Author: Dr Justin Marley

The Nature Podcasts reviewed here are of a typically high standard.  I thought the audio quality was very good. The hosts of the program speak clearly and slowly and there are helpful pauses between questions and answers which help the listener to take in the information that is being presented. In the Nature Podcast of November 19th 2009 (freely available here) there is a brief discussion of the works of Charles Darwin and the impact this had on his contemporary society. There is also a look at how Darwin’s theory of evolution spread throughout the world and some of the complexities of translating his works. In the Nature Podcast of November 26th 2009 (freely available here) there is a discussion of murine studies finding a relationship between osteoporosis and temperature regulation mediated through a protein Rank-L. There is also an interesting discussion of a study in which people were more likely to hear vowel sounds that sounded like a puff of air applied as a stimulus to their skin. The vowel sound involved pursing the lips which the researchers argue was analogous to the tactile stimulus that was applied to the skin and they speculate that sensory information from different modalities was being integrated before the decisions were made.

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The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

The blog reviewed here is ‘Practice what I Preach – A Child Psychiatrist Becomes a Parent‘. After receiving a comment on this blog from the author, an Australian Child Psychiatrist, recently, I became curious and had a look at the blog. I thought the premise for the blog was extremely interesting – what happens when a child psychiatrist becomes a parent and writes about the experience?

Appearance and Design

At the time of writing the blog has a grey background, blue title pane and white background for the articles. The articles consist of black text on a white background. On the right hand panel there are links to an About section, categories, a calendar as well as recent posts, blog statistics and a blogroll. The reader can also subscribe to the blog. There are also pictures in some of the articles which add to the presentation.

Content

The author who I will refer to as Dr D, an Australian Child Psychiatrist starts with this post explaining the motivations behind the blog. In this next article, Dr D describes the experience of being a patient and the thoughts she has about her interactions with the staff in this situation as a doctor patient. I thought this article was very interesting and reminded me of theme in the film ‘The Doctor‘. I think this will always be an interesting subject and can be very important for the introspection that contributes to the development of a speciality. In discussing this Dr D generated comments and this shared introspection was very interesting. In this post, Dr D discusses the issue of not getting enough sleep while in this article, Dr D talks about emotional attunement with the baby and mentions briefly theory in this area, an area which Winnicott wrote about (see review here). In this post, Dr D tells us about the sounds that her baby is beginning to make. What I found particularly interesting was when Dr D reviews the evidence base for when to use solid foods for feeding in coming to her own decision.

Conclusions

I found the premise behind Dr D’s blog extremely interesting and enjoyed reading through the articles which were filled with insights about the parenting process and also areas where the research or literature had something helpful to say.  Dr D writes candidly on the experience of parenting and I look forward to future posts.

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Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

The audiobook reviewed here is ‘The Voyage of the Beagle’ by Charles Darwin and narrated by Professor Richard Dawkins. It seems fitting that Dawkins should read this audiobook by Darwin as he travels on his historic voyage around the world. Dawkins narrates with an obvious passion for the work and each sentence is read so convincingly that it became easy to imagine Darwin’s corresponding experiences. Darwin’s writing in this book was a surprise to me. I had expected a concentrated description of the focus of his studies – the varieties of life that he witnessed. However Darwin takes considerable effort to describe not just the wonderful species that he came into contact with but also his own experience on what was a fantastic voyage around the world that would hold appeal to many over 150 years later. I was impressed when Darwin takes the time to describe the injustices that he witnessed against slaves with evident compassion for their plight. He describes the joy of being surrounded by the beautiful vistas, a visit to the Beagle by the Queen of Tahiti – Queen Pomarre, the anxiety of the sometimes dangerous encounters with indigenous tribes and the incomprehensible (to me) breakfast and lunch derived from a passing Armadillo.

Another striking feature is the eloquence of Darwin’s writing and this same writing had wide appeal to his Victorian audience on his return home. He writes humorously at times and I found myself laughing at some of the situations he  described. He also painted a vivid picture of the people that he encountered on his travels. However Darwin also delivers to us a vast number of observations about the taxonomies of the witnessed species but interspersed in the text in such a way as to become almost imperceptible except on further reflection. After this further reflection however it is possible to see at work the great mind of Darwin carefully abstracting his visual and auditory perceptions, integrating those abstractions into his internalised taxonomic structures and then attaching these new labels to his descriptions of the scenery to at once transform this same scene and offer the reader a new vision of the world through the eyes of a naturalist.

Throughout the work, Darwin also refers to the ‘countenance’ of the people he met during the journey and their facial expressions are described in various passages. It was tempting for me to suspect that he had already at this stage started to think about the expression of emotions in humans long before the publication of his book ‘The Expression of the Emotions in Man and Animals’ in 1872. Similarly there are various references to the pressures on animals in different environments. For instance in one passage he conjectures that a species of bird is adapting through generations so as to learn to avoid human predators which they were unable to do as individual birds in the short term.

This is a fascinating and well narrated book which is both entertaining without being too taxing and which gives an insight into Darwin and his experiences during this historic journey.

References

Charles Darwin. The Voyage of the Beagle. Narrated by Richard Dawkins. Originally published in 1837. Published as an audiobook in 2009 by CSA Word.

Charles Darwin. The Expression of the Emotions in Man and Animals. 1872.

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The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

The article reviewed here is ‘Patterns and Changes in Prescriber Attitudes Toward PDA Prescription-Assistive Technology’ by Arun Vishwanath and colleagues. The authors look at the characteristics of ‘early’ and ‘late’ adopters of PDA prescription-assistive technology. Their interest in attitudes is explained in the introduction when they cite research suggesting that attitudes towards new technology is correlated with adoption of this same technology.

They selected 244 clinicians  from an American academic tertiary care children’s hospital representing different professions but accounting for 90% of prescribers in the inpatient service. This high percentage suggests that the sample is likely to be representative of the inpatient prescribers. The prescribers had recently undergone training in the use of the PDA software. Commercial software was used and supplied by the company producing the software. Hospital and staff-owned PDA’s were used with the software and all PDA’s used in the course of the study were inspected to ensure that they met specific hardware standards. These standards in turn would ensure that the software was appropriately ‘responsive. Details of the training were given.

Assessments of clinician’s attitudes towards the technology before and after implementation were assessed using a Likert-scale questionnaire. The authors then state that the questionnaire design and administration was conducted by an external company that had previous experience with this type of research. Regarding the various tools that were used pre and post-implementation, the authors write that

‘All the measures used in the study were valid measures drawn from prior technology acceptance research and modified to suit the clinical context‘

I wasn’t sure of the type of validity that was being referred to and how the previous research tools were modified.  They also wrote that

‘All multi-item measures were reliable and achieved an acceptable alpha level‘ (alpha greater than 0.85).

