Dr Shock usually "hangs" in his chair. It feels comfortable. Read in this article in LifeScience why sitting up straight might be a bad advice. Scientifically tested with magnetic resonance imaging (MRI).
Thursday, August 23, 2007
Sit up straight?
Wednesday, August 22, 2007
Electroconvuslive therapy fourt edition by Dr Abrams
I read the first edition of this book while on holiday in France. We were cross-country skiing. Not that the weather was bad or the company boring but this book is very informative and easy to read. Read all the other editions as well. For me it is the most narrative book about ECT with a critical appraisal of all the scientific literature. Obviously written by an experienced and good clinician.
This book is reviewed on Medical Heaven, I couldn't have done a better job.
Ranking english written medblogs
A list of medical blogs based on a algorithm with the number of comments, posts, feed readers, incoming links. You can see the widget about it in my sidebar.
Here is a discussion about rating medical blogs.
Sampling sewage for local drug use
The researchers decline naming certain cities but they revealed one trend: use of methadone and methamphetamine (a prescription opiate withdrawal aid and speed) remained constant over 24 days in these cities, but cocaine consumption routinely spiked on the weekends.
A method of taking a small sample of incoming sewage at a water treatment plant is developed. This method can extract the record of local drug use
Environmental analytical chemist Jennifer Field of Oregon State University and her colleagues, using an automated system to test small samples automatically collected at wastewater treatment plants over a 24-hour period. Solids are centrifuged out and the sewage sample is then chemically separated in various compounds of interest chemically. By measuring the relative mass of the various residual chemicals, the chemists can then identify what specific drugs have been recently used in that community.
The technique might help communities determine where to apply law enforcement or track the success of targeted drug-use prevention efforts.
This article about sampling for local drug use appeared on Scientific American.
I remember an article in a Dutch newspaper mentioning that with a comparable method it has been shown that in Spain the abuse of cocaine is the highest of Europe.
Tuesday, August 21, 2007
Myths and stigma's about ECT
Leon Rosenberg, a former dean of medicine at Yale University, had just attempted suicide by overdose. He was admitted to hospital and prescribed electroconvulsive therapy, or ECT.
This is the start of an excellent article by Michael Evans an associate professor at the University of Toronto and staff physician at Toronto Western Hospital.
This article also discusses some other myths, for instance about depression:
Those on the outside still see it as not really a disease but a weakness. Those on the inside see it as a chronic disease like any other, but with a twist.
Or this one about suicide, one of the complications of depression:
"Heart attack victims are consoled ('Isn't it a pity?'); suicide victims are cursed ('How could he?')."
About ECT:
We discount a therapy that has proven effectiveness because of its image, yet every day embrace unproven therapies that have benefited from a public-relations makeover.
To my opinion the most nuanced view on side-effects of ECT:
Memory loss seems the side effect of most concern to patients. With current ECT, it is usually transient, but any unauthorized withdrawal from the memory bank is a travesty. The medical community has occasionally shown insensitivity to this, but researchers are now attempting to better delineate the cause and effect.
Monday, August 20, 2007
Homeopathy or poison for depression or mourning
Homeopathy claims that their pills go with your individual symptoms of depression and personality. Ignatius for instances cures "depression" after a loved one's death. Ignatius is made from the ignatius bean. Ignatius beans were frequently used as a cheap strychnine substitute for Strychnos nux vomica, strychnine. Ignatius beans are used chiefly as a homeopathic remedy, administered in very small doses because of extreme toxicity. Improper dosage-internal consumption of as little as a fraction of an ounce - can result in muscle spasms and painful convulsions and even death by asphyxiation.
Not only are homeopathic "medicines" usually expensive, their efficacy is not scientifically tested.
Recently there has been a debate about depression in the British Medical Journal. Gordon Parker defended the opinion that depression is over diagnosed. At first I didn't want to support his point of view, but calling mourning a depression as is done in this article promoting homeopathy for treating depression makes me uncertain again.
Sunday, August 19, 2007
Top 10 pdf tricks
In medicine as well as in other fields pdf files are widely used. A free reader from adobe is available. But if you need to do other things with the pdf files please go and see this article on lifehacker.com.
It has many suggestions for both Mac and Windows users.
The most important which I use a lot is:
1. merge pdf files
2. edit pdf files
3. save any file as pdf file.
10 Steps for doing better research
All you med students out there or other students. Here is an article on how to prepare a research paper.
On one of my favorite blogs on productivity, getting things done and lifehacks: lifehack.org.
10 tips to help you find, organize, and use the information you need to put together a decent research paper.
TimeLineMaker for Psychiatry
Patients in psychiatry have complicated medical histories. Patients with Bipolar disorder are one of them. Patients often have multiple episodes with different medication schedules, helpful or not. Life Charts are used for diagnostic and therapeutic purposes with these patients. Other mental illnesses also have a fluctuating course with partial or complete remission. A recent article on medgadget.com discussed TimelineMaker, a software package specifically designed to create clean looking time lines.
You quickly enter a series of events and details like time and place, click the button that generates the chart, and you automatically get a simple timeline. From here one can add details to the chart, move things around, add notes, and generally change the look and feel of the timeline.
Looks perfect to me for reconstructing patient histories, you can download a trial version at TimeLineMaker.
Here an example from the software maker:
Saturday, August 18, 2007
Patient telling his experience with ECT on YouTube
Precise description of electroshock treatment by a patient undergoing this treatment. He has prior experience with the treatment. Impressive account of the pros and cons.
