Welcome!

Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.


Tuesday, April 26, 2016

Building A Website-The Template

I've been blogging for a little over three years now, which is hard to believe. I feel like I'm about average on the tech-y scale, and I certainly feel like a web presence is an important thing for any business to have. But I'm just starting to consider setting up a website for my private practice.

The main reason I've delayed this long is that since I don't use email to communicate with patients due to privacy/confidentiality and delay-in-treatment concerns, there didn't seem to be a point to a website where the contact information consists of a phone number.

Also, I knew I'd want an attractive, professional-looking site, but I didn't want to pay a lot of money to a designer for a site, the function of which is to get people to call me. There are some nice mixes of low and high tech, like a wooden iPhone case, or 3D printing a yarn winder, but a website with a phone number didn't seem to qualify as such a mix.

I finally decided to cave when I was researching my Analytic Evidence post, and I checked out the website of John Thor Cornelius, whose YouTube presentation I referenced in the post. I'm not sure how he'd feel about my linking to his site, which is why I haven't done so.

It's a thoughtful site, not glitzy, not overwhelming, but with all the information prospective and current patients might need about his practice, in addition to the ability to pay bills via PayPal, and I thought, yeah, this can be done well.

There are companies out there that design websites just for doctors, but they're expensive, and I don't need or want all the EMR integration stuff. So I've pretty much decided that, at least initially, I'll design my own site, for free, or for as little money as possible, and then see how it goes.

A few things I need to figure out before creating my site:

I need to decide what information to include on it. I'll need a decent headshot, contact info with a map feature, and a brief paragraph describing myself and my practice philosophy, which means I need to figure out what my practice philosophy is. I'm pretty sure I have one, I've just never articulated it. And I need to articulate it in a way that feels confident and inviting, but not exhibitionistic.

I need to decide how much information to provide about myself. Is a CV a good idea? Will that much information interfere with therapy?

I need some kind of description of what patients can expect from treatment.

I need to include my practice policies, which I already have written up. And I want to include the Surprise Act forms indicating that I don't accept insurance, and what my fees are, because that way I don't need to hand the stupid forms to my patients.

And I'd like patients to be able to pay through the site, but I need to understand how that impacts privacy.

I also need to pick a free or cheap website builder. I did several online searches including "build your own website free", "website builder for physicians,", and "best website builder for doctors". After googling around, I found a few I want to look into:

Weebly
Wix
Sitebuilder
Duda
Squarespace
GoDaddy
Web.com

Web.com seems to have the highest rating when I looked up reviews, but my first concern was the template. Specifically, I wanted to find a template that looks like it's professional for a doctor, not professional for a lawyer, or a restaurant, or a dog-walker. My theory is that if such a template exists, then the company has probably had a number of doctors design sites through it, which feels like a "safer" bet to me. I don't want my site to look amateurish, but I also don't want it to look like I'm a graphic designer or the APA.

Note that contrary to my inclination, I'm not including images because I assume these sites are pretty proprietary with their stuff. Or maybe I'm wrong and they want the advertising.

Sitebuilder has a template category specifically for professional services, and it includes a physician page which is a little slick for my taste, but usable. What I didn't like about it was that it was the only site for which I had to register before I was allowed to see the available templates.

Weebly's closest business theme was for a law firm, and the next closest theme was a personal one that was basically a large business card.

Similarly, Wix's closest templates were Dentist and Doula.

Squarespace had nothing specifically medical, but I thought it had the most aesthetically pleasing themes.

GoDaddy has what I think of as a "jittery" site, where there's too much information thrown at you at once, and you just want to close the page. I don't think that bodes well for my own site. I did briefly look at their templates though, and I didn't much care for them.

The same was true for web.com-too busy, with only a small sampling of templates, all fairly ugly.

My favorite was Duda, which allowed access to templates, and had a specific medical template that looks about right to me. Also, their templates are responsive, which means they adjust themselves to whatever device the user is on, and can be customized for specific devices, i.e. you can make your smartphone page a bit different from your laptop page.

