I particularly liked this one, go seee the other 9 on Wacky Archives: 10 Ways They Failed
Probably all photoshopped but who cares.
Friday, March 21, 2008
10 Ways They Fail
Thursday, March 20, 2008
SSRIs Effective in Depressed Adolescents and Children?
Little attention is being payed to the efficacy of SSRIs for depressed children and adolescents. Most of the attention is on suicidal ideation and attempts due to these antidepressants.
The number of patients needed to be treated to gain an additional improvement was 9 for all SSRIs compared to placebo. For fluoxetine only it was 5. A number needed to treat of 9 is high and comes close to no use. A number of 5 tough sounds promising and is comparable to those reported for SSRIs in adults. Sertraline and citalopram showed only a moderate degree of efficacy and the other SSRIs a weak degree of efficacy.
This conclusion is based on a meta-analysis of 11 randomised controlled trials on the effect of SSRI treatment in children and adolescents with depression.
The randomised controlled trials were different in methodological approaches: enrolled population, sample size, diagnostic and outcome measures, and applied treatment schedule.
Nevertheless, with all these limitations SSRIs especially fluoxetine might be of benefit for severe or resistant depression in children and adolescents. Moreover, combination therapy with cognitive behavioral therapy in adolescents with moderate to severe depression is superior to medication or CBT alone. To my opinion this combination is the optimal treatment for severe or treatment resistant depression in adolescents and children.
The FDA black box warning for paroxetine in October 2004 resulted in a nonsignificant decline in antidepressant treatment of adolescents, including a significant deceleration in the rate of treatment with SSRIs other than paroxetine.
This outcome of a recent study published in the Archives of General Psychiatry of January 2008 neutralizes the concern expressed mostly by drug company supported publications about putting depressed youth at risk due to excessive decline in antidepressant prescribing.
USALA, T., CLAVENNA, A., ZUDDAS, A., BONATI, M. (2008). Randomised controlled trials of selective serotonin reuptake inhibitors in treating depression in children and adolescents: A systematic review and meta-analysis. European Neuropsychopharmacology, 18(1), 62-73. DOI: 10.1016/j.euroneuro.2007.06.001
Internet Addiction
A couple of weeks ago I posted on Internet Addiction in the DSM V?
Medicalize problems again. In an editorial in the American Journal of Psychiatry Internet Addiction is proposed as a new diagnosis in DSM V. Now the American Journal of Psychiatry used to be a serious peer reviewed journal although some of us doubt this feature for a while now.
On Mind Hacks there is another post about this editorial.
Why we have to describe this as an addiction still completely baffles me.
Wednesday, March 19, 2008
4 Ways to Store your PDF's
As blogger but also as doctor I am the proud owner of a lot of pdf's. Mostly scientific papers printed or downloaded from the University Library. Now that pile can grow to an enormous height.
How to save these files without being able to find them again when needed?
There are two ways off-line and two ways on line. The advantage of an on line library is that you can share the articles and read them anywhere with a computer or laptop. Real paper is easily scanned into a PDf in one step.
You just want to save tax documents on your computer, you want a quick and easy way to do it. While most scanner workflows require several steps to digitize documents, the Fujitsu ScanSnap transforms paper into PDF with a single button press.
Ways to store PDF's
- On a Mac I use Yep. Yep is software comparable to iTunes and iPhoto. You can store or let the program scan your hard drive for pdf files and tag them.
Start Yep for the first time and it automatically shows you all your PDFs tagged based on where they were found on your hard disk. But the real fun begins when you start adding your own tags. You'll never go back to a hierarchical filing system again.
You can search for files in yep based on tags. You can save these searches when you need them on more than one occasion. Comparable to play lists.Instead of having to decide which folder to store documents in, a simple, powerful tag mechanism we call the ‘ Yep Tag Cloud’ allows you to tag and retrieve documents with ease. In addition to tagging, there is a collection organizer similar to iTunes or iPhoto that lets you make ‘smart collections ’.
- On a windows computer I use endnote. You can download references from PubMed directly into endnote. You can than attach pdf's to their reference.
The “Link to PDF” field is renamed to “File Attachment” for organizing up to 45 files per reference. Your custom reference types can now be exported and imported between computers easily. And, you can control the display font for the “Search” window and reference field labels.
Via search you can retrieve the pdf files. - An on line solution is Connotea.The advantages being that you can tag the articles and retrieve them from any computer as long as your on line.
You will have to register. You can easily share your references with your colleagues. You can export the references for any reference database such as endnote, bibtex, and reference manager.
You can install a simple button on your browser to import thereference into your library. The only disadvantage is that you can't link to a pdf file.Saving references in Conntoea is quick and easy. You do it by saving a link to a web page for the reference, whether that be the PubMed entry, the publisher's PDF, or even an Amazon product page for a book. Connotea will, wherever possible, recognise the reference and automatically add in the bibliographic information for you. In Connotea you assign keywords (or 'tags') to your references. These can be anything you like, and you can use as many as you like, so there's no more need to navigate complicated hierarchies of folders and categories. Connotea shows you all the tags you've ever used, so it's easy to get back to a reference once you've saved it.
- The other on line solution is CiteULike. It is comparable with connotea but here you can save your pdf with the reference which is clearly an advantage compared to connotea. You can share your library with others, and find out who is reading the same papers as you. In turn, this can help you discover literature which is relevant to your field but you may not have known about.This system is also based on tags. You can import and export references.