Friday, August 17, 2007
Dr Shock sat in a Winston Churchill Chair
Dr Shock is in Scotland for a few days. This afternoon he had the pleasure of sitting in a Sir Winston Churchill chair, while sipping his afternoon tea. The hotel owning this chair is on the picture. The chair is made out of timbers from Blenheim Palace, the place were Sir Winston Churchill was born. The manufacturer also used copper left over from material from world war two.
Above the chair there was a certificate. Under the seat of the chair there was a sigar humidor. Most convenient, room for three Cuban sigars. Very solid made and comfortable.
Price 3250,- pounds.
Electroconvulsive therapy for students, physicians, psychiatrists, and other interested readers
The famous book Neuropsychopharmacology: The Fifth Generation of Progress is online available for free (as in free beer). It has a magnificent chapter about Electroconvulsive therapy.
Electroconvulsive therapy: sixty years of progress and a comparison with transcranial magnetic stimulation and vagal nerve stimulation
Thursday, August 16, 2007
A Drug company rewrites entry on Wikipedia
AstraZeneca deleted references to claims that taking Seroquel carries a risk for teenagers: they will be more likely thinking about harming or killing themselves when taking this drug. The deleter was a user of a computer shown to be registered to the drug company. The FDA proposed that makers of antidepressants including AstraZeneca update their text to include warnings over increased risk of suicidal thinking in young adults.
Dr Shock read this while in Scotland in The Times.
Wikipedia Scanner -- the brainchild of Cal Tech computation and neural-systems graduate student Virgil Griffith -- offers users a searchable database that ties millions of anonymous Wikipedia edits to organizations where those edits apparently originated, by cross-referencing the edits with data on who owns the associated block of internet IP addresses. This program cannot identify the individual behind the computer but it can identify the computer and the network it is on.
Other misuse of Wipipedia is on Godlike productions.
Would like to find some more pharmaceutical companies but the site is down, to many interested readers or drug companies again?
Highlights of american psychiatry through 1900
In 1860, Elizabeth Packard, who differed with the theology of her clergyman husband, was forcibly placed in an Illinois state hospital. She remained there for 3 years. At that time, Illinois law stated that "married" women could be hospitalized at a husband's request without the evidence required in other cases. Want to know how this ended?
The Question of Patient Restraint in 1900?
Women were not welcomed into the medical profession during the first half of the 19th century. Many arguments against women becoming physicians were physiological and neurological: would the education and training required make a woman unfit for her "primary duty," childbirth? And was rest (physical and mental) necessary during menstruation? Want to know when this was abolished?
American asylums were influenced by visits of their superintendents and others to European hospitals. Want to know about these developments?
Have a look at 19th-Century Psychiatric Debates.
Wednesday, August 15, 2007
Dr Shock is number 13 of 25 medblogs
Dr Shock is very honoured to be in the top 25 medblogs on number 13. My lucky number as well. The dutch website is called medgadget.nl
This blog also has en English version, with a ranking for English medical weblogs on which Dr Shock doesnot appear......yet.
But never mind, I write in English at least I try to write proper English.
Medgadget.nl:
I have been a big fan of Medgadget.com for a while now. You can read more about the founders at Planet.nl (dutch). That is why I thought it would be great to introduce a dutch alternative. At this site I will present the newest medical gadgets, medical technology and research. Now and then I will shine some philosophical light on some of the issues presented on this website.
Free Medical Journals
Free Medical Journals was launched in late February 2000, days before the inflation of the Internet bubble. Within a year, it had 15,000 visitors per day. In early 2007, these figures stabilized to around 7,000 daily visitors.
FMJ is a simplistic website: it only produces a list of free journals.Most articles from the journals listed at FMJ are freely available one to 6 months after publication. But there are also really free medical journals even for psychiatry
Tuesday, August 14, 2007
Brain perfusion and electroconvulsive therapy (ECT)
Hypoperfusion of parts of the brain in depressive disorder largely normalizes after response to antidepressants. Perfusion changes after response to electroconvulsive therapy (ECT) follows a different course. This interesting conclusion is recently published in the Journal of Nuclear Medicine. The design of this study delivers interesting results besides those already mentioned.
First they compared healthy controls with depressed patients without medication for at least 2 weeks before undergoing SPECT. Single photon emission computed tomography (SPECT) is a nuclear medicine tomographic imaging technique using gamma rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. However, it is able to provide true 3D information. Usually the gamma-emitting tracer used in functional brain imaging is 99mTc-HMPAO (hexamethylpropylene amine oxime). 99mTc is a metastable nuclear isomer which emits gamma rays which can be detected by a gamma camera. When it is attached to HMPAO, this allows 99mTc to be taken up by brain tissue in a manner proportial to brain blood flow, in turn allowing brain blood flow to be assessed with the nuclear gamma camera. Because blood flow in the brain is tightly coupled to local brain metabolism and energy use, the 99mTc-HMPAO tracer (as well as the similar 99mTc-EC tracer) is used to assess brain metabolism regionally.
Compared with healthy controls depressed patients had a significant lower regional cerebral blood flow (rCBF) before treatment over the frontal lobes and the subcortical nuclei (amygdala, caudate, thalamus and hypothalamus).
The effect of antidepressants and ECT were compared with these baseline measures after treatment. Another SPECT was performed after 6 weeks of medication or completion of the ECT course.
For those patients who responded to antidepressants, a significant increase in rCBF was found in the right parietal lobe of depressed patients. No perfusion changes were found in non-responders. No perfusion differences were found between medication responders and controls. In other words, responders on antidepressants had regained normal cerebral blood flow comparable to normal controls.