Well, okay, just this one image, since I'm saying it's my favorite:



Here's a spreadsheet summary of the templates:



Based on this information, I'm going to rule out GoDaddy, Sitebuilder, and Wix. I'm not crazy about Web.com but I'm going to keep it in the running because it gets consistently high ratings, so maybe there's more to it than I've seen thus far.



Friday, April 15, 2016

OOOOOOKLAHOMA!

Good news for doctors in Oklahoma, also known as the "Sooner State", "...in reference to the non-Native settlers who staked their claims on the choicest pieces of land prior to the official opening date."

I learned from an email from the National Board of Physicians and Surgeons (NBPAS, See, "Another Board", and "Summing Up 2015"), that in response to pressure from physician groups like NBPAS, the Oklahoma state legislature has passed a bill stating that Maintenance of Certification (MOC) cannot be required as a condition of licensure, reimbursement, employment or admitting privileges. The bill was approved by the governor on April 11, 2016.

The link to the bill is here. You need to click on "SB1148" in the upper left-hand corner to view the actual bill. The relevant language is the following, with an otherwise identical clause included further on for osteopathic doctors:

G.  Nothing in the Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment or admitting privileges at a hospital in this state.  For the purposes of this subsection, "Maintenance of Certification (MOC)" shall mean a continuing education program measuring core competencies in the practice of medicine and surgery and approved by a nationally-recognized accrediting organization.

Go, Oklahoma! And because I'm a little giddy about this small but important victory, I'm including this Sesame Street clip:








Wednesday, April 13, 2016

Investing in Mental Health

According to the NY Times, which does not lie, while mental health care is scarce in parts of the US, it's virtually non-existent in most of the world, with one mental health professional per 1 million people in developing countries.

This is the push behind the World Health Organization's (WHO's) goal to, "...move mental health to the forefront of the international development agenda," and the focus of a conference in Washington this week.

In support of this goal is a paper published yesterday in the Lancet Psychiatry, Scaling-up treatment of depression and anxiety: a global return on investment analysis, by Chisholm, et al. The study was funded by Grand Challenges Canada, which supports, "Bold Ideas with Big Impact in global health," and is, itself, funded by the Canadian government.

I was curious about the study, in particular, how they went about assessing something huge like economic impact of mental illness, and what interventions they think would be helpful. They used the OneHealth tool, which you can download here, to estimate the number of people with depression and anxiety disorders living in 36 large countries, constituting 80% of the world's population, and 80% of the global burden of depression and anxiety disorders. The countries were a mix of low-, middle-, and high-income. Incidentally, I didn't download the OneHealth tool even though it looks really interesting because it's designed for Windows, feh, and I would have to do funny things to my precious Mac to use it. But there's an introductory tutorial on YouTube, and boy does OneHealth have a lot of fascinating data for countries, and powerful functionality.


Quite reasonably, in my opinion, they excluded prevention as a type of treatment, because the evidence for it is weak, and not easily generalizable. Interventions included, "...basic psychosocial treatment for mild cases, and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases." The choice of intervention is based on WHO's Mental Health Gap Action Programme (mhGAP), where the recommended treatment for moderate to severe depression is:



Anxiety and mild depression are considered, "Other Significant Emotional or Medically Unexplained Complaints." In those cases, the recommended treatment is:



INT are advanced psychosocial interventions which take, "...more than a few hours of a health-care provider’s time to learn and typically more than a few hours to implement." They include Behavioral Activation, CBT, Contingency Management Therapy, Family Counseling or Therapy, Interpersonal Psychotherapy, Motivational Enhancement Therapy, Parent Skills Training, Problem-Solving Counseling or Therapy, Relaxation Training, and Social Skills Therapy.

I have to say I'm a little skeptical about how effective these interventions will be. However, their computations were based on the assumption that there would be only a 5% improvement in the ability to work, and productivity at work, as a result of treatment. So their expectations were modest-if someone would normally miss 20 days of work per year, how much money would it cost or save if that person only missed 19 days per year. At least, that's how I understand it.