CiteULike is a free service to help you to store, organise and share the scholarly papers you are reading. When you see a paper on the web that interests you, you can click one button and have it added to your personal library. CiteULike automatically extracts the citation details, so there's no need to type them in yourself. It all works from within your web browser so there's no need to install any software. Because your library is stored on the server, you can access it from any computer with an Internet connection.
My choices are yep and citeulike, any other suggestions, please let me know in the comments
ECT Treatment Number 2
A short description and a correction in this second post on The Angie by someone undergoing ECT treatment.
During ECT you are normally not intubated, this procedure only applies to pregnant women in their third trimester. They need to be intubated due to risks of regurgitation of gastric content.
The misunderstanding results from the mouth guard to protect your teeth during stimulation. Due to direct stimulation of the masseter your teeth are clenched. Like in the picture accompanying this post. The stimulation duration is only 4-8 seconds. After that the mout guard can be removed.
Tuesday, March 18, 2008
What electroconvuslive therapy is like
I recently made the decision to try and battle a lifelong struggle with depression with ECT, or electroconvulsive therapy. Because it’s such a hot-button issue in the field of psychiatry and there are many conflicting reports out there on the internet, I thought I would write, from the patient’s point of view, what getting an ECT treatment is all about.
In the interest of full disclosure, I would like to mention that I’ve only received one treatment so far. I’m hoping to use this blog to talk about my experiences as I go through them in the next few weeks while I’m getting the remainder of the treatments.
This is description of ECT by someone undergoing this treatment, I hope she or he will keep us informed about the ECT course on: The Angie, What electroconvulsive therapy is like.
Australian and New Zealand Clinical Practice Guidelines for the Treatment of Depression
While working on a new Dutch Guideline for ECT I discovered this guideline: Australian and New Zealand Clinical Practice Guidelines for the Treatment of Depression.
You can download the complete guideline (pdf 1.1 mb) or a summary. ECT is the fourth option in the treatment of depression in this guideline. They suggest to start with unilateral treatment unless the patient's prior response or urgency dictate otherwise. They even state that long-term maintenance ECT is not proven benefit. This made me wonder when this guideline was installed: 2004. We in The Netherlands are not doing that bad at all when considering our guidelines for the treatment of depression and ECT. Far more eye for the wish of the patient and symptoms, severity of illness of the depressed patient. In case of severe or psychotic depression ECT can be performed as first option
Monday, March 17, 2008
Interview with Gina Trapani on Tim Ferriss Blog
Tim Ferris is the author of the book: The 4 Hour Work Week. Read his book but beside some advice about avoiding to much meetings I found his book far less to the point and of relevance than the book by David Allen: Getting Things Done. But maybe that is an age thing, a generation gap. Not everyone shares this opinion.
Tim Ferriss has a blog and he recently interviewed Gina Trapani, the founding editor at Lifehacker and author of the brand-new book, Upgrade Your Life. I read her first edition of this book called Lifehacker, you can see the link on the right sidebar in the recommend books section of this blog. I ordered it special delivery but I am still waiting, will review it when I have read it, hopefully soon. In this interview they covered from morning routine to top downloads and more, they were able to cover a lot of topics in just 8 questions.
I liked this one:
4. What are some common “time management” tactics or approaches that you disagree with or don’t follow, and why?
To some degree, I reject the super-structured, old school of time management thought, the type of rigid planning where you say “from 10AM till 10:45 I’m going to work on TPS reports. From 10:45 to 11:15 check email,” etc. As a “web worker,” by nature I embrace serendipity and tangents, and like to keep myself open to working on unexpected things that excite me, even if they’re not in the plan. For example, a few years back, during some web surfing, I happened upon a tutorial on how to build Firefox extensions. I let myself go down the rabbit hole, so to speak, and now extension development is a big part of what I do.
Thanks Lifehacking.nl
Bipolar Disorder, Hands On Lecture
Dr. Kay Redfield Jamison, psychiatry professor at Johns Hopkins University School of Medicine, lived every day with the mania and severe depression that she had studied for years. She talks openly of the challenges she faced with the treatment and disclosure of her mental illness.
How Easter can Help depression
One of the 5 ways how easter can help with depression is chocolate.
Well we all know by now that chocolate isn't an antidepressant.
Chocolate craving might be a feature of atypical depression.
There is even doubt about the presence of flavinoids in most of the chocolate. Dark chocolate holds the higher concentration of flavinoids, these might be good for the heart.
Ah well just enjoy it because you like it is the advice of Dr Shock, but not to much.
Thanks Dr Confabula
Sunday, March 16, 2008
Free Photos
Beautiful pictures accompanying a post draws attention to the message or vice versa. Finding a good picture that emphasizes the message of the post is hard to get. Sometimes if I am lucky I can use one of my own. For presentations I have a set self made photo's about ECT.
Luckily there are few free photo sites such as:
- FreeFoto.com The site uses the following categories: USA, Business, Europe, Nature, Transport, United Kingdom, and other.
Our on-line images are covered by the Creative Commons license for non-commercial, no derivatives, attribution license (http://creativecommons.org/licenses/by-nc-nd/3.0/). This provides for use in any media providing it is not for commercial purposes and they are not making a derivative image or gallery.ANYONE, by which we mean commercial and non-commercial alike, can use FreeFoto.com images in an online setting, providing they provide attribution to the image and a link back to FreeFoto.com (either the image or the main site).