In contrast, rCBF was still lower in ECT responders than in controls, in the same region as before treatment as well as in the occipital and cerebellar regions. Especially this last finding is of interest since previous studies used the cerebellum as reference region for data analysis assuming the cerebellum had nothing to do with depression. The cerebellum was not traditionally considered a major contributor to the neurocircuitry of mood regulation. This assumption has to be refuted, cerebellar dysfunction is known to have an impact on cognition and affect.
The fact that further reduction in rCBF in posterior brain regions occur after response to ECT could be a state phenomenon or a trait phenomenon. Long term studies are needed to document the course of rCBF changes.
This is the Talairach under-surface view showing the Prefrontal Inferior Orbital area at the top of the picture and the Temporal lobes in the middle of the picture. With Major Depression we see significant decreased blood flow to both of these areas of the Brain as is shown here.
Reduced perfusion to the frontotemporal cortex bilaterally.
99mTc-HMPAO SPECT Study of Cerebral Perfusion After Treatment with Medication and Electroconvulsive Therapy in Major Depression
Yoav Kohn,Nanette Freedman,Hava Lester,Yodphat Krausz,Roland Chisin,Bernard Lerer,and Omer Bonne.
J Nucl Med 2007;48:1273–1278.
Google and Microsoft battle on health
Two giant competitors on the internet, Google and Microsoft, are competing on the issue of health. From pure gossip and circumstantial evidence it is suggested that Google would be interested in products to store and transport personal health information — information that is now often buried in paper files in doctors’ offices. Microsoft is looking at online offerings as well as software to find, retrieve and store personal health information on personal computers, cellphones and other kinds of digital devices — perhaps even a wristwatch with wireless Internet links some day.
Read all about it:
Wall Street Journal
New York Times
Article on this blog
Why not, although safety seems an important issue with these developments and getting people to trust this service a major challenge.
Monday, August 13, 2007
Older people with mental health problems face discrimination
A mental health pandemic and an inadequate Government response mean that over 3.5 million older people who experience mental health problems do not have satisfactory services and support, according to the final report from UK inquiry into Mental Health and Well Being in Later Life- a major independent inquiry by Age Concern.
As far as depression is concerned some conclusions from this report:
1. One in four older people living in the community have symptoms of depression that are severe enough to warrant intervention.
2. Only a third of older people with depression ever discuss it with their GP.
3. Only half of them are diagnosed and treated, primarily with anti-depressants.
4. Depression is the leading risk factor for suicide. Older men and women have some of the highest suicide rates of all ages in the UK.
Solutions from this report:
1. Ending discrimination is the first priority.
2. Prioritising prevention is essential. Many mental health problems in later life can be prevented.
3. Enabling older people to help themselves and each other is important.
4. Improving current services is necessary.
5. Facilitating change requires action in several areas.
I can't judge the political background of this report. As I learned from other sources mental health care for adults was in a deplorable state in the UK, probably improving in the recent years. So why shouldn't mental health care for the elderly have the same problem. As in most other western societies the percentage of elderly is increasing.
About the solutions the only ominous sign is that there is no where any mentioning of funding for these changes. I am curious for the promise that Age Concern have agreed to audit responses to these recommendations and report on progress in 2009.
As mentioned in an earlier article a part of the problem is the myth: the widespread defeatism which leads people to believe that mental health problems are an inevitable part of growing older and therefore nothing can be done.
The full report as well as the press release, and a summary can be downloaded on a website.
Newspapers also noticed the conclusions and have written articles about this report:
Telegraph
The Guardian
BBC News
Evening Standard
Sunday, August 12, 2007
Electroconvulsive therapy and pregnancy, a case report
Electroconvulsive therapy during pregnancy should be performed with caution. In a case report a woman with a first time pregnancy received ECT during pregnancy. She was on maintenance ECT, every 2 weeks during her pregnancy she received ECT. She had a bipolar depression and was only partially responsive to conventional medical therapy.
Fetal heart rates were recorded after each treatment but it was unclear how soon after the treatments and at what gestational age this testing began.
At 36 weeks she had an elevated blood pressure and elevated protein on a 24-hour analysis. Labor was inducted because of preeclampsia. The newborn unexpectedly had severe neurological deficits associated with multiple brain infarcts.
Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby. Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death.
A cause and effect relationship between ECT and the inter hemispheric infarcts cannot be established. Whether ECT in this case led to tetanic uterine contractions causing a fetal bradycardia or possibly induced a fetal arrhythmia, resulting in fetal brain injury, is purely speculative. This chain of events does not seem likely because uterine contractions of sufficient strength to severely limit placental blood flow probably would have been noticed by the patient. Other possible explanations for this complication could be the preeclampsia, and medication use is not mentioned in this case report.
There are no prospective or controlled studies exploring the effects of ECT on pregnancy and the foetus. Many case reports have been written but these data do not provide evidence for definitive conclusions. According to the editorial in the same issue of this case report:
How likely is it that a study could be done to show a statistically significant association between ECT and fetal brain injury? If the rate of neurological impairment in an unexposed control group was in the range of 1 in 1,000 births and the rate of injury in infants of ECT-exposed women was 10 times higher, a prospective cohort study would have to enroll over 1,000 women in both the treated and control groups to demonstrate this difference with statistical significance. Given the rarity of ECT use in pregnancy, such a study would obviously not be feasible.
Nevertheless the American Psychiatric Association has published guidelines for management of a pregnant patient undergoing ECT.
These guidelines are aimed at minimizing potential complications including aspiration and altered uteroplacental blood flow. Specific recommendations include
1. Consultation with an obstetrician before initiation of treatment.
2. Treatments performed in a facility with immediate access to obstetric care for emergencies.
3. Monitoring of fetal heart rate before and after treatments. Increase in monitoring at viability to include a non stress test with tocometry after treatments. Perform a Level 2 ultrasonography between 18 weeks and 22 weeks gestational age.
