Monthly Archives: January 2013

Major mental illness and the Love hormone

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Oxytocin for schizophrenia – More positive news

Oxytocin is a hypothalamic peptide which is involved in social cognition and social behaviour. It is sometimes colloquially referred to as the 'love hormone', given it's involvement in bonding, empathy and trust. In recent years, oxytocin has been proposed as a possible new treatment for psychiatric disorders in which inter-personal relationships are problematic. The list of candidate conditions has included social anxiety disorder, autism and schizophrenia.

In the case of schizophrenia, clinical trials have begun to appear in the last few years. Two American groups have reported promising findings in small-scale studies. New findings from a trial carried out by researchers based in Tehran are also positive. The Iranian trial has the advantage in that patients were followed up for 8 weeks, compared to 2-3 weeks in the US studies. It was also slightly larger in size.

In the Iranian study, the addition of oxytocin to risperidone led to improvements in the intensity of positive psychotic symptoms (hallucinations, delusions and suspiciousness). There were also improvements in negative symptoms (apathy, amotivation, reduced sociability), although this was less pronounced.

The authors concluded: “Oxytocin as an adjunct to risperidone tolerably and efficaciously improves positive symptoms of schizophrenia. In addition, effects on negative and total psychopathology scores were statistically significant, but likely to be clinically insignificant. The interesting findings from the present pilot study need further replication in a larger population of patients.“

The paper is available here

 

Stopping smoking reduces anxiety

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An Habitual Assumption now up in smoke

Conventional wisdom is that cigarettes help relieve stress. Every smoker will testify to the instant, deep calming effect of their favourite brand. How could it be otherwise?

But findings from a new study challenge this assumption. The researchers followed the progress of 491 smokers who had just completed a course of nicotine replacement therapy in an effort to quit. They measured anxiety levels at baseline and 6 months later.

empty ashtray

Those who were successful in quitting had a significant drop in their anxiety scores over the 6-month period. (In those who failed to quit, anxiety scores had increased slightly by 6 months). Remarkably, successful quitters whose main reason for smoking was to cope with stress experienced the largest fall in anxiety.

The authors concluded…

” People who achieve abstinence experience a marked reduction in anxiety whereas those who fail to quit experience a modest increase in the long term. These data contradict the assumption that smoking is a stress reliever, but suggest that failure of a quit attempt may generate anxiety“.

The abstract of the paper can be read here.

 

Complementary Treatments for Depression

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Exercise, meditation and nutritional supplements in depression: Helpful or not?

Since 1965 it has been clear from clinical trials that antidepressant medications are effective in major depression. However many patients are not keen to take tablets, expressing a wish for more 'natural' forms of treatment. Numerous alternative treatments have been advocated, but is there any evidence that any of these work? Here we briefly review the case for physical exercise, meditation (or mindfulness, as it is now known) and several nutritional supplements.

Alternative treatments as a group can often be criticised because they do not subject themselves to rigorous trials, as is the case with conventional treatments (pharmacological or psychological). This criticism is valid. Indeed it is only within the last 60 years that conventional medicine itself has demanded clear demonstrations of efficacy before a treatment can be licensed for a particular illness. The randomised, double-blind control trial (RCT) is the gold standard by which efficacy is judged. Until recently, very few alternative treatments were subjected to the strict demands of the RCT. But this is changing.

Is physical exercise beneficial in depression?

There is now good evidence that a programme of physical exercise is an effective treatment for depression. Researchers in Brazil conducted a metanalysis in which the results from 10 separate trials were pooled to give an overall finding. (Metanalysis is a powerful method for deciding whether a treatment works. All available trials are scrutinised, and those with no control group or no randomised allocation to drug or placebo are usually excluded on the grounds of being poor quality studies).

stretching exercisesThe main finding from the Brazilian study was that moderate exercise (3 times per week) was effective in reducing depressive symptoms. Those patients who were older, and those with milder depression derived the most benefit. It made no difference whether the exercise programme involved strength-training or aerobic training, although the authors showed a preference for aerobic training. The authors concluded:

“The present meta-analysis concluded that physical exercise, mainly aerobic training, improves the response to depression treatment. However, the efficacy of exercise in the treatment of depression was influenced by age and severity of symptoms“.

