Next episode of this vlog.
Sunday, August 19, 2007
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."
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