Category Archives: Academia

First academic boycott of the year.

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I’d like to thank Grant for pointing this out to me, but it looks like Elsevier has gone over the line here.

Institutions might think about whether they wish to receive money from a company like that in future. Worse still, is the revelation that Merck paid the publisher Elsevier to produce a publication.

The relationship between big pharma and publishers is perilous. Any industry with global revenues of $600bn can afford to buy quite a lot of adverts, and pharmaceutical companies also buy glossy expensive “reprints” of the trials it feels flattered by. As we noted in this column two months ago, there is evidence that all this money distorts editorial decisions.

This time Elsevier Australia went the whole hog, giving Merck an entire publication which resembled an academic journal, although in fact it only contained reprinted articles, or summaries, of other articles. In issue 2, for example, nine of the 29 articles concerned Vioxx, and a dozen of the remainder were about another Merck drug, Fosamax. All of these articles presented positive conclusions. Some were bizarre: such as a review article containing just two references.

In a statement to The Scientist magazine, Elsevier at first said the company “does not today consider a compilation of reprinted articles a ‘journal’”. I would like to expand on this ­statement: It was a collection of academic journal articles, published by the academic journal publisher Elsevier, in an academic ­journal-shaped package. Perhaps if it wasn’t an academic journal they could have made this clearer in the title which, I should have mentioned, was named: The Australasian Journal of Bone and Joint Medicine.

Things have deteriorated since. It turns out that Elsevier put out six such journals, sponsored by industry.

Now, I don’t really mind Big Pharma. I just assume, like Hollywood or MGM casinos, that their managers agenda is to maximise the return to their shareholders as it should be. I do have some concerns about academic publishers, and prefer open access as a model.  But the simple fact is that many academic and professional organizations use the commercial people. It means that you don’t have to “pay up front” to submit an article (in open access you pay for getting peer reviewed) and it generally means that the journal is run at a minimal loss. As a result of these issues, the ANZJP and Australasian Psychiatry, which are the organs of the RANZCP (which I have to remain a member of to continue to work), are run by SAGE.

But there are now a fair number of scientific bloggers saying that we should neither submit articles or peer review papers submitted to these journals. There is now a petition to sign.

All well and good. But the darn company has every academic library by the cojones. For they publish Lancet, Cell, and a pile of other high impact journals (I find it ironic that Lancet, which has been virulently anti war, is published by the same company that used to trade arms until there was a petition and boycott against this).

Now, there is a huge pressure of antipodean academics to publish in high impact journals. And Elseivier itselt monitors and promotes their journals as being high impact. From their website.

 

Martin Tanke, Managing Director of Elsevier’s Science & Technology Journals, added, “We continue to look at ways to improve the quality of our journals beyond the Impact Factor. Speeding up the reviewing process, investing in tools that further streamline the publishing process and continuous efforts to enhance peer review are some of our top priorities in this area. Let there be no doubt, however, that we are delighted to see this year’s significant Impact Factor increases.”

The Lancet and all three Lancet specialty journals improved their Impact Factors this year. The Lancet went up from 30.758 to 33.633, ranking 2nd in the Medicine, General & Internal category. Lancet Infectious Diseases and Lancet Neurology retained their #1 rankings in their respective categories, while Lancet Oncology saw its Impact Factor increase from 14.470 to 17.764.

Cell, the flagship journal of Cell Press, saw its Impact Factor increase from 31.152 to 32.401 and remains the number one research journal in the Cell Biology and Biochemistry & Molecular Biology subject categories. The impact factor for Immunity showed an impressive 18% increase to 24.221. Among Cell Press’s more recent suite of journal launches, Cancer Cell delivered a strong performance by showing an increase of almost 7% to 26.925, while Cell Stem Cell (increase to 25.943) and Cell Host & Microbe (increase to 13.728) continue to grow in their third year of impact factors.

To put that in perspective, psychiatry.net has tabulated the top medical journals.

There is one true Open Access journal in that list PLoS Medicine, and three semi open access (there is no time delay, but some parts are not accessible unless you subscribe) BMJ,  CMAJ and JAMA.  But Lancet has the kudos. And this is leveraged by Elsevier… who are trying to instead limit access.

