Monthly Archives: October 2010

News Round-Up:October 2010 4th Edition

A merger between the National Prescribing Centre and the National Institute for Clinical Excellence is taking place and scheduled to complete by April 2011. The National Prescribing Centre informs Government on the economic implications of medication prescribing.  At the Alzheimer’s Forum, there is a write-up of a study providing evidence that circulating Amyloid-Beta peptide may be deposited in the brain leading to Amyloid deposition which according to the Amyloid hypothesis leads to Alzheimer’s Disease. This contrasts with other models in which the disease is thought to occur when there is a disruption of clearance of the peptide from the brain into the circulation. A comparison (n=13734) of concurrent antipsychotic prescribing with Donepezil or Rivastigmine found a small (1%) but statistically significant difference with a lower prescribing rate in the latter although the interpretation is less than straightforward.  A small study (n=43) provided evidence of hyperacusis (14%) and tinnitus (19%) in Semantic Dementia which the authors interpreted as possibly related to cortical changes identified using structural MRI although there was no control group in the study. A longitudinal Swedish twin study looked at predictors of developing dementia and identified grip strength and ‘higher emotionality on the EAS Temperamental Scale’ as significant predictors. A small Japanese case control study (n=89) showed evidence of a significant association between Thyroid Stimulating Hormone levels and right Cerebral Blood Flow in Alzheimer’s Disease and it will be interesting to see further research in this area. Researchers in a Brazilian study used texture analysis (TA) on MR images to identify differences between people with Alzheimer’s Disease and amnestic Mild Cognitive Impairment in the area of the corpus callosum and thalamus. Level of education was correlated with performance on the Clock Drawing Test in this South Korean study (n=268). A small study compared people with Frontotemporal Dementia, Lewy Body Dementia, Alzheimer’s Disease and controls and found a prevalence of occasional microbleeds in the control group of 60% as well as a signifiantly higher prevalence within the Alzheimer’s Disease group. Arterial hypertension was the most common risk factor in Alzheimer’s Disease and Lewy Body Dementia. There is an interesting paper on the possible non-progressive nature of behavioural variant Frontotemporal Dementia. In an evaluation of 522 patients who underwent subthalamic deep brain stimulation for Parkinson’s Disease the mortality occurred in 0.7% of cases. Adverse hardware events occurred in 7% of cases and the researchers concluded that deep brain stimulation ‘can be considered as a safe procedure’.

There is a link to an interesting BPS article on ‘scientific discounting cognitions’ at this week’s Spike Activity at Mind Hacks. The article features a discussion with Professor Munro who has found that a person’s reception to new findings in science is influenced by their underlying values and the details are explored further in the article.

Ed Yong has an ‘missing links‘ article with interesting general science links and draws the readers attention to recent results from the 1000 Genomes Projection Consortium. There are more details on this at Nature and just to quote from the abstract

On average, each person is found to carry approximately 250 to 300 loss-of-function variants in annotated genes and 50 to 100 variants previously implicated in inherited disorders

and also

‘From the two trios, we directly estimate the rate of de novo germline base substitution mutations to be approximately 10−8 per base pair per generation’

This first figures are really interesting. If we can generalise from this data to the wider population that we would each have about 300 genes that aren’t functioning (I wasn’t clear on whether these are inherited or if they are de novo mutations).  Since mutations are the mechanism through which we become genetically differentiated, each mutation can produce a change which can lead to successful adaptations to the environment. Switching off a gene here or altering a gene there might in some way give a person a selective advantage that better enables them to pass on their genes. On the other hand there were an average of 50-100 genes that have been associated with ‘inherited disorders’. At the moment, the genome sequencing technology is not widely available and people might learn of an inherited disorder after clinical suspicion is raised and appropriate investigations are undertaken. However this technology will be widely available in 10 years time and we have to look realistically at the possibility that clinical practice will be transformed. Thus in ten years time, the general population might go to private companies to have their genomes sequenced, receive the results and then present to their doctors with a list of 50-100 variants asking for advice. This would have implications for primary and secondary care that will need to deal with both realistic and unrealistic expectations.

