Monthly Archives: July 2008

Book Review: Online Therapy. A Therapist’s Guide to Expanding Your Practice

Online therapy is a fast emerging field. Performing a google search using the term ‘online therapy’ will reveal over 8 million results. A book by Derrig-Palumbo and Zeine helps to make sense of this very heterogenous but influential area.  The book is divided into two parts – the first part being on the theory and the second part on the practical aspects.

The opening chapter explores different psychotherapeutic approaches online. The highlight for me was reading a conversation with Albert Ellis (pioneer of rational emotive behavioural therapy) about how he conducts online therapy. There were also interviews with practitioners of other approaches included family brief therapy, solutions based therapy, imago relationship therapy, transpersonal therapy – all in the context of online therapy. A chapter on common questions tackles some of the tricky issues such as the difference between online therapy and face to face therapy, geographical separation and crises. A chapter on ‘Clinical Guidelines and Approaches’ is useful for face-to-face therapy as well as online therapy, organising the therapeutic process into phases. The examination of transference and countertransference issues online gives insight into these processes themselves. For instance, if a therapist takes more time to respond, it may seem that they are paying less attention (if there is no visual contact).The ‘Effectiveness of Different Modes of Online Therapy’ chapter looks at some of the evidence of different approaches both in terms of delivery systems e.g. text, video and also in terms of populations. For instance there is evidence to support the use of online therapy in insomnia and post-traumatic stress disorder.

In the second part of the book a number of practical issues are discussed including an overview of setting up an internet practice, ethics and legal issues as well as marketing. The book is also supported by detailed appendices including a section on published guidelines for online therapy. This second part of the book is geared towards an american market and highlights both the complexities of practice and the geographical distinctiveness of practice (e.g. in terms of legal issues).

References

Kathleene Derrig-Palumbo, Foojan Zeine. Online Therapy: A Therapist’s Guide To Expanding Your Practice. Norton. 2005.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

‘Demoralisation Syndrome’

Is demoralisation an illness? Illnesses by definition are our creations. In other words they are ‘social constructs’. The International Journal of Social Psychiatry publishes papers on the social aspects of psychiatry. In a 2006 paper by Briggs and MacLeod, a ‘demoralisation syndrome’ definition was used to assess its probable existence in a group of refugees in New Zealand. The authors describe a syndrome ranging from disheartenment through to despair and demoralisation.

The study which I would consider a pilot study involved looking at the psychiatric casenotes of 64 refugees. The people had answered questions about other conditions (e.g. depression) and the researchers looked at these answers to see if their responses met the criterion for demoralisation syndrome. In 86% of cases, there were sufficient responses to meet a probable diagnosis of demoralisation syndrome. They also looked at whether this was related to diagnosed illnesses in this group including depression and PTSD. They found that there was no significant association between the occurrence of probable ‘demoralisation syndrome’ and PTSD or depression, thus supporting this as a separate entity.

We might expect that there would be a greater degree of demoralisation in refugees depending on the reasons that they had moved. Locating to another country, leaving one’s life behind and starting again in a position of uncertainty (although we don’t know the specifics) might be expected to create demoralisation. However there are some problems. Firstly demoralisation may be a symptom rather than a syndrome. For example, if someone said that they were feeling tired we wouldn’t say that they had an illness. This may just be their experience for a limited period of time – part of the range of ‘healthy experiences’. The next point is that only the case notes were examined. The patients weren’t seen during the research and asked questions directly. There was also no comparison group and the sample size was relatively small.

Having said that, this was a creative study, using previously acquired data to investigate the existence of a demoralisation syndrome. The authors have raised questions that can be investigated in subsequent studies. Will we ever be able to say we have an illness when we are feeling despondent? Time will tell

References

Briggs L and MacLeod A. Demoralisation – A useful conceptualisation of non-specific psychological distress among refugees attending mental health services. International journal of Social Psychiatry. 2006. 52(6). 512-524.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

CBT and Structured Care for Medically Unexplained Symptoms

A paper in the July 2008 issue of the British Journal of Psychiatry looks at interventions for medically unexplained symptoms. Medically unexplained symptoms are a tricky problem. As its name suggests, a patient reports symptoms to the doctor but no underlying cause is found. Research has shown that a number of people that present with such symptoms will continue to see the doctor about such symptoms for many years. In the study in the BJPsych, they trained some General Practitioners in Sri Lanka to be able to use Cognitive Behavioural Therapy for these symptoms. Cognitive Behavioural Therapy is a form of talking therapy which aims to change thinking and behaviour. In the study, 75 patients were given either structured care or CBT.