They were looking for the total cost of scaling-up treatment, as well as effects on three categories:

Health Return = increased healthy life years gained as a result of treatment
Value of Health Returns = I don't really understand this
Economic Return = enhanced levels of productivity


One table I initially skimmed over but now realize is quite important is:

Current and target levels of scaled-up treatment coverage for depression and anxiety disorders (all interventions combined), by country income level 


It reflects the idea I pointed out above that their expectations are modest. Currently, 7% of people who need it get treatment in low-income countries. With the scaled-up program, that number will rise to 34%, which means that 2/3 of people who need treatment won't get it.

The article notes that, "...very few studies have assessed the extent to which effective depression treatments get people back into work." So that's an important question to try to answer. They looked at absenteeism, meaning days lost to work, and "presenteeism", meaning partial days of impaired activity while at work. I guess that includes things like staring off into space.

Let's review. They used this powerful, OneHealth tool to see how many people in the world suffer from depression and anxiety. And they also used the tool to determine the economic impact of these illnesses when they're treated, and when they're not treated. Then they figured out how many more people would need treatment in order to get a 5% increase in productivity. They estimated the cost of the additional treatment, and they estimated how much money would be saved (or made, depending on your perspective) by having that many more people back at work.

And this is what they found:

Costs and benefits of scaled up treatment of depression and anxiety disorders, 2016–30


The total investment is $91.5 billion for depression, plus $55.7 billion for anxiety, equals approximately $147 billion.

They claim that, "...scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period [2016-30]." I don't understand how they determined this, but they placed an economic value on these healthy life-years, the "Value of Health Returns".  For depression, it's $258 billion, and for anxiety, $52 billion, for a total of $310 billion.

In terms of economics, they got $230 billion for depression, and $170 billion for anxiety. That's a total of $400 billion.

To summarize, just looking at pure dollar amounts, over a 15 year period, you put in $147 billion, you get out $400 billion, yielding a total benefit to cost ratio of 2.3-3 : 1.

The discussion describes some limitations. For example, it notes that is a modest return on investment. By comparison, in another OneHealth model, the benefit to cost ratio for malaria was 28-40 : 1. But they also mention that they didn't include things like reduction in unemployment- and welfare-benefits in their analysis, so that could change the ratio.

Another limitation is that unlike the prevalence of of depression and anxiety, the prevalence of treated depression and anxiety is unknown. Meaning that even if you invest in and set up programs, they may not be implemented well. Also, treating more people, for example in remote locations, may drive up the cost of treatment.

Plus, the study didn't consider the negative effect of maternal depression on early child development, the health, social, and economic benefits of effective treatment of maternal depression on the cognitive and physical development of newborns, the monetary and non-monetary impact of effective treatment on family and other caregivers, and the effect of depression and its treatment on physical health outcomes.

To these considerations I would add my own concerns about the particular interventions the WHO recommends. However, I will concede that while the whole endeavor is about the bottom line, and may not make that much emotional difference to that many people, some people will be helped, and that's more than are helped now. And, more importantly, if things work out like they want them to, they will have demonstrated that helping more people actually saves money. I hope they're right.





Thursday, April 7, 2016

Making My Comeback

I am very sorry for my long absence. I can come up with excuses, like I was out of the country, then sick, and the whole time working on what is turning out to be a very challenging article for The Carlat Report. All true, but still excuses.

I'm gonna show you some photos from Thailand, anyway:

6 foot shadow puppet


Street Market

Tuk Tuk

Detail from Wall Mural, Temple of the Emerald Buddha

I'm not gonna get into the part where I was sick, except to convey the one important lesson I learned, although it was too late to be of use to me: There are home IV services. You can google them, if you like. They're mainly for hangovers, and they come to your home and hang some lactated ringers, but they also cover the occasional flu and GI bug.  Good to know.

Now for some real content.