You will have to give your e-mail address, but than you can start the download. The picture is presented in a separate window were you can right click and save as.. The image above and below are from FreeFoto. It is Loch Awe in Scotland - A better site is freeimages.co.uk. All you have to do is join the mailing list and credit the source when using the image. I didn't join the mailing list but could still use the images with a simple right click and save picture as....
- On FreeStockPhotos.com you can only get photos with their name on it,
Every FreeStockPhotos.com photograph used must retain the domain name: FreeStockPhotos.com when used on the Internet, in a web page, in printed publications, or in any product, advertising, or packaging. This credit, however, may be cropped out or digitally removed from the photograph if it is included in readable type near each photograph, group of photographs, in the text, or in the credits.
Downloading them is easy. Just use right click with save picture as...
Did I mis any? Thanks
Saturday, March 15, 2008
Stroke Insight
Neuroanatomist Jill Bolte Taylor had an opportunity few brain scientists would wish for: One morning, she realized she was having a massive stroke. As it happened -- as she felt her brain functions slip away one by one, speech, movement, understanding -- she studied and remembered every moment. This is a powerful story about how our brains define us and connect us to the world and to one another.
Besides explaining left and right brain function she also reveals her thoughts and feelings during a stroke. It is also an example of a nice educational presentation.
No lectern, no walls. Her slides are simple but serve a necessary role. She also uses another powerful visual aid (but I won't give it away—watch it).
Thanks presentationzen.com
Talking of strokes, here are 4 simple signs to recognize stroke and probably save lifes
Friday, March 14, 2008
6 Reasons why Female Doctors won't Reach Senior Ranks
The suggestion is that feminisation of the medical workforce will degrade professional leadership, status and influence because women will compromise career aspirations for parenthood.
Since recent decades women comprise 60-75% of medical school entrants, at least in the UK and The Netherlands. However, only 1 in 10 medical clinical professors are women in the United Kingdom (UK). No female professor was employed in 6 medical schools. The presence of women in high ranking management and scientific jobs in Medicine has not increased.
How does gender affect aspirations in the medical workforce?
- Female medicals students were more prepared than male students to sacrifice high professional aspirations to the realities of parenthood. Men held to their high aspirations assuming their partner would care for the children
- There is a lack of female professional role models. Successful women are fewer in number
- Assumptions of female medical students are influenced by stereotypes. Women are portrayed as followers and part-timers. Men as leaders and full-time workers
- The dominant social picture is that of women being mothers and men being breadwinners
- Women are portrayed in humbler medical specialties, such as psychiatry, while men are portrayed in prestigious specialties, such as surgeons
- Lack of professional career advice to counterbalance these influences
These are the conclusions of a recent study published in Medical Education. This study involved students in their first clinical experience in Year 3 and 4. The design was to include a wide range of medical students with a wide spectrum of opinions. These students were interviewed with audio recording with a semi-structured, in-depth exploratory interview on which quantitative analysis was carried out by a female medical student researcher.
The authors concluded based on their results that more flexible work opportunities are needed as well as better career advice.
The question is how an increasing female workforce can be encouraged to seek career progression and an appropriate work-life balance.
But then, why should women want to adhere to demands placed on them by male dominance? What is your opinion, let me know in the comments
Related post on this blog:
Women Doctors more often wear White Coats in Media Portrayals
Drinkwater, J., Tully, M.P., Dornan, T. (2008). The effect of gender on medical students’ aspirations: a qualitative study. Medical Education, 42(4), 420-426. DOI: 10.1111/j.1365-2923.2008.03031.x
Thursday, March 13, 2008
Getting Things Done
When surfing the Internet and reading all kind of geeky, nerdy blogs I often stumbled upon Getting Things Done (GTD). From the posts I discovered some important parts of GTD. The first lessons I learned from these posts was the handling of e-mail. As a doctor, researcher and teacher I get a lot of e-mail each day. Adapting the workflow from GTD in Thunderbird with different folders for Action, Waiting On, Someday, and Archive I became a master in handling e-mail. No overcrowded Inbox anymore.
See also how e-mail can ruin your life
I even bought a labeler for files. But when getting used to my efficient mail handeling I started to wonder about the book. At first I kept telling myself that you could read about GTD online and using good software would do the trick. One of my recent acquisitions was Omnifocus. But in the end I decided to buy the book, Getting Things Done by David Allen.
And I am glad I did. I read it in a weekend. It is very clearly readable written. It is very practical. It takes you by the hand to get organized. Not only online but also in your office and home office. The practical advice is really worthwhile.
The book starts with an explanation of the mind set for GTD. One of the first chapters is about projects. Projects in the view of GTD are anything that you want to or have to do that takes more actions than one. That way a lot of things to do are actually projects. In these first chapters he discusses the essence of projects with why what how and when.
Next he takes you by the hand and tells you how to collect all your projects to do, how to organize your office and how to collect files, deal with your calendar etc.
An important task with Getting Things Done is to set aside a couple of hours a week for a weekly review. In this weekly review you have to take some time to collect all loose paper , notes, and lists. Life hack.org has a nice recent post about the weekly review in GTD from the David Allen
Since their are a lot of excellent blogs about I will not bother you further with a description of the book. Read about GTD online and buy the book, it is worth your while.
Improtant blogs about GTD are:
43 Folders
Lifehacker.org
Dutch readers should visit lifehacking.nl and try the tag slimmerwerken instead of gtd.
