Research have suggested that spiritual and religious beliefs may have a protective effect on health. One meta analysis (Hackney &Sanders , 2003) found a small positive correlation between religiosity and psychological status. Smith et al 2003 (meta analysis) showed religious/ spiritual belief to have a small negative correlation with depressive symptoms but the protective effect of belief was stronger on risk of major depression after significant life events. Not all studies have reported similar effects. A large Canadian community study showed that people who placed greater importance on spiritual values had higher odds of most psychiatric disorders (Baetz et al. 2006). A recent Korean study also showed that strong spiritual values are associated with increased rates of current depressive disorder (Park et al. 2012).
Most studies are cross-sectional in nature,there are only few prospective studies addressing this relationship, few of the smaller prospective studies have reported a protective effect for spirituality/ religious beliefs.
B. Leurent, I. Nazareth, J. Bellón-Saameño, M.-I. Geerlings, H. Maaroos, S. Saldivia, I. Švab, F. Torres-González, M. Xavier and M. King used the data from seven countries (part of depression in primary care study) to examine the impact of a religious or spiritual life view on onset of major depression over 12 month period.Patients were all recruited from general practices.Self-report version of the Royal Free Interview for Spiritual and Religious Beliefs was used to assess life view. Participants were asked to indicate whether their understanding of life was primarily religious, spiritual, or neither religious nor spiritual.All participants were re-evaluated for DSM-IV major depression after 6 and 12 months
A total of 10045 people took part in the study.75% of participants held a religious or spiritual understanding of life. Women were more likely have a religious or spiritual view of life.
Of participants reporting a religious understanding of life, 10.3 % experienced an episode of major depression over the subsequent 12 months, compared to 10.5 % of participants with a spiritual life view and 7.0% of the secular group. Participants with a spiritual understanding of life had a greater risk of major depression at 6 or 12 months than participants with neither a spiritual nor a religious life view when data was adjusted for all confounding factors (age, sex, education, employment, social support, past history of depression and country). Higher strength of belief in those who reported a spiritual or religious life view was associated with a greater likelihood of DSM-IV major depression over the subsequent 12 months after adjustment for all factors.People in the UK who had a spiritual understanding of life were the most vulnerable to the onset of major depression.
Strength of the study: large sample size, wider geographical coverage
Limitations: Participation rates were low in some countries. Findings from general practice attendees cannot be assumed to be generalisable to whole population.Only the overall life view was elicited.Participants may have difficulty in choosing between religiosity and spirituality as the ideas might be interpreted in different ways.
These results are different from some of the recent studies (Miller et al. 2012 Kasen et al. 2012). It reveals how complex such relationships are and that the assertion that religion and spirituality is good for mental well being is not supported by good evidence.
ECT is highly effective in achieving remission in major depression. High rates of relapse after remission remain a limitation with ECT. Even with continuation treatments ( antidepressants or ECT) relapse rates are high. Relapse rates are likely to be higher in recent studies possibly due to changes in the patient population now receiving ECT. ECT is given to resistant/ chronic and severe depression and that maintaining remission longer is likely to be an extremely difficult task.
Ana Jelovac, Erik Kolshus and Declan M McLoughlin report the results of meta analysis of the relapse rates in major depression after successful ECT. All studies in adult age depression ( unipolar or bipolar) where relapse was determined clinically in prospective follow up of at least 3 moths after response or remission with ECT where included in this analysis.The primary outcome was cumulative relapse proportion at the 6-month follow-up after last ECT.
32 studies met inclusion criteria . By 6 months, 34 % of patients who achieved remission after ECT and treated with continuation pharmacotherapy had relapsed. Realpse rates were lesser in earlier studies. No studies were identified between 70s and easily 90s .When only modern studies were included, relapse rate was 38%. This reached 50% at one year. Relaspe among those using antidepressants during ECT where less than those who started them after ECT.Those on continuation ECT also relapsed at the same rate as those on continuation medications. Relapse rates were lower when Continuation ECT was combined with medications ( 20% at one year based on small number of studies).
Systematic review did not identify any long-term studies directly comparing outcomes in ECT vs medication-treated patients. studies included are small, underpowered and predominantly observational studies.Substantial variability seen.Very few RCTs on continuation therapies. There is not enough studies to comment on antidepressant options post ECT.
There is no clear consensus on optimal post ECT relapse treatment plan. APA suggest medication or continuation ECT for all (2001).Most research in ECT in recent times have been on optimising the treatment parameters rather than on this important question i.e. on maintaining remission.
Conclusion: Nearly 40% of patents will relapse in 6 months following remission with ECT combined with conitunation pharmacotherapy . Almost half will relapse at one year. Placebo samples generally indicate relapse rates approaching 80% in this group of highly resistant difficult to treat condition.
Summary of the article:
Relapse following successful electroconvulsive therapy for major depression: a meta-analysis.