However, if this spreads… the papers that make it into the Lancet and Cell would be published by NEJM and Nature. So there is a vulnerability, It will be interesting to see how this works, but supporting SOPA and Digital Rights Management, mucking up my ability to use Zotero makes me sympathetic to something I reflexly oppose. A boycott.

The antidepressant you are on is probably OK.

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A little bit of evidence based medicine. There has been a meta analysis of all the newer antidepressants in the Archives of Internal Medicine. (Medline link). This is important as (a) the older antidepressants are hardly ever used because they have lots of side effects (or lots more, because the newer ones have side effects and (b) some of the newer antidepressants are now available from generic manufacturers.

I’m going to show you two forest plots. For there to be a signficant difference… the confidence intervals must not touch the vertical line.

SNRI vs SSRI, Arch Int Med 2011;155:772-85

Serotonin and Noradrenaline uptake inhibitors versus Serotonon only uptake inhibitors.

As you can see, there are virtually no differences between the serotonin and noradrenaline (neurotransmitter) medications and the serotonin alone group.

This is the SSRI (Serotonin alone) group.

SSRI vs SSRI Arch Int Medci 2011;155:772-85

Serotonin only antidepressants against each other.

Now, most trials are sponsored by drug companies. About 20 years ago, the companies under powered each trial (which showed the medications were equivalent , which allowed registration). Nowdays, they need to show superiority… which requires more participants, and more expense.

But the data here is similar to clinical lore. Most modern antidepressants work well enough. You select them by looking at side effects, tolerability, and what did not work last time.

When the first love is broken.

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Today my younger son will be given prizes. He will play at his school assembly. School will break up. And tonight he will travel to be with his mother. Last night we had to pack his bag, and this morning the batter for pancakes, his favorite, has been made.

Being a solo father, at times is painful. Yesterday Kate Scott presented some data on the male and female ratios for depression. It appears that living in a more traditional society increases the rates of depression in women… and substance abuse in women. But it is not marriage that seems to be the big trigger, but divorce.

When I turn to today’s readings I find some challenges.

REVELATION 2:1-2:7
1″To the angel of the church in Ephesus write: These are the words of him who holds the seven stars in his right hand, who walks among the seven golden lampstands:
2″I know your works, your toil and your patient endurance. I know that you cannot tolerate evildoers; you have tested those who claim to be apostles but are not, and have found them to be false. 3I also know that you are enduring patiently and bearing up for the sake of my name, and that you have not grown weary. 4But I have this against you, that you have abandoned the love you had at first. 5Remember then from what you have fallen; repent, and do the works you did at first. If not, I will come to you and remove your lampstand from its place, unless you repent. 6Yet this is to your credit: you hate the works of the Nicolaitans, which I also hate. 7Let anyone who has an ear listen to what the Spirit is saying to the churches. To everyone who conquers, I will give permission to eat from the tree of life that is in the paradise of God.”

Yesteday I saw young colleagues come out of a seminar on career development buzzing. They had been listening to each other’s research… and they remembered why they had entered the field at all.
But we tend to forget this. Life grinds. My emotions this morning are being managed… because not only is the son visiting his mother throughout Christmas, but she has come to Dunedin to attend things at his school that I cannot (which is good) and I have to support this for my son’s sake. The marraige is dead, but we stumble on.
God reminds us that he is not like that. He will not fail us. In fact, he will not put the burdens on us that tradition will.

MATTHEW 23:1-12
1Then Jesus said to the crowds and to his disciples, 2″The scribes and the Pharisees sit on Moses’ seat; 3therefore, do whatever they teach you and follow it; but do not do as they do, for they do not practice what they teach. 4They tie up heavy burdens, hard to bear, and lay them on the shoulders of others; but they themselves are unwilling to lift a finger to move them. 5They do all their deeds to be seen by others; for they make their phylacteries broad and their fringes long. 6They love to have the place of honor at banquets and the best seats in the synagogues, 7and to be greeted with respect in the marketplaces, and to have people call them rabbi. 8But you are not to be called rabbi, for you have one teacher, and you are all students. 9And call no one your father on earth, for you have one Father — the one in heaven. 10Nor are you to be called instructors, for you have one instructor, the Messiah. 11The greatest among you will be your servant. 12All who exalt themselves will be humbled, and all who humble themselves will be exalted.”

