A failed randomized controlled trial of Fluoxetine versus placebo in elderly stroke survivors due to reluctance and subsequent informal discussions by their treating physicians. Also due in part to high community prescribing rates of antidepressants by general practitioners. In a recent research showed that 15% of adults aged over 75 years are in receipt of an antidepressant prescription from their general practitioner, half of them for more than 2 years and many without formal review.
Now I am a strong supporter of placebo controlled trials. An important factor for success is the believe physicians and other health workers have in the importance of the trial. If the health workers are ambivalent you can forget it.
Why is a placebo controlled trial important for stroke survivors? The authors:
However, the evidence that antidepressants are effective is surprisingly weak, and although there is some indication that they produce improvement in mood symptoms we know little about specific indications or about complications of treatment. The latter are especially important since if treatment of depression is to have an impact on rehabilitation outcomes, then it needs to be given early at which time complications may be more likely.
Despite screening 641 patients they could only include 1 patient, so they gave up but nevertheless got their experience published, good for them as well as for the editors of the International Journal of Geriatric Psychiatry.
Ruddell, M., Spencer, A., Hill, K., House, A. (2007). Fluoxetinevs placebo for depressive symptoms after stroke: failed randomised controlled trial. International Journal of Geriatric Psychiatry, 22(10), 963-965. DOI: 10.1002/gps.1771
I am not a football fan but even I knew Paul Gascoigne was one of the great talents. He has not coped with the money, and the fame, and the alcohol. But what is to be done?
More than half the 28 new members of writers of the next edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) have ties to the drug industry, according to the Center for Science in the Public Interest’s Integrity in Science Watch.
Computer game players with more physical-aggressive personality manifest more violent behaviors in game playing with more violent interactions, more frequent punching and kicking actions, and more frequent shootings. This research is one of the first to show that personality is an important factor in how a game is played.
The most important contribution of this study is that it investigated the individual experience of game playing. Most of the existent studies, especially experimental studies, simply compare a group of people playing a violent game and another group playing a nonviolent game without taking into consideration that the violent content people are exposed to can vary to a great extent even when playing the same game. This study is the first that goes beyond contextual variables and actually considers the unique experience of each individual player.
How was it done?
Screen captures of 40 undergraduate students were studied. They independently played the game for 70 minutes, sitting separately from each other and wearing earphones. The video stream of the last 10 minute portion of their game playing was recorded using the software Snagit for content analysis.
Two popular computer games The Godfather (Game 1) and True Crime: Streets of LA(Game 2) were used. Both are third-person action games rated as Mature with violent physical force. Participants played either as a gangster in Game 1 or as a violent police officer in Game 2. Both games involved driving, shooting, fighting, and interactions with nonplayer characters (NPCs). In both games, players could use natural means (e.g., punch, kick) or weapons during violent interactions. Using two games rather than one was aimed to reduce the influence of a specific game. Eighteen of the 40 participants played Game 1, and 22 played Game 2.
Physical-aggressive personality was measured a week before participation using the physical aggression subscale in Buss and Perry’s Aggression Questionnaire.
Five dependent variables were used to measure the aggressiveness of participants’ game play: (a) frequency of PAT, (b) frequency of nonviolent interaction, (c) frequency of using natural means, (d) frequency of using firearm, and (e) percentage of two types of consequences: severe and mild. A PAT is an aggressive exchange that occurs between a perpetrator (P) engaging in a particular type of act (A) against a target (T).
The next step would be to examine whether aggressive game play actually mediate the effect of playing violent games. Will a violent game player later show more aggressive thoughts, affects and behaviors.
Limitations
A small sample size with undergraduates makes generalizability limited, the participants were mainly male, only 6 women participated. Aggressive thoughts, affects or behaviors after game playing weren’t measured. This would be of interest for the effect of violent game playing. Other factors such as playing against a human or a computer and playing on a 42 inch screen or a mobile phone screen can also influence game play.
Peng, W., Liu, M., Mou, Y. (2008). Do Aggressive People Play Violent Computer Games in a More Aggressive Way? Individual Difference and Idiosyncratic Game-Playing Experience. CyberPsychology & Behavior, 11(2), 157-161. DOI: 10.1089/cpb.2007.0026
Gadgets are nice, but are they worth all the trouble? Syncing, updating, charging, bloated software, to many features? Or should we go back to good old easy and fast notebooks of paper? Let me know in the comments.
Goodbye gadgets
After years spent tracking the latest gadget trends, handing over my credit card for a PDA upgrade every 4-6 months, and receiving odd glances in public for reading The Gawkish Geek’s Guide to Gadgets (monthly), I gave up my fancy gizmos and electronic organisers for good.
