Book review: "Dignifying dementia: A caregiver's struggle" by Elizabeth Tierney

I recently picked up this book (published a few years ago) by Elizabeth Tierney, which details the drawn-out loss of her husband to dementia. It is a book that sticks in the mind not just for its unflinching depiction of a pitiless disease (which I won't dwell on here), but also for the variability in the behaviour of those people charged with helping these patients.

The book opens with a description of the author's husband during his younger days. The author paints a picture of a cultured Irish emigrant with a dull job and a wicked sense of humour, dividing his time between the North and South of the USA, a life not unlike many others. The onset of symptoms of dementia sets off a string of visits to a variety of physicians. After many consultations and failures to respond to medication, he is given a diagnosis of probable Lewy body dementia. Even when this diagnosis is finally made, the author expresses a nostalgia for ailments that receive a simple recommendation for treatment. Like many people who suffer from Lewy body dementia, he has a bad reaction to many of the medications used in trying to treat dementia and associated problems that go with it, although the book doesn’t stray into an anti-pharmacological polemic.

The bedside manner of at least some doctors, however, is another matter. Having sat in on a memory clinic that treats caregivers and patients with respect, I found the behaviour of some physicians striking. Some of the doctors the author encounters seem to automatically assume she should just allow her husband to die. Another offers the author a recitation from The Bible. When she protests that she is not religious, the doctor replies that he is, and continues unphased with his quotations. 

The general financial challenge of a spouse with dementia is confronted (albeit in a family that are not as bad off as others), as well as the difficulty of finding good professional to act as home help. Again, the lack of compassion of at least some of the people who work in the area is striking (Oh, you mean speak to him like a REAL person?). When one reads through the litany of reasons why various staff are rejected one can imagine how, from the outside, the author might come across as highly demanding as an individual. Nonetheless, from inside the author's view, the demands of dementia quickly put this all back in context. 

Towards the end, the author has received help from excellent doctors and assembled a good care team, and sometimes has a little more free time on her hands than she had earlier in the disease. One can understand how healthcare professionals can get jaded about "heartsink" conditions such as dementia, where the patient is unlikely to ever return to "normality". However, even in the absence of a cure for this disease, one comes away from this book thinking that there is much room for improvement in the consistency of how people with dementia and those that care for them are treated.

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He ain't heavy, he's my carer

Depression treatment: ketamine and biological effects

Along with talking therapies, pharmacological approaches are often used to tackle depression. Selective serotonin reuptake inhibitors (SSRI's) are often a first choice for depression treatment, and while they work well for many people with depression, oftentimes they don't. When they are effective, SSRI's typically take weeks to kick in (an interesting recent paper has suggested a possible reason why).

But other drugs are being used to fight depression. Although ketamine is known as a drug of abuse, it is also used for a number of medical purposes, including as an anaesthetic. However, at sub-anaesthetic doses, ketamine may also have antidepressant effects. For psychiatrists and their patients, the exciting aspect of ketamine is that it has a positive effect in many patients who do not respond to other antidepressants, and this alleviation of depression has been evident within a matter of hours rather than weeks. The downside is that this positive effect may not persist for much longer than a week, so repeated doses may be required to maintain the effect.

What may be driving the effect of ketamine? It has been suggested that brain-derived neurotrophic factor (or BDNF for short) may play a role in depression. BDNF is used in the maintenance and function of neurons, but chronic stress may reduce BDNF levels, and this could act as a mechanism through which long-term stress leads to depression. Previous evidence has indicated that ketamine treatment can increase BDNF in people whose depression is alleviated by the drug. However, this previous study just looked a single dose.

A recent study from our group looked at multiple doses of ketamine, to examine whether multiple doses would lead to comparable effects on depression, and also on BDNF. Patients were recruited who had failed to respond to first-line pharmacological therapy-even after the time it would take to show an effect these classic antidepressants, they were still depressed. Ketamine was administered under controlled conditions, with doctors supervising patients for a sufficient length of time to ensure patients would be protected from any potential adverse effects. Patients reported on their levels of depression before and after three doses of ketamine, and blood samples were taken at these times to assess patient's levels of BDNF.

We defined a clinical response in depression severity as a 50% or more reduction in scores on the Hamilton Depression Rating Scale, a widely used scale for quantifying depression severity. Ketamine significantly improved depressive symptoms in a majority of patients, both after two hours and one week later, and this was the case after each dose. (It should be noted however that not all patients continued with a second or third dose).