I think we need to be very careful here. In the end, we depend on Jesus. And he reverses the commands…
… which is interesting. At this meeting, I am supposed to be leading. What this means is that I am either running sessions, grading posters, or organizing things that I had not thought we needed to do (good wine for the speakers? Two teleconferences? Find a speakerphone?… Done. To lead is to put the needs of others before yourself, at least in academe.
So we have to continually, continually, refer back to Jesus.
And Jesus was not being that sarcastic when he said the Pharisees sit on the Lar — that their theology was basically correct. But the hardness of the tradition, and the glosses on tradition, we oppressive, and at times contradicted the law. We therefore find our Lord and Master giving one of the most anticlerical speeches ever given.
And we need to follow him, and server, do good, and pray that our first love will be found. Because in this season, I confess mine is shattered.

CPAC Vancouver day 2.

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I got to two free papers talks today, and a drug sponsored meeting. From a new ideas point of view, the effect on testosterone during puberty in brain development — where it appears that there are changes in cortical thickness but in different hemispheres between boys and girls — was interesting. The same group from McGill also presented data on migraine as comorbid with mood disorders, and worsening the outcome.

The Astra-Zeneca sponsored talk was on treatment resistant depression. Three take home points (a) using measurements makes as much of a difference as giving medications (b) mindfulness therapy requires an hour of meditation a day — for therapist and client and (c) the most prescribed drug in the US is hydrocodiene… which is not available in NZ.

Nice people, sunny day, but the jet lag has cut in

CPAC Vancouver Day 1.

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I am in Vancouver at the Canadian Psychiatric Meeting, which is taking over two hotels…

By the time I got registered I had missed some of the first session, but did hear two talks — one on education on Mental Health and direct referral to community follow-up decreased liaison use and increased intern confidence in Ottawa, and a second on how a preclinical programme in Calgary decreases stigma and increases medical students choosing psychiatry.

I then went to a meeting designed to set up a nationwide group of tertiary psychiatrists dealing with the most seriously mentally ill. This was done years ago in Australia, NZ and the UK. It needs to be done in Canada, but they should look at what is happening elsewhere and build on that not just reinvent the wheel

After spending most of last night revising the talk, I had 15 minutes for 22 slides. With a very small audience — we started with six people in the room, of whom four were presenters.

However, that session included an analysis of community treatment orders which showed an improvement in death rate among those on orders (HR 0.6 95% CI 0.5 — 0.7). The author, Kisely, had done previous reviews which showed very little evidence for orders working.

The other two presenters talked about anxiety disorders and suicidal ideation (generalised worry and social phobia had higher associations)and Daneloo’s brief intervention being efficacious over 10 years.

I enjoyed that last session, even though the audience was small.

Cutting beds for the mad does not work.

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hoarding -- part of madness, perhapIn today’s paper is one of those events which happen if you have any form of community care for people who are actively psychotic. Any person who runs inpatient units (which I have done) will say that they cannot guarantee that such a tragedy will not happen on their unit, on their shift.

So my first reaction was “Thankfully not my unit” — then the inevitable guilt, because I do have sympathy for the family.

The family of attacker Jason Meradith Harvey, 39, are devastated about the assault, particularly since it was a family member who suffered 65 stitches and two skull fractures in the attack.

Harvey has been charged with the attempted murder of his brother-in-law, Mark Heighton, and an assault on his sister, Jo Heighton.

In the wake of the attack, Jo Heighton wrote to the Government asking when it would take action over Auckland District Health Board’s Te Whetu Tawera Unit.

The unit has been under considerable pressure for bed space and is cutting bed numbers.

Staff fear it will lead to patients being discharged too quickly to free up beds.

Harvey – a paranoid schizophrenic with substance abuse problems – had been discharged from Te Whetu Tawera five days before the attack. It was the third time he had been taken to the emergency mental health unit this year.

Harvey had also spent two extended periods at the Buchanan Rehabilitation Centre, a 40-bed mental health rehabilitation unit in Pt Chevalier.

via Mentally ill patient on a rampage – National – NZ Herald News.

One of the reasons I have sympathy for the family is that, like most people who work in mental health, I have been attacked. I have not been seriously injured — but people have tried to break my arm, punched me (a few episodes) and laid a bunch of complaints against me. The bruises fade. The compliants do not. And my experience is common.