A number of questionnaires were used and most used closed-questions but one gave the option for open-ended responses. Although I might have missed this I couldn’t find a clear definition of early and late adopters but the authors state that these groups can be distinguished on the basis of the results of a ‘five-item measure of the clinician’s attitude twoards PDAs, and a measure of the clinician’s likelihood to adopt the PDA within the next year’. Under the statistical analysis the authors write that

‘The data were analy(s)ed using the combination of multivariate techniques…..Segments were derived by applying a two-step clustering algorithm. The resulting segments were validated statistically using t-tests (Boneferroni adjustments) and theoretically compared to the EA and LA profiles suggested by diffusion theory‘

This excerpt is quite information dense and contains lots of different and complex statistical processes which would involve judgments as to their suitability. I would be interested to learn more about the analysis that took place at this stage. The use of the Boneferroni adjustments reflects that multiple comparisons were taking place on the dataset and that relationships were being explored rather than primary hypotheses tested. Another question I asked on reading this section is what was diffusion theory and why was it being used in this analysis?

The difficulty that I had with this analysis was that it led to the stratification of the sample into early and late adopters of the technology. I  would argue therefore that it is difficult to know how to apply this term in an intuitive way. For instance if I were to ask if a person were a late or early adopter I would need to refer to their exploratory statistical analysis of this group – I would argue that it becomes difficult to translate into other populations. If this is the case, then I would add that it means I don’t really know how meaningful this is to me. While intuitively we might know what early and late adopters of the technology might be this statistical meaning is very specific and defined by several layers of abstraction. If as a result I just say that early adopters are people that adopt the technology soon after its advent and late adopters otherwise, I will perhaps be able to apply this knowledge to other scenarios but as a result of the above arguments my conclusions may be markedly inaccurate.

Taking into account the previous arguments there are a number of observations that the authors have made about their groups of LA and EA’s. They identified the EA group as significantly younger than the LA group and tending to be residents rather than attending. On a number of measures the researchers found that after the intervention there were still significant differences between the EA’s and LA’s in their attitudes towards PDA’s. Essentially even after training early adopters generally had more positive attitudes towards PDA’s than late adopters.

In conclusion, I found it difficult to conceptualise the constructs of EA and LA’s. Even so, I could see that here was a method to create potentially useful categories on the basis of the statistical analysis and to identify significant associations which could then be used qualitatively. What I found interesting and to some extent predictable is that with interventions, people within one category tended to remain in that category. Perhaps this suggests that to have any impact particularly with attitudes there should be a sustained intervention, that such impact should be intended and that the systems have some advantage over contemporary systems. It is difficult for me to extrapolate further other than to say that attitudes do not necessarily have a direct translation into behaviours and triangulation can be helpful. As for the clinical utility of the PDA’s, this is a topic in itself and will be dependent on the hardware and software as well as the setting. Rapid changes in technology can also have an impact on the application of such studies.

References

Vishwanath A, Brodsky L, Shaha S et al. Patterns and changes in prescriber attitudes toward PDA prescription-assistive technology. International Journal of Medical Informatics. 78. 2009. 330-339.

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The paper reviewed here is ‘Symptoms as mediators of the relationship between neurocognition and functional outcome in schizophrenia:A Meta-analysis’ by Joseph Ventura and colleagues. In the conclusion to the abstract the authors write that

‘Although neurocognition and negative symptoms are both predictors of functional outcome, negative symptoms might at least partially mediate the relationship between neurocognition and outcome‘

The authors begin with an introduction in with a discussion of the literature on cognition in relation to negative symptoms. They state their hypothesis thus

‘that the meta-analysis would support a mediation hypothesis for negative symptoms based on the strength of the relationship between neurocognition and negative symptoms, and negative symptoms and outcome‘

The authors detail the methodology. There are 12 search terms that they used in the specified databases which included pubmed and Psycinfo. These 12 search terms did not include IQ or components of standardised test batteries. They did include terms such as executive function and working memory. They also manually extracted further references from retrieved articles. They retrieved 200 articles and further analysed these according to inclusion criteria. Thus diagnoses should be specified in the papers according to DSM criterion which thus excludes those papers which use ICD-10 criteria. I thought the other inclusion criteria seemed to me to be quite sensible and pragmatic e.g. the data in papers should not have been published previously elsewhere.

The authors state their definition of neurocognition and also their use of the MATRICS initiative for structuring domains of cognitive functioning to be used in the analysis and these are ’speed of processing, attention/vigilance, working memory, verbal learning, visual learning, and reasoning and problem solving’. They excluded social cognition which they thought to be another important independent mediator of the relationship in question. PANSS, SANS and SAPS were used for the assessment of positive and negative symptoms while functional outcome was divided into three broad areas which in turn had a range of outcome measures.

I didn’t understand the next stage. The authors aggregated the data from the neurocognitive domains into a single measure of neurocognition. I didn’t understand how aggregating speed of processing and problem solving for instance was meaningful. Each of these has been identified as a separate domain and so not only is data is being lost in this aggregation. However as the authors hint at in their discussion, not all of these domains are simply defined but are products of inter-related systems – different domains may share neural substrates. Thus if these domains are not entirely separate then I would argue that an additive operation is being applied to dependent data and that the result is not meaningful. I expected that individual test results would be aggregated and that after correcting for multiple comparisons effect sizes with p-values would be identified for the individual tests. While this would produce a large number of different results, these could be grouped after the initial analysis into broader categories if necessary.

The authors have identified a large number of studies according to clearly specified criteria and listed these in the paper together with a brief summary of each paper. The authors have aggregated the data into a single neurocognitive score which I didn’t understand. I would be interested to see an analysis of the interaction between individual test scores and the relationship between negative symptoms and functional outcome.

References

Ventura J, Hellemann G S, Thames A D et al. Symptoms as mediators of the relationship between neurocognition and functional outcome in schizophrenia: A meta-analysis. Schizophrenia Research. 113. 2009. 189-199.

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The article reviewed here is ‘The Genetic Basis of Human Brain Evolution’ by Vallender and colleagues. This is the 150th Anniversary of Darwin’s ‘On the Origin of Species’ and I thought it would be interesting to have a look at this article on the brain from an evolutionary perspective. This is a review article in Trends in Neuroscience by two american researchers, one in neurochemistry and the other in genetics. In the abstract, the authors write

‘…it has become possible only very recently to examine the genetic basis of human brain evolution. Through comparative genomics, tantali(s)ing insights regarding human brain evolution have emerged‘

The selection criteria for inclusion of studies is not stated although this is usual in a number of the reviews that I have seen. Introducing the reader to the subject, the authors then move on to look at genes which have changed in moving along the primate lineage from new world monkeys to humans. These include genes implicated in microcephaly, the Sonic Hedgehog gene (yes really!), the popular FOXP2 gene and SRPX2. There are various suggestions for why changes in these genes may be important including the possibility that the microcephaly associated genes products are important in cell-cycle control which in turn may influence the number of neuroprogenitor cells produced and hence brain size.

