Day 690

“Everything starts and ends in your Brain-Soul connection.
How your brain and soul work together determines how happy you feel, how successful you become, and how well you connect with others. The brain-soul connection is vastly more powerful than your conscious will. Will power falters when the physical functioning of the brain and the health of your soul fail to support your desires, as seen by illogical behaviours like overeating, smoking, drug and alcohol abuse, and compulsive spending.

It is the aim of The Amen Clinics to provide instructional programs and materials, evaluations and medical treatment where necessary to help you to understand and direct your mind to enhance your relationships, your work, and your health!”

Dr Daniel Amen is a psychiatrist in America who is a strong proponent of SPECT (Single Photon Emission Computerised Tomography) imaging of the brain. It bothers him that psychiatrists are the only medical specialists that never look at the organ they treat. Cardiologists, orthopaedic surgeons, neurologists look, whereas psychiatrists guess. As a result of which diagnoses are still made in the same way they were in the 1840s, based on symptom clusters. It’s like shooting in the dark especially when most psychiatric medications come with black box warnings that they might make the situation worse.

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Simply put, the images tell us 3 things about the brain – areas of good activity, too much and too little activity. In his TED talk he shows some very convincing pictures of brains ‘before’ and ‘after’ interventions. He also shows scans of 2 patients with clinical depression but very different scans, one showing gross under-activity and the other significant over-activity.

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He expresses great concern about the homeless people, criminals and soldiers returning from war zones who are not getting appropriate care as no one is looking at their brains and tailoring the care of their mental state.

He claims to have helped many people over the years using this technology but his work has been much criticised, firstly for not having enough evidence in its favour and secondly for the potentially harmful effect of the radio-nucleotide dye that needs to be injected in every patient. He has also amassed a great amount of wealth doing this work that insurers will not pay for. This  fact further discredits him within the medical community.

Would I have paid 3500 dollars for Saagar’s first assessment and scans at one of ‘The Amen Clinics’? Probably not. But it would have been good to have a more scientific approach to the diagnosis and management of his illness. It was like throwing darts in the dark. 

 

 

Day 678

Depression is a disease not just of the brain but of the whole body. This revolutionary idea has been researched for more than 20 years and some definitive answers are starting to emerge.

Normally our immune system is our friend and protector. It recognizes foreign bugs and injury and mounts an inflammatory response in order to preserve us. However, sometimes it misreads signals and attacks it’s own tissues. In this case, the NMDA receptors which play a key role in brain function.

Prof Ed Bullmore, Head of Psychiatry at University of Cambridge says, “Depression and inflammation often go hand in hand, if you have flu, the immune system reacts to that, you become inflamed and very often people find that their mood changes too.”

There is now a fair body of evidence to suggest that depression is not just associated with inflammation but could be caused by it.

A senior Rheumatologist draws a parallel between a well-established auto-immune disease, Rheumatoid Arthritis and Depression. He comments, “We scanned the brains of people with rheumatoid arthritis, we then gave them a very specific immune targeted therapy and then we imaged them again afterwards. What we are starting to see when we give anti-inflammatory medicines is quite remarkable changes in the neuro-chemical circuitry in the brain. The brain pathways involved in mediating depression were favourably changed in people who were given immune interventions.”

This innovation could mean that some day soon we will be able to order a blood test to help with the diagnosis of depression and offer appropriate treatment. The use of the phrase ‘pull yourself together’ will not be used as often as it is today.

Ref: http://www.bbc.co.uk/news/health-37166293

Day 657

When someone becomes depressed, many of their activities function as avoidance and escape from aversive thoughts, feelings or situations. Depression therefore occurs when a person develops a narrow range of passive behaviours. As a result, someone with depression engages less frequently in pleasant or satisfying activities and obtains less positive reinforcement than someone without depression.

40 years ago the first behavioural treatment for depression was described by Lewinsohn et al. Many successful trials were done which somehow got forgotten with the advent on CBT in the 1980s.

Behavioural Activation (BA) focuses on activity scheduling to encourage patients to approach activities that they are avoiding. It focuses on encouraging people to take part in meaningful activities that are linked to their core values. It helps people find out which activities make them feel better. Patients are also taught how to analyse the unintended consequences of their ways of responding, including inactivity and rumination.

A recent paper published in the Lancet by Richards et al at University of Exeter studied 440 people with depression. They were randomised into 2 groups – one received BA and the other received CBT. They found that BA, a simpler psychological treatment than CBT, can be delivered by junior mental health workers with less intensive and costly training, with no lesser effect than CBT. Hence, effective psychological therapy for depression can be delivered without the need for costly and highly trained professionals.

Professor David Richards says:

“Effectively treating depression at low cost is a global priority.
Our finding is the most robust evidence yet that Behavioural Activation is just as effective as CBT, meaning an effective workforce could be trained much more easily and cheaply without any compromise on the high level of quality.
This is an exciting prospect for reducing waiting times and improving access to high-quality depression therapy worldwide, and offers hope for countries who are currently struggling with the impact of depression on the health of their peoples and economies.”

UK is one of those countries.

Day 655

When I first came to the UK, a couple of myths in my mind about this country were busted within the first week.

  1. Education is free, so everyone must be literate and educated.
  2. The government looks after people who are unable to work, so everyone must be happy.

I was puzzled by the fact that at least 1 in 3 patients I saw before an operation were on regular antidepressants. Some patients took St John’s Wort. I had never heard of that before. Some didn’t admit to having any problems with their health but on a closer look at their notes, were taking antidepressants.

Over the last 10 years, the use of antidepressants has doubled in the UK. Some science tells us that these drugs have a history of proven efficacy and some other science tells us that the benefits are marginal and short term. Occasionally the effects are very harmful. One such effect is ‘Akathisia’, defined as a movement disorder characterised by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting. People with akathisia are unable to sit or keep still, complain of restlessness, fidget, rock from foot to foot, and pace.