In structured care, the patient had to see the GP on at least three occasions regarding the symptoms. After this the GP saw them again and used whatever methods they thought appropriate to deal with the symptoms. In the other arm of the trial (patients were randomly assigned to the groups), patients again received 3 mandatory sessions and then the GP used CBT approaches.

A few of the patients dropped out of both parts of the study. However when they analysed the final results, the researchers found that CBT was no better than structured care on a number of measures. They also found that both approaches improved patient’s general health (GHQ scores), complaints of illness symptoms (BSI scores) and number of visits to GP compared to baseline.

The authors gave a number of plausible reasons for why the CBT group did no better. These included the brief training in CBT given to the GP’s, the possibility that the structured care might have also included CBT or that the structured care approaches may have been equally effective. The important finding though, was that if the GP’s focus on dealing with the symptoms in a structured way, it can lead to improvement for the patient.

References

Sumathipala A, S Siribaddana, M Abeysingha, P De Silva, M Dewey, M Prince and A Mann. Cognitive-behavioural therapy v structured care for medically unexplained symptoms: randomised controlled trial. The British Journal of Psychiatry. 193. 51-9. 2008.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

The Riddle of Alzheimer’s: 115 and a Sharp Cookie!

I’ve just been reading a nice article by a group from China led by Sheng Chen. In this review article, several approaches to developing treatments for Alzheimer’s Disease are discussed. These focus on the amyloid precursor plaques, immunotherapy, neurofibrillary tangles, interfering RNA, gene therapy, neuroprotective agents, antioxidative and anti-inflammatory agents as well as adenosine receptor antagonists. The breadth of treatments available is staggering and there are a large number of clinical trials underway for these different options. The main area for research focuses on the amyloid precursor plaques. There are three enzymes that chop the plaques up into pieces. Two are bad enzymes – gamma secretase and beta secretase and one is a good enzyme – alpha secretase. Alpha secretase produces an end product which protects neurons. The other two produce end-products that can form plaques and harm neurons. So the focus of therapy is on increasing the activity of alpha secretase and decreasing the activity of beta and gamma secretase. For each of these strategies, there are many different approaches. The article is well worth a read although its a bit heavy going at times (depending on how familiar you are with the field).  Finally, I briefly checked out the abstract of a paper in Neurobiology of Aging. This was a very interesting report. A 115 year old lady was assessed using psychological testing. Her cognition was the same as someone in their 60′s.  MMSE score (a test of cognition) was 26 (That’s better than me on a bad day!). Sadly, she passed away at 115 and a post-mortem was carried out. She was found to have little evidence of atherosclerosis and there was very little evidence of the plaques described earlier in this article that you would expect to see in Alzheimer’s. Why some people have such stark differences as they age is still not clear although the debate invariably comes down to the specifics of genes, environment and their interactions.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

References

Chen S, Zhang X-J, Li L and Le W-D. Curr Neuropharmacol. 2007. Current Experimental Therapy for Alzheimer’s Disease. 127-134.

Dunnen W, Brouwer W, Bijlard E, Kamphuis J, van Linschoten K, Eggens-Meijer E and Holstege G. No disease in the brain of a 115-year old woman. Vol 29. Issue 8. August 2008. p1127-1132.

Review of Podcasts

Podcasts are a great way to learn about a subject quickly. In this posting, I’ve reviewed a few of the podcasts that are out at the moment.

The journal Science produces a weekly podcast. In the Podcast for the week of  25th July 2008 there is an interesting discussion of the possible function of sleep. By looking at the sleep patterns of 60 animals species (from pre-existing data), they found that social animals (animals that sleep in groups) sleep less than animals that sleep apart. They also found that if animals sleep on the ground where they’re more likely to be hunted by predators, they sleep less than those that sleep above the ground. The other finding was that animals that spend more time grazing, spend less time sleeping giving some possible clues about the evolutionary function of sleep.