The authors also discuss novel genes that have arisen in evolution including the mysterious Morpheus gene the function of which is as yet undetermined, the Opsin gene (thought to be directly related to the development of trichromatic vision in catarrhines) and GLUD2. They then go on to discuss the loss of genes including members of the olfactory gene family. They also look at the difficulties in understanding changes in gene expression in the human brain during evolution as well as some changes seen in non-coding regions. They also offer the following fascinating insight

‘..mammals in general and birds to some degree, exhibit a trend of brain expansion over evolutionary time that is absent in other vertebrates‘

The authors end by suggesting that future studies should focus on testing specific rather than general theories.

In conclusion, I found this to be a concise and accessible review of a fascinating subject. On the 150th Anniversay of the publication of ‘On the Origin of Species’ there has been much progress in evolutionary theory and subsequent reinterpretation of natural world phenomenon. In evolutionary psychiatry (see review here)  there has been an emphasis on laying the foundations with reference to common mental illnesses and how they might be shaped by the pressures of natural and sexual selection. The explanations have benefitted from insights gained from  the field of evolutionary psychology (see review of book on evolutionary psychology here). Adding a genetic strand to this understanding may give neuroanatomic insights into function and pathology which tie in with the understanding of neurodevelopment and neuropsychology. As the authors point out, this field is in its infancy and although it is too early to draw firm conclusions, I suspect these will quickly develop and form the foundations for this new discipline.

References

Vallender E J, Mekel-Bobrov N and Lahn B T. Genetic basis of human brain evolution. Trends in Neuroscience. Vol 31. No 12. pp636-644. 2008.

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Research in Dementia

A study in Nature Neuroscience suggests that Amyloid Beta is integral to memory function and that deviation from optimal levels is likely to lead to pathology. This in turn would suggest that removing Amyloid Beta from the plaque may not be a successful strategy in Alzheimer’s Disease if this optimal level is not addressed. However this discussion is taking place around cellular mechanisms and it will be useful to see how these predictions tie in with the relevant clinical trials. A suggestion has been made that a precursor to Nerve Growth Factor may be involved in the pathogenesis of Alzheimer’s Disease (AD) on the basis of a significant increase in the levels of the precursor in AD post-mortem samples and findings in a murine model. Stroke is related to dementia in a number of ways and modifying stroke risk factors can reduce the risk of dementia. Thus a prospective study (n=3298) with a follow-up period of 9 years showed that moderate or heavy exercise was asssociated with a significantly reduced risk of developing stroke. Thus the risk was 2.7% in those with moderate-to-heavy exercise and 4.6% in those with no exercise*. A potentially very useful study used the Alzheimer’s Disease Neuroimaging Initiative dataset to develop a method of analysing MRI data which involves two scans and a focus on loss of tissue in the Entorhinal Cortex and it will be intereresting to see the results of further research in this area. A 32-year prospective study – the Prospective Population Study of Women in Gothenburg found an association between central adiposity in middle age and prevalence of subsequent dementia. They did not find the same relationship between BMI and subsequent dementia but the central adiposity was associated with an approximate doubling of the prevalence of subsequent dementia.

General

The researchers in a study in Neuron found an association between modifications of cortical theta oscillations and the perception of intact sounds when presented with fragmentary sounds. Thus the implication is that there is an EEG correlate of auditory illusions. A recent study looking at falls in older adults found associations with a number of medications. The researchers in another study looking at falls in the elderly (the MOBILIZE study, n=729) found that those with chronic pain were significantly more likely to fall than their counterparts without*** An American study showed that just  under half of the 3 to 6 year olds in the study were concerned about becoming obese and one-third wanted to change an aspect of their appearance. Another American study (due to be published next year and with n=184) contrasted brief motivational interviewing with a control intervention (warning about the hazards of drinking and driving) in drink-driving recidivists was associated with a 30% reduction in repeat offences. Another study offers preliminary insights into the potential role of the delta waves generated in the hippocampus and the authors hypothesise on the basis of their results that the frequency of the delta waves code information about the type of processing that should take place in different regions – processing about the past or present.

Evolutionary Psychiatry

The new buzz word in this area is ‘primate archaeology’ which is an attempt to integrate a number of areas including primatology, anthropology and psychology. This article summarises this new ‘movement’ and looks at some very interesting research into the use of stone tools by chimpanzees in what is being described as a parallel with the advent of the stone age in humans.

DSM-V

DSM-V is due to appear in 2012. A twitter campaign has been started to petition for the inclusion of Depressive Personality Disorder in DSM-V. Professor Simon Baron-Cohen has argued against the removal of the Asperger Syndrome label in this New York Times article. Dr Anestis offers his views on this article and Baron-Cohen responds in this blog post.

Psychiatry 2.0

In a small study, participants were observed using search engines. The researchers concluded that search strategies were influenced by the learning styles of the participants and that participants often used search engines to confirm then own recall of a subject. A recent MyPublicServices event was held to discuss ways in which social media might impact on public services. It was suggested at the conference and reported in this article, that social media may impact on public health service delivery as it has done in many other sectors and that a constructive approach to using social media in th9s area could be adopted. One research study into viral marketing campaigns focused on the characteristics of e-mavens – people who spend a lot of time online**. E-maven’s characteristics were identified and those that were more likely to forward viral material onto others scored more highly on measures of individualism and altruism. On the subject of viral marketing – these usually pass me by but this one is pure genius! The video was made by the staff at Providence St Vincent Medical Centre in Portland, Oregon to raise awareness of Breast Cancer. Enjoy!

* The recent finding that dog owners get more exercise than gym-users may be of relevance in this regards. Thus it would be interesting to see the risk of dementia in dog owners (there are forms of pet therapy that have been employed for use in people with dementia although this is a slightly different issue)

** I’m not sure if this group would be considered at risk of the very controversial diagnosis of ‘internet addiction’ although this illustrates very nicely the balance between what some might consider illness behaviour and what others might consider socially constructive behaviour.

*** The study was partly funded by Pfizer

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I’ve broadened out the podcast reviews to encompass media which include film and video particularly as there is an ever increasing amount of material on YouTube.

The topic I chose for this review is social anxiety and social phobia (or social anxiety disorder) on YouTube. I found quite a large number of videos on this topic but have just reviewed a small proportion of them here. The majority relate to social phobia and one to social anxiety and they are divided into education and experiential videos.