Wednesday, March 12, 2008
New Anxiety Disorder Discovered: Disconection Anxiety
Cyberspace takes it tole. After Internet addiction, Video Game addiction there is now a new anxiety disorder discovered: disconnection anxiety.
The American consumer is more connected and has more instant access to people and information than at any time in history. Losing that access creates disconnect anxiety.
What is disconnection anxiety?
Disconnect Anxiety refers to various feelings of disorientation and nervousness experienced when a person is deprived of Internet or wireless access for a period of time.
Overall, our research finds that 27% of the population exhibit significantly elevated levels of anxiety when disconnected. In terms of profile, 41% of this group are 12-24, 50% are 25-49 and 9% are over the age of 50.
So "elderly" experience less or no disconnection anxiety (duh)
Teens feel deprived form their friends, they suffer mostly from the social consequences of their disconnection. Afraid to be cut-off from their friends
Young adults also fear their disconnection from work. Afraid they will miss opportunities.
Boomers also use their gadgets for safety, without it they miss their "lifeline" or a "safety net". They feel safer when carrying it
Who discovers this crap?
Solutions Research Group (SRG) is a consumer research firm with special expertise in media, technology,wireless, leisure, youth and multicultural markets.
Based in Toronto, the firm is best known for its syndicated quarterly tracking studies of consumer behavior, including Digital Life America in the U.S. and Fast Forward in the Canadian market. www.srgnet.com
Medicalizing adaptation to new developments again. I won't be surprised if they come up with cognitive behavioral therapy for disconnection anxiety.
Thanks engadget
You can download the report on engadget.
Making Music with Only Windows 98 & XP Sounds
This is a video of some music a guy made using only sound effects from Windows. The video is of the music playing in ModPlug Tracker, the program he used to put it all together. The music only lasts for 1:31, then he starts going through all the different sounds he used.
It is amazing what he can do with these simple sounds.
Thanks geekologie.com
Related posts with music:
Spill the Wine
Gotta Digg, Digg This
Tuesday, March 11, 2008
Long Term Side Effects of Electroconvulsive therapy in Bipolar disorder
Patients with bipolar depression treated with ECT in the past (on average 45 months ago with a standard deviation of 21 months) only performed significantly worse on the Californian Verbal Learning Test compared to patients with bipolar disorder not previously treated with ECT.
These bipolar patients previously treated with ECT also had significantly more subjective memory complaints.
These two conclusions were drawn from a recent study in which 3 groups of subjects were compared. A group with bipolar disorder previously treated with ECT at least 6 months before memory assessment, a group of patients with bipolar disorder with an equal past illness burden but that had never received ECT and a group of healthy controls. All groups were matched for sex and age.
Now why was this research done?
Cognitive effects of ECT is largely studied in unipolar depressed patients, seldom solely in bipolar patients.
Unipolar and bipolar disorder differ from each other not only in demographic and clinical features but also in treatment and medications.
Some studies suggest that people with bipolar disorder are generally more likely to have cognitive deficits when euthymic than people with unipolar depression. This might be due to the disease it self or due to medication or both.
Extrapolating results from research with unipolar depression and cognitive side effects of ECT to bipolar patients might for these reasons not be very reliable.
Up until this reasoning I can follow the importance of further research into this matter of side effects of ECT and bipolar disorder. But the method used in this trial doesn't remotely answer this question alas.
The researchers didn't focus on the most important side effects of ECT such as retrograde amnesia and anterograde amnesia. They used memory tests not very specific for the cognitive side-effects of ECT.
Confounding factors such as medication used prior to testing and during testing as well as other important clinical variables influencing outcome could not be excluded due to small sample size. The differences found could be explained by these variables instead of ECT treatment.
Patients were not randomized to ECT or no ECT.
So what is the bottom line then?
It is still possible that patients with bipolar disorder will have a different long term outcome after ECT than unipolar patients. This research shows that although not very focused on the usual side effects of ECT the cognitive changes are small and are unlikely to influence the risk-benefit ratio of ECT.
In a recent post I mentioned the opinion that some subjective memory complaints can be considered as a somatoform disorder
A post about a memory test for retrograde amnesia
Everyday memory not affected by ECT
Bipolar disorder and ECT
MacQueen, G. (2007). The long-term impact of treatment with electroconvulsive therapy on discrete memory systems in patients with bipolar disorder. Journal of Psychiatry and Neuroscience, 32(4), 241-249.
Monday, March 10, 2008
Maintenance ECT does not produce cognitive side effects
Electroconvulsive therapy (ECT) for depression is the only treatment that is usually stopped when the patient has recovered. After successful ECT antidepressants are prescribed to prevent relapse. Since the widespread use of antidepressant pharmacotherapy, the indication for Electroconvulsive therapy (ECT) is often a medication resistant depression. Patients usually were treated with several antidepressants before ECT. Even with medication treatment failure for depression ECT is still very efficacious.
Depressed patients with pharmacotherapy treatment failure may benefit from the prophylactic effect of the same (class of) drug during maintenance therapy after response to ECT. Some patients relapse during adequate treatment with antidepressants after successful ECT. These patients usually will have another ECT course after which maintenance ECT is an option when antidepressants before and after ECT have failed to prevent relapse.
Maintenance ECT is effective in preventing relapse and recurrence in patients who have shown an initial response to ECT. During manintenance ECT the frequency of treatments is lowered. During a course patients are usually treated twice or three times weekly. During m-ECT this frequency can be lowered to once every 4 weeks. ECT frequency is lowered in small steps, from once a week to once every fortnight. In the first four months the frequency is lowered any further than once every two weeks.