As had previously been shown, BDNF was reduced in those suffering from depression at baseline compared to healthy controls. Ketamine increased BDNF at one week after the first dose in those patients whose depression was alleviated by ketamine. However, this rise in BDNF did not occur after a second or third dose. So, although ketamine was keeping depression levels down for most of these patients, BDNF was not showing a persistent increase that mirrored this. The results, in this case, did not seem to support the idea that changes in BDNF goes hand-in-hand with an alleviation of depression.

As a comparison, we also looked at depression levels and BDNF in response to electroconvulsive therapy* (ECT), which is also used to treat depression in people who have not seen improvement after first-line treatment. Again, ECT was administered under controlled conditions, with patients being monitored for any side effects. Similar to ketamine, ECT reduced depression in the patient group. ECT did not increase BDNF at a one-week follow-up, although previous evidence has suggested that BDNF may be increased one month post-ECT.

Future research may tell us more about how ketamine has the rapid impact that it does upon depression. Understanding these mechanisms in greater depth may ultimately allow for treatments which target these mechanisms more specifically, thus minimising the risk of side effects.

Allen, A.P., Naughton, M., Clarke, G., Dowling, J., Walsh, A., Ismail, F., Shorten, G., Scott, L., McLoughlin, D., Cryan, J.F., Dinan, T.G. (in press). Serum BDNF as a peripheral biomarker of treatment-resistant depression and the rapid antidepressant response: A comparison of ketamine and ECT. Journal of Affective Disorders. doi: 10.1016/j.jad.2015.06.033

*I should note here that although ECT has had a very negative portrayal in some classic films, ECT as it is administered today is not only effective, but is also not the painful experience one might see in a film, as patients are prepared by being given an anaesthetic and muscle relaxant before the procedure. Nonetheless, like other treatments for depression, it is still associated with the risk of side effects.

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FormaLabs: Bringing science to the 99%

FormaLabs are a new “biomaker” space in Cork who describe themselves as aiming to “bring science to the 99%”. I recently attended a really interesting event by Professor Steve Potter, about DIY neuro-hacking, and how the increasing affordability of neuroscience and biomarker technologies will make it possible for non-professional scientists to conduct their own research. He used the interesting analogy of astronomy, where amateur astronomers have made relevant discoveries for years with their home telescopes.

The event included a demonstration of a number of these pieces of equipment, including kit for measuring EEG (albeit with not as many electrode sites as the type one would see in a well-funded lab) as well as heart rate and heart rate variability. Unfortunately, we couldn't get a demo of the most out-there equipment that monitors rapid eye movements in to induce lucid dreams (Prof Potter says he has used this and found it effective-want want want). 

It was great to see a wide variety of attendees, from professional researchers to kids, and the audience contributing so many ideas.

As FormaLabs are still being established, they are always looking for labs/groups etc. to help with setting up workspaces where non-professionals can engage in science. Check them out here:

http://formalabs.org/

https://twitter.com/FormaBiolabs

Book Review: "Black Sheep: The Hidden Benefits of Being Bad" by Richard Stephens

Senior lecturer in psychology at Keele University and fellow blogger Richard Stephens has a new book out. Aimed at a general audience, it concerns the hidden benefits of bad things, from drink to sex to death. To be fair, the review won't be totally unbiased when the author does cite a review paper I published with Andy Smith, but I hope it will be informative.

Stephens has not been one to stay on a single research topic, so the diversity of the book takes in varied subjects Stephens has researched. This includes his Ig Nobel -prize winning research on swearing, which found that swearing increased people's tolerance for pain (particularly people who habitually swear less; save it for a special occasion). He also covers work looking at whether chewing gum can alleviate stress (to be honest the jury's still out on that one-it seems to be better at maintaining alertness). The chapter on alcohol also makes reference to his ongoing interest in hangovers, and how those who are prone to alcoholism are counter-intuitively prone to worse hangovers.

The net does widen to some weird and wonderful stuff that Stephens (to the best of my knowledge) has not been directly involved with, This includes attempts to go beyond retrospective accounts of near-death experiences to prospectively examine a large number of patients with conditions that might lead to a near death experience prior to having one. (Quite a tall order, and one that unsurprisingly hasn't proved successful so far). He also covers classic research on whether inducing a state of (non-romantic) fear makes men more likely to ask someone out on a date, and the intriguing topic of boredom.

