Monthly Archives: November 2009

Review: The Genetic Basis of Human Brain Evolution

The article reviewed here is ‘The Genetic Basis of Human Brain Evolution’ by Vallender and colleagues. This is the 150th Anniversary of Darwin’s ‘On the Origin of Species’ and I thought it would be interesting to have a look at this article on the brain from an evolutionary perspective. This is a review article in Trends in Neuroscience by two american researchers, one in neurochemistry and the other in genetics. In the abstract, the authors write

…it has become possible only very recently to examine the genetic basis of human brain evolution. Through comparative genomics, tantali(s)ing insights regarding human brain evolution have emerged

The selection criteria for inclusion of studies is not stated although this is usual in a number of the reviews that I have seen. Introducing the reader to the subject, the authors then move on to look at genes which have changed in moving along the primate lineage from new world monkeys to humans. These include genes implicated in microcephaly, the Sonic Hedgehog gene (yes really!), the popular FOXP2 gene and SRPX2. There are various suggestions for why changes in these genes may be important including the possibility that the microcephaly associated genes products are important in cell-cycle control which in turn may influence the number of neuroprogenitor cells produced and hence brain size.

The authors also discuss novel genes that have arisen in evolution including the mysterious Morpheus gene the function of which is as yet undetermined, the Opsin gene (thought to be directly related to the development of trichromatic vision in catarrhines) and GLUD2. They then go on to discuss the loss of genes including members of the olfactory gene family. They also look at the difficulties in understanding changes in gene expression in the human brain during evolution as well as some changes seen in non-coding regions. They also offer the following fascinating insight

..mammals in general and birds to some degree, exhibit a trend of brain expansion over evolutionary time that is absent in other vertebrates

The authors end by suggesting that future studies should focus on testing specific rather than general theories.

In conclusion, I found this to be a concise and accessible review of a fascinating subject. On the 150th Anniversay of the publication of ‘On the Origin of Species’ there has been much progress in evolutionary theory and subsequent reinterpretation of natural world phenomenon. In evolutionary psychiatry (see review here)  there has been an emphasis on laying the foundations with reference to common mental illnesses and how they might be shaped by the pressures of natural and sexual selection. The explanations have benefitted from insights gained from  the field of evolutionary psychology (see review of book on evolutionary psychology here). Adding a genetic strand to this understanding may give neuroanatomic insights into function and pathology which tie in with the understanding of neurodevelopment and neuropsychology. As the authors point out, this field is in its infancy and although it is too early to draw firm conclusions, I suspect these will quickly develop and form the foundations for this new discipline.

References

Vallender E J, Mekel-Bobrov N and Lahn B T. Genetic basis of human brain evolution. Trends in Neuroscience. Vol 31. No 12. pp636-644. 2008.

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News Round-Up: November 2009 5th Edition


Research in Dementia

A study in Nature Neuroscience suggests that Amyloid Beta is integral to memory function and that deviation from optimal levels is likely to lead to pathology. This in turn would suggest that removing Amyloid Beta from the plaque may not be a successful strategy in Alzheimer’s Disease if this optimal level is not addressed. However this discussion is taking place around cellular mechanisms and it will be useful to see how these predictions tie in with the relevant clinical trials. A suggestion has been made that a precursor to Nerve Growth Factor may be involved in the pathogenesis of Alzheimer’s Disease (AD) on the basis of a significant increase in the levels of the precursor in AD post-mortem samples and findings in a murine model. Stroke is related to dementia in a number of ways and modifying stroke risk factors can reduce the risk of dementia. Thus a prospective study (n=3298) with a follow-up period of 9 years showed that moderate or heavy exercise was asssociated with a significantly reduced risk of developing stroke. Thus the risk was 2.7% in those with moderate-to-heavy exercise and 4.6% in those with no exercise*. A potentially very useful study used the Alzheimer’s Disease Neuroimaging Initiative dataset to develop a method of analysing MRI data which involves two scans and a focus on loss of tissue in the Entorhinal Cortex and it will be intereresting to see the results of further research in this area. A 32-year prospective study – the Prospective Population Study of Women in Gothenburg found an association between central adiposity in middle age and prevalence of subsequent dementia. They did not find the same relationship between BMI and subsequent dementia but the central adiposity was associated with an approximate doubling of the prevalence of subsequent dementia.