During the course of ECT the most important side effects retrograde- and anterograde amnesia. To my opinion these cognitive side-effects do not increase and even might decrease during m-ECT. Cognitive side-effects during m-ECT are hardly studied because of small sample size and lack of control group.
In a recent study 12 patients receiving maintenance ECT were tested before and 90 minutes after an ECT treatment. Twelve other patients were tested at arrival in the hospital and 90 minutes later before receiving their maintenance ECT. The experimental group, tested before and 90 minutes after ECT did not show significant learning, attention or frontal decline in the second assessment after the ECT session, in comparison with the control group. However their visuospatial ability was lower than it was in the control group after after the second assessment. ECT sessions may cause some acute, mild dysfunction of visuospatial function.
Limitations of this study
Small patients samples (12 in each group).
No long term memory assessment
From this study we can not state that there are no adverse cognitive effects after one m-ECT session. But a lower frequency of treatments with a longer interval between treatments is probably to long to increase cognitive side effects. m-ECT does not produce clinical significant adverse cognitive side effects in contrast to an acute course of ECT
This research agrees with my clinical impression, anyone another opinion?
Related posts on this blog
Cognitive side-effects of ECT in adolescents
Everyday memory not affected by ECT on the long term
Side-effects of ECT how do they work out
Sackeims letter to the editor about memory loss due to ECT
RAMI, L., GOTI, J., FERRER, J., MARCOS, T., SALAMERO, M., BERNARDO, M. (2008). Cognitive functions after only one ECT session: A controlled study. Psychiatry Research, 158(3), 389-394. DOI: 10.1016/j.psychres.2007.01.005
Games with Electroshocks
Sure, your games are thrilling and all, but they don't exactly cause actual pain, do they? Well, that's all going to change thanks to the two twisted dreamers who started the company Mindwire, and their electroshock feedback device, the V5. That's right, next time you get fragged in Unreal, sacked in Madden, or robbed in GTA -- you get shocked in real life. Just the sadistic thrill you've been after, right? The device works by splitting your controller input to the "brain" of the V5 and your console, then sends electric jolts via electrode pads on your skin. Right now the company has a model tested and working with the PS2, Xbox, GameCube, and PCs, though they appear to be making preparations for current gen consoles in the next iteration of the device. If you're content with the choices at hand, this self-torture can be yours for £99.99 (or around $201). Check the totally awesome video after the break to see the V5 in action.
You can watch a video while someone is playing with this device attached on Engadget: The Mindwire V5 turns gaming into pure electroshock torture
Sunday, March 9, 2008
Why Can't We find a Gene for Depression?
The estimated heritability of depression is 40-50%. This is based on twin studies and family studies. Than why is it we can't find the gene?
- There are different subtypes of depression such as melancholic type, Seasonal Affective Disorder, Bipolar depression. These different types of depression will not be explained by one gene or set of genes, or polymorphisms of genes.
- Research until now may have varied in inclusion criteria and diagnostic criteria
- Genes responsible for depression may differ with ethnicity. Chines might have different gene locations responsible for depression than Caucasian depressed patients
- Besides ethnicity, gender may also play a role in genetics, depression is twice as common in females than males.
- Depression is a complicated disease. Different systems could affected. A variety of different neurotransmitters and hormones can be involved. In some patients the cortisol stress system is involved with depression in others not. In some patients SSRIs are effective, others need other kind of antidepressants or treatments.
- And last but not least, depression can have many causes of which heritability is just one and it doesn't have to be present at all.
There was some hope when Caspi et al showed that the 5-HTT genotype (serotonin transporter gene)moderates the depressogenic influence of stressful life events. It moderated the effect of life events that occurred not just in adulthood but also of stressful experiences that occurred in earlier developmental periods. Consistent with the Gene x Environment hypothesis, the longitudinal prediction from childhood maltreatment to adult depression was significantly moderated by 5-HTTLPR. Childhood maltreatment predicted adult depression only among individuals carrying an s allele but not among l/l homozygotes.
Since then some research and meta analyzes revealed contradictory results of this G x E interaction. Sometimes a modest association of the short allele and depression was shown and sometimes no association could be found.
This could be due to the aforementioned reasons in this post. In a recent publication of research with the serotonin transporter polymorphisms the authors investigated in 340 Caucasian patients with a major depressive episode the influence of the subtype of depression (melancholic depression versus atypical depression) and gender.
They found support for an association of genetic variation increasing serotonin transporter activity with the melancholic subtype of depression as well as evidence for a potential female-specific mechanism underlying this effect. The longer more active L allele of the serotonin transporter gene is significantly associated with melancholic depression, particularly in female patients. A L allele increases serotonin transporter activity and/or density
This contradicts the earlier finding by Caspi, they showed an influence of the short allele and early life stress and depression.
The authors argue that the short s allele increases the risk of neuroticism , harm avoidance and a depressogenic effect of neuroticism. The long allele increases the risk of melancholic type of depression without prior neuroticism. This remains entirely speculative and brings us back to the previous mentioned reasons why we can't find a gene for depression.