Discussion Point

I came across this story which I found quite disturbing – ‘US child sued for bicycle crash‘. There were two children involved and the point here is that they were both just 4 years of age at the time of the incident. However the children were racing their bikes under the supervision of the mother when they crashed into an 87-year old lady who was subsequently admitted to hospital with a hip fracture and then died three weeks later. Before her death, she had initiated a law suite which was then taken up by her son and estate after her death. Although this is clearly in the jurisdiction of law and in particular US law there are more general implications for society and for capacity (capacity also being an important issue in mental health services). My initial thoughts were what was the role of the mother’s supervision? Did the children understand the implications of what could have happened? and more specifically did they had the capacity to ride their bicycles on the pavement? However the case focuses on the issue of negligence. In other words were they negligent in riding their bicycles into the lady? The court filings are here and includes the following

The sole issue before the Court is whether an infant aged four years, nine months, is non sui juris, incapable of negligence as a matter of law, under the facts presented

Non sui juris is latin for ‘Not his own master’ and is defined in terms of legal capacity in West’s Encyclopedia of American Law here . The document goes on to quote from a 1979 ruling

in considering the conduct of an infant in relation to other person or their property, the infant should be held to a standard of care…by what is expected of a reasonably prudent child of that age, experience, intelligence and degree of development and capacity

The document goes on to cite the conclusions from another case

parental supervision is unlikely to affect the sui juris status of a child above the age of four unless the parent has taken an active role in encouraging the child’s conduct

answering the question of parental supervision before concluding

Because defendent-movant has utterly failed to allege, let alone establish, facts constraining the Court to a single inference, defendant-movant’s sui juris status is a matter of fact for a jury, and this motion to dismiss must be denied

So there is the conclusion and at the end of the document, the judge puts a date and time for counsel to appear. From a mental health perspective however there were a few things that were of interest here. The first was that in considering dismissal of the case, there was no explicit reference within the document to the psychological consequences of the trial on the children themselves. The children are a few years older now. What happens if there is a prolonged trial and the children are successful in their defence then what will it have cost them psychologically? There are a number of possible consequences but this will depend on the children’s resilience as well as a number of other factors. However in this case, the trial is essentially revolving around whether these children had responsibility for events which were associated with a death regardless of whether there was a causal relationship. By proceeding there must be an inference that the children are going to spend a period of time focusing on their actions at age 4 which were associated with a death and which are now being examined within the criminal justice system. The ‘non sui juris’ safeguard is reassuring for those under age 4 as in such cases there might be parallels with the Little Albert case particularly as there is exposure to the possible trauma of a court trial. For these children though there is no such safeguard but there is also the question of whether they have capacity at various stages in the court proceedings and if not what the implications of this are for what is happening to them and which is beyond their control.

Here the problems for the children themselves are just the start. What is also concerning is that there are already a number of cases that have completed in the USA with children as young as 6 although it remains to be seen if other countries will follow suit. Also the legal system would be expected to systematically adapt to these changes which has the potential to reinforce this behaviour.  However if these age barriers for prosecution are being lowered what will be the further implications for society? Here again there may be some implications for mental health services. The criminal justice system is a very powerful system which in impressionable, very young children has the potential to significantly influence their understanding of their own actions, their understanding of their relationship with society, to influence their relationship with family when family has been helpless to prevent proceedings and to influence core beliefs about themselves regardless of trial outcomes. While none of these events may have been or will be traumatic, for those that are traumatic there are numerous consequences including post-traumatic stress disorder. At such an impressionable age there is the possibility that such consequences can shape personality and that there might be chronic mental health implications. Unfortunately it is not possible to proceed further without recourse to facts and figures and perhaps a longitudinal study of children who have been through the court system at such an early age may be helfpul in advising the criminal justice system as to the appropriateness of a prosecution. However if there are demonstrated consequences then society will face the problem of how to reconcile this with criminal justice system proceedings.

Appendix

There is further coverage of the legal decision here, here, here, here, here, here and here.

Index: An index of the site can be found here. The page contains links to all of the articles in the blog in chronological order. Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk. 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 author is not responsible for the contents of any external sites that are linked to in this blog.

Podcast Review: Age to Age

There is a podcast in the Medical University of South Caroline ‘Age to Age’ series freely available here. The podcast is a short interview between author Sally Smith and Mary Peters who has started up a business in the USA with an emphasis on delivering care in the home environment to older adults. The interview covers a number of sensitive issues such as the guilt that family caregivers may experience when they feel they haven’t done enough for their relative even after going to considerable lengths. There are also issues that at the time of writing are more relevant to the USA healthcare system. This is another brief episode in the ‘Age to Age’ series which raises the profile of important issues in healthcare delivery to older adults.

Index: An index of the site can be found here. The page contains links to all of the articles in the blog in chronological order. Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk. 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 author is not responsible for the contents of any external sites that are linked to in this blog.