General

The researchers in a study in Neuron found an association between modifications of cortical theta oscillations and the perception of intact sounds when presented with fragmentary sounds. Thus the implication is that there is an EEG correlate of auditory illusions. A recent study looking at falls in older adults found associations with a number of medications. The researchers in another study looking at falls in the elderly (the MOBILIZE study, n=729) found that those with chronic pain were significantly more likely to fall than their counterparts without*** An American study showed that just  under half of the 3 to 6 year olds in the study were concerned about becoming obese and one-third wanted to change an aspect of their appearance. Another American study (due to be published next year and with n=184) contrasted brief motivational interviewing with a control intervention (warning about the hazards of drinking and driving) in drink-driving recidivists was associated with a 30% reduction in repeat offences. Another study offers preliminary insights into the potential role of the delta waves generated in the hippocampus and the authors hypothesise on the basis of their results that the frequency of the delta waves code information about the type of processing that should take place in different regions – processing about the past or present.

Evolutionary Psychiatry

The new buzz word in this area is ‘primate archaeology’ which is an attempt to integrate a number of areas including primatology, anthropology and psychology. This article summarises this new ‘movement’ and looks at some very interesting research into the use of stone tools by chimpanzees in what is being described as a parallel with the advent of the stone age in humans.

DSM-V

DSM-V is due to appear in 2012. A twitter campaign has been started to petition for the inclusion of Depressive Personality Disorder in DSM-V. Professor Simon Baron-Cohen has argued against the removal of the Asperger Syndrome label in this New York Times article. Dr Anestis offers his views on this article and Baron-Cohen responds in this blog post.

Psychiatry 2.0

In a small study, participants were observed using search engines. The researchers concluded that search strategies were influenced by the learning styles of the participants and that participants often used search engines to confirm then own recall of a subject. A recent MyPublicServices event was held to discuss ways in which social media might impact on public services. It was suggested at the conference and reported in this article, that social media may impact on public health service delivery as it has done in many other sectors and that a constructive approach to using social media in th9s area could be adopted. One research study into viral marketing campaigns focused on the characteristics of e-mavens – people who spend a lot of time online**. E-maven’s characteristics were identified and those that were more likely to forward viral material onto others scored more highly on measures of individualism and altruism. On the subject of viral marketing – these usually pass me by but this one is pure genius! The video was made by the staff at Providence St Vincent Medical Centre in Portland, Oregon to raise awareness of Breast Cancer. Enjoy!

* The recent finding that dog owners get more exercise than gym-users may be of relevance in this regards. Thus it would be interesting to see the risk of dementia in dog owners (there are forms of pet therapy that have been employed for use in people with dementia although this is a slightly different issue)

** I’m not sure if this group would be considered at risk of the very controversial diagnosis of ‘internet addiction’ although this illustrates very nicely the balance between what some might consider illness behaviour and what others might consider socially constructive behaviour.

*** The study was partly funded by Pfizer

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Media Review: Social Phobia on YouTube

I’ve broadened out the podcast reviews to encompass media which include film and video particularly as there is an ever increasing amount of material on YouTube.

The topic I chose for this review is social anxiety and social phobia (or social anxiety disorder) on YouTube. I found quite a large number of videos on this topic but have just reviewed a small proportion of them here. The majority relate to social phobia and one to social anxiety and they are divided into education and experiential videos.

In this video, the lecturer gives a talk on social phobia with a case study and he also goes over some of the diagnostic criteria. He also goes over some of the treatments and is in two parts which in total runs to about 13 minutes. This cartoon features what sounded to me like adolescent narrators who explain social phobia with references to the amygdala and prefrontal cortex. The video also explains how it affects people and includes references to pharmacotherapy and psychotherapy runing to five and a half minutes. I wasn’t sure of the age of the target audience but the video is well presented and covers a lot of the basic information accessibly. This video is effectively a small number of slides displayed sequentially with background music. The slides contain some details about social phobia but I didn’t find them to be as informative as some of the other videos but this would be useful to someone who wants a rapid overview.