In this video, the lecturer gives a talk on social phobia with a case study and he also goes over some of the diagnostic criteria. He also goes over some of the treatments and is in two parts which in total runs to about 13 minutes. This cartoon features what sounded to me like adolescent narrators who explain social phobia with references to the amygdala and prefrontal cortex. The video also explains how it affects people and includes references to pharmacotherapy and psychotherapy runing to five and a half minutes. I wasn’t sure of the age of the target audience but the video is well presented and covers a lot of the basic information accessibly. This video is effectively a small number of slides displayed sequentially with background music. The slides contain some details about social phobia but I didn’t find them to be as informative as some of the other videos but this would be useful to someone who wants a rapid overview.

From the experiential perspective, there were a number of videos communicating the inner experience of social phobia. The diagnosis of social phobia is taken in good faith and the people in the videos explain what this means to them experientially. The videos can be very involved and would be orientated towards an adult audience. Certainly in putting together videos of their experiences these people are very courageous and I wondered how the nature of audience affected the social anxiety. For instance if the audience will view the video many years after it was made, how does this interact with the social anxiety? In this video, the quietangel123 has put together images and music to convey the experience of being alone although the term social anxiety disroder is used in the title. AlanJones78 narrates with a background picture about his experience of social anxiety over five minutes explaining the thoughts and feelings he has. Nayomee77 presents two videos (here and here)  on her experiences of social phobia and the difficulties she has had in trying to cope with this. These videos have generated a lot of viewings and comments.

These are just a few of the videos that I came across on YouTube but there is already quite a lot of material showing how differently people can communicate the theoretical aspects of social phobia and even how the experiences can be communicated by those suffering with social anxiety and just how much of an effect this can have on a person’s life. Communities can build up in the YouTube forum and it would be interesting to know if this is beneficial through text comments and video responses.

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The audiobook reviewed here is the ‘Borderlands of Science’ written by Michael Sherman and narrated by Grover Gardner. Gardner narrates at a moderate pace and with an expression that is able to keep the listener engaged over the 13 hours of the audiobook. Sherman’s book is about the areas at the ‘edge’ or borders of science and includes a discussion of the distinction between what he considers science, non-science and nonsense. I found myself sympathetic at times to Gardner’s arguments as he employs reasoning and evidence in his investigation of various fields. I found a central theme running through the book was that of evolutionary theory be this in the discussion of Edward Wallace’s codiscovery of natural selection and interest in spiritualism or a comparison of Darwin and Freud. Sherman is rather dismissive of Freud and psychoanalysis and relatively early in the book refers to psychoanalysis as a pseudoscience and later in his comparison of Freud and Darwin paints the picture of Freud as a celebrity in passing who’s writings have not stood the test of time in contrast with Darwin as a hero who’s greatness has increased through time as the validity of his theories have become increasingly evident. The manner in which Sherman paints the endeavours of a global body of psychoanalysts with a single label ‘pseudoscience’ is in my opinion unfortunate. This contrasts with Sherman’s discussion of the works of Frank Sulloway in establishing retrospectively a relationship between the works of great scientists and birth order supported in this same retrospective analysis with commentary on their personalities. While Sherman admonishes another author for the use of ‘confirmatory bias’ he himself applies this same bias to Freud by carefully selecting those statements made by Freud along with biographical details about him which when pastiched, caricature him as a self-styled conquistador who was preoccupied with his image and mythology. Freud has written on numerous occasions with humility imploring those who study his writings to employ them with due caution and to improve upon his theory. While there is much about Freud’s writings and approach that can be criticised he was a keen observer of human nature and had conducted basic science research and studied with one of the leading neurologists of his time Charcot before developing his methods of psychoanalysis. Freud’s writings are filled with references that will be familiar to clinicians such as the exclusion of organic states when examining the cases of ‘neurosis’ along with discussion with medical colleagues about appropriate management. This suggests that his practice was not an isolated ad hoc experimental journey led from his inner fantasy life but is instead an attempt to understand the mind through a systematic analytical process by a physician who was well versed in basic research methodology and who in his practice communicated, sought the opinions of and referred through patients to his colleagues in the medical profession. Indeed Sherman could on looking closely at some of Freud’s writings (see reviews here and here) see someone with similar values to himself as when Freud writes

‘There is no authority higher than reason’

Such parallels become obvious secondary to a thorough analysis of the relevant branch of the history of science – in this case psychoanalysis.

Similarly the field of psychoanalysis is far from an outdated model with no progress in research as suggested by Sherman but instead is supported by a variety of research studies broaching multiple disciplines (see as an example the debate (Wolpert and Fonagy, 2009)). Returning to the historical analysis by Sulloway as described by Sherman we hear of various speculations about the basis for these birth order findings. However it must be borne in mind that this is a retrospective analysis of a select group of figures. The speculation that follows can itself be considered prescience, in the sense that these speculations need to be backed up with evidence to stand on a firmer footing. These same speculations attempt to attribute a meaning that we can understand but ironically the meaning for an individual is much more likely to be afforded through the work done with an individual in therapy (depending on the objectives) than by the application of the results of group data analysis to an individual. Such group data works best at the group level but could properly be considered to offer a guide when applied to the individual because of the large number of confounders that may operate upon the relationship of interest. In addition the use of a five-factor model along with the birth-order is essentially a quantitative analysis. On the other hand an important feature of psychoanalysis which sets it up as a soft target is the use of a qualitative approach in which language and non-verbal communication aids the therapist in their role. Interestingly in communicating to the listener just what science is, Sherman is using the medium of language in a way which makes approximations and assumptions about the audience which may or may not be correct, references relationships and appeals to both reason and the emotion. In order to do so, it is reasonable to assume that Sherman values this medium sufficiently to use it as a vehicle for his message and in so doing he shares such an approach with therapists who communicate with each other through language and use language as a medium for therapy.

The end result is that Sherman espouses a view of science in which Darwin’s theory of natural selection is an example par excellence of the results of this approach. However if science is an attempt to gain a better understanding of the universe, neutral and undisturbed by our values and prejudices then our path to this understanding does not need to be constrained by a single approach – the quantitative approach generating large data sets and supported by unquestionable statistics with very small p-values. There should be a tacit acknowledgment that there are areas where the descriptive language differs – such as the languages that optimally describe the mind and the brain (see review here). Indeed it is the language of the mind that Sherman uses when he appeals to our reasoning and our emotions and which he does so adeptly. What I consider to be a hidden subtext of the validity of quantitative versus qualitative methodology is illustrated by Sherman’s quotation of an fMRI study in which the findings are used to ‘debunk’ a psychoanalytic explanation. This is done by referring to the ‘expertise’ of the neuroimaging researcher but the dangers of glossing over the many assumptions in such research have been well illustrated (see review here).

