Monday, July 15, 2019

Comments by pdesilva

Showing 16 of 16 comments.

  • I have some difficulty, but very minor compared to the overall job as an Old Age Psychiatrist. You are guided by ‘Primum non Nochare’ (firstly no harm); the last bit of the Hippocratic Oath, and sticking rigidly to the evidence base re treatments. I am a Cochrane collaborator, and use their library of systematic reviews a lot, when discussing options with patients and their carers.

  • Hi Fiachra, the link between untreated schizophrenia and Early or First Onset Psychosis and Diabetes is genuinely interesting, sorry it contradicts your world view.

    It was spotted initially by Kooy in 1014 (Brain), replicated by Mukherjee in 1989 (Lancet), further replicated by King in 2017 (Journal of Clinical Psychiatry). We suggested the common cause might be inefficient or low numbers of Glucose Transporters (GLUT) 1 & 3 in the brain. Lieberman and colleagues (our competition) suggests that the common problem might be intercellular signalling (an equally reasonable explanation). Tempting to think treatment might involve oral hypoglycaemic agents for both at an early stage Metformin has been ineffective, but of course, it does not have hypoglycaemic effects. As far as I know, the joint psychosis / hyperglycaemia cases haven’t been linked with longer CAG repeats.

  • On Schizophrenia, how do you explain the X 5 higher rate of Diabetes in first onset / drug naïve people with schizophrenia? Also note higher rate of Diabetes among first degree relatives. Both Diabetes (sp. Type 1) and Schizophrenia also have higher numbers of CAG repeats.
    Shola

  • in the UK, we recommend Aripiprazole (5-10mg daily) as a means of coming off other antipsychotics, in order to beat the Dopamine receptor hypersensitivity problem (recently highlighted by Robin Murray in the Schizophrenia Bulletin (Mistakes I have made in my research career).

  • Would the NHS look at successful alternatives – Yes, if there is sufficiently good evidence as determined by NICE.
    NHS drop the illness of schizophrenia/ Possibly if methods like open Dialogue is successful at the ongoing multicentre trial 9again via NICE)

    By the way, there is no such thing called schizophrenia, there appears to be at least ‘schizophreniform’ subtypes based on pathophysiology. More public knowledge about these will increase the effort by ordinary people to use non drug methods. Also a prize for the best effort will help.

  • As a busy clinician in a very deprived area of North East England, I am daily made aware of easy it is to control psychiatry as a specialty, by various means including arbitrarily cutting funding, blackmailing us with potential ‘risk’ if we don’t do things like detaining people or prescribing ECT.

  • Hi both, I guess I am a Critical Psychiatrist, very much a practicing clinician in the North of England. In Geordie land, we don’t have abstract discussions on topics such as central government cutbacks, stigma, new tech. Paranoid is not a technical term, more in keeping with public stigma.
    Shola

  • Dear Scintilla and Fiachra, would it be wise to ‘bury the hatchet’ at this stage and allow all of us to continue a very important debate as to how, as psychiatrists, we can learn outside the box to prepare ourselves for the 21st century with all the attendant issues of minimal state funding for mental health, increasing public use of new tech for monitoring and treating mental health symptoms, lack of spiritual values (compassion, mercy, repentance) in the mental health field?
    Kind regards to you both.
    Shola

  • Thanks Eric for touching on the usually unspoken of issue; waste in psychiatric practice.
    Recently the COBRA study (RCT involving 3 centres, 200 patients in each arm) found out that Behavioural Activation performed as well as face to face CBT in moderate depression, as well as being at least 30% cheaper, due to the cost of therapist time, less training costs. Furthermore, Community Treatment Orders didn’t show any cost reductions regarding readmissions, medication utilisation in another RCT (OCTET).
    Furthermore, we are aware that the effect size of CBT is dropping, despite improvement of therapist fidelity with the CBT process. So, the better the therapists get, the worse the outcome!. To be fair, this is exactly what was seen on effect sizes with SSRI’s, Atypical and now Clozapine. There is also the costs of DNA’s, drop outs, sickness absence of staff, duplication of IT systems (leading to snail mail) and justifiable complaints leading to financial compensation.

    Similar to you, I am also ‘going solo’ or ‘off grid’ and publishing independently. I think Critical Psychiatry needs to get more mainstream, involving grater recognition by the general public and generalist doctors (including primary care physicians, medical students). We need to promote true resilience, wellbeing and dare I say it, more spirituality about life involving repentance, mercy and looking out for others independent of monetary gain. Churchiology has failed to grasp this nettle, and subsequently become irrelevant in people’s eyes including people who are ‘poor in spirit’ (Jesus’s sermon on the mount)

  • I find attending other people’s conferences much more interesting, as I get to ask stupid questions, then to find out the big experts don’t have a clue (for example pathogenesis of epilepsy, how the ketogenic diet works).

    On how to expose the cracks, I have got an idea. I have been, over the last 2 years, a specialist advisor to the Care Quality Commission (CQC) in England, took part in 23/56 full inspections of the mental health organisations. The CQC has just published its findings. The key concerns were inadequate joined up care with primary and acute services, poor physical health care of psychiatric patients and polypharmacy in managing challenging behaviour by Learning Disability and Old Age sub-specialities, typically involving off-label prescribing of anti-psychotic and anti-epileptic drugs. The CQC also commented on the lack of shared decision making (‘co-production’) between patients, carers and clinicians on treatment and risks management. Perhaps this lack of co-production is consistent with increasing numbers of detentions under the Mental Health Act in England over the last 5 years.

  • Also, the more basic question (forwarded by eugenicists and social Darwinists); can you assume that smaller brains or part of brains imply less competent social, occupational and spiritual competency?