Blog Review: Evolutionary Psychiatry

The blog reviewed here is the Evolutionary Psychiatry blog by Dr Emily Deans MD. This is a blogspot blog. The articles feature on the central pane which is light brown on a beige ‘faded world map’ background. Articles are titled, dated, tagged and identify backlinks. The articles feature text with hypertext links where appropriate. On the right side of the screen are links to the About section, similar blogs, followers and a chronological index of posts. At the time of writing there are 88 posts. In the About section, Deans writes that

‘I’m a psychiatrist in Massachusetts searching for evolutionary solutions to the general and mental health problems of the 21st century’

She writes further in the introductory post about the paleolithic period as one in which she will find these solutions. This is a period spanning some 2.5 million years which utilised stone tool technology and which has given rise to the so-called paleolithic diet. The basic premise is expanded on in this post in which Deans writes that

‘Ancient humans ate wild game (including marrow and organ meats), shellfish, fish, tubers, green leafy vegetables, eggs, fruits, and nuts’

and that

‘Anthropological evidence and epidemiological studies of modern and past hunter gatherers, as well as agrarian societies of the last 10,000 years, show us that the physical health of hunter gatherers far surpasses the health of grain-based societies

However this can be contested on multiple grounds. Fauna has changed considerably over terrain and time periods. Agriculture was a feature of Ancient Egypt and yet a recent study provided evidence of reduced risk of cancer in this civilisation although longevity may have been diminished relative to life expectancy in many countries today (I think there was almost certainly a selection bias in the sample set in terms of representation of the society). Additionally Homo Neanderthalensis specimens are found with evidence of multiple pathology and diminished lifespan compared to modern life expectancy. Thus the term ‘physical health’ is rather broad and could be more usefully tightly defined. However the choice of the paleolithic period both here and in the wider background literature is one in which I don’t think simple assumptions can be derived. If we talk about stone tool technology then there are many primates today that have been found to use such technology including chimpanzees (that can properly be considered as omnivores). If our common ancestors were also capable of using such tools then the paleolithic period could be extended by some several million years. Even here the tool use of Capuchin monkeys in South America could extend this even further by tens of millions of years (although a critic may counter that such tool use may represent the very gradual development of a culture over this time period and that this might not therefore be relevant to our concestors). More recent debates have focused not on the importance of grain or tool use but instead on cooking as a key turning point in the evolution of the hominid brain because of the high energy use of the brain and the energy/efficiency advantages that cooking confers.

Even though the above suggests that the central assumptions are far from straightforward, Deans goes on to provide the reader with fascinating anthropological insights into diet. In this post for instance Deans draws attention to the diet of the Kitavans in Papua New Guinea and a reduction in prevalence in various diseases. There’s also this post examining links between depression and diabetes which I suspect is a very useful way to be able to make evolutionary links. The posts are quite detailed and Deans looks at the research, carefully explaining the background for readers unfamiliar with the nuances of the subjects under discussion. In some posts, Deans polarises the issues which I think makes them more accessible to the general reader. One example is this post on the benefits of zinc supplementation in depression. However I think that these matters are never straightforward (my dysfunctional assumption perhaps!). This paper for instance summarises research in this area. Although there is an impressive amount of data supporting the hypothesis, the authors write that

However, another study in an aging European sample found no association between mood and zinc status; zinc status was within the normal range, which suggests that the potential influence of zinc on mood may be small and undetectable when zinc status is within normal limits

There are also a few posts discussing the possible relationship between diet and Alzheimer’s Disease such as this one. Deans has a very good grasp of biochemistry and is versatile in interpreting the research literature. She also uses a simple hypothesis – that dietary grain is bad for health. A simple hypothesis can also be a prejudice and this is both an advantage and disadvantage. The advantage of this approach is that Deans can refine her understanding of this relationship with time and work on assumptions further downstream – in effect developing a theory as a collection of hypotheses. However, the disadvantage is that this assumption may prove incorrect which would have implications for the subsequent ‘downstream’ work and as discussed above the validity of this hypothesis is far from clear cut. There is another element to Dean’s writing however and that is the biocchemical approach to mental illness. I don’t think this is by itself the right level of analysis to provide a complete answer to the questions posed but the specialised knowledge that is demonstrated here can give very valuable insights into mental illness. The quote above (regarding zinc) illustrates the point that biochemical effects are likely to be small in terms of phenomenon as complex as mental illnesses and broader explanatory models are required on a theoretical basis. However this approach is very well suited in informing hypotheses for empirical testing where there may be a practical clinical benefit once the research has been conducted. Evolutionary psychiatry is developing significantly as is the understanding of human evolution and it will be interesting to follow developments on this blog.

Index: An index of the site can be found here. The page contains links to all of the articles in the blog in chronological order. Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk. 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 author is not responsible for the contents of any external sites that are linked to in this blog.