 8 Effects of TMS on Brain Function but how does TMS work?

Etiquette Based Medicine

Does my Old World origin bare fruit in my work? Read it in this Perspective of the New England Journal of Medicine: Etiquette Based Medicine.

I would propose a similar approach to tackling the problem of patient satisfaction: that we develop checklists of physician etiquette for the clinical encounter. Here, for instance, is a possible checklist for the first meeting with a hospitalized patient:

1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

rTMS not Effective for Depression

Rapid Transcranial Magnetic Stimulation (rTMS) to the left prefrontal cortex is not more effective than sham rTMS for depression. This was the result of a recent published randomized controlled trial with 4 month follow-up.

rTMS is a non-invasive method to stimulate the brain. Weak electric currents are induced in the cortex of the brain by rapidly changing magnetic fields (electromagnetic induction). This way, brain activity can be triggered with minimal discomfort, no need for anesthesia, and no cognitive side-effects. Side effects of rTMS are: discomfort or pain from the stimulation of the scalp and associated nerves and muscles on the overlying skin and hearing from the loud click made by the TMS pulses.

The most recent Cochrane review concluded that there is no strong evidence for benefit from using transcranial magnetic stimulation to treat depression, although the small sample sizes do not exclude the possibility of benefit. Since then (2002) 8 randomized controlled trials were published about rTMS and depression, you can read about these trials here.

After the review only one other randomized sham controlled trial was published about rTMS for depression.

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

Since some previous studies used relatively non-intense stimulation parameters in
the absence of a true placebo condition this trial used an intensive form of rTMS treatment:
Research physicians administered TMS at 110% resting MT (motor threshold) at frequency 10 Hz, in 5-second trains. Twenty trains were given each session with inter-train intervals of 55 seconds. Thus a total of 1000 TMS pulses were given per session and 10 000 per course.

In addition, very few reported meaningful follow-up data, in this study subjects were followed up for 4 months. To prevent unblinding placebo rTMS was delivered in the same way as real rTMS but using a purpose-built sham coil (Magstim Co.,Whitland, UK) that was visually identical to the real coil and made the same clicking sound but did not
deliver a magnetic field to scalp or cortex.

And these are the results:
Overall, Hamilton Depression Rating Scale (HAMD) scores were modestly reduced in both groups but with no significant grouprtime interaction (p=0.09) or group main effect (p=0.85) ; the mean difference in HAMD change scores wasx0.3 (95% CIx3.4 to 2.8). At end-of-treatment time-point, 32% of the real group were responders compared with 10% of the sham group (p=0.06) ; 25% of the real group met the remission criterion compared with 10% of the sham group (p=0.2) ; the mean difference in HAMD change scores was 2.9 (95% CI x0.7 to 6.5). There were no significant differences between the two groups on any secondary outcome measures. Blinding was difficult to maintain for both patients and raters.

In a comment they still want us to believe that rTMS can be promising. In the comment comparison is mad with antidepressants and ECT but these treatments have been studied far more often resulting in not very great advantages but much more evidence and meta analysis with greater power. Moreover, as with other failing treatments in the past rTMS is studied in all kinds of diagnoses. rTMS for Stroke?
A study by a group out of the University of Cologne in Germany has demonstrated that rTMS over the unaffected motor cortex of patients that have had a stroke will make their use of the affected hand more efficient and quicker.

rTMS for Parkinson's disease and Dystonia?
Most studies to date have shown beneficial effects of rTMS or tDCS on clinical symptoms in Parkinson’s disease (PD) and support the notion of spatial specificity to the effects on motor and nonmotor symptoms. Stimulation parameters have varied widely, however, and some studies are poorly controlled. Studies of rTMS or tDCS in dystonia have provided abundant data on physiology, but few on clinical effects.

Nah, get out of here..........

There is now even deep TMS
This specific technology can excite or inhibit more areas of the brain than conventional TMS. Regular TMS is basically limited the brain's outer layer, the neocortex, and can only reach about 1 to 2 centimeters into the brain. So it is limited in its ability to affect many brain areas. The new deep tms can stimulate inner brain areas without inducing unbearable electromagnetic fields cortically. This device currently has almost magical properties and it is somewhat difficult to distinguish company hype from real clinical benefit. I'm not sure at this point how selective this targeting technique is. I think it will be fairly difficult to selectively turn on or off specific brain areas without having unintentional effects.

Or cTMS.
Researchers have developed a better way to manipulate a person's brain functioning. They have created a new type of transcranial magnetic stimulation (TMS) device (called controllable pulse width TMS or cTMS for short) that will allow rectangular pulse shapes of the magnetic fields. This device will enable researchers to control the width of the magnetic pulse that passes through the subjects skull.

Will keep you posted on all this, will it help TMS?. Let me know in the comments what you think?
Mogg, A., Pluck, G., Eranti, S., Landau, S., Purvis, R., Brown, R., Curtis, V., Howard, R., Philpot, M., McLoughlin, D. (2008). A randomized controlled trial with 4-month follow-up of adjunctive repetitive transcranial magnetic stimulation of the left prefrontal cortex for depression. Psychological Medicine, 38(03) DOI: 10.1017/S0033291707001663
Ebmeier, K., Herrmann, L. (2008). TMS – the beginning of the end or the end of the beginning?. Psychological Medicine, 38(03) DOI: 10.1017/S0033291707001651

Wednesday, May 7, 2008

Elderly Refuse Clinical Trials

A failed randomized controlled trial of Fluoxetine versus placebo in elderly stroke survivors due to reluctance and subsequent informal discussions by their treating physicians. Also due in part to high community prescribing rates of antidepressants by general practitioners. In a recent research showed that 15% of adults aged over 75 years are in receipt of an antidepressant prescription from their general practitioner, half of them for more than 2 years and many without formal review.