In June 2008′s Nature Neuropod, a number of interesting topics were discussed. Neanderthals were found to have the same variation of FOX-P2 gene as modern humans. Fox-P2 is a transcription factor – that is a gene which affects the expression of other genes. Fox-P2 has been shown to be associated with a condition known as developmental verbal dyspraxia (a condition of speech and language). There is an ongoing project to compare Neanderthal, chimpanzee and human genomes. The idea is that finding genes specific to humans will give us a greater understanding of the evolutionary process. Cortical thinning in sensory-motor areas is associated with the occurrence of Tics in certain body parts in people with Tourette’s. This is an interesting finding as Tourette’s is classically thought of as a disorder of the basal ganglia. People with schizophrenia may have a family history or not. The ratio is about 40:60. In one study, researchers were interested in the occurrence of spontaneous mutations in non-familial schizophrenia, known as copy number variants. People normally have two copies of a gene, one from the father and the other from the mother. With copy number variants they have either one or more than two copies of the gene. The study findings makes sense if we consider schizophrenia as a neurodevelopmental disorder i.e. resulting from the way the brain develops in the foetus and early childhood. Steve Pinker talks about a new book he has written on language and discussed his thoughts on the relationship between language and thought.

In the NEJM Podcast for the week of July 10th. The NEJM reports on a mental health parity bills which have been supported by the house and the senate, with however different wording in both cases. The parity bills relate to the higher cost of insuring people with a mental illness. The bill has stalled however as the house and senate differ in their definitions of mental illness. In the June podcast of the American Journal of Psychiatry, there were again a number of interesting issues. Reduced amygdala response in adolescents with ‘callous and unemotional traits with conduct disorder or oppositional disorder. Shown emotional or non-emotional faces – whilst being fMRI scanned. Healthy subjects showed more activation of the Amygdala when shown emotional faces than did the adolescents with ‘callous and unemotional traits’. There was also an implication of the connections between the ventromedial prefrontal cortex and amygdala in this difference. This supports a model in which antisocial behaviour is related to not being able to process the emotional reactions of other people. An interesting case report discussed is a 55 year old lady with treatment resistant depression refractory to treatment with single antidepressants, combination therapy, augmentation strategies, ECT and cingulotomy. She finally improved with deep brain stimulation which adds to the recent publication of the success of deep brain stimulation in depression.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

Review of Carlat Psychiatry Blog

I’ve been looking at the Carlat Psychiatry Blog which makes for a very refreshing read. Dr Daniel Carlat is a psychiatrist with a special interest in psychopharmacology and is an assistant clinical professor at Tufts University. Carlat was disillusioned with the world of pharmaceutical sponsored talks and medical education and decided to break away from this scene. He started up his own industry-free continuing education newsletter – the Carlat Psychiatry Report. Last year he started up the Carlat Psychiatry Blog, a blog in which he voices strong opinions on the influence of Big Pharma in psychiatry. In his blog recently, Carlat comments on the investigation into APA funding by congress. It turns out that Carlat was already recruited by the APA to investigate this internally and obviously isn’t allowed to comment on the contents of the internal investigation.

Why is Carlat’s blog refreshing? I think that its healthy for psychiatry to have a critical voice. After all, isn’t this what science is about? Isn’t science about the search for a deeper truth which means trying to knock down hypotheses if they don’t hold up in the light of evidence. Carlat’s blog is in my opinion about questioning those parts of practice in the real world which might obscure this process of reaching this truth. Furthermore this occurs because of a conflict between the culture of science and the culture of business.

The essence of the conflict between the science culture and the ‘commercial culture’ is as follows. Let’s suppose that a talk is being given on depression. The talk is given by Doctor A, and is sponsored by Pharmaceutical Company B which produces antidepressant C. During the talk Doctor A presents evidence on drug C’s effect, using papers (provided by Pharmaceutical Company B) to a group of doctors. Suppose there are 20 studies that have been performed on drug C. Many arguments would run along the lines that not all of the study data will be presented to the doctors and that it would be biased. I would argue that this is an inherent assumption and it occurs for a very simple reason – the attribution of intentionality.

