Tuesday, November 12, 2019

Comments by InfiniteJest

Showing 8 of 8 comments.

  • Hi Saul,
    You seem to “blame” the victim for experiencing rumination by thinking without deciding. My understanding of rumination, both from published scientific journals and personal experience, is as follows:
    Ruminative responding in major depressive disorder (MDD) is defined as a recurrent,
    self-reflective, and uncontrollable focus on depressed mood and its causes and consequences (1-3). Higher levels of rumination have been found to predict both more severe depressive
    symptoms in depressed individuals (4) and the onset of depressive symptomatology in nondepressed people (5). Although ruminative responding is not considered a criterion symptom of depression in DSM-5 or ICD-10, measures of rumination nonetheless consistently (and often, perfectly, e.g., 6) differentiate depressed from never-depressed individuals. Indeed, theorists have posited that rumination is a central aspect of the phenomenology of MDD (7).
    If you wish to review the cited references, and I encourage you to do so, they are:
    References
    1. Morrow J, Nolen‐Hoeksema S (1990): Effects of responses to depression on the
    remediation of depressive affect. Journal of Personality and Social Psychology. 58:519‐527.
    2. Nolenhoeksema S (1991): RESPONSES TO DEPRESSION AND THEIR EFFECTS ON
    THE DURATION OF DEPRESSIVE EPISODES. Journal of Abnormal Psychology. 100:569‐582.
    3. Whitmer AJ, Gotlib IH (in press): An Attentional Scope Model of Rumination.
    Psychological Bulletin.
    4. Kuehner C, Weber I (1999): Responses to depression in unipolar depressed
    patients: an investigation of Nolen‐Hoeksema’s response styles theory. Psychological
    Medicine. 29:1323‐1333.
    5. Nolen‐Hoeksema S, Wisco BE, Lyubomirsky S (2008): Rethinking Rumination.
    Perspectives on Psychological Science. 3:400‐424.
    6. Hamilton JP, Furman DJ, Chang C, Thomason ME, Dennis E, Gotlib IH (2011):
    Default‐mode and task‐positive network activity in Major Depressive Disorder:
    Implications for adaptive and maladaptive rumination. Biological Psychiatry. 70:327‐733.
    7. Lyubomirsky S, Tucker KL, Caldwell ND, Berg K (1999): Why ruminators are poor
    problem solvers: Clues from the phenomenology of dysphoric rumination. Journal of
    Personality and Social Psychology. 77:1041‐1060.

    Turning now to your “SNAP CLUB” game, am I correct in understanding the rules as:
    SNAP CLUB
    1. Do anything you want, any time you want.
    2. When you decide to do something, at the moment when you decide, SNAP YOUR FINGERS.

    As you may be aware, anhedonia is recognized as a hallmark symptom of depression. Anhedonia, the inability to experience pleasure, is included as a primary symptom in the diagnostic criteria for clinical depression in both the Diagnostic and Statistical Manual of Mental Disorders -Fourth Edition (DSM-IV; American Psychiatric Association, 2000) and the International Statistical Classification of Diseases and Related Health Problems (World Health Organization, 1992).
    Along with other symptoms used to clinically diagnose Major Depressive Disorder, are lack of interest, lack of enthusiasm, reduced attention span, reduced concentration, loss of energy, and excessive fatigue.
    While some people experiencing depressed mood may benefit from games and other diversionary activities, patients with Major Depressive Disorder or refractory depressive disorder may likely find the first rule overwhelming and implausible. Of course, I am referring to patients who suffer from severely treatment-resistant depressive disorder, as determined by one or more accepted assessment tools, i.e. the Antidepressant Treatment History Form (ATHF), the Thase and Rush Staging Model (TRSM), the European Staging Model (ESM), the Massachusetts General Hospital Staging Model (MGH-s), or the Maudsley Staging Model (MSM).
    If you doubt that treatment-resistant depression is somehow different from feeling depressed, I recommend you read some research on the subject. May I suggest:
    Treatment-resistant Depression: A Separate Disorder, Hans-Jürgen Möller, Florian Seemüller, Rebecca Schennach and Ramesh K. Gupta (2013), also Definitions and Predictors of Treatment-Resistant Depression, Daniel Souery and William Pitchot (2013).
    Lastly, you might find it informative to review:
    Toxic Effects of Depression on Brain Function: Impairment of Delayed Recall and the Cumulative Length of Depressive Disorder in a Large Sample of Depressed Outpatients, P. Gorwood, et al, Am J. Psych. 2008; 165:731-739. This article has been widely cited for its finding, gathered from over 8,000 patients, that “There is a current tendency to demean the
    significance of depressive symptoms as evidence of distress rather than illness. We would not seek to dispute the distress, but our data support the hypothesis that recurrent or prolonged depression has effects on the brain that make it a significant and disabling illness.”
    Also, “Atrophy of the hippocampus is one of the most consistent imaging findings in major depressive disorder. This has highlighted the potential role of physiological stress as a core mediating factor (often assuming a neurotoxic effect of cortisol on the hippocampus) and has
    emphasized the need for antidepressant treatments that might prevent or even reverse hippocampal atrophy.

  • Saul,
    Your game may be of help to some people who are experiencing a depressed mood. However, the individuals that qualify for experimental intra-cerebral neurosurgery in efforts to treat their refractory depressive disorder are suffering something altogether different.
    Severely refractory major depressive disorder, sometimes referred to as malignant or insidious depression, is not easily or effectively treated by playing a game.
    It is a progressive, neurodegenerative disease that causes increasing cognitive dysfunction, impaired memory and executive functioning, and these impairments not only persist if the depressive episode remits but these cognitive deficits persist and accrue with subsequent depressive episodes.
    These toxic effects of major depressive disorder can be observed in the reduced volume of the hippocampus, reduced volumes of cortical grey matter, and a number of other gray matter abnormalities that progressively worsen with each subsequent episode.
    If you have scientific evidence that demonstrates how your simple game can effectively treat these gravely suffering patients and halt or reverse the damage to their brains and cognitive functioning, that would be wonderful. So far, my brief search for such evidence did not produce any such results.