Baune, B.T., Hohoff, C., Mortensen, L.S., Deckert, J., Arolt, V., Domschke, K. (2007). Serotonin transporter polymorphism (5-HTTLPR) association with melancholic depression: a female specific effect?. Depression and Anxiety DOI: 10.1002/da.20433
Saturday, March 8, 2008
4 Blog Posts about ECT: pregnancy, a love letter, and is ECT the treatment for you?
The first post on PsychCentral about a letter from James Potash, a well-known researcher from Johns Hopkins who has made his career by studying the genetic basis of mood disorders and schizophrenia and possible overlaps. This so called love letter for ABC News is to postive about ECT to the taste of the author: John M. Grohol, Psy.D.
Don’t get me wrong — I know people who have successfully underwent ECT. Most say they are thankful for the option. But it is not the cure-all this article makes it out to be. It is still an extreme procedure requiring a lot of forethought prior to accepting it, and the research is far from clear as to its long-term effectiveness and efficacy.
The other blog post over at: Center for Women’s Mental Health Blog is about pregnancy and ECT
Despite evidence that electroconvulsive therapy (ECT) is a safe and effective treatment for many psychiatric illnesses during pregnancy, many clinicians and patients are still reluctant to pursue this option, concerned that it will harm the fetus or incur extra risk for the patient. Ultimately, the clinician must weigh the risks to both mother and fetus involved in not treating a woman who suffers from severe psychiatric symptoms against the risks involved in ECT treatment, and facilitate the most appropriate clinical intervention for the individual patient.
Related post on this blog:
ECT and pregnancy: a case report
Another excellent explanation of ECT from the department of psychiatry from the Michigan University: ELECTROCONVULSIVE THERAPY (ECT):
IS ECT THE TREATMENT CHOICE FOR YOU?
Why electroconvulsive therapy works on brainblogger
Friday, March 7, 2008
Why do Psychiatrists Like Detectives
Since recent Dalziel and Pascoe is my favorite detective series.
Detective Superintendent Andy Dalziel is more caveman than new man -- a cigarette-puffing, beer-swigging detective with a large gut, a foul mouth and a scowl that seems carved into his face. With his thick Yorkshire accent and his abrasive demeanor. (from NYT)
I have watched dectectives for ever. I can even remember I Spy and Miami Vice. But I got really interested with Morse. He didn't conform to the TV stereotype of policemen. He was middle aged, out of condition, single, intellectual, loved classical music and real ale.
To me the attraction is about the detectives them selfs. Always professional, unorthodox in their methods but good at their job. Struggling against new logo's, rules and regulations lay down upon them by their organizations. Yes the same struggle doctors have as well these days.
Besides idealization and identification with the detectives there are some analogies between detective fiction and clinical method. Clinicians or psychiatrists use observation, they need an ability in deduction, logical thinking and an ability to spot inconsistencies to solve a case or the symptoms of a patient.
Clinical reasoning is comparable to detective fiction. The interview is both for detectives and psychiatrists a vital investigative tool.In detectives psychological and social circumstances play an important role as well as in psychiatry.
After Morse I got addicted to A Touch of Frost and The Inspector Lynley Mysteries. With Silent Witness in 1996, the BBC created a pathologist-led detective team with Amanda Burton. I didn't like that series so much, she was to much self-defeating.
In around 2000 big T.V. companies like CBS made shows that focussed on crime/science, that then became known as "forensic and crime shows". Their unique selling point was the use of computer generated graphics to show, not tell, the science and show the seemingly impossible detail of what happens to humans in murders. This kind of series soon lost my interest. To unreal, to technical and boring in the end. You now have a couple of them all using the same formula.
Besides the good and bad guy scenarios in detective series you can put yourself in their place and associate yourself with a character in the series. Curiosity is another important characteristic of detectives as well as doctors. Solving the puzzle with various hints together with the detective is what attracts.
Which detectives do you like and why?
Thursday, March 6, 2008
How does music improve mood state?
Music exposure increases Brain Derived Neurotrophic Factor (BDNF) in the hypothalamus. This factor protects neurons from the damaging effects of stress and it decreases the overactive stress system in stress related disorders such as major depression. The antidepressive effect of music could be mediated by an increase in hypotahlamic levels of BDNF.
Music is also associated with decreased Nerve Growth Factor (NGF) in the hypothalamus. NGF is increased in stressful conditions such as depression and it activates the stress system. A reduction of NGF may contribute to a decrease of the stress system and enhance the anti-stress effect of music.
These effects were shown in a study with 20 mice. They exposed 10 mice to new age type music. Daily 6 hours during wake for 21 consecutive days. 10 other mice were treated the same way as the experimental mice besides the exposure to music. After this period the researchers studied the hypothalamus of all mice. They found an increased level of BDNF in the mice exposed to music and a decreased NGF level in this same brain region.
Limitation
The effect of other types of auditory stimuli (other music such as funk, hip hop or noise) was not investigated. Different types of music or noise might produce different effects.
What kind of music do you look and lifts your mood? Let me know in the comments
ANGELUCCI, F., RICCI, E., PADUA, L., SABINO, A., TONALI, P. (2007). Music exposure differentially alters the levels of brain-derived neurotrophic factor and nerve growth factor in the mouse hypothalamus. Neuroscience Letters DOI: 10.1016/j.neulet.2007.10.005BDNF
Effects of stress and BDNF's link in depression.
Exposure to stress and the stress hormone corticosterone has been shown to decrease the expression of BDNF in rats, and leads to an eventual atrophy of the hippocampus if exposure is persistent. Similar atrophy has been shown to take place in humans suffering from chronic depression.Music used: The Romantic Sea of Tranquility, by Enya; The Heart of Reiki, by Merlin's Magic; Zen Garden, by Kokin Gumy; Feng Sui, by various artists.