Auckland’s central unit has had a series of incidents, There have been formal complaints to the centralised Health and disability commission that are publicly available. These are critical. There have been a series of high level reports but little action.

I trained in Auckland. I now work in Otago. There is a huge difference. We have some bed pressure — but we have around 45 — 50 (depending on Southland staffing) acute and 30 sub-acute beds for 400 000 people. Auckland is around 500 000 and has but 54 beds and shares all the sub-acute resources (which is two or three units of 15-20 beds each across the Northern Region which has 1.4 million people. In practise, these beds are not available.

This means that I have an ability to slow down the process of inpatient care. If something is not going well, if there is risk, if there is no adequate community care, at present* I can take a little more time.

Time is important. There are no gold tests for madness. I cannot point to a lesion on a MRI, or EEG, or blood test and reliably say that that it means anything. Moreover, the medications do not work all the time — in the first episodes they probably work about 80% of the time regardless of what is used, but it takes weeks to see a response. Longer term, 20% — 40% of people with schizophrenia don’t achieve clinical remission Sorting out what medications work, what support mechanisms work, and what rehabilitation is going to be appropriate and work for any one person and family is not magical. It takes time and talking.

And here beds matter. The hospital management, throughout the Western world, will not accept over crowding since it is linked with patient to patient violence.  We have de-institutionalised. Less beds are seen as better. But too few beds means you shorten stays to the point where people are discharged still mad. You have become a sedation service. And… given that the average community worked in Auckland used to have 60 people on their lists (this may have improved) the one visit a week you can reasonably expect a district nurse to give the person who is mad may not be enough to contain them.

There are some solutions that have worked, historically, but they are not politically palatable.

  1. Resurrect the long term psychiatric hospital — aiming for around 1 bed for every twenty to forty thousand population. People who have ongoing histories of aggression and treatment resistant madness used to be managed in total institutions, where the structure of the supervised week contained them. This approach is still used in forensic wards, but that is after the crime is committed.
  2. Increase the Assertive Community Teams without removing the current community mental health teams. The law needs to change so such a team can remove all monies from the person who is mad, and so that they can be seen daily, or thrice daily (case loads of 10 -15 people per worker). There should not be a “waiting list” for this.
  3. Increase the number of acute beds to 1:7 500 population.
  4. Move from an inpatient specialist team which can be influenced by powerful people (Auckland’s unit used to have John Read, who is actively anti medication, as its head of psychology. I am unsure as to if he is still there). Instead, have the inpatient care supervised by the community psychiatrist — either from the assertive or ordinary team. As a rule, if someone needs admission, they need specialist follow-up.
  5. Listen to the families and caregivers. Listen to the nurses. Listen to the patient If they are scared, they are probably right.

Nothing on this list is new. What is lacking is the poltical will to admit that we have moved too far down a path of liberalism, that the ideology of recovery has reached its limits, and that the human need for shelter and emotional asylum remains.

Cutting beds does not work. Destroying mental health workers by repeated enquiries does not work. Giving the system the tools that allow them take the time to build working relationships with the mad has a better chance of working.

 

 

 

Why smoking bans on psych wards have problems.

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Tim Dare is an Auckland lecturer in ethics I have considerable respect for. He has had a leader in the herald, on the current move to ban smoking inside psychiatric wards. This follows banning smoking inside prisons.

A survey of the effects of a smoking ban at Britain’s most secure psychiatric hospital, Rampton, though for the most part endorsing the ban, could not ignore disturbing trends which appear to raise doubts about the therapeutic merits of the ban. A comparison of violent incidents and the need to remove patients to ‘seclusion’ before and after the ban showed a dramatic increase among pre-ban smokers. Self harm and aggressive incidents increased by 25% and resort to seclusion doubled. (These rates would likely be worse at other hospitals: Rampton is unusually well resourced). Unsurprisingly, British Mental Health Foundation surveys have shown significant staff concern that smoking bans are a drain on resources (BBC Online 2009 (2009-06-21)). There is every reason to think the ban will require extra resources in New Zealand too, resources which could go into patient care.