The Pill That Steals Lives’ is a book written by documentary maker Katinka Blackford Newman. It is one woman’s terrifying journey to discover the truth about antidepressants.

In it she talks about one year of hell that she lived through after being started on Escitalopram(Lexapro). She describes the thoughts of violent acts that crept into her mind while on that drug. She got full blown delusions about having killed her two young children. She had to be hospitalised and was put on multiple medications that made her loose the ability to look after herself or her children.

More than 10 years ago America’s National Institute of Mental Health set out to measure the effectiveness of antidepressants. They found that only 26%of patients responded positively to these meds and at the end of one year only 6% were well. Conclusion: ‘the findings revealed remarkably low response and remission rates’.

Saagar was started on Citalopram (a drug used for unipolar depression and unsuitable for young people) 4 weeks before his death. The dose was doubled from 10 to 20 milligrams per day, 2 days before his death. The riskiest time is when they are started, when they are stopped and when the dose is changed. How much did these medicines contribute to his death? We will never know.

Day 581

After more than a year of Saagar’s death I could see that nothing at all had changed. Nothing was going to change. There is no power behind a Coroner’s inquest report, no legal, professional or financial implications for anyone concerned. Hence no lessons learnt.

I approached the GMC for help with the view that may be they will see things as they are and have more power to influence change but this is the letter I received from them today:

“In January 2016 documents regarding Saagar’s care were referred to a GMC Medical Case Examiner for review. I can confirm that the Case Examiner was specifically dealing with Dr GP and any issues surrounding his fitness to practise when they reviewed the documents. A decision was made by the Case Examiner that there was nothing contained within the documents which would call into question Dr GP’s fitness to practise and that as such the case should be closed with no further action.”

  1. Really? Is this protectionism or is it a reflection of a deeper level of ignorance within the medical community than I thought?
  2. Am I the one who’s crazy? Imagining things? Over-reacting? Making false judgements just because I am grieving?
  3. The job at hand is clearly much harder than I thought it might be. I can teach children to ask for help. I can teach parents and teachers to identify signs of crisis and get professional help for them. They can take them to the GP. And then what?

The GP may ask them to fill out a PHQ-9 questionnaire. They may score 27/27. The GP might not discuss that with the parents. Not get anyone’s advise on the phone. Not refer them to a mental health specialist. They may send them home with a medicine that might worsen their suicidal ideation. They may also reassure them that they will get better.

That is like sending someone with terminal cancer home with the assurance that they will get better. That however would be unacceptable because cancer is a physical illness.

Severe depression can be invisible to the untrained eye. So, it’s ok for GPs to send young men with the greatest degree of depression home. Unquestionably.

‘Parity of esteem’ is a joke.

 

Day 565

What people do may be a better marker of depression than how people say they are feeling. Behavior can be objectively measured using mobile phones. It is an active sensing and prediction platform to identify behavior changes when individuals suffer from common colds, influenza, fever, stress and depression.

Studies have found a strong relationship between location (using GPS) and clinical PHQ-9 scores. The daily pattern, variability and extent of communications can also be analysed to give valuable clues to changing trends in activity. It is possible to monitor depression passively using phone sensor data. This has significant public health implications. Most people are unwilling to answer questions repeatedly over long periods of time, while passive monitoring could improve the management of depression in populations, allowing at risk patients to be treated more quickly as symptoms emerge or monitoring patients’ responses during treatment.

The efficacy of smartphone sensors and self reporting for mental health care has not been proven yet and remains a very important research question in the pervasive health community.

2 billion people already carry their smartphone with them most of the time. Even the cheaper models have sensors that can track movement and activity, generating data to provide insights into our wellbeing.

StayClose is a free family care app, powered by Touchkin’s predictive care platform. The app helps families care for loved ones while being afar by enabling them to know how they are, without having to ask. They can also share a touch or video moment, or do something to help, like send a ride to take them to the doctor.

For example, when a person is depressed, their phone is likely to show more time spent at home, unusually low activity, changes in communication or sleep patterns. It is possible for a machine learning engine to learn anyone’s phone’s normal sensor patterns and generate alerts if unusual activity indicates any health issues.

I look forward to collaborating with Touchkin for a few pilot studies in London.

 

 

 

 

Day 532

Cardiac arrest, stroke, seizures, a blood clot in the lungs, pneumonia – these are examples of modes of death. The root cause of all these symptoms could be cancer. But when we speak of these deaths, we acknowledge that these patients died of cancer, whatever the modality.

The root cause of at least 70% of suicides is depression. Yet, we say they died of ‘suicide’ as though they had a choice in the matter. In fact, they did not choose to have depression just like patients who die of cancer do not choose to have cancer.  Suicide is only a symptom of the underlying illness, which Is often a deep depression. So, in effect they died of depression.

Depression is a much misunderstood condition as it is far more complex than general sadness. It is a devastating illness that robs people of their focus, restorative sleep, memory, sex drive, ability to work, play and love. So much so that it can cause them to loose their will to live. It is scientifically proven that depression activates the pain circuits in the nervous system causing immense torment and agony.

It is a global epidemic and the incidence is increasing with every generation.

The use of antidepressants has gone up by 300% in the USA over the last 20 years. These drugs may contrarily worsen suicidal ideation in the young. Psychiatric pharmacology is still a very poorly understood blunt instrument. Yet, it is easier for doctors to prescribe pills rather than invest time and effort in people to make them feel better. As a result more and more misunderstood drugs are being dished out for a misunderstood condition and people are dying as a result.

Robin Williams died of depression.
Saagar died of depression.