4. Routine anesthetic measures (leftward tilt of trunk, adequate oxygenation, hydration, and muscle relaxation, nonparticulate antacid, consider intubation in the third trimester).
But above all ECT in pregnancy should only be used in cases of emergency in which any delay is life threatening or when medication has failed. Given the risks of non treatment of major depression and the undefined risk of ECT in pregnancy, we must, as the authors of this case report suggest, use drug therapy as our first-line approach to treatment. The neonatal risks with pharmacotherapy are real, but adverse effects generally do not have long-term consequences. Most importantly, in contrast to ECT, large-scale studies on drug therapy have been performed, allowing the risks to be quantified.
Let's be careful out there. Sgt. Phil Esterhaus, Hill Street Blues.
Article:
Pinette MG, Santarpio C, Wax JR, Blackstone J. Electroconvulsive therapy in pregnancy. Obstet Gynecol 2007;110:465–6.
Editorial:
Is Electroconvulsive Therapy in Pregnancy Safe?[Editorial]
Obstetrics & Gynecology. 110(2, Part 2) (Supplement):451-452, August 2007.
Saturday, August 11, 2007
The switch that lifts depression, from Best of the Brain
Helen Mayberg found the switch that lifts depression in area 25, a spot deep in the cortex. This area is the key conduit of neural traffic between the thinking frontal cortex or forebrain and the central limbic region that plays a role in emotions and which appeared earlier in our evolutionary development. This area is overactive during depression or sadness. "Like a gate left open" she says. In contrast to this area both the frontal cortex and limbic region were less active as discovered with positron-emission tomography (PET)in depressed patients with Parkinson's disease compared to not depressed patients with this neurological disorder. Area 25 was also hyperactive in depressed patients without neurological disease. Patients that recovered form depression showed a rise in frontal activity and a calming in area 25. Area 25 also dampened when depressed patients responded to cognitive therapy.
The whole story from the discovery of the relation between area 25 and depression to Deep Brain Stimulation (DBS) is told in a very readable chapter of the book: Best of the Brain from Scientific American, Mind, Matter, and Tomorrow's brain. Received this excellent book just a few days ago and read two chapters already in bed before going to sleep. I even finished the chapters before falling a sleep, that's a remarkable quality of the writers, usually it takes 10 minutes before I fall a sleep. I am very enthusiastic about this book so I had to tell you this story before reading the whole book and writing a complete review. Anyone with interest in the brain and results of recent research should read this book. It is easy to read. For the table of content please see The Dana Foundation. The Dana Foundation is a private philanthropy with principal interests in brain science, immunology, and arts education.
Now back to the discovery of area 25 and DBS. With a group of researcher at the University of Toronto they sought a way to return the area back to normal activity. The group decided to try inserting electrodes in area 25 in a dozen severely depressed patients that had not responded to several antidepressants and ECT. A pair of electrodes and slender leads were slid in to area 25 after drilling a pair of nickel-size holes in the skull. A pacemaker was attached to the leads and placed under the collarbone. After turning the pacemaker on two thirds of the patients were completely recovered, never felt better.
Not only was there a new cure found for severely depressed patients not responding to the usual treatment but also our way of thinking about the brain has changed. The brain works as a system of coordinated functions that arise from different regions, rather than as a single unit.
The chapter holds even more background information and interesting results with cognitive behavioural therapy and brain imaging, go get it.
Thursday, August 9, 2007
6 Tips on Staying Up-to-Date on Anything
As mentioned before I use my blog for fun and staying up to date on the most important topics for my work. Since I am working as a psychiatrist in a University Hospital my interests are several. Depression, electroshock, education and research to name a few. Computers and internet not only for work but also to work as efficient as possible. GTD has no secrets for me anymore but I still waste a lot of time reading about the tips and tricks online.
On one of my favourite blogs their was an article on 6 tips on staying Up-to-date in genetics, but genetics can be replaced by anything such as depression, GTD etc. The author added a few more suggestions of which I recognised many. I use these strategies to fill my blog and some more, but maybe one day I will reveal these tricks with the title: How does a shrink keep up?
The blog also has an interesting article how to use your blog to build an educational portfolio. An educational portfolio is a collection of research ideas, projects, presentations, manuscripts and published articles. A blog can be the perfect solution to building an electronic educational portfolio.
Increased rate of suicide among women with cosmetic breast implants
Among women with implants, a statistically significant 3-fold excesses of suicide and deaths from alcohol or drug dependence, as well as an excess of deaths from accidents and injuries consistent with substance abuse or dependence was found . The increased risk of suicide was not apparent until 10 years after implantation. This was found in a study of a nationwide cohort of 3527 Swedish women with cosmetic breast implants. This study had a mean follow-up of 18.7 years (range, 0.1-37.8 years). This number of deaths in this group was compared with the number expected among the age- and calendar-period-matched general female population of Sweden. The abstract of this study from the Annals of Plastic Surgery
The excess of deaths from suicides, drug and alcohol abuse and dependence may be due to an underlying psychiatric condition among these women.
From an article on Anxiety, Addiction and Depression Treatments
It needs to be made clear that the number of women whose causes of death could be linked to mental health concerns was small even within the study. The death rates were much higher than the population at large, but only future research will allow stronger conclusions. What is clear at this juncture is that more thorough pschological screening, both before and after surgery, might be appropriate. Elective cosmetic surgery should not be restricted or at all impeded by these screenings, but it would make sense that since we know there is a connection, that we use it to help improve the lives of those who may unknowingly be dealing with depression, anxiety or any number of mental health conditions.