Wednesday, March 5, 2008
Why it is better not to tell your patient the price of their medication
Higher priced placebo analgesics are significantly more efficacious than lower priced placebo analgesics. This explains the popularity of high-cost medical therapies (eg, cyclooxygenase 2 inhibitors) over inexpensive, widely available alternatives (eg, over-the-counter nonsteroidal anti-inflammatory drugs) and why patients switching from branded medications may report that their generic equivalents are less effective.
82 healthy paid volunteers were recruited using an online advertisement. Each participant was informed by brochure about a (purported) new opioid analgesic approved by the Food and Drug Administration; it was described as similar to codeine with faster onset time, but it was actually a placebo pill.
After randomization, half of the participants were informed that the drug had a regular price of $2.50 per pill and half that the price had been discounted to $0.10 per pill. All participants received identical placebo pills and were paid $30. Participants were blinded to the study purpose, and researchers were blinded to group assignment.
Electrical shocks were applied to the wrist. They were calibrated to the pain tolerance for each participant. Next the participants had to rate the pain on a visual analogue scale. Shocks up until this pain level were then applied. After the first shock a placebo analgesic was given. This was followed by the same pain stimulus. After each shock the participants had to score their pain.
Results
In the regular-price group, 85.4% (95% confidence interval [CI], 74.6%-96.2%) of the participants experienced a mean pain reduction after taking the pill, vs 61.0% (95% CI, 46.1%-75.9%) in the low-price (discounted) group (P = .02). Similar results occurred when analyzing only the 50% most painful shocks for each participant (80.5% [95% CI, 68.3%-92.6%] vs 56.1% [95% CI, 40.9%-71.3%], respectively; P = .03).
Limitations
These findings need to be replicated in broader populations and clinical settings to better understand how communicating quality cues with patient populations can maximize treatment benefits and patient satisfaction.
Other possible influences on efficacy I can think of are: color, brand, advertisement.
Any other suggestions?
Waber, R.L. (2008). Commercial Features of Placebo and Therapeutic Efficacy. Journal of the American Medical Association, 299(9), 1016-1017.
Tuesday, March 4, 2008
Internet Addiction in DSM V?
Medicalize problems again. In an editorial in the American Journal of Psychiatry Internet Addiction is proposed as a new diagnosis in DSM V. Now the American Journal of Psychiatry used to be a serious peer reviewed journal although some of us doubt this feature for a while now.
As arguments reports are used instead of studies published in peer reviewed journal. These reports come from South Korea:
Using data from 2006, the South Korean government estimates that approximately 210,000 South Korean children (2.1%; ages 6–19) are afflicted and require treatment. About 80% of those needing treatment may need psychotropic medications, and perhaps 20% to 24% require hospitalization
Now this looks like an epidemic to me, not a psychiatric diagnosis.
Also China is mentioned as suffering from this problem
At a recent conference, Tao Ran, Ph.D., Director of Addiction Medicine at Beijing Military Region Central Hospital, reported 13.7% of Chinese adolescent Internet users meet Internet addiction diagnostic criteria—about 10 million teenagers.
Now we all know why China wants to restrict Internet access and Internet cafes.
An explanation for Internet addiction could be a creative manner of censorship by the Chinese government. Internet is a relatively new phenomena in China, a side effect of its booming economy and technological advances, but how to control this development and how to fit it in with its communist government? Indeed Internet addiction.
And you can read about the treatment options for Internet addiction in a previous post on this blog: Electroshock treatment for Internet addiction
By the way this treatment was implemented by the same Mr Ran Director of Addiction Medicine at Beijing Military Region Central Hospital.
I hope the committee for the DSM V will be more critical about their task and evidence for this diagnosis. This proposal has nothing to do with pharmaceutical industries I hope.
What do you think should there be a diagnosis of Internet Addiction in the next DSM V?
Monday, March 3, 2008
6 Different Definitions of Treatment Resistant Depression
- Failure to respond to 1 adequate trial of an antidepressant
- Failure to respond to one or more adequate trials of antidepressants
- Failure to respond to 2 adequate trials of antidepressants
- Failure to respond to 2 adequate trials of antidepressants form different classes (e.g. SSRI and TCA)
- Failure to respond to 2 or more adequate antidepressant trials
- Failure to respond to 2 or more adequate antidepressants from different classes
Some authors and researchers object to the phrase failure to respond. They find this phrase blaming the patient. It is not the patients fault an antidepressant isn't working or not working enough. Most of these researchers are authors of ECT publications. ECT is sometimes used as the last treatment option if antidepressants have failed. They prefer: pharmacotherapy treatment failure.
These six definitions were found in a systematic review of all randomized controlled trials on somatic treatment of treatment resistant depression. They found 233 references of which only 47 were RCT's with unipolar depressed patients older than 18 years published in peer reviewed English Journals. Mostly publications about TRD is expert opinion on the subject. This publication is a systematic review.
In the majority of papers the information on the type of assessment for antidepressant resistance was not available. Two studies used a prospective assessment off TRD, 7 were retrospective assessed.
The majority of studies did not provide the maximum dose required to describe a previous treatment as a failure or success. 18 studies did not present information regarding requirements for prior treatment length.
Most studies did not use a thorough diagnostic evaluation, ideally performed with the use of a structured clinical interview, in case of treatment resistance.