From the experiential perspective, there were a number of videos communicating the inner experience of social phobia. The diagnosis of social phobia is taken in good faith and the people in the videos explain what this means to them experientially. The videos can be very involved and would be orientated towards an adult audience. Certainly in putting together videos of their experiences these people are very courageous and I wondered how the nature of audience affected the social anxiety. For instance if the audience will view the video many years after it was made, how does this interact with the social anxiety? In this video, the quietangel123 has put together images and music to convey the experience of being alone although the term social anxiety disroder is used in the title. AlanJones78 narrates with a background picture about his experience of social anxiety over five minutes explaining the thoughts and feelings he has. Nayomee77 presents two videos (here and here)  on her experiences of social phobia and the difficulties she has had in trying to cope with this. These videos have generated a lot of viewings and comments.

These are just a few of the videos that I came across on YouTube but there is already quite a lot of material showing how differently people can communicate the theoretical aspects of social phobia and even how the experiences can be communicated by those suffering with social anxiety and just how much of an effect this can have on a person’s life. Communities can build up in the YouTube forum and it would be interesting to know if this is beneficial through text comments and video responses.

 

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Blog Review: Movies and Mental Illness

The blog reviewed here is ‘Movies and Mental Illness’. The blog is described as

A blog that Danny Wedding, Mary Ann Boyd and Ryan Niemiec will use in preparing the 4th Edition of movies and mental illness

While I wasn’t able to find many details in the contributors section about the authors at the time of writing, a quick google search reveals that Danny Wedding is a Professor of Psychiatry and that Ryan Niemiec has authored another book on positive psychology at the cinema. If my search results for Mary Ann Boyd are correct (I may have misattributed) then she is a prolific author of nursing books including textbooks. It thus appears that the group have produced a large and impressive body of work between them.

Appearance and Design

There is a white background with a white rectangular title section. The articles have a white background with orange text in the article title section. The main text in the article uses a black font. Articles also detail the author, comments and tags. On the right hand panel there are links to other sites of interest, previous posts and archives. I found it very easy to navigate through the archives section – the results are displayed on a single page. Further, the articles are displayed in full rather than needing the reader to click on a tab to reveal the full article (which would take up more time).

Articles

The first article in the database is a brief commentary on the 1948 film ‘The Snake Pit’. There are links within the articles to the relevant film details in the Internet Movie Database. What is interesting here as with other blogs is that the readers can contribute to the articles in the commentaries section adding different perspectives as in this post about the film ‘Off the Map‘ which explores clinical depression. I found this review of ‘Night Watch‘ to be quite interesting because Wedding writes that he is left puzzled after watching the film which seems to have no purpose. This in itself is useful as by showing us what a film shouldn’t be according to Wedding, we can work out what a film should be and this in turn gives a value to that same film. There were a number of reviews that draw attention to films with interesting subject matter and these include reviews of Mozart and the Whale on Asperger syndrome, Das Experiment which is apparently analogous to the famous Stanford prison experiment from 1971 and Grey Gardens exploring folie a deux.

Conclusions

This is an interesting blog which publishes a few articles in a month and at the time of writing there were four archived months in 2009. The articles are brief and focus on films that the author has found interesting. Some of the reviews are longer and focus on issues related to the films. This blog should appeal to those in particular who have an interest in the representation of mental illness in films.

 

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Book Review: The Borderlands of Science

The audiobook reviewed here is the ‘Borderlands of Science’ written by Michael Sherman and narrated by Grover Gardner. Gardner narrates at a moderate pace and with an expression that is able to keep the listener engaged over the 13 hours of the audiobook. Sherman’s book is about the areas at the ‘edge’ or borders of science and includes a discussion of the distinction between what he considers science, non-science and nonsense. I found myself sympathetic at times to Gardner’s arguments as he employs reasoning and evidence in his investigation of various fields. I found a central theme running through the book was that of evolutionary theory be this in the discussion of Edward Wallace’s codiscovery of natural selection and interest in spiritualism or a comparison of Darwin and Freud. Sherman is rather dismissive of Freud and psychoanalysis and relatively early in the book refers to psychoanalysis as a pseudoscience and later in his comparison of Freud and Darwin paints the picture of Freud as a celebrity in passing who’s writings have not stood the test of time in contrast with Darwin as a hero who’s greatness has increased through time as the validity of his theories have become increasingly evident. The manner in which Sherman paints the endeavours of a global body of psychoanalysts with a single label ‘pseudoscience’ is in my opinion unfortunate. This contrasts with Sherman’s discussion of the works of Frank Sulloway in establishing retrospectively a relationship between the works of great scientists and birth order supported in this same retrospective analysis with commentary on their personalities. While Sherman admonishes another author for the use of ‘confirmatory bias’ he himself applies this same bias to Freud by carefully selecting those statements made by Freud along with biographical details about him which when pastiched, caricature him as a self-styled conquistador who was preoccupied with his image and mythology. Freud has written on numerous occasions with humility imploring those who study his writings to employ them with due caution and to improve upon his theory. While there is much about Freud’s writings and approach that can be criticised he was a keen observer of human nature and had conducted basic science research and studied with one of the leading neurologists of his time Charcot before developing his methods of psychoanalysis. Freud’s writings are filled with references that will be familiar to clinicians such as the exclusion of organic states when examining the cases of ‘neurosis’ along with discussion with medical colleagues about appropriate management. This suggests that his practice was not an isolated ad hoc experimental journey led from his inner fantasy life but is instead an attempt to understand the mind through a systematic analytical process by a physician who was well versed in basic research methodology and who in his practice communicated, sought the opinions of and referred through patients to his colleagues in the medical profession. Indeed Sherman could on looking closely at some of Freud’s writings (see reviews here and here) see someone with similar values to himself as when Freud writes