The Washington Post and medgadget.com also discuss this research
Tuesday, August 7, 2007
NICE information for the public about electroshock
On this site a clear and concise description of indications for electroshock (ECT) are given by NICE. NICE produces guidance in clinical practice. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in the United Kingdom. This information on electroconvulsive therapy is provided for use by the public and provides an explanation of the guidance.
NICE was asked to look at the available evidence on electroconvulsive therapy and to provide guidance that will help the NHS in England and Wales decide when it should be used. This resulted in a nice pdf file with that information.
Found a new depression center
So now and then good information can be newly discovered on the web. The website from thirdage.com has very good information on depression. It is divided in an Indepth section with background information on depression and a section Living with depression. In this last section all kinds of everyday questions about depression are answered, such as:
1. Depression in men, how is it different?
2. Can folic acid help ease depression?
3. How to choose a therapist
4. Talk therapy or drug therapy: which is better.
The information is up to date, clearly written, objective and the authors are all MD's. The background of this website is hard to discover, if anyone finds a about section please let me know. I couldn't find any clues for conflicts of interests.
Monday, August 6, 2007
What is the best design? Continuation on antidepressants
Continued treatment for 6 to 12 months beyond the acute phase of depression reduces the risk of relapse to 50%. Patients taking antidepressants during the continuation phase are at least 50% less likely to experience a relapse compared to patients with placebo. These continuation studies of antidepressants have used two different designs:
1. Patients are initially treated with an antidepressant, responders are then randomised to continue with the antidepressant or switched to placebo in a double-blind matter, both doctor and patient don't know what they are on.
2. Patients are treated with an antidepressant or placebo in a double blind fashion, responders to active treatment and placebo are continued on the treatment to which they initially responded.
The authors of this study in the Journal of Clinical Psychopharmacology hypothesised that the design of the study would impact on the likelyhood of relapse (getting a depression again). They speculated that the first design would result in more relapse since there is an obvious change in treatment, patients can be aware that they initially received active medication, and there is now a change that they will will be switched to placebo. Expectation of a positive outcome in this design would be lower.
The authors conducted a meta-analysis of antidepressant continuation studies and compared the relapse rates using these 2 different designs. They identified 16 continuation studies of new-generation antidepressants, 11 using the first design and 5 using the second design.
In the second design the frequency of relapse was lower compared to the studies using the first design. Also the difference between relapse with the antidepressant and placebo was greater with this design.
The design of these studies has a significant impact on the absolute percentage of patients who relapse on both active medication and placebo, as well as an effect on the difference between relapse frequency between antidepressant and placebo.
Other factors such as longer continuation phase, demographic factors, depression severity, broader definition of treatment response during the acute phase, and a broader definition of relapse did not explain the outcome of this meta-analysis. Drug withdrawal did not account for the difference in absolute relapse rates related to study design.
Treatment optimism for patients and raters may explain reduced relapse rates in the second design. Design should be taken into accoun when comparing results of continuation studies.
Impact of Study Design on the Results of Continuation Studies of Antidepressants.
Brief Reports
Journal of Clinical Psychopharmacology. 27(2):177-181, April 2007.
Zimmerman, Mark MD; Posternak, Michael A. MD; Ruggero, Camilo J. PhD
Sunday, August 5, 2007
Hearing voices located in Schizophrenia
Highlighted areas in the picture above indicate increased activation associated with emotional auditory stimuli in 21 patients with Schizophrenia compared to 10 healthy controls. This result was obtained in a study with functional magnetic resonance imaging (fMRI) comparing 21 male patients with Schizophrenia and persistent auditory hallucinations. On average the patients started to hear voices at age 23. Their average illness duration was 15 years.
The results showed functional abnormalities and corresponding gray matter deficits in several brain regions associated with regulating emotion and processing human voices.
From medicalnewstoday.com
"The results showed abnormalities in specific areas of the brain associated with the capacity to process human voices," said lead author, Luis Mart'-Bonmat', M.D., Ph.D., chief of magnetic resonance in the Department of Radiology at Dr. Peset University Hospital in Valencia, Spain. Dr. Mart'-Bonmat' said. "Using MRI to mark brain regions that are affected in both structure and function will help pinpoint specific abnormalities associated with the disease and ultimately enable more effective treatment."
Saturday, August 4, 2007
Dutch elderly afraid of electroshock
38 of 50 patients refused randomisation beforehand because of fear of electroconvulsive therapy (ECT). An in depth interview showed that fear of brain damage by ECT played a major role. This recently published study was a feasibility study testing the efficacy and safety of ECT, prescribed in an earlier phase of treatment than last resort. This study would test the efficacy of ECT versus nortrityline among depressed elderly (> 59 years) who had not responded to sertraline, a selective serotonin reuptake inhibitor (SSRI).
In the Netherlands and most other European countries ECT remains underused and practised mostly as a last resort treatment. Especially depressed elderly could benefit from ECT in an earlier phase since delay may worsen their situation and outcome. Elderly who refuse to drink are at greater risk compared to adults, elderly usually have somatic comorbidity, elderly have more different drugs for somatic illness subscribed with dangers of interaction with antidepressants, elderly usually do not tolerate antidepressant due to side effects. All reasons why ECT might be a safer and more efficacious alternative. From retrospective studies efficacy of ECT in the depressed elderly are promising. From these studies it is expected that elderly might benefit more from ECT than adults.
The wrong assumption that ECT causes brain damage might be a vestige of the seventy's and the dark period of the anti psychiatry in the Netherlands in that same period. They probably still have the wrong scene from one flew over the cuckoo's nest in their head, the scene after the lobotomy which most people confuse with the result of ECT. Moreover the practice of ECT in that movie was how it was performed in early the 30's of the previous century. Due to this lack of knowledge a efficacious treatment is underused in this group.