Jelovac A, Kolshus E, McLoughlin DM. Neuropsychopharmacology. 2013 Nov;38(12):2467-74
Biomarkers help us to measure predisposition to a specific condition, or the presence or progress of a pathological state. Alcohol use disorders are common and having good biological markers that accurately reflect both the degree of drinking and the presence of a genetic predisposition to alcoholism can help in identifying , monitoring and managing alcohol dependence.
Eri Hashimoto et al provides a review of this area in this consensus paper by WFSBP task force. This summary will be around the state markers as they are immediately relevant to clinical practice.
There are no biomarkers that can directly identify alcoholism . We have state markers that can detect the timing and intensity of an individual’s alcohol use.
GGT :(gamma-glutamyltransferase) :Early indicator of chronic heavy drinkers, liver disease. Widely used. Medications that induce the microsomal enzymes and conditions like hepatic congestion ,diabetes and pancreatitis can increase GGT. Half life of GGT is one month.
CDT:(Carbohydrate-Deficient Transferrin): Highly specific to alcohol use. Appears to be the most sensitive and specific single test for detecting more recent moderate to heavy alcohol intake (∼7–10 drinks a day). Test and assay are highly standardized, automated and inexpensive; in many places, it is commonly used . Half life 1s 15 days.CDT is significantly more sensitive than GGT in detecting relapses.
MCV: Sustained and regular excessive drinking is important for elevating MCV levels .It may take several months for changes in drinking to be reflected in MCV levels and hence is generally less useful. High values are maintained for long periods after stopping drinking.
AST and ALT: Are more useful to detect liver disease. AST/ALT ratio is thought to be indicative advanced alcoholic liver disease rather than heavy alcohol consumption. The AST/ALT ratio appears to be a useful index for distinguishing non-alcoholic steato hepatitis (NASH) from alcoholic liver disease (a ratio of <1 suggests NASH and values > 2 are strongly suggestive of alcoholic liver disease.
Others: FAEE (fatty acid ethyl esters) ,WBAA (whole blood-associated acetaldehyde) and MAO-B (monoamine oxidase B) are useful in determining recent alcohol use. EtG (ethyl glucuronide) and ethyl Sulphate are used to determine 24 hr sobriety. FAEE (fatty acid ethyl esters) can differentiate recent heavy drink in a social drinker from a heavy chronic drinker.
Detecting recent consumption?: Ethyl glucuronide (EtG) and ethyl sulfate (EtS), both direct metabolites of ethanol, can indicate even a minor intake of alcohol up to 80 hours after alcohol has been eliminated from the body. Urinary EtG/EtS can potentially monitor relapse in patients in active treatment programs. Phosphatidylethanol (PEth) is another marker whose diagnostic specificity is theoretically 100% with half-life in blood of 4 days.The amount of alcohol consumed highly correlates with the blood concentration of PEth; thus, PEth appears to be a more sensitive indicator of alcohol consumption than traditional alcohol markers. It is a more sensitive bio- marker than serum CDT for the detection of relapse drinking.
Conclusion: State markers differ in their utility. Combining biological markers with per- formance of the alcohol use disorders identification test (AUDIT) questionnaire can be helpful in clinical settings. New markers could be particularly useful in detecting minor relapses in clinical/criminal justice settings.
Summary of the article:
Consensus paper of the WFSBP task force on biological markers: Biological markers for alcoholism.
Hashimoto E, Riederer PF, Hesselbrock VM, Hesselbrock MN, Mann K, Ukai W, Sohma H, Thibaut F, Schuckit MA, Saito T. World J Biol Psychiatry. 2013 Dec;14(8):549-64.
Cognitive abilities are affected in different ways in various mental disorders. Some of these deficits are seen only during the active period of illness, but some changes are observed prior to the onset of mental disorder as well as in remission state. It is also possible that some changes are progressive, for example studies suggest that individuals with depression is likely to be at increased risk for dementia. What about the risk of dementia among individuals with bipolar disorder ?
Studies by Kessing et al ( 1994-2010) using the national registry data in Denmark revealed that patients with a history of admission for bipolar disorders had an increased risk of later diagnosis of dementia compared with general population.
Wu K-Y et al investigated this relationship using Taiwanese insurance database.98.4% of population is enrolled on this to receive clinical services. A random sample from a 10 year period was used in this analysis. For inclusion as eligible cases, subjects had to have at least three consistent diagnoses of dementia and be older than 45 years.Down syndrome individuals were excluded. Control group was those with no claims for dementia during the same period. For the exposure variable ( i.e. bipolar disorder), only those who had had at least three consistent bipolar diagnoses in either inpatient or outpatient claims data were included. Confounding factors (cardiovascular risk factors, medical comorbidities, and psychiatric disorders) were taken in to account in the regression models.
Subjects with bipolar disorder had a 4 fold higher risk of dementia than the controls [adjusted odds ratio (aOR) = 4.07; 95% CI: 3.08–5.37] . Risk was high for senile and pre senile dementias.
Claims data have the usual limitations. i.e. regarding the reliability and validity of the diagnoses of bipolar disorder and dementia. However only patients who had at least three consistent diagnoses (for both bipolar disorder and dementia) identified from out- patient and inpatient claim data were only included. Medical records were not available to link the claim data.Detailed information (clinical subtypes of dementia, severity of bipolar disorder, and number of acute relapses etc) were not available.
