Reflections on January 2009

There was quite a lot going on in January! The year started off with a very controversial paper in neuroimaging which broke lots of conventions in the process of examining research methodology. There have been concerns that it could affect issues such as publishing and funding and we will need to see how this develops. Curiously this paper, released two months ago is already associated with its own merchandise range (of mugs) which I thought was a little bit out of the ordinairy.  There was media interest in an important study looking at antipsychotic use in dementia in nursing homes and another study identifying an autosomal dominant gene associated with a FTD-like dementia with a delayed phenotype (in the 80’s). A gene-mediated relationship between separatation anxiety and adult panic disorder was identified in a large Norwegian Twin Study. In a study of early intervention in psychosis, the authors suggest that the prodromal phase is incorporated into the critical period. The WHO Safe Surgery program was associated with a 50% reduction in deaths in another study in which staff used a 19-point checklist showing the importance of process.

There were a number of papers (with a focus on Mild Cognitive Impairment) which were reviewed together with a number of pocasts and blogs including Dr Shock. In addition to having valuable information on depression and ECT, Dr Shock also gives lots of useful tips for those developing their own blogs or wanting to make use of internet technology. There were a number of books reviewed and of particular interest were Dawkins ‘The Ancestor’s Tale’ and Damasio’s ‘Descartes Error’ which tackles Cartesian Dualism and challenges the separation of cognition and emotions.

Research in Dementia

There has been widespread reporting in the UK media about a study investigating the use of antipsychotics in people with dementia which shows increased mortality relative to those taking placebo. The dementia antipsychotic withdrawal trial (DART-AD) was a 12-week placebo-controlled trial in which patients in nursing homes were continued on one of five antipsychotics (thioridazine (which has since been withdrawn from general use), chlorpromazine, haloperidol, trifluoperazine and risperidone) or switched to oral placebo. 165 people were included in the trial, evenly divided between the two groups and survival in the groups were found to be 70% v 77% at 12 months (antipsychotic v placebo), 46% v 71% at 24 months (antipsychotics v placebo) and 30% v 59% at 36 months (antipsychotics v placebo). Important question here however include the indication for the antipsychotic and the choice of antipsychotics for inclusion.

In a cross-sectional study of 76 people without dementia (mean age 67, 36 with mild cognitive impairment), FDDNP-PET signals (FDDNP stands for 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-napthyl}ethylidene) malonitrile and is a compound which binds to plaques/tangles) was correlated with older age, impaired cognition and APOE-4 carrier status. In a 6-year Swedish cohort study looking at risk of dementia and the traits of neuroticism and extraversion, there was found to be an increased risk of dementia in those with high neuroticism and high extraversion compared to those with low neuroticism and low extraversion (Hazards Ratio 0.51 (CI 95% 0.28-0.94). An autosomal dominant condition similar to leukodystrophy has been suggested to account for a presentation similar to Frontotemporal Dementia after a series of autopsies were undertaken in affected people. What is interesting about this condition is that it sometimes doesn’t present till the eighth decade of life. After cells have differentiated, recent research suggests that the nuclear pore complex deteriorates in an age-dependent manner allowing leakage of proteins into the surrounding cytoplasm (and also the reverse). This would suggest a need for new supplemental treatment approaches. A relatively large 12-month follow-up study of 325 people who had undergone 123I-FP-CIT-SPECT scans found that the SPECT scans were useful in discriminating Lewy Body from non-Lewy Body Dementia. A rating panel utilised other clinical measures of the presentation. These ratings were then compared with the SPECT scan results. In the probably Lewy Body Dementia group the sensitivity was 63% and the specificity was 100%. It would be interesting to see the results at two years. There is a description of a care pathway for advance decisions and power of attorney for use in people with Huntington’s Disease.

Research in Liaison Psychiatry

A case-control study of 113 people with Chronic Fatigue Syndrome (CFS) and 124 controls showed a 6-fold increase in Chronic Fatigue Syndrome with self-reported childhood trauma. CFS was more likely if there was PTSD in addition.

Research in Child and Adolescent Psychiatry

In a Norwegian twin study involving 712 adults, childhood separation anxiety disorder, CO2 hypersensitivity and adult panic disorder were influenced by a single variable which in turn was determined mainly by genetic factors. A prospective cohort study of 1037 children followed into adulthood found that lower IQ was a predictor for depression and anxiety in adulthood, whilst higher IQ was a predictor for adult mania. The authors recommend that this information is utilised in service development. In a study which looked at MRI scans of three groups – children with ADHD treated with psychostimulants, children with ADHD not treated with psychostimulants and age matched controls – the hypothesis being tested was that psychostimulants would interfere with cortical development using cortical thickness as a marker. The findings showed however that the children with ADHD not treated with psychostimulants were characterised by a thinner cortex than the other two groups while the psychostimulant treated group did not differ from the controls contrary to the null hypothesis. In an fMRI study of four groups – boys with ADHD, boys with ADHD with hyperactive-inattentive subtype, boys with conduct disorder and age matched controls – there was found in the conduct disorder subgroup to be reduced activation during a sustained attention task, in the insular cortex, hippocampus and anterior cingulate cortex and cerebellum whilst in the ADHD group there was found to be reduced activation in the ventrolateral prefrontal cortex and increased activation in the cerebellum. In another fMRI study there was an association with a reduction in Amygdala activation in response to presentation of fearful faces in boys with conduct problems and callous-unemotional traits.