‘There is no authority higher than reason’

Such parallels become obvious secondary to a thorough analysis of the relevant branch of the history of science – in this case psychoanalysis.

Similarly the field of psychoanalysis is far from an outdated model with no progress in research as suggested by Sherman but instead is supported by a variety of research studies broaching multiple disciplines (see as an example the debate (Wolpert and Fonagy, 2009)). Returning to the historical analysis by Sulloway as described by Sherman we hear of various speculations about the basis for these birth order findings. However it must be borne in mind that this is a retrospective analysis of a select group of figures. The speculation that follows can itself be considered prescience, in the sense that these speculations need to be backed up with evidence to stand on a firmer footing. These same speculations attempt to attribute a meaning that we can understand but ironically the meaning for an individual is much more likely to be afforded through the work done with an individual in therapy (depending on the objectives) than by the application of the results of group data analysis to an individual. Such group data works best at the group level but could properly be considered to offer a guide when applied to the individual because of the large number of confounders that may operate upon the relationship of interest. In addition the use of a five-factor model along with the birth-order is essentially a quantitative analysis. On the other hand an important feature of psychoanalysis which sets it up as a soft target is the use of a qualitative approach in which language and non-verbal communication aids the therapist in their role. Interestingly in communicating to the listener just what science is, Sherman is using the medium of language in a way which makes approximations and assumptions about the audience which may or may not be correct, references relationships and appeals to both reason and the emotion. In order to do so, it is reasonable to assume that Sherman values this medium sufficiently to use it as a vehicle for his message and in so doing he shares such an approach with therapists who communicate with each other through language and use language as a medium for therapy.

The end result is that Sherman espouses a view of science in which Darwin’s theory of natural selection is an example par excellence of the results of this approach. However if science is an attempt to gain a better understanding of the universe, neutral and undisturbed by our values and prejudices then our path to this understanding does not need to be constrained by a single approach – the quantitative approach generating large data sets and supported by unquestionable statistics with very small p-values. There should be a tacit acknowledgment that there are areas where the descriptive language differs – such as the languages that optimally describe the mind and the brain (see review here). Indeed it is the language of the mind that Sherman uses when he appeals to our reasoning and our emotions and which he does so adeptly. What I consider to be a hidden subtext of the validity of quantitative versus qualitative methodology is illustrated by Sherman’s quotation of an fMRI study in which the findings are used to ‘debunk’ a psychoanalytic explanation. This is done by referring to the ‘expertise’ of the neuroimaging researcher but the dangers of glossing over the many assumptions in such research have been well illustrated (see review here).

I would argue that when a subject such as psychoanalysis is reduced to a simple notion then significant elements of truth and utility get lost in the process. By this stage it is all too easy to apply the rather dubious notion of ‘pseudoscience’. As Einstein once said,

‘Everything should be made as simple as possible but not simpler’

Of note, Einstein was working as a clerk at the patent office, isolated from the scientific community when he submitted his theory of relativity for publication, a theory which would be paradigm shifting and which he no doubt recognised as such. Interestingly Sherman discusses the above characteristics but in another context in which he predicts those who do not contribute meaningfully to science.