Hello Moleskine
In recognition of the intense effort it takes for a self-confessed gadget geek to drop his ‘habit’, I hope you won’t mind when I admit to replacing it with another: the love of Moleskine notebooks. These simple notebooks are both beautiful and relatively gentle on the wallet.
My Mind is Green Of all the mind types, yours has the most balance. You are able to see all sides to most problems and are a good problem solver. You need time to work out your thoughts, but you don’t get stuck in bad thinking patterns. You tend to spend a lot of time thinking about the future, philosophy, and relationships (both personal and intellectual).
This week here at Doc Gurley is the Grand Rounds Smack Down edition, where the best contenders of the health care blogosphere wrestle down and dirty with tough, scary topics. Just like being in the ring, there’s no orderly progression of characters here – this ain’t ballet, folks. At any moment, something huge and impressive could come flying out of left field and hit you (ka-pow!) right between the eyes! There’s no first, no last – we’re here to entertain (and take out a few bad guys while we’re at it). We’ve got a lot of contestants, oops, I mean, submissions, vaulting into the ring. One thing’s for sure – if you hang with it to the end of this week’s match, right up to the point when the lights dim in the arena, you’ll be entertained.
Genotyping the serotonin transporter gene polymorphism could be a tool for predicting response to a certain treatment pathway. Patients with the s/s genotype who according to the literature seem to be at risk for a less favorable response to antidepressant monotherapy might particularly benefit from augmentation strategies.
Thus, early lithium augmentation in these patients (with the s/s genotype) could be a promising strategy and might help to reduce the occurrence of treatment resistance in depressive disorders.
Serotonin is an important neurotransmitter believed to play an important role in depression. The variant of this gene affects how much serotonin transporter protein is produced. This protein is involved in reuptake of serotonin in the synaps. Individuals with the short allelic form of this variant showed an increased risk of depression compared to those carrying the long allele but only when exposed to adverse life events or maltreatment. There have been some nonreplications, but these have been outnumbered by the number of replicated findings.
Moreover having the two short alleles of this serotonin transporter gene (s/s) results in poorer response to an antidepressant. According to this new research two short alleles also predict a better response to lithium addition if the antidepressant fails.
Although the definition of treatment resistant depression is not always clear, there are several options for treatment resistant depression resulting in 9 possible steps for treatment resistant depression. I am convinced that especially lithium addition is a very effective treatment strategy if an antidepressant fails and should be preferred above more experimental addition strategies such as atypical antipsychotics. Lithium addition can result in a response rate up to 50% in treatment resistant depression and has been studied in many RCT’s, reviews and meta analysis.
In this published research patients had not responded to several antidepressants during an average of 32 days (SD 12.9):14 patients (30%) received tricyclic antidepressants, 15 patients (30%) SSRI, 15 patients (30%) venlafaxine, two patients (4%) atypical antidepressants (trazodone, nefazodone), one patient (2%) mirtazapine, another patient (2%) tranylcypromine and two patients (4%) antidepressant combination therapies (trimipramine plus paroxetine; amitriptyline plus tranylcypromine).
That brings us immediately to the limitations of this study. The heterogeneity of the preceding antidepressant treatment and the short duration of antidepressant pretreatment. This short duration might not be sufficient to declare nonresponse to an antidepressive trial.
So next time a more homogenous patient sample with evident and clear definition of treatment resistant depression.
Results In the Cox regression survival analysis, three factors remained as contributors to remission during the observation period: the 5-HTTLPR genotype, the diagnosis of a unipolar/bipolar depression and the existence of psychotic features, but only the 5-HTTLPR genotype reached statistical significance.
The gene coding for the serotonin transporter (5-HTT) has been located on chromosome 17q11.2. A polymorphic region (5-HTTLPR) has been identified upstream of the transcription starting point. It generally consists of either 14 or 16 repeated elements generating a long (l) or a short (s) allele. The s-allele is associated with lower gene expression activity in vitro. This genotype has been connected with the pathogenesis of affective disorders and suicidal behaviour and might be an interesting model for a genotype–environment relationship.
Besides these finding on the serotonin transporter gene,patients with a TRD had a larger number of risk genotypes than treatment responders, who in turn had a greater number of risk genotypes than the healthy controls. This finding supports a model in which the additive small effects of multile risk genes explain depression and treatment resistance
Stamm, T.J. (2008). Serotonin transporter gene and response to lithium augmentation in depression. Psychiatric Genetics, 18(2), 92-97.
In this edition of our newsletter we bring a few articles and recent news pieces that shed light on what “Use It or Lose It” means, and why we can start going beyond that to say “Use It and Improve It.”
When other treatments fail, deep-brain stimulation (DBS) may offer hope to patients suffering from chronic and severe depression, according to a study presented here at the 76th Annual Meeting of the American Association of Neurological Surgeons (AANS).