That is especially troubling in the case of patients subject to compulsory treatment orders under the Mental Health Act, who have been placed in care following a hearing in which a mental health expert has satisfied a judge that the patient’s health needs are sufficiently significant and pressing to warrant compulsory treatment. Under those circumstances, there is extra reason to ensure that the ‘treatment opportunity’ used to justify hospitalisation is not compromised and that the scope of treatment is not extended beyond that necessary to address the triggering health concerns.

People who are detained under a mental health act are not there to be punished, but to be helped. Smoking is not good for your health =– true,  but stopping smoking abruptly can alter levels of antipsychotics, and that can be bad. Where I work, we offer gum and patches…. but many people want to smoke.

I’d rather put effort into getting the patient to agree to see a psychologist or take medications, These are the urgent priorities. Working on smoking cessation, improved diet, weight management and treating the consequences of the same are important — and are not the priorities during and acute admission in a society where there are minimal long term beds and the bulk of care occurs in the community.

In crisis, don’t trust.

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Some people say that crises are danger and a chance to grow. They misinterpret Chinese characters, they discuss the root causes of the crisis, they look to their leaders for solutions.

Classical conservatives know this. They listen to the psalmist.

Psalm 146

3 Do not put your trust in princes, in mortals, in whom there is no help.4 When their breath departs, they return to the earth; on that very day their plans perish.

via Daily Lectionary Readings — Devotions and Readings — Mission and Ministry — GAMC.

Leaders see crises as a chance to reform, to put forward a solution (which may or may not work), to do something. We should mistrust this. Sometimes the correct thing to do is nothing.

Good leaders are judged not by the victories they have, or the laws they have passed, but by the holiness, peacefulness and neighbourliness of the population. Good leaders rule in historically boring times. Bad leaders overstretch their people with multiple, conflicting goals, some of which are not attainable.

In a crisis, do not trust your leaders. Trust your neighbours more. Trust God, and only trust God fully.

Diagnosis and undiagnosis

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Figure 1 Distribution of proportion of variance explained estimates across all outcomes for different classifications of behavior disorder (continuous, dichotomous) and outcomes. The area within each box indicates interquartile range (IQR); the area within the whiskers indicates the lowest datum still within 1.5 IQR of the lower quartile and the highest datum still within 1.5 IQR of the upper quartile; closed dots indicate extreme outliers (>3 IQR). CD = conduct disorder; ODD = oppositional defiant disorder; ADHD = attention-deficit/hyperactivity disorder. From Fergusson, J Abnormal Psychology, 2010 Nov;119(4):699-712.

This post started as a comment on Alte’s place. She describes herself as having attention deficit problems:

On the one hand, I have boundless physical and mental energy, bordering on hyperactivity. On the other hand, I’m constantly battling fatigue and struggle to concentrate on even the simplest of tasks. Especially on the simplest of tasks, in fact. I find mental challenges relaxing and energizing, and mental ease stifling and exhausting. I’m intelligent and bursting with creativity, but I’m a college dropout who still doesn’t know her phonics or math facts. Four times five is… is… do you have a calculator I could use? Let’s discuss Euclid instead, please, or allow me to read an economic journal to relax after the mental stress of multiplication tables.

I’m quite aware that there is pressure on many mental health workers to diagnose. Particularly if a child is having difficulties, the roving support teachers will have in their head a diagnosis before referring to a doctor. People arrive with a diagnosis.

And this is the difficulty. To the graph — this is data from the Christchurch Child development Survey. It is looking at conduct disorder, Attention Deficit and Oppositional Defiant Disorder. The first thing to note is the graph implies that NO one factor can explain more than 20% of the variance (in “all behaviours” — which was mainly adult criminal behaviour, unemployment and substance abuse). Secondly, there no one factor that is explanatory. Things over lap. If you use the DSM as a checklist, you don’t end up with one diagnosis — you end up with none or several.