In other parts of the book, Shermer is convincing as in his discussion of the Piltdown Man hoax and his treatment of the life of Wallace and his heretical traits. Sherman is extremely comfortable and knowledgeable in writing about Wallace and there is much to learn from the story of the cocreator of the theory of natural selection. Sherman is also comfortable in tackling controversial areas and uses his knowledge of science to convincingly address problems that do not seem to have obvious answers. Shermer’s approach polarises the subjects he explores and this can be useful in helping to make decisions that apply to those areas. At the same time, as in the case of psychoanalysis which does not adhere to Shermer’s idealised scientific method outlined above, it impacts not just on the theory but also has the potential to impact on the wider culture related to that body of theory and sensitivity is merited in any such discussion.

References

Michael Shermer. The Borderlands of Science. Narrated by Grover Gardner. Books on Tape. 2001.

Wolpert L and Fonagy P. There is no place for the psychoanalytic case report in the British Journal of Psychiatry. In Debate. pp483-487. 2009.

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Review: Ubiquitous Healthcare Service Using Mobile Phone Technology

The article reviewed here is a South Korean paper on ‘Ubiquitous Healthcare Service Using Zigbee and Mobile Phone for Elderly Patients’ by Hak Jong Lee and colleagues. In the introduction the authors discuss the ever more pervasive nature of technology. While noting the focus on hospital information systems, they note the possibility of using technologies to allow communication between the hospital and patients outside of the hospital. They note that a new wireless internet protocol Zigbee has been developed which offers a number of advantages including low power consumption. Such technology is being increasingly used in consumer electronics and the researchers were interested to see how this might be applied in healthcare. They therefore looked at a specific population – older adults – and wanted to see if they could monitor glucose levels and ECG’s in the community.

The study was a small prospective study (n=29) carried out in 2005. I found it slightly amusing that the 6-page article had been initially received in June 2006 and that the revised version was received in July 2008 when it was accepted. However delays between submission and publication in journals can be due to the logistics involved. I wasn’t clear on how sample selection was achieved and this will have a bearing on the results as successful use of the technology requires that the subject is able to use several technologies effectively. 9 subjects in the study received an ECG vest which they wore and which took readings every hour. If they were symptomatic (e.g. with palpitations) they would press a button to initiate a data capture. 20 of the subjects used a glucometer – to measure blood glucose levels. The subjects were trained in the necessary skills to ensure that the data was transmitted from the equipment to the web using a web-based program. A nurse contacted patients once weekly to administer a questionnaire regarding ‘convenience and satisfaction’. The details of the questionnaire were not included in the paper, nor were details regarding the validity and reliability of this instrument. Technical data regarding the equipment such as error rates were also identified.

With regards to the glucometer readings, the researchers found that information loss between the glucometer and the web-based service occurred in 22% of recordings and that this occurred at several points along the pathway including the mobile phone and a defect of the glucometer. A problem noticed by the participants was a large difference between the new wireless enabled glucometer and readings on the previous glucometer causing several subjects to withdrawal. However overall satisfaction was rated as 8.5/10 by the subjects (which most probably represents the intuitive meaning of scoring out of 10 which is commonly used outside of the research field). In terms of the ECG monitoring, some of the subjects withdrew from this part of the study due to a

fear of transmission of electromagnetic waves, skin eruption at the place where the ECG line and electrode were attached to the body and troublesome problems of attaching ECG

Interestingly only 57.9% of the transmitted data from the ECG was considered useful. The mean satisfaction score for the ECG sensor was 5.79. Discomfort occurred as a result of the ECG being attached to the body for 24-hour periods. As there was frequent transmission of data, the battery life of the mobile phones was also an issue.

In conclusion, this was a proof of principle. The technology itself proved effective here but it must be remembered that the technology does not occur in isolation but instead must operate within the wider healthcare environment. This in turn is dependent upon cultural factors, budgets, infrastructure and an appropriate evidence-base for the relevant healthcare service. Many technologies that achieve the chosen objectives and fulfill a useful function do not pass on into the mainstream as these barriers must be overcome. The researchers note that the emphasis in this study was on the technical aspects of the technology rather than the clinical utility. The rate at which data loss occurred as well as the need for participants to use several pieces of technology and the relatively small sample size means that further studies should examine the clinical utility in more detail. Glucose and ECG monitoring are potentially useful in various services and if a successful technology is achievable then it offers an opportunity for leveraging healthcare resources. Other types of monitoring device have the potential to be utilised using the same wireless protocols although this is already occurring using a variety of other technologies also. This study illustrates some of the difficulties that a technological solution to a healthcare problem needs to overcome in order to be of clinical utility. If such barriers are consistently overcome then this would enable new services to be developed and may impact on outcome measures in services.