If a company has data on 20 studies for the drug, why not just present this all, so that people can judge the data for themselves. This is where an implicit assumption about the actions of companies existing in a commercial environment enters the picture. Pharmaceutical company B will have shareholders, and indeed has responsibility to these shareholders. The assumption is that the shareholders will be looking solely for return on investments – dividends or an increase in share price – which in turn would be brought about by amongst other things an increase in the company’s profitability. So then the argument runs that the company would be looking to make more money.

Now if we return to the presentation, it can be argued that the company would be interested in sponsoring the event to increase the number of doctors prescribing, thereby increasing sales, profitability and ultimately making more money for the company. (There are many other reasons that a company may sponsor the presentation however). If the company wants more doctors to prescribe, then it can be further argued that they would want to provide the best possible image for the drug – one of the basic principles of branding.

Returning to the 20 trials. Suppose that 10 showed good results and 10 showed bad results. If we applied simple marketing principles – showing the 10 good trials and ignoring the 10 bad trials would be expected to show a better image for the drug. However, missing the 10 drug trials with negative results means that not all of the available evidence is being weighed up. In effect, the ability to challenge the hypothesis of the drug’s efficacy is being suppressed as a result of marketing principles. A nice image which should be more profitable is coming at the cost of science’s ‘warts and all’ image.

The same argument can be applied whenever there is a conflict of interest. Suppose that a research group has spent 20 years pushing a certain theory. Its entirely possible that this group might not want to publish a study with negative results or may choose to write a review of favourable papers. They are usually balanced by other groups pushing competing theories. In this sense, the pharmaceutical companies also compete with each other for market share and head-to-head studies of drugs provide an equivalent arena for testing competing theories of drug efficacy.

However compared to the academic research group, the commercial interests of pharmaceutical companies produce an immediate set of additional assumptions (outlined above) which must be countered in research studies or presentations. This in turn relates to the cultural context of business activities.

The above are arguments. The specifics must be analysed in each situation – for each company, drug and location. This is why Carlat’s blog is so necessary. It gives another opportunity for debate and although this isn’t good for branding, it is good for science.

However, there are two further considerations. Firstly, the debate should be brought with caution. The caution is that less informed readers may mistake a strong viewpoint for a debunking of a medication and this may cause them to stop this medication. Secondly, the objectives in the debate must be clear. For instance, suppose all spin was removed. Does the spin on a drug affect a patient’s perceptions and partially their psychological response to the medication? Would the inability to engage in marketing practices for a drug lead to the demise of a company which has further potentially life-saving treatments in the pipeline?

Carlat’s blog provides a view which challenges others. This is invaluable. In the Hegelian Dialect it is suggested that society moves forwards by a synthesis resulting from the conflict between thesis and antithesis and so we can see how Carlat’s challenges may help to move society forwards.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

Round Up of Psychiatry News (19-25th July 2008)

A big story as reported earlier in this blog is the congress investigation into the finances of the American Psychiatric Association. This is a new move away from investigating individual practitioners and there are undoubtedly many complexities in this ongoing story. In Ireland, official figures released, show that 3600 children are awaiting assessment by a psychiatrist and of these 1000 children may have to wait more than a year. In Canada, a charity ‘Mind and Brain Canada’ is being established to raise awareness of mental illness in Canada.

An investigation into brain structure using diffuse tensor imaging in people with Tourette’s, and published in the Journal of Neurology, Neurosurgery and Psychiatry, found no association with the presence of antibodies against the basal ganglia. The basal ganglia is part of the brain which is involved in movements. As Tourette’s involves involuntary movements and there is thought to be some connection with these types of antibodies, this research provides evidence against this model. A study showing deep brain stimulation is a viable treatment for treatment resistant depression was published in Biological Psychiatry and reported in the media. A recent study published in BMC Neurology has shown that administration of an anti-TNF drug leads to a rapid improvement in verbal skills in people with Alzheimer’s. This adds to the study published in last week’s Lancet about Dimebon.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.