Article Discussed:
Research Letter
ECT in the treatment of depressed elderly: lessons from a terminated clinical trial
M. L. Stek, F. B. van der Wurff, B. M. J. Uitdehaag, A. T. F. Beekman, W. J. G. Hoogendijk
Department of Psychiatry, Vrije Universiteit/VuMC and GGZ-Buitenamstel, Amsterdam, The Netherlands
Department of Clinical Epidemiology and Biostatistics, Vrije Universiteit/VuMC, Amsterdam, The Netherlands
Thursday, August 2, 2007
Deep Brain Stimulation resolves coma
A 38 year old man in Minimal Conscious State (MCS) for 6 years after closed head injury after an assault was implanted bilateral Deep Brain Stimulation electrodes in his head with the tips in the central thalamus. The electrodes were turned off and on at random during different periods of 30 days. The patient was assessed by a neuro-rehabilitation team ignorant of the stimulation schedule. The patient was more alert during the DBS-on periods, he could use his limbs after instruction, and he could chew and swallow food when it was placed on his tongue. The observed improvements in arousal, motor control and behavioural persistence were due to the DBS. It seems there is another indication for DBS coming: chronic Minimal Conscious State with widely preserved brain structure and clear evidence of interactive behaviour (command following, verbalisation and inconsistent communication).
Progression and long term outcome has to be assessed after this promising result.
DBS is already used for Parkinson's disease when all other options failed and sporadically for depression, again when all other options have failed.
From:
Nature 448, 600-603 (2 August 2007) | doi:10.1038/nature06041; Received 13 April 2007; Accepted 22 June 2007
Behavioural improvements with thalamic stimulation after severe traumatic brain injury
N. D. Schiff, J. T. Giacino, K. Kalmar, J. D. Victor, K. Baker, M. Gerber, B. Fritz, B. Eisenberg, J. O'Connor, E. J. Kobylarz, S. Farris, A. Machado, C. McCagg, F. Plum, J. J. Fins & A. R. Rezai
Wednesday, August 1, 2007
Suicide rates increase with hot weather
Analysis of more than 50,000 suicides in England and Wales between 1993 and 2003 showed the suicide rate rose when average daily temperatures topped 18C. The study appears in the British Journal of Psychiatry and is mentioned on the site of BBC News.
The researchers discovered that a rise of 1 degree C (celsius) above 18 C increases the suicide rate with 4%.
Proposed explanations:
1. Higher degree of aggression and impulsivity due to the hot weather.
2. The use of more alcohol in hot weather
If the hot weather starts suddenly the risk is higher than when people can adapt to the higher temperatures. Overall three-quarters of all suicides were by men and the largest number of suicides took place on Mondays. No spring or summer peak in suicide was found.
Tuesday, July 31, 2007
Michelangelo Antonioni, depressed?
Today I read in the newspaper that another important film director had died: Michelangelo Antnioni. His movies Identificazione di una Donna and Blow Up made an ever lasting impression on me, more than any other movie by Ingmar Bergman. Not that those two film makers could easily be compared, their style and themes differed remarkably. Reading about Ingmar Bergman I was surprised to learn that he suffered from depression and even had to be hospitalised for his depression. I wondered whether Antonioni also suffered from depression during his life. In an obituary in the Herald Tribune I learned that In 1954 the 12-year marriage of M. Antonioni to Letizia Balboni fell apart. Antonioni sank into a deep depression. His insomnia worsened. Often he spent the early morning hours writing screenplays.
This is the only reference to a probable depression I could find. Does anyone know more about Antonioni suffering from depression?
The movie "The Passenger" made by Antonioni is about a melancholic, depressed, and jaded television reporter (Jack Nicholson) assuming the identity of a dead man while at a hotel in a north African country, not knowing that the man was a renowned arms smuggler.
Have to have a look at this movie.
Shock, the healing power of electroconvulsive therapy
Recently read a review about this book in the Journal of ECT by Prof Max Fink and one by Dr Geller for Psychiatric services from the American Psychiatric association. The first review is only accessible for subscribers to the journal of ECT, the second review can be read online.
This quote from the online review sums up the conclusions from both authors:
Shock is recommended to all professionals not only to inform themselves about the history and current state of ECT but also so they can recommend it to patients. Any patient considering ECT would do well to read Dukakis and Tye's take on this intervention. There is no better material currently available that would allow a patient to provide true informed consent for ECT than reading Shock cover to cover.
Monday, July 30, 2007
Don't send your soldier longer than 13 months to battle
In a recent article in British Medical Journal it is concluded that an association was found between deployment for more than a year in the past three years and mental health that might be explained by exposure to combat. In other words: Personnel who were deployed for 13 months or more in the past three years were more likely to fulfil the criteria for post-traumatic stress disorder, scored worse on the general health questionnaire, and have multiple physical symptoms.
Ingmar Bergman depressed?
The death yesterday of Swedish cinema legend Ingmar Bergman drew stirring tributes in his homeland as well as other countries form all over the world. An article on news.com.au. drew my attention to the fact that Ingmar Bergman suffered form depression. He was hospitalised for depression. According to a biography it was in the year 1976 which was a traumatic one in the life of Ingmar Bergman. On January 30, while rehearsing Strindberg's "Dance of Death" at Stockholm's Royal Dramatic Theatre, he was arrest by two plainclothes policeman, booked like a common criminal, and charged with income-tax fraud. The impact of the event on Bergman was devastating. He suffered a nervous breakdown as a result of the humiliation and was hospitalized in a state of deep depression. Even though the charges were later dropped, Bergman was for a while inconsolate, fearing he would never again return to directing. He eventually recovered from the shock, but despite pleas by the Swedish prime minister, high public figures, and leaders of the film industry, he vowed never to work again in Sweden. This is confirmed on another website about film directors.