You may recall that a few months ago, I went into this rabbit hole about statistics and flu vaccination. I looked at an article by Talbot et al, that the CDC is using to support its recommendation for universal influenza vaccination. First I finagled around for a while trying to figure out how the article obtained its statistics. When I had finally done that, I considered the conclusions from those statistics, and decided they were erroneous-meaning that even if the statistics are accurate, they don't prove what the authors claim they prove, namely, that there is a 71% reduction in flu-related hospitalizations in patients who have been vaccinated against flu, vs. those who haven't. Instead, I believe what they demonstrate is that flu vaccination resulted in a 71% reduction in flu INFECTION, in their study population, which consisted exclusively of patients who were already hospitalized for something that resembled flu. These are very different conclusions, and if you check my post, you can see where I demonstrated that with the study's data, it's possible flu vaccination reduced flu-related hospitalization, but it's also possible it increased it. They don't have the right data to know.

Since I'm not a statistician, I asked a few people who I thought knew more statistics than I if my conclusion was correct, but I couldn't seem to get a clear answer. I even wrote to the Cochrane Review about it, then promptly forgot I had done so.

Well, they responded, and this is en excerpt (most) of their reply:

Our opinion on the Talbot, et al observational study is as follows:

The public health significance of the study is limited for multiple reasons including the inability to estimate absolute treatment effects and number needed to vaccinate. Without this vital information it is difficult to determine the value of the intervention for public health use. Furthermore there is no information on harms reported therefore we have no idea of the balance between positive and negative outcomes. It is well known that observational studies tend to be associated with higher risk of bias compared to randomised clinical trials. Bias introduced by the design usually has the effect of exaggerating the effects of the intervention, in this case influenza vaccines. Coupled with absence of any mention of harms is well within the narrative findings of our reviews.

The assumptions required for validity of the case-positive, control-negative study design are not stated in the paper and no information is provided on whether they have been met. For example, a critical assumption is that the risk of non-influenza ILI needs to be the same in vaccinated and non-vaccinated individuals1. This may not be the case as shown by Cowling et al who reported an increased risk of non-influenza respiratory virus infections associated with receipt of inactivated influenza vaccine2. Stratification by disease severity (apparently not measured in this study) is needed because this is likely to be associated with a person’s probability to seek medical care as well as vaccination status3. If the vaccine modifies the conditional probability of developing symptoms after infection with influenza then the odds ratio may be biased3.

The case-positive, control-negative study design is not recommended for study of patients hospitalised for influenza-related illnesses because hospitalisations may occur due to complications that become manifest after the virus is no longer detectable3. It is notable that only 10% had positive RT-PCR tests; surprisingly low given the participants were selected and recruited during the influenza season. 

Further weaknesses of the study include selection bias as only 169 of 413 eligible participants were included in the analysis. Only 17 had a positive RT-PCR test making estimates from statistical modelling unreliable. 

Given these multiple methodological concerns we consider the study to be at high risk of bias; providing very low quality evidence. 


References
1Broome, C., Facklam, R., Fraser, D. Pneumococcal Disease after Pneumococcal Vaccination — An Alternative Method to Estimate the Efficacy of Pneumococcal Vaccine. N Engl J Med 1980; 303: 549-552.
2Cowling, B., Fang, V., Nishiura, H., et al. Increased Risk of Noninfluenza Respiratory Virus Infections Associated With Receipt of Inactivated Influenza Vaccine. Clin Infect Dis. 2012 Jun 15; 54(12): 1778–1783.
3Foppaa, I., Haberc, M., Ferdinandsa, J., Shaya, D. The case test-negative design for studies of the effectiveness of influenza vaccine. Vaccine 31 (2013) 3104– 3109. 



Cochrane replied to my inquiry! I feel so important! Sure, they didn't really answer my vanity question of, "Did I catch the CDC in a big statistical boo boo?" But that's probably for the best. What they do seem to be saying is that the the study is poor enough that it's not even worth considering the validity of its conclusions, which still supports my contention that this is a terrible study to use as part of the recommendation for universal flu vaccination.


The Cochrane people also suggested that I post our exchange in PubMed Commons as comments to the Talbot et al study, which I told them I would like to do, but haven't gotten around to yet.

That's my bit for today. I will try to be less neglectful of the blog, going forward.





Tuesday, March 1, 2016

Benzodiazepines are Confusing

For about a year now, I've been trying to figure out what to make of data coming in about the association between Benzodiazepine (BZD) use and dementia.