References

Lee H J, Lee S H, Ha K-S, Jang H C, Chung W-Y, Kim J Y, Change Y-S and Yoo D H. Ubiquitous healthcare service using Zigbee and mobile phone for elderly patients. International Journal of Medical Informatics. 78. 2009. 193-198.

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Review: Research Report on Pain and Depression in Older People

The paper reviewed here is ‘Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking’ by Bonnewyn and colleagues. In the conclusion to the abstract the authors write that

(Painful physical symptoms) were more likely in people with a 12-month major depressive episode (MDE) than in those without (OR=2.0)

In the introduction, the authors cite research showing a prevalence of pain in older adults of between 25 and 88%. The authors then briefly discuss the pain-depression dyad explaining the antecedent and consequence hypotheses which expand on the nature of the dyad. The aims of the study are clearly outlined and include an evaluation of the relationship between pain and depression in a community-dwelling sample of older adults (65 years and older) as well as the interactions with the use of mental health services and benzodiazepine use.

The data was obtained from the European Study on the Epidemiology of Mental Disorders (ESEMeD) a study which was initiated by the World Health Organisation. Data was obtained from 6 countries – France, Germany, Italy, Belgium, Holland and Spain. The researchers write that some of the specifics of the sampling process have been described in another paper. I wasn’t clear on the details of the sampling method as a result and the researchers note that

a stratified, multistage, clustered area, probability sample was used

59.4% of the sample were female and 38.4% were age 75 and over. 36.3% of the sample lived in rural areas compared to 26.6% that lived in urban areas. The majority of the sample (52%) had 0-11 years of education. Participants were interviewed using the Composite International Diagnostic Interview with major depressive disorder diagnosed using DSM-IV criteria and a list of questions used to detect the presence of painful symptoms specifying within the last 12 months in some of these questions. They were also asked if they had one of a number of chronic medical conditions some of which are common medical conditiosn (e.g. asthma and diabetes). They were also asked about antidepressant and benzodiazepine use. Their estimated point prevalence of painful physical symptoms in the sample was 31.8% and although they were calculated as more common in men there was no confidence intervals for this comparison. PPS were significantly more likely in females with major depressive episode than those without. Using depression as the dependent variable, the researchers ran a multvariate analysis which identified female gender and pain as predictors of depression. Without major depression, the likelihood of antidepressant use was three times greater in those with painful physical symptoms compared to those without. For participants with depression, there was no significant difference between those with and without painful physical symptoms in the use of antidepressant medication. There was a doubling in the use of benzodiazepines in those without major depression but with painful physical symptoms (PPS) compared to those with major depression but without PPS. Major depression was also found to be signficantly associated with benzodiazepine use.

In the discussion, the authors note that from their results somatic conditions mediated the relationship between depression and pain. The authors also  comment on the two-fold increase in PPS with major depressive episode and the increased prevalence of PPS with female gender. Whilst these latter two findings were consistent with previous literature, like the researchers I found the results for antidepressant and benzodiazepine use interesting. Firstly antidepressant use was found to be higher in those without major depression but with pain. The use of benzodiazepines was increased in those with major depression also. I wasn’t clear if there was a prominent anxiety component in those using benzodiazepines but given that only 20% of those with depression were receiving antidepressants a different pattern of prescribing could be explored. This however would depend on local guidelines particularly as the sample is taken from 6 countries.

In conclusion, I thought there were some interesting findings here particularly the use of antidepressants in those with pain but not major depression. It could be that the depression had been previously treated and was in remission. Alternatively it could mean that the subject or the prescriber had intended for the antidepressants to be used for the pain. It would be interesting to see how factors such as pain duration and intensity impact on antidepressant use. The paper provides valuable insights into the relationship between pain and depression in older adults and I would be interested to see in particular if there are any follow-up studies examining the use or underprescribing of antidepressants as well as benzodiazepine in the same or other regions.

References

Bonnewyn A, Katona C, Bruffaerts R, Haro J M, de Graaf R, Alonso J and Demyttenaere K. Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking. Journal of Affective Disorders. 117. 193-196. 2009.

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