In December 2009 there was an issue in Psychological Medicine that was completely devoted to a proposed structure of psychiatric classification. Given the issues that arise around symptoms reoccurring, it suggested that we look at clusters of conditions. Part of the data for this was a reanalysis of how many symptoms contribute to various syndromes. The externalising disorders therefore don’t fit neatly into the classification system:

From the perspective of the current DSM, our focus is primarily on substance dependence, antisocial personality disorder and conduct disorder because these disorders have received the most research attention in studies focused on evaluating aspects of an externalizing spectrum conceptualization. Specific features of other disorders may also be understood as elements within an externalizing spectrum; for example, hyperactive/impulsive aspects of attention deficit hyperactivity disorder (ADHD) may be more relevant than inattention; and the impulsivity aspects of borderline personality disorder (BPD) may be more relevant than instability in self-image

Krueger RF, South SC. Externalizing disorders: cluster 5 of the proposed
meta-structure for DSM-V and ICD-11. Psychol Med. 2009 Dec;39(12):2061-70.

In children, all this is complicated by the reality of our education system. State education, despite efforts with the highly able and less able, is tuned for the majority of students — who by definition are of average ability. The highly bright often act differently, and this can be seen as abnormal.

The things that hunt with high intelligence (hyperfocusing and the associated inattention to cues, rapid processing, and rapid progress) lead to children being bored. And bored, intelligent children either tune out or do something. This can lead them being labelled wrongly.

Truly hyperactive children can appear to be oppositional. Oppositional children are often inattentive.

All of these groups may offend, distress, and disrupt the teaching space. Good teachers manage this. But, in this era of DSM, bad teachers reach for the diagnosis. And this leads to a need for as, Martyn Patfield has recently written undiagnosis.

A colleague commented recently that she spent a large proportion of her time ‘undiagnosing’ patients. I take her to mean that she challenges diagnoses which the patient has been given (and perhaps feels some attachment to) because the diagnosis is either clearly wrong or has little validity and also because the diagnosis is having a detrimental effect on the patient. Her use of the verb ‘to undiagnose’ has elements of humour and irony but it is interesting to think more about why it lingers as a useful word, even after the joke is over. 

Read More: http://informahealthcare.com/doi/full/10.3109/10398562.2010.539226

The author was concentrating on the patient. Undiagnosis is needed for other reasons as well. A false diagnosis means that people are getting therapies that they do not need, and may harm them. At the same time, people who need therapies may not get them (there is an opportunity cost in treatment) and (particularly if the disorder is fashionable) the suffering of the truly disabled may be trivialised by those who decide they would like a label that is currently fashionable.
NB. I am quoting from a series of papers that are not freely available, so to keep within fair use rules I’m omitting many details.

Installing Revman 5 in Fedora 14.

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Revman is the main programme used by the Cochrane Collaboration for preparing systematic reviews. It is also an extremely useful programme for doing any meta analysis. The programme is closed source, but is freely available from here You need the jave 6 version of the file whic is currently called. RevMan_5_unix_java6.sh

Download the file onto your hard disk. For the sake of this, let’s say it is now saved in download.

I have found installing this in ubuntu incredibly easy. It is quite simply

$ sudo sh RevMan_5_unix_java6.sh

.

Now, for various reasons, mainly about the migration away from gnome, I am not that enamoured with ubuntu. In fedora the situation is more complicated. You need to (a) make the file executable (b) ensure that you have the 32 bit libraries java libraries installed and (c) install as a superuser (or root) if you want any ability to update.

After some experimentation, this can be done with three commands.or five lines.

$ cd ~/Downloads #move to where the file is
$ su #become superuser, without changing where you are
# chmod 755 RevMan_5_unix_java6.sh #change permissions to allow anyone to read and execute the file
(for 64 bit systems only)
# yum install java-1.6.0-openjdk.i686 #installs the 32 bit versions of gnu java 1.5
]# sh RevMan_5_unix_java6.sh #install the file…. which should work.

You will end up with a menu item called “Review Manager 5″ under “other”. There are a couple of traps — in F14 the 32 bit files were recompiled for i686 processors and I’m fairly sure older versions of Fedora compiled to i536 or i386 — if you put the wrong suffix into “yum install java-1.6.0-openjdk.i686″ nothing will happen. (If you are running the 32 bit version of fedora, that line, of course, is redundant, but I run my machines using 64 bit software)

WIth the caveat that I have only tested this on a Fedora XFCE spin system, this may be of some use to people running other red hat based operating systems. I would appreciate comments on this.

.

UPDATE 7 June 2011

Installed Revman v 5.1 onto Fedora 15 Gnome 3. Some issues with gtk missing the pk-gtk and canberra-gtk module, but installed correctly.