To start from the very beginning, I recognize that BZDs are potentially addictive, can cause gait and memory impairment, and precipitate withdrawal seizures with continued use, and don't mix well with other drugs like EtOH and Opioids, for instance. They're not ideal drugs.

But for a certain subpopulation, they're helpful. Anxious people who are on other meds that don't quite hold them, and who don't escalate their doses, for instance. Patients who are scared of flying, and who need a Xanax to get them there, and another to get them back. And sure, everyone knows BZDs have, at best, a short duration of helping with insomnia, and still, some patients do well with them long-term.

I'm definitely more liberal with BZDs than I was taught to be as a resident, where they were viewed as the evil purview of manipulative drug seekers. I consider that perspective a bit extreme. On the other hand, I try to encourage other methods for coping with anxiety, and taper patients off them, when I can.

Lately, though, I've been worrying about the connection between BZDs and dementia. In a 2012, French study by Billioti de Gage, et al, 1063 men and women, (mean age 78.2) who were dementia free were followed for up to 15 years. Those who used BZDs prior to the onset of the study were excluded, so only  those who used BZDs three or more years into the study were included. They found that new use of BZDs was associated with an increased risk of dementia (multivariable adjusted hazard ratio 1.60, 95% confidence interval 1.08 to 2.38). They also found that:

"Results of a complementary nested case-control study showed that ever use of benzodiazepines was associated with an approximately 50% increase in the risk of dementia (adjusted odds ratio 1.55, 1.24 to 1.95) compared with never users. The results were similar in past users (odds ratio 1.56, 1.23 to 1.98) and recent users (1.48, 0.83 to 2.63) but reached significance only for past users."

This was the part I found particularly perplexing. I didn't understand this separate, complementary study, or what to make of "ever use" vs. "never use".  For instance, what are the implications for someone who gets a versed fentanyl drip for a colonoscopy? Does that constitute "ever use"?

Other studies  cited by this one demonstrate increased risk of dementia in chronic use, former use, and ever use (please see study for citations). The "ever use" particularly bothered me, because why should I encourage patients to stop taking BZDs if their risk is already well-established.

Another study, (same author, 2014) looked at people already diagnosed with Alzheimers, and considered a dose response relationship to BZDs. They found an association with "ever use", but not with cumulative dose. Also, the strength of association was greater for long half-lifed BZDs than for short half-lived. There were a whole bunch of confusing points and confounders.

Finally, there's this study:
Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study, by Gray, et al, published in the BMJ last month. It's a prospective, population-based study done in Seattle, "To determine whether higher cumulative use of benzodiazepines is associated with a higher risk of dementia or more rapid cognitive decline."

They had 3434 participants age > 65, dementia-free at study entry. They screened for dementia every 2 years over the course of 10, with the CASI (Cognitive Abilities Screening Instrument), and got data about BZD use via computerized pharmacy records.

They concluded:

The risk of dementia is slightly higher in people with minimal exposure to benzodiazepines but not with the highest level of exposure. These results do not support a causal association between benzodiazepine use and dementia.

There's so much inconsistency here that I don't know what to think. At least all three of the articles are open access.

I'm off to the Far East for several weeks, see you when I get back.


Friday, February 19, 2016

Tequila MOC-kingbird

First, sorry about my prolonged absence. I've been writing an article for Carlat, and it's taking up all my time.

Second, sorry about the title. I'm pretty sure I saw a cocktail called, "Tequila Mockingbird" on some restaurant menu, but I can't remember where. And then an MOC topic came up, so.*

Got this email today:

AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY EXPANDS
IMPROVEMENT IN MEDICAL PRACTICE (PIP) OPTIONS FOR DIPLOMATES

February 18, 2016, Buffalo Grove, Illinois --- The American Board of Psychiatry and Neurology, Inc. (ABPN) has expanded the options for diplomates for their one required Improvement in Medical Practice (PIP) activity every three years to include any Clinical Module OR Feedback Module activity listed on the ABPN website.

Effective immediately, this development now gives diplomates more flexibility with the Part IV requirement for their maintenance of board certification.