Research in Psychosis

There was a recent study in the New England Journal of Medicine, looking at both typical and atypical antipsychotics and finding an increased risk of cardiovascular events which was dose dependent. In an Eli-Lilly funded study of 7658 people with schizophrenia switched to or initiated on one of four antipsychotics, the median time to discontinuation was 30 months for Olanzapine, 23.1 months for Risperidone, 13.9 months for Quetiapine and 12.5 months for Haloperidol. There is a critical period hypothesis which states that there is a critical period of a psychotic illness during which time deterioration occurs more rapidly. In an 8 year prospective cohort study of people with first-episode psychosis the duration of untreated psychosis predicted outcome at the end of the study. However due to the study type there was no comparison group. The authors suggest that the prodromal period should be included within the critical period. An imaging study with 17 people at risk of psychosis, 10 with psychosis and 15 controls found that there were intermediate patterns of activation in the at-risk group between controls and those with psychosis. Specifically this involved the anterior cingulate cortex and inferior frontal cortex in a verbal fluency task and the dorsolateral prefrontal cortex, inferior frontal cortex and parietal cortex in the N-back task.

Research in Mood Disorders

In a report from the Sequenced Treatment Alternatives to Relieve Depression Study (STAR*D), 2875 people with major depressive disorder receiving citalopram were included in the analysis. 23.5% of participants were identified as having melancholic features and this group was associated with lower remission rates on the Citalopram (absolute reduction of 8.4% relative to the non-melancholic group). After adjustment for clinical features and demographic variables there was no significant difference between the groups. A longitudinal study of 242 people with bipolar disorder with both typical and atypical features showed that there was no difference between the two groups in terms of response to Lithium over a 20-year period on the mean morbidity index. In an american study, 314 psychiatrists were surveyed and 80% reported that they did not use clinical scales in the assessment and treatment of depression and a number of reasons for this were given. Placebo response in paediatric antidepressant trials was found to correlate with the number of sites involved in the study as well as the severity of the depression. The authors found an increasing placebo response (which is similar to a finding reported in an article on dementia research last year) and concluded that this could be due to milder cases of depression being included, increasing numbers of study sites in trials and non-publication of negative studies. There is an interesting editorial by Professor Gordon Parker from the Black Dog Institute in which he looks at some of the reasons why a meta-analysis might produce results different from those seen in clinical practice. This follows on from the 2007 meta-analysis by Kirsch and colleagues. There are some really good points made here amongst which are the sample population in RCT’s (many people with more serious depression may be excluded from trials) as well as expectations of improvement which needs to be compared with pre-morbid functioning. A 12-week double-blind trial (n=485) of Aripiprazole v Haloperidol (5-15mg) in bipolar mania or mixed states found both to be significantly better than placebo in improving Young Mania Rating Scale scores.

Research into Eating Disorders

A retrospective cohort study of Swedish women treated for anorexia in an inpatient setting showed a Standardised Mortality Ratio for all causes of death of 6.2. The authors caution that as treatment was in the inpatient setting it was likely to represent more severe illness. The risk was still elevated some 20 years after the initial admission although  this decreased over time.

Miscellaneous

One study was particularly interesting in terms of methodology. In this study, outpatients in a substance misuse service used ‘ecological momentary assessment’ (EMA) to report their mood, exposure to drug-use triggers and craving. The assessment was completed by utilisation of a handheld device. Another technique was developed which is thought to have a saved a considerable number of lives in surgery. In the World Health Organization’s Safe Surgery Saves Lives program, a 19-point surgery checklist was associated with a reduced rate of death from 1.5% to 0.8% in 3733 non-cardiac surgical operations before the checklist was introduced and 3955 operations after the introduction of the checklist. Whilst not directly related to psychiatry (except in the case of psychosurgical operations) this research shows the important benefits of process. Ethicists are joining ward rounds over in the United States where they contribute to the decision making processes in complex cases. Also an ancient brain from approximately 6000 years ago has been discovered in a cave (it was preserved due to the dry conditions) in Armenia with evidence of intact surface vessels. Such a find is potentially very interesting as even in the space of tens of thousands of years there is evidence of evolutionary changes in the brain.