I would argue that when a subject such as psychoanalysis is reduced to a simple notion then significant elements of truth and utility get lost in the process. By this stage it is all too easy to apply the rather dubious notion of ‘pseudoscience’. As Einstein once said,

‘Everything should be made as simple as possible but not simpler’

Of note, Einstein was working as a clerk at the patent office, isolated from the scientific community when he submitted his theory of relativity for publication, a theory which would be paradigm shifting and which he no doubt recognised as such. Interestingly Sherman discusses the above characteristics but in another context in which he predicts those who do not contribute meaningfully to science.

In other parts of the book, Shermer is convincing as in his discussion of the Piltdown Man hoax and his treatment of the life of Wallace and his heretical traits. Sherman is extremely comfortable and knowledgeable in writing about Wallace and there is much to learn from the story of the cocreator of the theory of natural selection. Sherman is also comfortable in tackling controversial areas and uses his knowledge of science to convincingly address problems that do not seem to have obvious answers. Shermer’s approach polarises the subjects he explores and this can be useful in helping to make decisions that apply to those areas. At the same time, as in the case of psychoanalysis which does not adhere to Shermer’s idealised scientific method outlined above, it impacts not just on the theory but also has the potential to impact on the wider culture related to that body of theory and sensitivity is merited in any such discussion.

References

Michael Shermer. The Borderlands of Science. Narrated by Grover Gardner. Books on Tape. 2001.

Wolpert L and Fonagy P. There is no place for the psychoanalytic case report in the British Journal of Psychiatry. In Debate. pp483-487. 2009.

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The article reviewed here is a South Korean paper on ‘Ubiquitous Healthcare Service Using Zigbee and Mobile Phone for Elderly Patients’ by Hak Jong Lee and colleagues. In the introduction the authors discuss the ever more pervasive nature of technology. While noting the focus on hospital information systems, they note the possibility of using technologies to allow communication between the hospital and patients outside of the hospital. They note that a new wireless internet protocol Zigbee has been developed which offers a number of advantages including low power consumption. Such technology is being increasingly used in consumer electronics and the researchers were interested to see how this might be applied in healthcare. They therefore looked at a specific population – older adults – and wanted to see if they could monitor glucose levels and ECG’s in the community.

The study was a small prospective study (n=29) carried out in 2005. I found it slightly amusing that the 6-page article had been initially received in June 2006 and that the revised version was received in July 2008 when it was accepted. However delays between submission and publication in journals can be due to the logistics involved. I wasn’t clear on how sample selection was achieved and this will have a bearing on the results as successful use of the technology requires that the subject is able to use several technologies effectively. 9 subjects in the study received an ECG vest which they wore and which took readings every hour. If they were symptomatic (e.g. with palpitations) they would press a button to initiate a data capture. 20 of the subjects used a glucometer – to measure blood glucose levels. The subjects were trained in the necessary skills to ensure that the data was transmitted from the equipment to the web using a web-based program. A nurse contacted patients once weekly to administer a questionnaire regarding ‘convenience and satisfaction’. The details of the questionnaire were not included in the paper, nor were details regarding the validity and reliability of this instrument. Technical data regarding the equipment such as error rates were also identified.

With regards to the glucometer readings, the researchers found that information loss between the glucometer and the web-based service occurred in 22% of recordings and that this occurred at several points along the pathway including the mobile phone and a defect of the glucometer. A problem noticed by the participants was a large difference between the new wireless enabled glucometer and readings on the previous glucometer causing several subjects to withdrawal. However overall satisfaction was rated as 8.5/10 by the subjects (which most probably represents the intuitive meaning of scoring out of 10 which is commonly used outside of the research field). In terms of the ECG monitoring, some of the subjects withdrew from this part of the study due to a

‘fear of transmission of electromagnetic waves, skin eruption at the place where the ECG line and electrode were attached to the body and troublesome problems of attaching ECG‘

Interestingly only 57.9% of the transmitted data from the ECG was considered useful. The mean satisfaction score for the ECG sensor was 5.79. Discomfort occurred as a result of the ECG being attached to the body for 24-hour periods. As there was frequent transmission of data, the battery life of the mobile phones was also an issue.

In conclusion, this was a proof of principle. The technology itself proved effective here but it must be remembered that the technology does not occur in isolation but instead must operate within the wider healthcare environment. This in turn is dependent upon cultural factors, budgets, infrastructure and an appropriate evidence-base for the relevant healthcare service. Many technologies that achieve the chosen objectives and fulfill a useful function do not pass on into the mainstream as these barriers must be overcome. The researchers note that the emphasis in this study was on the technical aspects of the technology rather than the clinical utility. The rate at which data loss occurred as well as the need for participants to use several pieces of technology and the relatively small sample size means that further studies should examine the clinical utility in more detail. Glucose and ECG monitoring are potentially useful in various services and if a successful technology is achievable then it offers an opportunity for leveraging healthcare resources. Other types of monitoring device have the potential to be utilised using the same wireless protocols although this is already occurring using a variety of other technologies also. This study illustrates some of the difficulties that a technological solution to a healthcare problem needs to overcome in order to be of clinical utility. If such barriers are consistently overcome then this would enable new services to be developed and may impact on outcome measures in services.

References

Lee H J, Lee S H, Ha K-S, Jang H C, Chung W-Y, Kim J Y, Change Y-S and Yoo D H. Ubiquitous healthcare service using Zigbee and mobile phone for elderly patients. International Journal of Medical Informatics. 78. 2009. 193-198.

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The paper reviewed here is ‘Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking’ by Bonnewyn and colleagues. In the conclusion to the abstract the authors write that

‘(Painful physical symptoms) were more likely in people with a 12-month major depressive episode (MDE) than in those without (OR=2.0)‘

In the introduction, the authors cite research showing a prevalence of pain in older adults of between 25 and 88%. The authors then briefly discuss the pain-depression dyad explaining the antecedent and consequence hypotheses which expand on the nature of the dyad. The aims of the study are clearly outlined and include an evaluation of the relationship between pain and depression in a community-dwelling sample of older adults (65 years and older) as well as the interactions with the use of mental health services and benzodiazepine use.