The ABPN Improvement in Medical Practice Unit is a quality improvement exercise designed to identify and implement areas for improvement based on the review of one’s own patient charts (Clinical Module), involvement in personal or institutional quality improvement activities, or feedback from peers or patients via a questionnaire/survey (Feedback Module).

“These additional options for fulfilling the requirements of MOC Part IV recognize the importance of patient and/or peer feedback to the process of physician quality improvement, and it should also make it easier for many ABPN diplomates to document their quality improvement activities,” said Larry R. Faulkner, MD, ABPN President and CEO.

More details, including full option lists for both the Clinical and Feedback Module activities, are available on the ABPN website.

Reading this evoked a kind of comical fury in me. The ABPN is stooping pretty low, but it just won't bow to the pressure to remove Part IV. In case you've forgotten, and who wouldn't want to, there's lots of controversy about the Part IV Performance in Practice (PIP) modules, which you often need to pay for, and which have not been demonstrated to do anything but raise blood pressure. The American Board of Internal Medicine (ABIM) caved to its protesting diplomates, suspending Part IV until 2018. But the ABPN did not.

If the Board thinks PIP is so valuable, why agree to make it an either/or with a form that any diplomate can fill out five times by herself, asking her friends for their approval and signatures, in exchange for her own?

I checked out the ABPN products list page, and after a click or two, I got this:


The bottom part scrolls to more options, and it's almost this difficult to read. The important column here is, "PIP F", the feedback modules. It took me a little while to find the right one. There were a couple "page not available" dead ends, as well as ones that didn't apply, like the adolescent feedback and patient forms. I've discussed my thoughts about patient feedback forms elsewhere.

The main form you need, if you're willing to be the ABPN's bitch and do this, is the ABPN's Peer Feedback Form (NOT the AACAP's form, which gets you a description of MOC). It gives you a 1-6 Likert scale in six areas:

Patient Care
Medical Knowledge
Interpersonal and Communication Skills
Practice-Based Learning and Improvement
Professionalism
Systems-Based Practice

'Nuff said.

I had already decided to wait to see if the ABPN makes any concessions about Part IV and the meaningless, expensive recertification exam that exists to pay ABPN salaries, to decide if I want to bother re-certifying again, or to fulfill any of the requirements other than CME. I'm taking this concession as a sign that I should keep waiting.



* I just Googled "Tequila Mockingbird", and I got a link to this book:



Maybe I saw it in a bookstore? The drinks have names like, "Last of the Mojitos", "One Hundred Beers of Solitude", and, "The Rye in the Catcher". It looks like fun.

Tuesday, February 2, 2016

Laughing Rats

I attended a talk a couple weeks ago at The New York Psychoanalytic Society and Institute (NYPSI), given by Jaak Panksepp, and entitled, Cross Species Affective Neuroscience. It was a really good talk that I'll try to summarize here. Panksepp spoke using a power point that didn't quite work right, through no fault of his own, and gave a talk similar to his TEDx talk about affect in non-human animals, and the way humans can be understood by studying these animals, particularly with respect to depression. His part was followed by the discussant, Jean Roiphe, who presented a corresponding analytic perspective, and highlighted points of overlap and divergence.

First, the speakers. This is from Wikipedia:



And Jean Roiphe's description from the NYPSI site is:

Clinical Associate Professor of Psychiatry, Weill-Cornell Medical College
Associate Attending Psychiatrist, New York-Presbyterian Hospital
Training and Supervising Analyst, New York Psychoanalytic Institute


One of Panksepp's main points is that affect is the foundation for all consciousness, and that most learning takes place through affective shifts. This reminded me of a guy from my medical school class who decided he should memorize everything by singing, because while the Complement pathways eluded him, he could still remember every TV commercial jingle he learned as a kid.

Panksepp briefly addressed the question of why one would choose to study emotional feelings in animals, which is to say, whether animals have minds at all, and pointed out that animal lovers' beliefs that this is the case is an argument from empathy, and that LeDoux is skeptical about whether animals have feelings.

