Tag Archives: research

Zapping the Blues: The effectiveness of magnetic and electrical stimulation for treatment-resistant depression.

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Blake glad day

Treatment-resistant depression (TRD) affects 1-3% of the population. Recently Holtzheimer & Mayberg reviewed the effectiveness of a range of new and promising techniques based on direct neural stimulation. The list includes Transcranial magnetic stimulation, Transcranial direct current stimulation, Magnetic seizure therapy, Vagus nerve stimulation and Deep brain stimulation.

The prototype of course is ECT (electroconvulsive therapy), which is a highly effective treatment for melancholic depression, but suffers from the effects of a negative historical portrayal. The authors present a balanced and elegant appraisal of the current state of affairs for the new techniques which can be read here in full. The summary points are as follows…

Transcranial magnetic stimulation (TCMS)

– FDA (US food & drug administration) approved.

– Uses rapidly alternating magnetic fields to induce current in the underlying cortex.

– 10 to 30 treatment sessions over 2-6 weeks.

– Controlled trials have been positive.

– Response rates in TRD: 20-40%.

– Remission rates in TRD: 10-20%.

– Repeated courses may maintain initial benefits.

Transcranial direct current stimulation

– Delivers a low-intensity direct current to the underlying cortex.

– 5 times per week treatments for several weeks.

– Fewer side effects than TCMS?

– Antidepressant effects claimed from a small number of open and controlled studies.

– Response, remission & relapse rates are unclear.

Magnetic seizure therapy

– Seizures are induced using a transcranial magnetic stimulation device.

– Antidepressant effects from a small number of open studies.

– Claims for less side-effects than ECT, but may be less effective.

Vagus nerve stimulation

– FDA (US food & drug administration) approved.

– Electrical stimulation to the left vagus nerve through an implanted pulse generator.

– Open-label response rates in TRD: 30-40%.

– Open-label remission rates in TRD: 15-17%.

– No evidence for efficacy in a large controlled study.

– Simple surgical procedure.

Deep brain stimulation.

– Precise neurosurgical implantation of electrodes using stereotactic techniques.

– Remission rates in TRD: 40-60%.

– Relapse in remitted patients is uncommon.

– Complex surgical procedure.

Holtzheimer & Mayberg conclude, “Neuromodulation for depression is at an exciting and promising stage of development, and continued well-conducted research will help clarify and realize its potential“.

 

Psychosis Research. Where have we been & where are we going?

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phenotype and genotype

The Institute of Psychiatry at The Maudsley is the largest centre for psychiatric research in Europe. Recently a group of leading researchers were tasked with summarising an area of research as it pertains to psychosis and psychopharmacology.

The outcome was a series of short lectures, delivered to a lively audience of psychiatrists, mental health workers and psychologists at The Maudsley. The lecture slides and audio are now available below and constitute a unique training resource for those who treat patients.

1. Sir Robin Murray,
“Psychosis research: Deconstructing the dogma“
2. David Taylor,
“Current Psychopharmacology: Facts & Fiction“
3. Oliver Howes,
“How can we Treat psychosis better?“
4. Marta DiForti,
“An idiot's guide to psychiatric genetics“
5. Sameer Jauhar,
“Ten psychosis papers to read before you die!”
6. Paul Morrison,
“Future antipsychotics“

 

Cool Memories: The Recurring Crisis of Psychiatry.

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The diagnostic system for delineating psychiatric disorders ('The DSM') is in it's fifth rewrite. It had been anticipated that advances in fMRI imaging and molecular genetics would have finally put psychiatric diagnoses on a medical footing. Alas fMRI has failed to live up to it's promise. And genetics, if anything, has been too powerful – by toppling the whole framework of DSM.

A new paper by Juan & Maria-Ines Lopez-Ibor captures the zeitgeist, but also reveals that the current debates and controversies are nothing new. For over 150 years, psychiatry/psychology has struggled to establish itself as a natural science because of three major issues – 1. Classification difficulties. 2. The mind-brain duality problem. 3. The perils of phrenology (localisationism).

[The full paper can be read here].

These issues have been acknowledged many times before, but never as a collective – and perhaps never as elegantly (even with some minor errors of translation from Spanish into English).

On classification…

“Psychopathological phenomena certainly exist and can be observed and experienced as such. However, psychiatric diagnoses are arbitrarily defined and do not exist in the same sense as psychopathological phenomena do”.

On dualism…

“Dualism manifests itself in the separation of mental and physical diseases, of psychiatry and the rest of medicine, of neuroses and psychosis, of biological research and interventions from other psychosocial approaches and in the proliferation of psychiatric sub-disciplines”.

& on phrenology (localisationism)…

“A phrenological approach still survives in neurological and psychiatric research…This approach has been extended to the neuropharmacology attributing specific neurotransmitters psychological functions”.

The text may be gloomy, for some. Others may engage in playful delight at references to Plato, Greisinger and the Upanishads. A follow up paper is in press (this was part 1), and much is promised…

“Modern science and modern medicine are, no doubt, the greatest achievements of humankind having change for the better of millions of human beings. We are not arguing to throw the baby with the water in the tub, but to look for fresh water to replace or replenish the existing one. This we will do in the second part of this article”.

 

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