Conclusion:Subjects with a previous diagnosis of bipolar disorder may be at increased risk of subsequent dementia, even after controlling for pertinent risk factors.
Comment: Elderly individuals with history of bipolar disorder requires closer monitoring for possible cognitive decline on a regular basis.
Summary of the article:
Increased risk of developing dementia in patients with bipolar disorder: a nested matched case-control study.
Wu KY, Chang CM, Liang HY, Wu CS, Chia-Hsuan Wu E, Chen CH, Chau YL, Tsai HJ. Bipolar Disord. 2013. Do15: 787–794
Many changes occur in brain while an individual experience a depressive episode. This include alterations in cortical activity,shrinkage of neurones, changes in connectivity and loss of volume.Some of these changes are shown to correlate with depression severity .It is assumed that reduced neural plasticity could be fundamental to these changes. The counter argument is that the loss of motivation and effort is key to the observed changes.
Normann et al ( 2007) used changes in visual evoked potentials (VEP) in response to repeated visual stimuli as a means of examining changes in synaptic plasticity in depression and showed that increases in VEP amplitude were significantly smaller in depressed subjects compared with healthy controls.
Michael J Player and team of researchers from Australia under took the present study to assess neuroplasticity in depressed subjects compared with controls using a brain stimulation protocol (PAS:Paired Associative Stimulation) that induces temporary neuroplastic changes independent of subject effort. EMG was recorded from right first dorsal interosseous muscle.Motor evoked potentials (MEPs) were elicited by Transcranial Magnetic Stimuation (TMS). TMS to the left motor cortex was combined with electrical stimuli to the right ulnar nerve proximal to the wrist. Two hundred pairs of stimuli (TMS and ulnar nerve) were given.A motor learning task was added to see whether neuroplasticity as measured by the PAS protocol was related to functional ability.
The expected increase in cortical excitability with PAS is considered to be at least partially dependent on associative long-term potentiation.LTP is crucial for neural plasticity.
Both groups were similar to start with.There was a significant increase in the amplitude of motor evoked potentials (MEP) after PAS for the control group , whereas there was no change for the depression group .The amplitude decreased as depression severity increased.However the PAS results did not correlate with motor learning, nor appear to be related to BDNF measures.
Limitations: The majority of depressed subjects were on antidepressant medications ( i.e. what would be their effect?). To understand whether it is a state or trait phenomenon, neuroplasticity need to be measured while depressed as well as during remission. Neuroplasticity was assessed in the motor cortex, which is not considered the primary site of cerebral dysfunction in depression.
Conclusion: There is deficit of neuroplasticity in depressed subjects. It is possible that the mechanisms underlying LTP induction were impaired in the motor cortex in depression.
Sexual behaviour of the population is of immense interest to psychiatrists. The sexual behaviour/ practices/preferences are changing reflecting other changes in society. National Survey of Sexual Attitudes and Lifestyles survey ( UK) provide interesting insights in to this under researched area.This survey is done at 10 year intervals having started in 1990.
Catherine H Mercer et al report the findings of the third wave of survey.They used a multistage, clustered, and stratified probability sample design. All participants completed face-to-face interviews and a self report.Technology was used to avoid the interviewer seeing the responses of the participants during interview. Each interview lasted one hour.Sample was broadly representative of the British population in the age group 16–74 years.Response rate was 58%. Interviews were completed with 15162 participants .
Median age at first heterosexual intercourse was 17 years in both sexes.The proportion reporting first heterosexual intercourse before age 16 years increased. 31% between 16-24 reported having heterosexual intercourse before age 16.
Number of partners: Men have average 12 partners , women have 8. This was 13 and 7 respectively 10 years ago. However median number of partners remained same 6 ( men) and 4 ( women).Two thirds had only one partner in the past year. 23% had no partner in the past year.
Frequency: On average sexual intercourse happens 5 times in a month.This was 6 in the last survey.
Attitudes: 60% of the sample agree that same-sex relationship is not wrong at all. 9% do not think one night stand as wrong.
Practices: 60% have given or received oral sex last year. One third have masturbated in past 4 weeks.12% of women had same-sex experience.
Trends: Among women, same-sex relationship, average number of male partners ( life time) and having the experience of anal sex are increasing.Same sex relationship is more accepted.20% of men and 13% of women do not consider this as wrong. Women are more becoming tolerant of this.
Caution: Willingness to report and social desirability bias may contribute to differences. Methods adopted are same in recent two surveys.
Conclusion: Age at first sexual intercourse in people in Britain has decreased. Average number of partners have increased, this increase is more in women.Frequency of sexual intercourse has decreased.Sexual activity continues into later life. experimentation with sexual repertoires and sexual orientation has increased, especially by women, and the gap between the sexes are narrowing.
Summary of the article:
Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal).Lancet. Nov 2013. ahead of print. Catherine H Mercer et al published online November 26, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)62035-8