So adolescents your not alone. Elderly are not alone as well, in The Netherlands it was hard to find elderly for a study that 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).

Now I am a strong supporter of placebo controlled trials. An important factor for success is the believe physicians and other health workers have in the importance of the trial. If the health workers are ambivalent you can forget it.

Why is a placebo controlled trial important for stroke survivors?
The authors:

However, the evidence that antidepressants are effective is surprisingly weak, and although there is some indication that they produce improvement in mood symptoms we know little about specific indications or about complications of treatment. The latter are especially important since if treatment of depression is to have an impact on rehabilitation outcomes, then it needs to be given early at which time complications
may be more likely.

Despite screening 641 patients they could only include 1 patient, so they gave up but nevertheless got their experience published, good for them as well as for the editors of the International Journal of Geriatric Psychiatry.
Ruddell, M., Spencer, A., Hill, K., House, A. (2007). Fluoxetinevs placebo for depressive symptoms after stroke: failed randomised controlled trial. International Journal of Geriatric Psychiatry, 22(10), 963-965. DOI: 10.1002/gps.1771

Tuesday, May 6, 2008

Gazza in Trouble Again

Paul Gascoigne alias Gazza is in trouble again apparently. reported by the Daily Mail
On NHS Blog Doctor

I am not a football fan but even I knew Paul Gascoigne was one of the great talents. He has not coped with the money, and the fame, and the alcohol. But what is to be done?

Next the NHS Doc gets furious about the hypocrisy in a comment on the article in the Daily Mail. He is right about 2 things, Gazza was an exceptional talent and the comment is ludicrous.

DSM V and Author Conflicts

More than half the 28 new members of writers of the next edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) have ties to the drug industry, according to the Center for Science in the Public Interest’s Integrity in Science Watch.

A lot of my Dutch and Belgian colleagues are in the United States these days. They are visiting the APA Annual Meeting in Washinton DC.

I thought they should know this, hope they kept on reading this blog.
The conflicts of interests were posted online by the APA last week (look here). They ranged from small to extensive.

You can read some more about this on Pharmalot

But then we already knew this didn't we?

Monday, May 5, 2008

More Agressive People Play The Game More Violently

Computer game players with more physical-aggressive personality manifest more violent behaviors in game playing with more violent interactions, more frequent punching and kicking actions, and more frequent shootings. This research is one of the first to show that personality is an important factor in how a game is played.

The most important contribution of this study is that it investigated the individual experience of game playing. Most of the existent studies, especially experimental studies, simply compare a group of people playing a violent game and another group playing a nonviolent game without taking into consideration that the violent content people are exposed to can vary to a great extent even when playing the same game. This study is the first that goes beyond contextual variables and actually considers the unique experience of each individual player.

How was it done?
Screen captures of 40 undergraduate students were studied. They independently played the game for 70 minutes, sitting separately from each other and wearing earphones. The video stream of the last 10 minute portion of their game playing was recorded using the software Snagit for content analysis.

Two popular computer games The Godfather (Game 1) and True Crime: Streets of LA(Game 2) were used. Both are third-person action games rated as Mature with violent physical force. Participants played either as a gangster in Game 1 or as a violent police officer in Game 2. Both games involved driving, shooting, fighting, and interactions with nonplayer characters (NPCs). In both games, players could use natural means (e.g., punch, kick) or weapons during violent interactions. Using two games rather than one was aimed to reduce the influence of a specific game. Eighteen of the 40 participants played Game 1, and 22 played Game 2.

Physical-aggressive personality was measured a week before participation using the physical aggression subscale in Buss and Perry’s Aggression Questionnaire.
Five dependent variables were used to measure the aggressiveness of participants’ game play: (a) frequency of PAT, (b) frequency of nonviolent interaction, (c) frequency of using natural means, (d) frequency of using firearm, and (e) percentage of two types of consequences: severe and mild. A PAT is an aggressive exchange that occurs between a perpetrator (P) engaging in a particular type of act (A) against a target (T).

The next step would be to examine whether aggressive game play actually mediate the effect of playing violent games. Will a violent game player later show more aggressive thoughts, affects and behaviors.

A small sample size with undergraduates makes generalizability limited, the participants were mainly male, only 6 women participated. Aggressive thoughts, affects or behaviors after game playing weren't measured. This would be of interest for the effect of violent game playing. Other factors such as playing against a human or a computer and playing on a 42 inch screen or a mobile phone screen can also influence game play.
Peng, W., Liu, M., Mou, Y. (2008). Do Aggressive People Play Violent Computer Games in a More Aggressive Way? Individual Difference and Idiosyncratic Game-Playing Experience. CyberPsychology & Behavior, 11(2), 157-161. DOI: 10.1089/cpb.2007.0026