Never knew this before.
“I think it's difficult to understand and to fully comprehend the enormous contribution Bergman made to cinema and theatre, not only in Sweden but also abroad.”
Sunday, July 29, 2007
Rule the Web, book review
This book by Mark Frauenfelder, the founding editor of BoingBoing.net holds a treasure of useful information on the WEB. It's a guide to getting things done with the web. It has a companion website which to my opinion doesn't ad much to all the information in this book. The book is divided in 11 chapters. The first chapter is about creating and sharing, it has a lot of information on building websites, blogs, wikis and what have you, on the web. Chapter 2 holds information about browsing and searching the web. Mainly about Google, but then this is the best search engine. Next chapter is about selling and shopping: how to find promo codes and ebay tricks are some of the discussed topics. Chapter 4 is about health, exercise, and sports and chapter 5 about media and entertainment. This last chapter is full of information about movies, how can I play movies on ipod, how do I play old msdos games on my computer and so on. The chapter about travel and sightseeing not only suggest sites to plan your trip or to make a travelblog but also practical information about finding cheap hotels, the best seats on a particular plane. The chapters work, organisation productivity and communication have tips for email, skype, projects, bookmarks. The chapters Toolbox and Protecting and maintaining have a lot of information about how to keep your computer healthy and protect and improve your hardware. In conclusion the best information on getting things done with the web. The book is not for continuous reading although it is written accessibly, it is an excellent dictionary for the web.
My favorite tips from Rule the Web:
1. How can I get promo codes when shopping online
2. How can I search for a book on more than one site at once?
3. How can I plan a vacation with my friends
Saturday, July 28, 2007
Counting is done in the parietal part of the brain
A new study has found that there is a set of cells in the top rear of the brain that apparently keeps score. A team of Duke University researchers report in PLoS Biology that they discovered a pocket of "accumulator neurons" in the region of a monkey brain called the parietal cortex that appears to integrate and sum up the total quantity of individual items. Researchers focused on this region of the brain because previous human studies indicated that damage to the intraparietal portion of the brain impairs numerical processing. The researchers speculate that the information in these intraparietal neurons is then passed to another population of cells in the prefrontal cortex, which then fine-tunes the calculation into an exact value.
Myth: Depression is a Normal Part of Aging
This myth about depression in old age is one of many. If you know another myth about aging please tell me in a comment.
When people get older a lot can happen, you can loose your spouse, have to take medication for all kinds of ilnesses, you loose friends etc. Feeling blue is a normal part of life at any age. When this turns into depression it is something completely different. Depression increases the risk of suicide, it is not self limiting, and can be treated. The best advice is to consult your family doctor and visit the website from consumeraffairs.com with some more information.
Myth: Treating a depressed elderly won't work. Fact: Antidepressants, ECT, and cognitive therapy are all effective in the elderly
Friday, July 27, 2007
Why are there so many great unmarried women and no great unmarried men?
The answer is because alfa males spreads smells that attracts female. At least in rodents this is proven by a study with a nice design. They first exposed female mice to soiled bedding from male mice as a source of pheromones. They proofed that a 7-day exposure of female mice to soiled male bedding increased the production and survival of new neurons in the hippocampus. The authors also exposed female mice to the bedding of castrated males. Castration removes pheromones from the urine by eliminating circulating testosterone. Bedding from castrated males did not stimulate neurogenesis. This pheromone-induced neurogenesis appears to ultimately determine female mating preference for dominant males. The preference of female mice for dominant males is explained by pheromone-induced neurogenesis in the olfactory system and hippocampus.
From the articles:
Nature Neuroscience - 10, 938 - 940 (2007)
Alpha males win again, by Derek P DiRocco & Zhengui Xia
Nature Neuroscience - 10, 1003 - 1011 (2007)
Male pheromone–stimulated neurogenesis in the adult female brain: possible role in mating behavior. By Gloria K Mak, Emeka K Enwere, Christopher Gregg, Tomi Pakarainen, Matti Poutanen, Ilpo Huhtaniemi & Samuel Weiss
Thursday, July 26, 2007
Assertive Community Treatment, helps when hospital use is high
In clinical trials of intensive case management for people with severe mental illness inconsistent effects on the use of hospital care are reported. In a systematic review published in the British Medical Journal this seems to be related to high hospital use by the participants. Intensive case management works best when participants tend to use a lot of hospital care and less well when they do not. It might not be necessary to apply the full model of assertive community treatment to achieve reductions in inpatient care, but focus on the patients that get hospitalised frequently.
Teen depression, nobody is immune
Teen depression or depression during adolescence can be hard to discover. Even young good looking kids can suffer from it. In an article called: Depression has many faces, the author Jessica Lopez describes the "faces of depression" in teens and the troubles these teens can experience. Besides mentioning the symptoms of depression there is also a myth versus fact part in this article.
Myth: Telling an adult that a friend might be depressed is betraying a trust. If someone wants help, he or she will get it.
Fact: Depression, which saps energy and self-esteem, interferes with a person's ability or wish to get help. It is an act of true friendship to share your concerns with an adult who can help.
Reading this nice article I came across an excellent website called KidsHealth.org.