    Current neuroscience understanding is that the more important bit is interneuron connectivity, especially between distant regions of the brain, both frontal to more posterior (sp. occipital, cerebellar) and inter hemispheric. This is not directly connected with volume, and is more associated with white matter integrity (which is why serious imaging researchers are concentrating on DTI imaging in psychiatric conditions).

    I think comparing brain volume is a bit like what we (as naughty boys in the wee room) did in nursery and primary school. At least when we moved to year 2, compared how far the wee went, a much better measure of function, but equally questionable without looking at long term outcome in terms of prostatic enlargement in late life. Sorry to bring the tone of this discussion down to my usual (Geordie) standards, but it is so very silly.
    Shola

  • Hi all, my immediate impression having looked at the methodology, subject selection and stats is a very unprofessional ‘usual Lancet rubbish’. I must disclose that I have fallen out with both editors of the Lancet and BMJ about overdramatising findings to gain readership and maintain their high impact factors, as exemplified by the MMR (Lancet) and Statin (BMJ) stories. I did suggest to the 2 that next time I would complain to the Press Complaints Commission. They also got upset with me as I suggested that critical analysis of their papers was better in the Daily Mail (whose health editor is very good). I would stick to the Nature journals, and NEJM.

    On the study specifics, this was a brave attempt to get big numbers, but with all the attendant problems of an international multicentre study, which have been described in before (I was involved in the Intercept study on the suicide protection potential of Clozapine in psychosis). A snapshot process of subjects of a large variety of ages, will come up with overlap between subject / control findings, all very predictable. I think they were hoping to get separation in basal ganglia areas but couldn’t, so focussed on the hippocampal / amygdala changes instead. They forgot to mention that the Hippocampus and Amygdala are the most plastic of brain organs, readily reducing in volume in response to persistent high stress and Hypercortisolaemia (caused by all kinds of conditions, both physical and mental adversity, including mixed abuse by elders).

    The IQ difference between subjects and controls is interesting, I am sure the authors are regretting not controlling for this in their initial subject selection, as it totally moves the focus to this statistically more robust finding. I was pleased to find that ADHD drugs did not seem to make a blind bit of difference, and is used simply for sedation and school room control, and might explain hippocampal / amygdala loss due to these children struggling to use their preferred way of learning, and getting stigmatised by teachers and peers. School would be a horrible experience for them (need a good naturalistic study on this I think).

    Finally the authors provide their own criticism; the need to concentrate on longitudinal structural imaging to look at brain maturation in these different conditions. This is best done at a single centre, and needs much smaller, but carefully selected group of subjects and controls. However, there are ethical issues involved in annual MRI screening, including confounding study results. This is being done by NIH in early onset psychosis.

    Ethically, my fear is how politicians and the general public would interpret the finding of ‘smaller brains in ADHD’ This has the (sickly) smell of Eugenics and Social Darwinism, with the potential to reduce reasonable adjustments to help these children learn in their preferred way. Also, when selecting for apprentice schemes and jobs, could a diagnosis of ADHD based on MRI scans limit success in employment, limit driving licences being given? What happened in Germany in the late 1920’s (A life not worth of life) is not that long ago.
    Shola

  • On the Lancet study (Subcortical Volume Differences in ADHD, Hoogman et.al, Pub 15.2.17)
    Hi all, my immediate impression having looked at the methodology, subject selection and stats is a very unprofessional ‘usual Lancet rubbish’. I must disclose that I have fallen out with both editors of the Lancet and BMJ about overdramatising findings to gain readership and maintain their high impact factors, as exemplified by the MMR (Lancet) and Statin (BMJ) stories. I did suggest to the 2 that next time I would complain to the Press Complaints Commission. They also got upset with me as I suggested that critical analysis of their papers was better in the Daily Mail (whose health editor is very good). I would stick to the Nature journals, and NEJM.

    On the study specifics, this was a brave attempt to get big numbers, but with all the attendant problems of an international multicentre study, which have been described in before (I was involved in the Intercept study on the suicide protection potential of Clozapine in psychosis). A snapshot process of subjects of a large variety of ages, will come up with overlap between subject / control findings, all very predictable. I think they were hoping to get separation in basal ganglia areas but couldn’t, so focussed on the hippocampal / amygdala changes instead. They forgot to mention that the Hippocampus and Amygdala are the most plastic of brain organs, readily reducing in volume in response to persistent high stress and Hypercortisolaemia (caused by all kinds of conditions, both physical and mental adversity, including mixed abuse by elders).

    The IQ difference between subjects and controls is interesting, I am sure the authors are regretting not controlling for this in their initial subject selection, as it totally moves the focus to this statistically more robust finding. I was pleased to find that ADHD drugs did not seem to make a blind bit of difference, and is used simply for sedation and school room control, and might explain hippocampal / amygdala loss due to these children struggling to use their preferred way of learning, and getting stigmatised by teachers and peers. School would be a horrible experience for them (need a good naturalistic study on this I think).

    Finally the authors provide their own criticism; the need to concentrate on longitudinal structural imaging to look at brain maturation in these different conditions. This is best done at a single centre, and needs much smaller, but carefully selected group of subjects and controls. However, there are ethical issues involved in annual MRI screening, including confounding study results. This is being done by NIH in early onset psychosis.

    Ethically, my fear is how politicians and the general public would interpret the finding of ‘smaller brains in ADHD’ This has the (sickly) smell of Eugenics and Social Darwinism, with the potential to reduce reasonable adjustments to help these children learn in their preferred way. Also, when selecting for apprentice schemes and jobs, could a diagnosis of ADHD based on MRI scans limit success in employment, limit driving licences being given? What happened in Germany in the late 1920’s (A life not worth of life) is not that long ago.
    Shola