Panksepp, himself, believes that animals have feelings and that all their experiences are labeled "good" or "bad"; that animals can tell us if something is rewarding or punishing. And here, the definition of "good" = leads to survival, while the definition of "bad" = leads to destruction.

He noted, quite emphatically, that in his opinion, all feelings are based in the subcortical system, and pointed out that while Damasio initially believed feelings are generated in the neocortex, he later switched to Panksepp's position, and acknowledged so, which earned him Panksepp's label of, "mensch". Panksepp does not feel similarly about LeDoux.

Panksepp described the seven emotional systems in the brain. This is one of the places where his slides malfunctioned, so I'm taking this from the slide in his TEDx talk:


SEEKING----Enthusiastic
RAGE---------Pissed Off
FEAR---------Anxious
LUST---------Horny
CARE--------Tender and Loving
PANIC-------Lonely and Sad
PLAY--------Joyous

He mentioned that dopamine and the nucleus accumbens are the foundation for all positive emotions, and that this probably represents a general purpose learning system. He also mentioned the association between the Hypothalamus/PAG/Amygdala and the ANGER system.

He returned to his discussion about the subcortical system as the foundation of feelings and consciousness, and pointed out that rats with no neocortex behave "normally", and that raters were not able to differentiate these from rats with neocortices.  In fact, the neocortex-less rats showed more interest in their environment than the normal rats. No inhibition, I suppose.

He focused particularly on the SEEKING, PLAY, and PANIC systems, because these were areas of exploration that have shown promise for the treatment of depression.

SEEKING is associated with the Medial Forebrain Bundle. Bilateral lesions in this region yield profound depression, while bilateral deep brain stimulation in this region yields an antidepressant effect.

One medication that usefully impacts the SEEKING system and acts as an antidepressant is very low dose buprenorphine, which makes juvenile animals play more. He claimed that drug withdrawal shows similarities to the experience of separation distress, which is a model for depression via the PANIC system.

Opioids mediate every good feeling ever studied, and in fact, contact comfort, known to be effective at soothing panic, doesn't work as well if opioid receptors are blocked.

Oxytocin is just as powerful as opioids with respect to depression, in its re-creation of mothering attachment. This has implications for placebo effect, since handing someone a placebo is an act of caring.

Panksepp cited a very small study he did with Yovell using buprenorphine to treat depression and suicidality. The suicidality results are what he included in his slides:


He also spoke about a study using bilateral Deep Brain Stimulation (DBS) to act on the SEEKING system in 7 subjects with treatment resistant depression. 6/7 responded well, with a marked improvement in planning for their futures. It turned out that in the one non-responder, the DBS had missed on one side.

Finally, and to me this was the most important part, he talked about an antidepressant he has been researching, a tetrapeptide called, GLYX-13, that acts on the PLAY system. The results have been promising, with decreases in depression thought to be mediated by promoting positive social feelings, including laughter. Panksepp is big on laughter, and is known for tickling rats to get them to laugh. Unfortunately, he seemed to indicate that GLYX-13 was bought up by a company with a competing antidepressant, so it may not make it to market.

His slides really gave out at this point, so he handed the stage over to Jean Roiphe for her discussion. Spoiler alert: It's quite brilliant, and if you don't think so after reading my summary, it's only because I didn't do it justice.


Roiphe described being on safari a decade ago, watching animals spending their days grazing on the veldt, except when they sensed a predator, at which point they would take evasive action. This was pretty much all they did, and it correlates well with the SEEKING and FEAR systems. It made her wonder, now that our survival is so much more assured, at least in some parts of the world, what has happened to our emotional meanings? We now fill our free time with things like art and science and architecture and literature and blogging, but we also fill it with neuroses, anxiety, eating disorders, perversions, and all the many clinical presentations we see in our work.

She noted that while the seven emotional systems are preserved in our brains, it's important to remember that, paraphrasing Kandel, humans now change more by cultural than by biological evolution. At the same time, it's also important to establish a line of communication between those who study the subjective aspects of the mental apparatus, such as psychoanalysts, and those who study its objective aspects, such as neuroscientists. And that the mind is simultaneously and always both a psychological and a biological entity.