KidsHealth is the largest and most-visited site on the Web providing doctor-approved health information about children from before birth through adolescence. Created by The Nemours Foundation's Center for Children's Health Media, the award-winning KidsHealth provides families with accurate, up-to-date, and jargon-free health information they can use.
It also has information about teen depression for parents, and teens.
Tuesday, July 24, 2007
Adolescents brain and Depression
Symptoms of depression in adolescents look like those of depression in adults. Before the late 1970s the existence of depression in adolescents was controversial. The last two decades research has shown that adolescents are capable of experiencing episodes of depression comparable to adults. As a beginning psychiatrist I wouldn't believe that adolescents could be depressed, all other diseases starting in young life such as ADHD, Autism I did accept. Depression such as adults can experience, no.
Epidemiological studies estimate the prevalence of depression in adolescents is 5-8%. Despite similarities there are also notable differences in treatment response of depressed adolescents compared to adults.In contrast to adults TCA do not appear effective for the treatment of depression in children and adolescents.
Recently I discussed the brain changes during adolescence.
There are notable neurobiological differences between depressed adolescents and adults:
1. Adolescents do not have subtle thyroid alterations as in adults with depression
2. Growth hormone probes in adolescents donot differ between depressed adolescents and healthy adolescents in contrast with most adult depressed patients. Adolescents do not differ in growth hormone secretion after administration of clonidine, L-Dopa and dextroamphetamine.
3. Cortisol hyper-secretion is rare in adolescent depressed patients in contrast to depressed adults.
4. There is no blunted corticotrophin secretion after CRH infusion with depressed adolescents compared to a not depressed groups. In adults 50% of depressed patients have a blunted corticotrophin release.
5. Depressed adults have changes in cellular immunity such as changes in lymphocytes or lymphocyte subset number. In adolescents no studies reported changes in lymphocyte or lymphocyte subset number.
Depressed adolescents share another similarity with depressed adults, EEG changes during sleep are comparable between these groups:
1. prolonged sleep latency
2. sleep continuity disorders
3. reduced time until rapid eye movement (REM) period
4. increased REM density
5. decreased alfa (stage 3 and 4) sleep (this last one not with adolescents)
Neuroanatomical differences between adults with depression and adolescents has hardly been a subject for research. In adults the most important findings in MRI research are abnormal amygdala volumes, although the direction of this abnormality varies across studies. Volumes of the hippocampus have been found to be reduced in most, though not all, studies of chronic or recurrent adult depressives.
MRI findings in 20 children and adolescents with depression:
1. smaller amygdalas in depressed children compared to healthy subjects, reduction of left and right amygdala volumes
2. Hippocampus volumes did not differ between the groups
3. No significant correlation were found between amygdala volumes and depressive symptom severity, age at onset, or illness duration
How can these differences between early onset depression and adult depression be explained? There are three kinds of factors that me contribute to these different findings.
1. Development factors
Many of the neurobiological systems implicated in the pathophysiology of adult depression are not fully devloped until adulthood. For instance serotonin content and synthetic activity matures relatively early, the serotonergic innervation of the prefrontal cortex is achieved at age 5-6 years. In contrast the development of norepinephrine and dopamine content and synthetic activity continues through puberty with dopamine innervation of the prefrontal cortex not finalised until to early adulthood. Corresponding with these changes there are developmental differences in sensitivity to various pharmacological agents.
2. Stages of illness
Biological correlates and treatment response of patients with recurrent episodes of depression may differ from a single episode. Most adolescents experience their first depression in this life-phase. There is also some evidence that HPA axis disturbances differ between recurrent illness and patients experiencing their first episode. Differences in the neurobiological correlates of depression across the life cycle may reflect course-of-illness factors and not fundamental differences in the pathophysiology of the disorder.
3. Heterogeneity in clinical outcome
Several studies have reported that as many as 20 to 40% of children and adolescents with depression experience a manic episode within 5 years of their initial episode of depression. Adolescents in normal control may also switch group status over time In a longitudinal study 23 % of the normal control subjects had an episode of depression during the 7 year interval follow-up. Studies that failed to use normal controls subjects at low familial risk for affective disorder may have obscured group differences in neurobiological studies with child and adolescent probands.
These findings highlight the need for careful characterization of normal control subjects and the importance of longitudinal follow-up data
Conclusion
There are many differences in the neurobiological correlates and treatment response of depressed adolescents and adults. We currently do not know if adolescent- and adult onset depression are one and the same disorder. Systematic longitudinal research is needed that accounts for:
1. developmental stage
2. stage of illness (number of episodes, total duration)
3. familial factors
The results suggest that early onset depression shares some but not all of the neuroanatomical features of adult onset depression. This raises the possibility that the pathophysiology of early onset depression may differ from adult onset depression, despite similarities in phenomenology. This in turn may have implications for the treatment of childhood depression.
Signs of brain shrinkage seen in soccer players
Using high-resolution MRI brain scans, researchers found evidence of reduced gray matter in the brains of 10 male college soccer players, compared with 10 young men who had never played the sport.
Gray matter refers to the brain tissue that controls thinking and memory. The significance of the relatively smaller gray matter volume and density seen in these players is not yet clear, the researchers say.
This may be due to repeated knocks on the front of the head called "heading". More research is needed to flesh out the potential long-term brain injury risks associated with soccer.
The brief report can be found in: Clinical Journal of Sport Medicine. 17(4):304-306, July 2007.
Title: Evidence of Anterior Temporal Atrophy in College-Level Soccer Players.
Shock value
This is the title of an article in the Washington Post online. Another with opinions from different professionals, psychiatrists and psychologists alike as well as patients view. This article put's ECT in a historic perspective and also discusses a recent article in the JAMA which is described in this blog a few day ago.
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