The data was obtained from the European Study on the Epidemiology of Mental Disorders (ESEMeD) a study which was initiated by the World Health Organisation. Data was obtained from 6 countries – France, Germany, Italy, Belgium, Holland and Spain. The researchers write that some of the specifics of the sampling process have been described in another paper. I wasn’t clear on the details of the sampling method as a result and the researchers note that

‘a stratified, multistage, clustered area, probability sample was used‘

59.4% of the sample were female and 38.4% were age 75 and over. 36.3% of the sample lived in rural areas compared to 26.6% that lived in urban areas. The majority of the sample (52%) had 0-11 years of education. Participants were interviewed using the Composite International Diagnostic Interview with major depressive disorder diagnosed using DSM-IV criteria and a list of questions used to detect the presence of painful symptoms specifying within the last 12 months in some of these questions. They were also asked if they had one of a number of chronic medical conditions some of which are common medical conditiosn (e.g. asthma and diabetes). They were also asked about antidepressant and benzodiazepine use. Their estimated point prevalence of painful physical symptoms in the sample was 31.8% and although they were calculated as more common in men there was no confidence intervals for this comparison. PPS were significantly more likely in females with major depressive episode than those without. Using depression as the dependent variable, the researchers ran a multvariate analysis which identified female gender and pain as predictors of depression. Without major depression, the likelihood of antidepressant use was three times greater in those with painful physical symptoms compared to those without. For participants with depression, there was no significant difference between those with and without painful physical symptoms in the use of antidepressant medication. There was a doubling in the use of benzodiazepines in those without major depression but with painful physical symptoms (PPS) compared to those with major depression but without PPS. Major depression was also found to be signficantly associated with benzodiazepine use.

In the discussion, the authors note that from their results somatic conditions mediated the relationship between depression and pain. The authors also  comment on the two-fold increase in PPS with major depressive episode and the increased prevalence of PPS with female gender. Whilst these latter two findings were consistent with previous literature, like the researchers I found the results for antidepressant and benzodiazepine use interesting. Firstly antidepressant use was found to be higher in those without major depression but with pain. The use of benzodiazepines was increased in those with major depression also. I wasn’t clear if there was a prominent anxiety component in those using benzodiazepines but given that only 20% of those with depression were receiving antidepressants a different pattern of prescribing could be explored. This however would depend on local guidelines particularly as the sample is taken from 6 countries.

In conclusion, I thought there were some interesting findings here particularly the use of antidepressants in those with pain but not major depression. It could be that the depression had been previously treated and was in remission. Alternatively it could mean that the subject or the prescriber had intended for the antidepressants to be used for the pain. It would be interesting to see how factors such as pain duration and intensity impact on antidepressant use. The paper provides valuable insights into the relationship between pain and depression in older adults and I would be interested to see in particular if there are any follow-up studies examining the use or underprescribing of antidepressants as well as benzodiazepine in the same or other regions.

References

Bonnewyn A, Katona C, Bruffaerts R, Haro J M, de Graaf R, Alonso J and Demyttenaere K. Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking. Journal of Affective Disorders. 117. 193-196. 2009.

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The paper reviewed here is ‘Predicting Age-Specific Dosing of Antipsychotics’ by Uchida and colleagues. This is an opinion piece rather than a systematic review or research study which thus affords it more flexibility in the approach to the subject although firmer conclusions can be expected in other types of article in the evidence-base hierarchy. The authors consider the interaction between age and the loading dose for antipsychotics which the authors point out is especially important given the recent studies and reports on antipsychotics in specific populations (see here for example)*.

The authors argue citing evidence in the process, that with increasing age there is a loss both of the clearance of a drug (specific example given) and a decrease in the number of D2 receptors available for binding, a figure which decreases linearly with each passing decade. They also argue that surveys of prescribing data show age associated changes in the prescribed dose of antipsychotics for people with schizophrenia which supports the hypothesis that lower doses of antipsychotics should be prescribed in older age. This in turn is in keeping with various expert consensus guidelines. However there are obvious cultural factors that influence such prescribing and the authors note these confounders. The authors then outline a strategy for making predictions of D2 occupancy based on the plasma levels of an antipsychotic and to ensure this is applied across the lifespan. They have further studies in preparation.

Having such data is obviously extremely important and would imply that plasma levels would become clinically meaningful. There are several complexities that occur in this regards however. In older adults, polypharmacy is common relative to the population of younger adults which has the potential to influence plasma drug levels. While it can be argued that if there is a linear relationship between D2 occupancy and plasma drug levels the measured values still give useful information, such interactions may produce fluctuations in these drug levels which in turn would be expected to influence D2 occupancy. Nevertheless this argument would need supporting data. Another complexity here is that the drug clearance is influenced both by renal pathology and a number of other factors. This leads onto the point that with increasing age, comorbidity and polypharmacy may lead to an increasingly heterogenous population. This in turn may make it difficult to utilise a single model effectively and may necessitate solutions which organise this complexity in ways which facilitate prediction. This speculation also is in need of supporting data. Finally, particularly with the atypical antipsychotics, the actions have been argued to be effected not just at the D2 receptors but at a range of other receptors including other dopamine receptor subtypes, serotonin receptors, histamine receptors and so on. Thus it could be argued that an investigation of the same relationship between occupancy status and plasma drug levels could provide data contributing to more complex and realistic models.

The approach to studying lifespan changes in loading dose of antipsychotics is encouraging and it will be interesting to see the development of comprehensive age-related pharmacodynamic and pharmacokinetic models which are of clinical relevance and which can be combined with changes in practice to improve outcomes.

* The authors declare a potential conflicts of interests which include financial support from several pharmaceutical companies.

References

Uchida H, Pollock B G, Bies R R and Mamo D C. Predicting Age-Specific Dosing of Antipsychotics. Clinical Pharmacology and Therapeutics. Vol 86. Number 4. October 2009. 360-362.

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Miscellaneous

Using data from the National Epidemiological Survey on Alcohol and Related Conditions, an american study involving data on 43,000 people, older adults (over the age of 60 in this study) with alcohol dependence consumed an average of 40 alcoholic drinks per week compared to ‘between 25 and 35 drinks a week’ in the younger group. An american study is looking at whether PTSD can be predicted by incorporating a number of biological markers. The Lean Healthcare Academy recently had an awards ceremony and a hospital which implemented the Productive Ward was the recipient of an award. The Productive Ward and related Productive Series involve a systematic process to enable improvements in outcome measures such as efficiency (see review here). It is interesting to see how American and Japanese culture and technology is being used to improve care for patients in the NHS in an ever more connected world. The Productive Ward series is covered at the National Institute for Technology here. The series also includes approaches to improve outcomes in community care as well as other types of service.

News Round-Ups

Over at the Clinical Cases and Images blog there is a summary of recent news tweets. Alz Forum have got coverage of the recent Clinical Trials in Alzheimer’s Disease conference in Las Vegas here. They look at the Wisconsin Registry for Alzheimer’s Prevention study, the Memory Capacity Test and research on the CogState test amongst others. The Schizophrenia Research Forum have coverage of a recent murine study showing an association between mutations in the dysregulin gene (which has been associated with schizophrenia in genome wide association studies) and the function of fast-spiking interneurons.  Mind Hacks has coverage of a number of studies including one in which sounds presented during sleep were associated with improved learning on spatial tasks.