A wide variety of terms has been used to decsribe TRD:
- treatment-resistant
- treatment-refractory
- therapy-resistant
There is still an absence of definitive consensus about a general suitable definition for TRD. There is also a lack of how to assess the presence of TRD.
So what needs done is an international consensus about what is TRD and how should we assess it.
Conclusions
There is a clear need for an internationally shared framework of concepts and methods for the investigation of TRD that could reduce current idiosyncrasies and provide a reference system. Such a foundation is essential for the interpretation of research findings and for their translation to clinical practice.
What are your thoughts about this subject, do you use a definition?
Related posts
One of my most read posts on this blog is:
9 Steps for Treatment Resistant Depression (TRD)
Genes and TRD
5 Features of Pseudoresistant Depression
9 Videos on ECT
BERLIM, M., TURECKI, G. (2007). What is the meaning of treatment resistant/refractory major depression (TRD)? A systematic review of current randomized trials☆. European Neuropsychopharmacology, 17(11), 696-707. DOI: 10.1016/j.euroneuro.2007.03.009
Sunday, March 2, 2008
Does anyone walk less than a radiologist?
Radiology is a fairly sedentary occupation. Unlike other physicians, who spend their days scampering from patient to patient or slogging through endless hospital rounds, we sit quietly in the dark all day, staring at images. After learning of the following paper via the Dr Shock MD PhD, I began to wonder -- just how sedentary is my specialty? This seemed like a fine topic to research for a Leap Day post.
The Samurai Radiologist wears a pedometer every day to keep track of my her activity (or lack thereof). She made a plot of her daily step count and compared the results with the other groups mentioned in the article.
Curious, go read this excellent post about the walking habits of an radiologist.
Runners High
On pure pedantry the author discusses an article in which the runners high is shown with imaging.
The authors of the article discussed measured the resting endorphin activity in the brains of 10 athletes using PET scans. They then sent the runners out on a 2 hr run. After they returned they put them back in the scanner and looked at endorphin activity again. They compared the images before and after the run to look for what areas of the brain had greater endorphin activity.
This result provides further evidence that the runner's high is caused by endogenous opioid release in the brain. What is interesting to me is that you see similar brain activation for a variety of different types of rewarding events -- whether they be drugs or video games or anything. I seem to remember that they even showed that in academics these parts of the brain are activated when they learn! This similarity of reward activation in a variety of behavioral contexts implies two things: a common system for analyzing rewards and a wide variety of things that humans have found to activate this system. It would appear that it really is "whatever floats your boat" that you find rewarding.
The results and details are presented in this post on pure pedantry
Related post on this blog: What do addiction and running have in common
5 Tips for Safe Medical Web Surfing
In short:
- Find the right search engines such as medlineplus.gov and healthfinder.gov. Sites that end with .edu or .gov are usually more trustworthy. Watch out for commercial websites on health.
- Find smart bloggers with the same disease
- Invest in the tutorial of pubmed.gov
- Read the About me when visiting medical websites and be sure they are doctors.
- Visit sites from annual meetings, for instance from the American Psychiatric Association
For some more information visit CNN.com/health.
Thanks Lifehacker.com
Saturday, March 1, 2008
Milk Dry One Patient Sample
Research with patients is challenging and can be very rewarding and I mean not only for the researcher. To my opinion research ads value to patient care. Usually patients participating in research are better cared for, their treatment is more according to well documented and evaluated protocols. Monitoring makes wait and see impossible.
Results from these patient centered trials benefits patient care at the short and long term. If a treatment center publishes their results these results are usually implemented in their treatment protocols.
There is also a downside to this. Trials usually also means a lot of testing and blood samples to be drawn. I think these disadvantages out ways the benefits in patient care. One restriction is that study design should be good enough to make the results worthwhile. I hate it when authors excuse the lack of a control group or placebo group as can be read in a recent post about Vagus Nerve Stimulation research
The authors mention the argument sometimes used that it is unethical to use a controlled design with a sham condition. We are talking about patients treated with 3-7 different antidepressants and/or ECT. Mostly ill for years. I think it unethical to conduct another uncontrolled trial which will help our knowledge about the efficacy of VNS no further. Besides implanting a VNS is not peanuts nor going to a protocol of up to 1 year.
When preparing a lecture this dilemma about study design came to my mind. I have never seen a sample used for so many publications in high ranking medical journals than the patients taking part in a Vagus Nerve Stimulation research.
The research and follow up in 222 patients was used for several publications. The first publication was a terrific placebo controlled comparison of VNS with placebo. There was no significant difference between both groups. After that the patient sample was used for a follow-up of 12 months in total. Data from this sample is used in at least 3 other studies but all open and uncontrolled. Adding nothing or little to our knowledge for the use of VNS in depressed patients.
What do you think?
See also on this blog: VNS for depression an update
40 Facts about Sleep
- Humans sleep on average around three hours less than other primates like chimps, rhesus monkeys, squirrel monkeys and baboons, all of whom sleep for 10 hours.
- Ten per cent of snorers have sleep apnoea, a disorder which causes sufferers to stop breathing up to 300 times a night and significantly increases the risk of suffering a heart attack or stroke.
These are only two facts of the 40 facts about sleep you probably never heard
Related posts on this blog about sleep:
Stop prescribing sleep drugs period, first find out the underlying cause of this complaint.
A better sleep without pills
10 tips to sleep better
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