Medical Articles

Voodoo Correlations in Social Neuroscience was reviewed here and has taken on a life of its own.

Event-related potentials in the assessment of Mild Cognitive Impairment was reviewed here.

APOE status and Association to Learning was reviewed here.

Intranasal Administration of Acetylcholinesterase Inhibitors was reviewed here.

Social Psychiatry Articles

Breaking Down Barriers was reviewed here.

Making the CPA work for you was reviewed here.

Choosing Health: Supporting the Physical Health Needs of People with Severe Mental Illness was reviewed here.

Mental Health Taskforce: An Introduction was reviewed here.

Psychology Related Articles

Winnicott on fidgetiness was reviewed here.

Spatial navigation deficit in Amnestic Mild Cognitive Impairment was reviewed here.

Frequency and course of Mild Cognitive Impairment in a Multiethnic Community was reviewed here.

Mild Cognitive Impairment: Cognitive Screening or Neuropsychological Assessment was reviewed here.

Blogs Reviewed

Dr Shock MD PhD was reviewed here.

EMDR International Association Blog was reviewed here.

Corpus Callosum was reviewed here.

Science Insider was reviewed here.

In Practice was reviewed here.

Blog News

A paper which is causing a lot of heated discussion in the blogosphere is titled ‘Voodoo correlations in social neuroscience‘ by Vul and colleagues. This was initially reported on at Mind Hacks (see here). Neurocritic has been reporting in depth on this and is in his element (see December 2008 (31.12.08 ) and January 2009 (15.1.09) posts). A preliminary response to the paper by one author is located here and aside from the current debate contains some useful points for those interested in interpreting imaging studies. There are various points being made such as the reporting that has occurred in the media before the authors have been able to respond in print, the effect of reporting on perceptions of social neuroscience research and the potential benefits of the current dialogue. On the 10th anniversary of Nature Neuroscience, there is a post outlining the most cited studies the most popular of which was a study looking at the development of Parkinson’s Disease in people chronically exposed to pesticides.

Podcast Review

Shrink Rap Radio #1 was reviewed here.

John Betts on Jungian Psychology #3 was reviewed here.

John Betts on Jungian Psychology #4 was reviewed here.

John Betts on Jungian Psychology #5 was reviewed here.

Books Reviewed

The Ancestor’s Tale by Dawkins was reviewed here.

Descartes Error by Damasio was reviewed here.

Pocket Atlas of Normal CT Anatomy of the Head and Brain was reviewed here.

The Biology of Belief by Bruce Lipton was reviewed here.

Pocket Atlas of Cranial Magnetic Resonance Imaging here.

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.

6 thoughts on “Reflections on January 2009

  1. Pingback: Reflections on January 2009 The Amazing World of Psychiatry: A … | CARE 4 YOUR PET

  2. Dr Justin Marley Post author

    Dear Cinderkeys,

    Thanks for your comments. You’ve raised some nice points about the study.

    There was a screening questionnaire administered over the telephone which focused primarily on fatigue. However a sample of those who were fatigued were then invited for clinical interview and the diagnosis of Chronic Fatigue Syndrome (CFS) was made using the Centre for Disease Control (Fukuda) Criteria from 1994. These are well established criteria for the diagnosis of CFS.

    Your second point was about depression. This was quite interesting as the researchers deliberately included people with Anxiety, Depression and Post Traumatic Stress Disorder as I presume that they wanted to learn something more about the interactions with childhood abuse and CFS. As you say, there was a significant difference between those with and without CFS. People with CFS were more likely to have depression than those without. Could this therefore be confounding the outcome – could it be that depression accounts for the relationship? Well, the authors answered this by performing a regression analysis. When they used this method for looking at relationships, they found that the relationship between childhood abuse and CFS remained after anxiety, depression and PTSD were taken into consideration (although they also found that PTSD was associated with a 9-fold increased risk of the relationship between childhood abuse and CFS). However the characteristics of the people included in the study should also be considered (e.g. 18-59 year-olds (mean age 44), living in Georgia, responding to a random telephone survey, and without any of the following:- psychosis, bipolar disorder, substance misuse within 2 years or eating disorders within 5 years) in generalising to other populations. The relationship is also being examined retrospectively so this is showing an association. Another type of study would be needed to look at causality.

    Regards

    Justin

    Like

  3. Gregory Despain

    The importance of “dealing with adult ADD” is some what quite significant to how we can achieve a positive life. Attention deficit disorder is not just common in Young kids, but also hugely unrecognized in young and old adults, its still a rather difficult issue to pinpoint the exact root cause of it. Some common signs of adult ADD and ADHD can be, and is medically misunderstood for depression are, stubbornness, poor organizational skills, procrastination, poor financial management, very moody, easily bored, and rather forgetful, these are the more common signs that have relation to ADD and ADHD.

    Like

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