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
Saturday, August 4, 2007
Dutch elderly afraid of electroshock
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.
Monday, July 23, 2007
Discover your learning style
Discovered my learning style in a modern outfit online. From Lifehacker I did a survey on DVC learning Style Survey.
These are my results from the survey:
You learn best when information is presented visually and in a written language format. In a classroom setting, you benefit from instructors who use the blackboard (or overhead projector) to list the essential points of a lecture, or who provide you with an outline to follow along with during lecture. You benefit from information obtained from textbooks and class notes. You tend to like to study by yourself in a quiet room. You often see information "in your mind's eye" when you are trying to remember something.
Learning Strategies for the Visual/ Verbal Learner:
To aid recall, make use of "color coding" when studying new information in your textbook or notes. Using highlighter pens, highlight different kinds of information in contrasting colors.
Write out sentences and phrases that summarize key information obtained from your textbook and lecture.
Make flashcards of vocabulary words and concepts that need to be memorized. Use highlighter pens to emphasize key points on the cards. Limit the amount of information per card so your mind can take a mental "picture" of the information.
When learning information presented in diagrams or illustrations, write out explanations for the information.
When learning mathematical or technical information, write out in sentences and key phrases your understanding of the material. When a problem involves a sequence of steps, write out in detail how to do each step.
Make use of computer word processing. Copy key information from your notes and textbook into a computer. Use the print-outs for visual review.
Before an exam, make yourself visual reminders of information that must be memorized. Make "stick it" notes containing key words and concepts and place them in highly visible places --on your mirror, notebook, car dashboard, etc..
What I like about this survey is the practical and modern advice you get. I suggest all students in particular medical students should do the survey. It will deliver some new tricks and this survey is better than the surveys I did when being trained as a teacher.
These result probably also explain my interest in websites and good design as well as gadgets.
Sunday, July 22, 2007
For Adolescents no additional benefit of cognitive behavioural therapy with an antidepressant
There was no evidence of a protective effect on suicidal thinking or action with the addition of CBT to an antidepressant in depressed adolescents. In contrast to an earlier study in the United States cognitive behavioural therapy (CBT) does not improve outcome of treatment with a selective serotonin reuptake inhibitor (SSRI). On second look the US study also did not show additional benefit of CBT added to a SSRI (fluoxetine). Moreover the results of the US trial limits generalisability since it excluded adolescents with active suicidal intent, self harm, severe conduct disorder, and active substance abuse. Certainly suicidality is a core feature of severe depression. More than half of the participants were recruited from advertisement.
This trial in Great Britain is of more importance since it includes moderate to severely depressed adolescents and this randomised controlled trial had a follow-up of 28 weeks and it did not exclude suicidal adolescents nor psychotic depressed patients. They were all outpatients. CBT was offered weekly for 12 weeks, then fortnightly for 12 weeks with a final session at 28 weeks (total 19 sessions). The focus of usual care was an explanation of depression and attention to recent family or peer group conflicts. Comorbidity problems were also attended to when required, including liaison with schools and other agencies.
Overall outcome on the long term (28 weeks) was not bad at all: 7/94 (61%) of those in the SSRI alone group and 52/98 (53%) of the CBT plus SSRI group were much or very much improved. Again no significant difference but a good response for adolescents with a severe depression.
One weakness is the absence of a placebo arm, which we considered to be unethical in such ill patients, so we cannot draw any conclusions regarding overall effectiveness of treatment.Now this is the most regrettable remark in this article about this excellent trial. Since there is such difficulty in deciding what is the best treatment for adolescents with depression as well as so much uncertainty about the benefit or harm from the use of antidepressants it is most unethical not to include a placebo arm in this kind of randomised controlled trials. If we want to get any further in the treatment of a sever illness we shouldn't choose for the easy way out.
Saturday, July 21, 2007
Depression as side effect of drug against obesity or overweight
Acomplia (rimonabant) from sanofi-aventis has serious psychiatric side effects, namely depression. The European Medicines Agency (EMEA) recommends not prescribing this drug to patients with a depression or on antidepressants.
More information medicalnewstoday.
Electroshock (ECT) Round Up
This blog about depression and it's treatment especially with ECT is in the air for a while. I hope a lot of readers benefit from these scribbles. The truth be told, I learn a lot from writing these articles. Mostly I gather a lot of information for my work as a psychiatrist which end somewhere in a drawer or the "round archive" without being read at all. Since writing this blog I actually read them and when appropriate post the information on my blog. Surfing on the net nowadays is always accompanied by the question: Is this information relevant, blogable?
Now I take the privilege today to look back on my posts and make a round up of the most important sites with information about ECT relevant for interested readers in this subject, hope you like it.
1. About ECT for bipolar disorder from healthyplace.com, also more general information about ECT, the procedure, side effects.
2. Take it easy on ECT. Opinion of a patient treated with ECT about the side effects and the discussions about this topic in the media.
3. Another patient's opinion about ECT and it's side effects adding to the discussion in the media.
4. Electroconvulsive therapy (ECT): Treating severe depression and mental illness. Information by the Mayo Clinic. Very informative for patients facing the choice.
5. ECT get's a makeover. On ABC News, the opinion of patients and doctors.