She spoke about the value of linking the two approaches, in both directions. For psychoanalysis, the value is having neurological correlates to analytically abstract concepts of the mind, because the former are technologically easier to study, with the proviso that this may not simplify matters all that much, since different neuroscientists can interpret "brain data" differently, as in the above example of Panksepp vs. LeDoux.

And for neuroscience, the value is in learning about the complexity of subjective experience, and recognizing that the human condition is impossible to understand or even study without taking the subjective into account.

In some respects, the emotional systems described by Panksepp correlate with Freud's affect theory, in which affect is a way for a person to tell if his or her drives are being satisfied. Or not. I feel good or I feel bad. This experience is pleasant, that one is unpleasant. However, the seven emotional systems are instinctual, do not need to be learned, and involve behavioral responses, whereas Freud's affect theory involves only a pressured sense that something needs to be fulfilled, and this may or may not lead to a behavioral response, but always leads to mental activity, to thought as trial action. This is a good example of why it's important to avoid the trap of trying to create one to one correspondences between approaches.

Freud's ideas about affect evolved over time, along with his changing theory of anxiety, and his shift from the topographic model (unconscious vs. conscious) to the structural model (id, ego, superego), but ultimately, affect became tied to ego function, as a way for the ego (which acts as a combination of party coordinator and chaperone) to mark the need for some kind of response to something, whether that something is internal or external.

This is similar to the concept of the seven emotional systems as survival mechanisms-X happened, I feel Y in response, and now I need to do Z. The difference lies in the connections between affect, ego function, and object relationships. Human emotions such as guilt, shame, and envy, are generated by the development of the ego in a complicated social context. Uniquely human affects and moods and their corresponding pathologies arise from the interactions of cortical regulatory effects on subcortical systems, and these are mediated by the ego, which becomes itself under the influence of the people around it.

Ego functioning often involves "taming" certain affects, especially through thought and language, but it also involves intensifying some affects, so that people can feel truly alive. A full human life can't be reduced to an all or nothing switch of feeling in response to external events.

We can illustrate the role of the ego in human experience by examining Panksepp's model for depression, which involves the malfunction of the PANIC, SEEKING, and/or PLAY systems. This model corresponds well with anaclitic depression, in which babies separated from their mothers for extended periods became despondent, emotionally withdrawn, and frequently died. Strikingly, Spitz, who studied the syndrome, noted that a way to prevent this deterioration was to find a suitable substitute caregiver, and to allow the babies to move around outside their cribs (see this post). This meshes well with the involvement of both the PANIC/separation distress and SEEKING systems.

Spitz attributed the need for the babies to move around not to an innate SEEKING system, but to a need for discharge of aggression. The absence of aggression is where Panksepp's model for depression diverges from psychoanalytic models, in which aggression is central. Freud's, Mourning and Melancholia, reflects the idea that sadness is not the same as depression, which results when a loss, usually of an ambivalently loved object, precipitates rage, which is then directed towards the self.

There are other types of depression, as well. In an ego depression, the actual self falls short of the wished-for self, as in the loss of a job, or the limitations that come with aging. Depression results when there is an aggressive attack on the self for these losses, "I have failed." In a superego depression, the actual self falls short of the wished for self in moral or ethical values, which results in an aggressive attack on the self: "I'm bad, I should be punished."

Panksepp also considered the evolutionary advantage of depression as a shut down mechanism in PANIC situations. But a psychoanalytic perspective includes not only the concept of depressive pathology, which is a source of immense suffering and need for treatment, but also depressive capacity.

Depressive capacity includes the ability to tame or appropriately redirect aggression, and to tolerate the inevitable disappointments and losses of life. It involves the willingness to accept responsibility for our moral failings by not hiding behind depression-inducing guilt, or other defenses such as blame or projection. And it requires the ability to relinquish ones unattainable dreams, to accept the lack of fulfillment of ones impossible wishes, and to bear the limitations in ones self.

That was pretty heavy. Now this. I mentioned the problem with Panksepp's power point for a reason. He didn't get to show the video of himself tickling rats. So here it is: