POLLing

It's been a while now since Jim Amos, George Dawson, and I started POLL, our free online journal club, where we post an open access article, and ask for discussion.

At first, we were posting our articles on our respective blogs, but then, with some discussion and show of interest, we switched to LinkedIn as a venue, thinking it would be more professional, and could encourage a larger audience. We tried to keep up at the rate of a new article each week, with credit mostly to Jim Amos, but that was a bit much to manage. So then we moved to every other week.

Unfortunately, with the exception of one or two instances, no one was participating in the discussions. I don't know if people weren't interested in the particular articles, or the questions weren't evocative enough, or the venue wasn't working, or we weren't doing enough to promote it, or any of a number of reasons I haven't thought of.

I don't want to give up the idea of on online journal club, because I think it's a perfect venue, and a great way to demonstrate an interest in lifelong learning without shelling out thousands of dollars for meaningless CME.

So I am really, genuinely asking for people's opinions. Are you interested in an online journal club? If so, why, and if not, why not? What venue are you interested in-LinkedIn, individual blogs, twitter, a separate blog, facebook, other suggestions? What would be the function of an online journal club, for you? What topics would you like to see covered? Who would you like to see participate? Who would you like to select the articles? Would you like to be involved in selecting the articles? Should there be separate journal clubs for separate topics? What should the frequency be?

I'm not sending out another survey, because they're so sparsely responded to that it isn't useful. But I really think this is a great opportunity for people with common interests to have open discussions about important professional topics. So please make your voice heard and comment.

Thanks.

New POLL Article: Childhood Emotional Maltreatment

I'm posting a new POLL article on LinkedIn, entitled:

Childhood Emotional Maltreatment Severity Is Associated with Dorsal Medial Prefrontal Cortex Responsivity to Social Exclusion in Young Adults

Abstract

Children who have experienced chronic parental rejection and exclusion during childhood, as is the case in childhood emotional maltreatment, may become especially sensitive to social exclusion. This study investigated the neural and emotional responses to social exclusion (with the Cyberball task) in young adults reporting childhood emotional maltreatment. Using functional magnetic resonance imaging, we investigated brain responses and self-reported distress to social exclusion in 46 young adult patients and healthy controls (mean age = 19.2±2.16) reporting low to extreme childhood emotional maltreatment. Consistent with prior studies, social exclusion was associated with activity in the ventral medial prefrontal cortex and posterior cingulate cortex. In addition, severity of childhood emotional maltreatment was positively associated with increased dorsal medial prefrontal cortex responsivity to social exclusion. The dorsal medial prefrontal cortex plays a crucial role in self-and other-referential processing, suggesting that the more individuals have been rejected and maltreated in childhood, the more self- and other- processing is elicited by social exclusion in adulthood. Negative self-referential thinking, in itself, enhances cognitive vulnerability for the development of psychiatric disorders. Therefore, our findings may underlie the emotional and behavioural difficulties that have been reported in adults reporting childhood emotional maltreatment.

The study looks at reactions to the Cyberball game, in which the participant plays a game of cyber-catch with the computer and two other players, one male and one female. In the first, inclusion, part of the game, the computer throws the ball to each player an equal number of times. In the second, exclusion, part, the computer throws the ball to the subject once or twice a the beginning of the game, and then never again. The game is supposed to be a model for social exclusion.

The study examined severity of childhood emotional maltreatment using the Dutch version of something called the Childhood Trauma Questionnaire.

They looked at Mood and something called, "Need Threat", after the inclusion section, then after the exclusion, and then after the whole thing was done:

The Cyberball game didn't seem to have much differential effect between groups, and what you see is mostly a difference in baseline, unrelated to the game. The main difference seemed to be in fMRI, with greater childhood emotional maltreatment corresponding to greater dorsal medial prefrontal cortex activity:

It's hard to know how much this matters, in the grand scheme of things-whether people who suffered childhood emotional maltreatment are really more vulnerable to social exclusion, and if the difference in brain activity amounts to a difference in perceived experience, and greater vulnerability to other pathology.

But please take a look at the article and let me know what you think, either here, or on POLL.

POLL!

We did it! Drs. James Amos and George Dawson (of the Real Psychiatry blog) and I created a LinkedIn group entitled, Psychiatry Online Lifelong Learning (POLL).  Here's the description:

This is a free Psychiatry journal club. Links to free articles, along with managers' initial comments, will be posted at regular intervals. Enthusiastic discussion is highly encouraged.
The purpose of this group is to foster professional interaction and collaboration, and to promote the principle of lifelong learning so important to continued growth as a clinician. 
The group is primarily intended for psychiatrists, but anyone with an interest in psychiatry, and a scientific bent, is welcome to apply for membership.
We ask simply that comments be respectful and relevant to the discussion at hand.

And guess what? The first discussion has already begun, kicked off by none other than Dr. James Amos of The Practical Psychosomaticist blog. There's a timely article entitled,

Collaborative Care for Patients with Depression and Chronic Illnesses, byWayne Katon, et al.

So don't delay! Head on over to LinkedIn, and apply for membership. If you don't already have a LinkedIn account, it's free and easy to set one up, and not a bad thing to have, in any case.

We're really excited about this, and we'd like it to be something good for everyone. So please help us, and yourself, out by joining and participating.

Thanks.

HAM-D'ing It Up

Last month I published a post entitled, Lifelong Learning-A New Frontier. In it, I introduced the idea of an online journal club, and I threw down the gauntlet with a challenge-let's talk about this paper:

A Rating Scale For Depression, by Max Hamilton

So here I am, talking about it. In written form.

In case it isn't obvious, this article introduced the Ham-D, or Hamilton Rating Scale for Depression, which is still in use.

And in case you happen to think there's something new under the sun, the paper begins with, "The appearance of yet another rating scale for measuring symptoms of mental disorder may seem unnecessary, since there are already so many in existence and many of them have been extensively used."

The year is 1960.

I'm gonna go on to delineate some random thoughts and reactions to the paper, in the hope that this will encourage dialogue, as might take place in an in-person journal club.

The first thing old Max H does is describe the purpose and appropriate usage of this particular rating scale. Or more accurately, what it's purpose isn't:

1. It's not devised for normal subjects
2. It's not self-rating
3. It's not about social adjustment/behavior
4. It's not broad range

Rather, it focuses on the measurement of symptoms in individuals already diagnosed with depression.

The present scale has been devised for use only on patients already diagnosed as suffering from affective disorder of depressive type. It is used for quantifying the results of an interview, and its value depends entirely on the skill of the interviewer in eliciting the necessary information… It has been found to be of great practical value in assessing results of treatment.

One question I have is, who makes the diagnosis? And based on what diagnostic system? The DSM-II was published in 1968, which means the HAM-D was developed to assess depression in people who may or may not have met the DSM-V criteria for Major Depression, were they being assessed today. So is it still appropriate to use the scale?

The scale includes 17 variables related to depression, plus 4 additional variables, diurnal variation, derealization, paranoid symptoms, and obsessional symptoms, that are either related to type rather than severity or intensity of depression (diurnal variation), or are seen only rarely in the context of depression (the other three). Each variable is rated on either a 5 point (0-4) or a 3 point (0-2) scale, with the latter in use when quantification is difficult, e.g. insomnia and agitation. It's interesting to note that on the modern HAM-D form, agitation is measured on a five point scale, which Hamilton found "impracticable".

The scale was written with the intention of having a given patient rated by two different raters. Where only one rater is available, the score should be doubled.

Some caveats for the raters:

1. No distinction is made between intensity and frequency of a symptom-the rating is at the discretion of the rater, who is expected to take both into account.
2. Depressive Triad: depressive mood, guilt, suicidal tendencies-the rater needs to avoid a  halo effect, e.g. giving guilt and depressive mood the same rating because they're closely related.

Table 1 is the correlation matrix.

It's how well each individual symptom correlated with each of the other individual symptoms. So, for example, Depression has a 1.0, since it correlates 100% with Depression. Guilt correlates with depression 49.1% of the time, and 100% with Guilt, etc.

This is followed by the extraction of some data, summarized into 4 factors-not sure how these are obtained.
As I understand it (poorly), factor analysis is a way to take your data and look at it as fewer variables than you started with. I briefly perused the Wiki Article, which seemed to involve some Linear Algebra. And since it's been many a year since I was intimate with eigenvectors, I'm gonna leave it at that. In other words, it's magic.

But, for example, Factor 1 has high correlations with depressed mood, guilt, suicide, delayed insomnia, work and interests, retardation, genital, and insight; And low correlation with agitation and anxiety, so they call it a "retarded depression"
This, so the article claims, corresponds well with the classical description of depression.

Which one? Melancholia? Seems like.

Finally, the end of the paper includes several case descriptions, not just scores. This is in stark contrast to today's style. I suppose this is knowable, but I don't know it-were most papers written with case descriptions then?

Please comment so we can get a discussion going. It's a short paper. Check it out.

Lifelong Learning-A New Frontier

This post is tangentially about Maintenance of Certification (MOC). So before I get to the main point, I want to refer readers to Jim Amos' blog, The Practical Psychosomaticist. The link will take you to a form letter to oppose MOC and MOL (Maintenance of Licensure). Dr. Amos generously gives me top credit for it, but it's actually a letter he sent to the AMA and APA, that I modified to make it convenient for other people to use.

Check it out, consider how you feel about MOC and MOL, and if you're so inclined, mail it off.

I've already written about my feelings regarding MOC. So let's get to the main topic, Lifelong Learning. Let's assume the world suddenly becomes a sensible place, and the inane requirements for MOC are done away with. No expensive recertification exam, no dumb PIPs, no useless CME credits. I still consider it my obligation to stay current, so I can take better care of my patients.

What I do now, and would probably continue to do in the aforementioned utopia, is subscribe to The Carlat Report and UpToDate. The Carlat Report doesn't take money from drug companies or other sponsors. And UpToDate is just an excellent resource all around. And no, they're not paying me to write this. (Full Disclosure: I was paid by The Carlat Report for my article in their May edition, but that's the extent of my financial relationship with them).

I've also recently subscribed to NEJM's Journal Watch Psychiatry, but I'm just testing it out at this point, so I can't comment.

But here's a new idea. Or maybe it isn't new, but I don't know about it:

Online Journal Club!

It's the kind of thing that LinkedIn and Facebook lend themselves to. Post a free article online, maybe once a week, allow some time for people to read it, and then ask people to write in and discuss it.

People could suggest articles, and vote on which one they want to read next. And it's free. And collaborative. And the kind of thing I tried to do with my residents, back when I was a unit chief.

A book club would work, too, but that would involve a purchase.

There are all kinds of online learning resources:

MIT's OpenCourseWare
MIT and Harvard's EdX
The Khan Academy

Why not, The Psychiatry Collaboration?

I'd love for readers to comment on this post. Let me know what kind of lifelong learning works for you. Where do you go to stay current? Would you participate in a free online journal club?

How about this article:

A Rating Scale for Depression, by Max Hamilton
J. Neurol. Neurosurg. Psychiat., 1960, 23, 56.

I found the link to it on the BMJ site. I've never read it before, and sure, it's from 1960, but it might be interesting and fun to read about the early development of the HAM-D.