The full paper can be read here.

Meditation (Mindfulness)

Mindfulness is a currently fashionable psychological approach for the treatment of depression, which has its roots in eastern meditation techniques. The various traditional schools of meditation differ in flavour, but all centre on the idea of mastering an unruly and restless mind. Mindfulness training involves short sessions in which the aim is to direct consciousness towards full immersion in the activity at hand, rather than on the mind's incessant chatter. But does it work?

meditation candle

A recent review from the US attempted to tackle this question. However the authors were unable to reach a definitive conclusion. At present there are not enough studies, of sufficient quality, to yield an answer. They point out that further (and more robust) trials are needed, but they regard mindfulness as a promising approach to depression. They remark:

“Regardless of the various limitations present in the available literature, findings to date have consistently demonstrated that training focused on improving attention, awareness, acceptance, and compassion may facilitate more flexible and adaptive responses to stress“.

The full paper can be read here.

Nutritional Supplements

Vitamin deficiencies (especially B-vitamins) can cause neuropsychiatric disorders, although this is very rarely seen now in developed countries. But the idea of supplementation is to provide additional quantities of a specific nutrient in an effort to obtain a therapeutic effect. Three nutrients in particular have attracted attention as possible treatments for depression: folic acid, S-adenosylmethionine (SAM-e) and omega-3 fatty acids. A recent Canadian paper has reviewed the evidence.

nutritional supplements

Omega-3 fatty acids (fish oils) have been shown to possess antidepressant properties in a metanalysis of 16 trials. SAM-e has also been shown to be effective in a metanalysis of 7 trials. The evidence in support of folic acid has been more limited. One of two trials was positive and further work is needed. The authors conclude:

“Physicians should consider screening for and treating folate deficiency but the benefits of folate supplementation remain unclear. Limited evidence supports the use of omega-3 fatty acids and S-adenosylmethionine, but further research is required“.

The full paper can be read here

 

 

BD or not BD?

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The Bipolar Spectrum: can brain scans resolve diagnostic uncertainty?

The concept of manic-depression was extended some years back to cover less extreme manifestations characterised by hypomania (Bipolar II), as well as the classical form, defined by mania (Bipolar I). But other forms (perhaps less dramatic, though still a cause of much suffering) also exist.

These ‘softer’ forms of bipolar illness appear to blur into unipolar depression and perhaps also with the category which has been termed, borderline personality disorder. Although there has been a trend to view psychiatric disorders as points on a spectrum, rather than as discrete, encapsulated diagnoses, many psychiatrists would hesitate to equate borderline personality disorder and bipolar illness. Ultimately the matter will be resolved when we fully grasp the underlying neurobiology of affective disorders.

A new paper from researchers based in Sydney provides an authoritative and balanced account of the current state of our knowledge. The authors elegantly summarise the functional MRI literature across the hypothesised spectrum. One feature appears to be common across the various disorders – limbic hyperactivity. Perhaps this is not so surprising as the limbic system is the ‘seat’ of emotion, and all the various disorders/forms are characterised by emotional upset.

But there also appear to be differences. For example, the orbitofrontal cortex (a higher centre, which ‘dampens’ and regulates emotion) appears to be underactive in bipolar I, but not in unipolar depression nor in borderline personality disorder.

Further work will be needed before clear-cut conclusions can be drawn. The authors conclude…”Eventually, as the respective signatures of personality-based emotional dysregulation and bipolar mood dysregulation become increasingly crisp, we may be able to use functional neural profile to assist in clarifying diagnosis or treatment options in clinically muddy presentations, although a great deal of work will need to be done before imaging will be sufficiently robust to be used in this manner.”

The full paper can be read here:

http://www.expert-reviews.com/doi/pdfplus/10.1586/ern.12.126