Psychiatry 2.0

The Google Wave tool which has been recently rolled out enables live collaboration using a number of tools and in this article Leah Betancourt discusses some of the ways this is being used in the creation, dissemination and discussion of news. Conventional methods for disseminating scientific/clinical information including conferences, journals and books are now in the process of being transformed by such tools. Another development which has the potential to have a profound impact on society, Government 2.0 was discussed at a recent conference. The idea here is that citizens can both engage with and contribute to the decision-making process of government. As an example this may impact on the way in which different segments of society are represented and this in turn could impact on health and illness on a number of levels. The American Association for the Advancement of Science has set up an expert lab to help government engage with citizens using technology and enabling them to tap into ‘crowd expertise’. There is a video on the expert lab here. In an american survey by Manhattan Research, 39% of doctors stated that they had communicated with patients online although the insurance-based nature of the healthcare system may influence such relationships. An article here looks at how doctors are using technologies such as twitter and the iPhone in their practice.  Meanwhile the Danish Government is intending to go paperless by 2010.

It is a privilege for the TAWOP blog to have been included in a list of 100 blogs for psychology students and there are many interesting blogs included in this list.

Appendix

Researchers at the Universities of Warwick and Manchester compared a course of therapy costing £800 with the effects of an increase in salary or lottery winnings. Their findings apparently showed that the £800 course of therapy produced an increase in a measure of well-being that was  equivalent to that produced by a pay rise or winnings of £25,000 causing the researchers to conclude that therapy was ‘32 times more cost-effective at increasing happiness than money’ (quote from news report).  However I wasn’t able to find the study (perhaps its preprint) and wasn’t clear on what the outcome measures were and the details of the therapy. In a press release from the company producing the devices a study (n=7) provided preliminary evidence that Deep Transcranial Magnetic Stimulation could improve scoreson measures of auditory hallucinations and psychosis. However these were described as interim results and from the limited information in the press release it looks as though a further 13 patients are to be included and so it will be interesting to further review these results when the study has been completed and submitted for publication.

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On a visit to Sandeep Gautam’s Mousetrap blog I came across this video and Gautam takes the opportunity to further discuss the contrasting Eastern and Western values in terms of illnesses such as psychosis. The video that Gautam refers to consists of a presentation by Dr Devdutt Pattanaik who describes himself as a medical doctor who has gone on to advise businesses on ideas, mythology and beliefs. I found this video interesting for a number of reasons. Firstly Pattanik gives an extraordinairy performance – a showcase for just how good a presentation can be. He weaves a narrative into his presentation with the meeting of Eastern and Western cultures. He uses some slides, but these really fade into the background because he carries the presentation through his charismatic performance. It is almost as though he is negotiating with the audience at each point. Secondly the content of the presentation is very interesting also in that he contrasts Eastern and Western lifestyle approaches. It can be argued that there is no single Western or Eastern approach, making contrasts difficult. Nevertheless Pattanaik considers beliefs about the many idealised approaches in Eastern culture, the recognition of the sheer magnitude of possibilities that are available in life and the person’s place in the greater scheme of things with a western approach which is closely aligned to success, goal setting and a single life in which to achieve all that is necessary. Pattaniak suggests that where Eastern and Western civilisations meet and these differences are not understood it will result in difficulties. Pattanaik focuses on the example of western businesses that need to adjust when operating in the East. However if such arguments are valid they have applications elsewhere. For instance with migration from East to West or West to East, families will have to adapt to these new values and this process of adaptation can influence health which is an area that has been studied extensively e.g. in transcultural psychiatry. The implication that health can be influenced indirectly by cultural mythology is on reflection quite profound. The adjustments that families make when moving between civilisations has been explored in literature and film also. Nevertheless even when there are such differences there are also many similarities. Education is assessed in both the East and West and the outcome of this goal-orientated process influences lives in both cultures. From an evolutionary perspective, competition features in a number of ways and this can itself be considered a goal-orientated process which is found in both Western and Eastern cultures whether implicit or explicit in various settings. Pattanaik’s presentation is a useful starting point for discussing cultural differences.

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The blog reviewed here is ‘We’re Only Human‘ by Wray Herbert.

Appearance and Design

At the time of writing on the left hand side of the title pane the initials APS and the words ‘Association for Psychological Science’ appear while to the right is the title – ‘We’re Only Human’. The APS initials appear at the bottom of the screen also. However I wasn’t able to find an about section. A quick google search reveals a bio on Wray Herbert who is described as having 25 years experience in writing about science and medicine and writes in a number of prestigious publications. On the right hand pane there is a link to podcasts which leads through to a website for the Association for Psychological Science. The right hand pane also contains links to past months in the archives as well as links to previous posts and an RSS feed. The background for the site is dark red, with the articles containing black text on a beige background and a brown paint-like theme running in horizontal and vertical strips across this background.

Content

Herbert writes about articles that appear in the journal Psychological Science and effectively weaves them into a narrative through devices such as the personal anecdote and the discussion of popular films. The articles typically are a few paragraphs long and summarise the material in an easily ‘digestible’ form. Herbert also covers evolutionary psychology in a number of articles also.

• The blog starts in May 2006 with an article on crossword puzzles and Herbert interprets an imaging study with altered activity in the visual and temporal cortices during task completion. There were a number of articles that I found interesting
• This article discusses research suggesting some characteristics of eye gaze in a sample of older adults and the suggestion that gaze can be a means for regulating emotions
• This article looks at a study examining the performance of autistic children and adults on cognitive tasks in comparison with a control group
• This article looks at a study examining the effects of loneliness in young and older adults
• An article on a study showing a link between the readability of instructions for exercise and the likelihood of carrying out exercise in a student population
• An article on the possible evolutionary benefits of positive emotions
• An article on research into different patterns of  internet use in adolescents with different health effects
• An article on a study looking at the relationship between walking backwards and vigilance!
• An article on a study looking at meaning making and Kafka

Conclusions

The blog is an accessible means for keeping a finger on the pulse of some of the psychology research that is coming out and which features in the journal ‘Psychological Science’. The research is varied and the articles effectively convey the meaning of the research.