  • James,
    I can identify with your frustration. There’s little doubt that medical advances for treatment of mental illness have a very long way to go and have not progressed anywhere near what the public believes.
    However, from reading your posts one gets the impression that you are functioning fairly well. Maybe not where you want to be but you are able to get out, meet with other writers, and more. In patients enrolled for DBS for severely refractory major depressive disorder, such functioning was not possible. The patients viewed DBS as their last chance to get out from under the crushing weight of depression, even if it meant allowing someone to drill into their skull and experiment directly on their brain.
    I say this, not to glorify those who were DBS Guinea pigs, but rather to encourage you to locate the most qualified and most experienced psychiatrist that has proven expertise in working with patients with your diagnoses.
    Perhaps this sounds trite and dismissive. I assure you it is not. It is my sincere recommendation, based on 30+ years of wrangling with serious depressive disorder. Cultivating a mutually respectful Doctor-patient relationship with the right psychiatrist can be the most successful treatment possible.
    I don’t care if they aren’t covered by your insurance. If you really want to get better, start prioritizing where you spend your money. Also, be willing to travel to see them. It may be necessary to find the experienced pdoc you need.
    The biggest mistake you can make is thinking that you know what treatment is best for you and then trying to find a doctor who will prescribe it. You will soon find that doctors view such patients as noncompliant and undesirable. Basically you alienate the person you are paying to help you! Not a recipe for success.
    If you are truly suffering, not merely wanting to feel better than you do, do yourself a favor and locate a true ally in you battle. Don’t try to go it alone.
    I truly hope you find what you’re looking for.

  • Herb,
    Thank you for sharing your experience with VNS. I don’t doubt that treatments like VNS and DBS may be effective in some patients. And for those fortunate patients, the treatment can be a lifesaver.
    The problem is when the percent of “successful” outcomes is low, e.g. <20%, and the costs and risks of the treatment are considerable, how does one decide? And should insurance be required to cover the treatments?
    You mentioned a study site with a 50% response rate. That sounds great. But numbers can be deceiving. How many subjects were in the study? Was it a randomized double-blind trial? If is was, and if the number of subjects was significant then the sponsors should carefully evaluate what was done differently. In a clinical trial there shouldn't be opportunities for different sites to vary the study protocols. And sometimes there are data outliers. That's the nature of a study.
    I'm glad that VNS has been beneficial for some and believe similarly that some benefit from DBS. However, data from open label trials is notably unreliable, as the placebo effect can be quite amazing. The field of hospice is loaded with cases of placebo effect achieving what medicine could not. I don't believe that every successful treatment is due to placebo effect, however it is a powerful influence that is hard to separate from an open label study. Perhaps these recent, large scale failed clinical trials of DBS for refratory depression will afford valuable lessons in study design and improved standards for patient rights and treatment.

  • (vnstherapy) Herb, I’m glad you commented on the importance of a treatment’s benefit — even if that benefit is to a minority of study subjects. VNS went through a convoluted path to FDA approval, with the FDA even going against its own report recommendation.
    When a treatment provides benefit to a small percentage of subjects, it often signifies an inadequate understanding of the condition, the treatment, or both.
    DBS seems to be far more effective in open-label case studies. When subjected to the rigors of double-blinded study, the response rates were not significantly different that sham stimulation.
    Please note that the ~17-18% response rate is just that… a “response.” “Response” to a treatment describes an acute effect, rather than a continuous state. It is also important to note that a “response” does not equate to a patient achieving “remission” or “recovery” or “normalcy.”

  • The author is to be commended for capturing the extreme futility, despair and hopelessness that brings these severely depressed patients to try this treatment of last resort. If asked, most patients would tell you that without the hope for success of the DBS treatment, they were facing death.
    It is easy to see how such patients are enticed into being human lab rats for unproven experimentation. There exists a compelling need for greater protections of such patients, as multi-billion dollar corporations are quick to slough off these patients’ needs, all in the name of improving stock value and shareholder profits. Meanwhile, very real people, these patients are left to endure and pay for the lasting adverse effects they received during the study.
    The author writes with a depth of insight that evidences extensive research and thorough interviewing of subjects. The intertwining of the story’ various threads is captivating. I hope that she may consider following up with a companion piece in the future and I look forward to reading more articles by her. Kudos!

  • Seems odd, doesn’t it? Although, to be accurate, it should be noted that increasing numbers of clinical trials are investigating psilocybin, LSD, ketamine, MDMA and other “mind-altering” substances for efficacy in treating a variety of mental illnesses, including major depression.

    As for “patent” issues, you would be surprised at what can be done to protect and monetize specific formulations or treatment methods.

  • It seems you are very comfortable imposing your views on others with respect to how they wish to live or die. As more and more medical professionals and others see fit to apply reason and respect for suffering patients, it is becoming more and more accepted that competent adults should not be deprived of assistance in dying where the individual clearly consents and suffers from an intolerable and irremediable medical condition. Whether the cause of their suffering is physical or mental is of no significance.
    To assert that someone does not have the right to die because you think that their condition (neuro-progressive depression, bipolar disorder, or schizophrenia, etc.) do not qualify as diseases in your view, is to parse words and demean the suffering of a significant portion of the population.
    It appears most evident that you have not suffered or been close to someone who suffers from the worst stages of these conditions, or perhaps there would be more empathy.
    Medical science is far from perfect. Yet in the absence of effective treatments, patients will try anything for relief. Even death.