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The book reviewed here is ‘Socialnomics’ by Erik Qualman and narrated by Nick Sullivan. I was interested in listening to this audiobook in order to gain insights into wider cultural changes driven by social media technology. Such cultural changes are closely intertwined with illness in numerous ways and whilst illness is not the subject of the book I expected that the material would be indirectly relevant. Sullivan gives a solid performance as the narrator, using subtle changes in intonation at time to highlight the more important material. Turning to Qualman’s work itself, I found that this covered a variety of social media technologies such as YouTube, Google and Facebook. He looks at how social media transformed politics with the example of Barack Obama’s political campaign in the run-up to his election as president. Qualman also addresses the business sector illustrating how social media will affect their relationship with customers. I was puzzled by Qualman’s use of the term ’schizophrenic behaviour’ when referring to behaviour that changed from one situation to another. I thought perhaps what Qualman was referring to here was persona, the promotion of a behaviour appropriate to the social context and indeed a little after the initial reference he indeed refers to persona. He even recognises the serious nature of schizophrenia and emphasises this when using the term although. Apart from this Qualman covers a broad range of material, suggesting future trends in places and speculating on potentially successful strategies for companies. There are a number of stories that feature throughout the work that serve as exemplars of the phenomenon that Qualman is describing. One of the themes that emerged within the book was that social media is accessed by people of all ages. Qualman also discussed how social media is influencing the relationship between employers and employees. On a broader note, I thought many of the points could be generalised to the relationship between organisations of varying sizes and individuals both inside and outside of these organisations. Thus a number of the arguments could be applicable to non-business organisations e.g. government and non-government organisations. These in turn would have some relevance to healthcare delivery on a number of levels. I found Qualman’s book to be informative and helpful in providing an overview of the influence that social media is having on wider society.

References

Erik Qualman. Socialnomics. Narrated by Nick Sullivan. Audible inc. 2009.

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The paper reviewed here is ‘The Use of Health Information Technology in Seven Nations’ by Jha and colleagues. The authors examine the uptake of electronic health records (EHR) in 7 industrialised nations – the Uk, Netherlands, Australia, New Zealand, Germany, Canada, United States and conclude in the abstract that they

‘found that many have achieved high levels of ambulatory EHR adoption but lagged with respect to inaptient EHR and HIE (Health Information Exchange)‘

The authors suggest in the introduction that there has not been uptake of EHR in all parts of the US (although the article was published in 2008) and they were interested to see how the uptake of EHR compared to other industrialised nations. This was done with a view to identifying methods of improving uptake of EHR in the US.

In the methodology, the authors describe some of the terms in more detail. Thus they describe the HIE as the transfer of clinical information from one organisation to another. Interestingly the definition of EHR that they use includes decision support tools. The authors are quite rigorous in their approach to identifying relevant information – they conduct a literature search using established medical databases such as Medline, others using search engines such as google and also make contact with recognised experts in each of the six non-US nations in the study. I couldn’t find any reference however to the keywords that were used in the medline search which would be useful for replication purposes. The authors note that there has been a recent paper providing the information they need on the US explaining why the US is excluded from the above searches.

In the results section the authors note that due to the definition of EHR that they use there were few studies that fulfilled the criteria for identifying the relevant information. The only studies that included this information examined ‘ambulatory care’ which I understand to refer to care which doesn’t require inpatient admission. The authors were able to identify relevant studies in four of the countries and needed to utilise expert opinions for the other countries. There was sufficient information on the US however. They give figures for the US and I think that 10% of single practioner practices use EHR while up to 50% use EHR in larger practices (although they had used the term HER which I suspect is a typing mistake). While the figures for Canada for EHR came out at about 20% the figures for the UK revealed uptake of about 89% in General Practices. In the Netherlands this was figure was 98% for GP’s. Figures of 79% for GP’s in Australia and 92% of primary care providers in New Zealand were documented.

In the US they identified figures in hospitals of about 5-15% although commenting that the reliability of the data was relatively low. For other countries there was data on features such as electronic prescribing but little commentary on EHR. Thus there appeared to be a consistent pattern from the available data of higher uptake of EHR in primary rather than secondary care.

In terms of health exchange information networks they identify Infoway in Canada which focuses on uptake of EHR and HIE strategies, non-profit regional health information organisations in the US and the Switchpoint in the Netherlands amongst others. The authors cite pay-for-performance as one of the factors influencing the uptake of EHR in their study. They also note that the US has a number of measures of performance but these have not in general been linked to incentives.

The authors present their data in a number of tables and their discussion extends to electronic prescribing along with a number of other recommendations. The paper is informative, the methodology clearly stated and the researchers have identified relevant contact figures for further information in a number of the nations under study. The multiple data sources is a particular strength of the study. I found in particular the comments about clearly identifying performance measures to be particularly interesting. The use of electronic health records in itself does not necessarily imply that there is a high quality of healthcare as there are many other factors which determine the quality of a service most obvious amongst which are the healthcare practitioners themselves. However it might be expected that electronic health record systems would improve efficiency of workflow, information retrieval and contribute effectively towards decision-making. This is a useful comparison of national services which could serve as a template for future comparisons.

References

Jha A K, Doolan D, Grandt D, Scott T and Bates D W. The use of health information technology in seven nations. International Journal of Medical Informatics. 77. 2008. 848-854.

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The article reviewed here is ‘Literature and Happiness’ by Norman Holland and published in the journal Psyart in 2007. Psyart publishes articles which examine psychological perspectives on the arts. In the abstract (headnote), Holland writes that

‘I maintain that we do literature because it is fun, because it makes us happy. And it makes us happy because the act of experiencing literature mimcs the brain processes of successful living‘

I was intrigued to read a little more to see what Holland meant by this. He begins by looking at the origins of the word happiness and an overlap with terms such as luck in indoeuropean languages. He then describes a modern meaning in which the pursuit of happiness is validated in a western society. Indeed this features in the positive psychology movement (see review here). He writes about reading for pleasure and as a literary critic and then discusses psychologist Mihalyi Csikszentmihalyi’s description of happiness in flow – equivalent to absorption in a task. He then equates the first type of reading – the reading for pleasure with the activation of a wanting and liking system – the neurological correlates of which are the mesocortical and mesolimbic systems. He refers to a Seeking model described elsewhere with regards to the wanting and liking systems. This is where he draws the analogy with ’successful living’ as he suggests that the cycle of wanting and liking are routine and exclusive drivers of our behaviours. With regards to literary criticism he relates this to activity within the peri-aqueductal grey matter (PAG). The connection he makes is with a theory of ‘personal style’ described elsewhere in which the PAG plays a prominent role.

In terms of other articles reviewed previously this has a different tone far removed from papers describing studies with quantitative and qualitative methodologies. The article is essentially an essay in which a structured hypothesis is described. There are various methodologies that could be used to explore this model in further detail ranging from focus groups through to surveys and imaging studies. Nevertheless this ‘top-level’ informal-at-times discussion is just as valid as rigorous qualitative or quantitative studies in that it disseminates a speculative model which can lead to further discussion. There are many reasons for reading and many functions that it may satisfy as well as numerous brain regions or systems that may be involved in the process quite apart from the PAG, mesolimbic and mesocortical systems although each should start with a suitable evidence to justify their inclusion in the model. Is my peri-aqueductal grey matter helping ‘me’ to write this review? I’m not entirely sure, but until I’d read this paper I wouldn’t have entered my stream of consciousness. There at least it has already had some success.

References

Holland N. Literature and Happiness. Psyart. Gainesville. 2007. I page. ISSN: 10885870.

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