For a book teeming with different ideas, at times it feels as though Stephens does have to make an effort to keep things under one overall, unifying theme. It's a good skill to have when one has restless interests, although perhaps it's a bit regrettable in our postmodern age that theses and monographs have to conform to always having their own "grand scheme of things". The breadth of human experience, even within a single aspect of cognition, doesn't always lend itself to a unifying theory.

Despite the tongue-in-cheek "bad to the bone" posturing, this is a prosocial book. Stephens does not only want to create an enthusiasm for science, but also to make it more approachable. This book is also an attempt to defend psychological science in particular, and especially any such science which does not smack of the "harder" science end of psychological research ("but where was the fMRI scan???"). Stephens is careful to bring the non-psychologist along with him whether he is discussing theory or comparing double-blind experiments to short online surveys. If the book gets the broad audience it courts then I'd be surprised if a few of its lay readers don't feel motivated to begin their own pursuit of psychological research.

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Exhibition review: "We Do Not Leave Pyramids"

And if you must build pyramids along the way, build them in the knowledge that they will soon crumble and disintegrate, disappearing in the distance as you move onto the next phase.
Chris Clarke, from the program foreword

I try to take in art galleries when I get a chance; I particularly enjoy going to final year exhibition. This review of 2015's final year art exhibition at the Crawford is somewhat belated, but then again maybe it's good to write about these works a little later, if only to show that they are not just vanishing into the ether.

On the topic of final year exhibitions, I remember severely disliking a series of paintings at the National College of Art & Design, Dublin a few years back. They were were very small drawings that depicted vaguely gross activities, but drawn in the manner of a 9-year-old child. Even though I can enjoy ugly art (Bacon springs to mind) I didn't care about the artist's point, it was just lacking in skill.

One set of images that strikes me is Elaina Walsh O'Reilly's pictures. Although these images may not be pretty, they are the antithesis of that kind of delibrately childish, wilfully shit art that annoyed me at the NCAD exhibition. They have depth and richness that shines through any layer of dark and grot.

They are inspired by melacholy. The deep greens and blacks of these images wash a wave of sadness over the frame. The human figure could be swimming or dancing, but the face seems sucked downwards into the heavy cloth. Walsh O'Reilly describes the figures as trapped in a perimeter that on one level can be easily broken. However, to me the density of these images hint that there is some level of difficulty in moving away from these feelings.

Jennifer Ahern's work is a walk-in spiral wall of collage. It reminds me somewhat of the artwork of "In Utero" by Nirvana, or a less violent version of "Reek of Putrefaction" by Carcass. In fact, with the torn fragments of text this could be like many postmodern album notes for Radiohead, ...Trail of Dead, ZooTV-era U2 etc.

Despite this initial impression of image overload, the focus on the female body, and how our media represent it, means this is not just a (comment on) info saturation. The changing dominant colours of the spiral give it the feeling of a life cycle, However, the spectre of objectification hangs over the collage. The body can be exposed at any point-wherever you go, there you are, and of what use are you?

Two works touching on similar themes also catch the eye. Victoria Callinan looks at the concept of the selfie; composing a particular image of oneself for the online world. Killian O'Dwyer's work is about gender performativity through the lens of "low-brow" culture (you can hear the bassline of "Anaconda" pounding as you approach his installation). Besides the thematic similarity between these two pieces, they both use the installation space to the full, turning artwork into a bedroom. Although O'Dwyer's work seems at some level to be confrontational in its use of pornography and USA hubris, and although the implicit fug of moral panic and cyberbullying hangs over Callinan's, there's a strange homeliness to these voyeuristic and consumerist pieces that suggest they've both caught a little bit of the zeitgeist.


Obviously these are just snapshots of a small minority of the work at the exhibit. As with any of these things, in a few years most of the students won't be working full-time as artists. But a few of these pieces remind me of a snippet of a review on the blurb of Euginedes' debut novel "Virgin Suicides": they are not just "promising"-they have arrived fully formed.

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Mindfulness update: Weeks 1-4

"Much of the practice is simply a remembering, a reminding yourself to be fully awake" 

Jon Kabat-Zinn

In a previous post I discussed mindfulness. I’m putting my time where my mouth is and doing an 8-week course in mindfulness based stress reduction (MBSR). Here’s the story up to half-time:

WEEK 1: At the first class we perform body scan. With our eyes closed, we slowly bring our attention to different parts of the body. If our minds wander off, we are encouraged to bring the focus back to what’s going on with our body. No need to have a go at yourself for letting your mind wander-just bring the focus back to the body scan. After the first meeting we are encouraged to engage in body scan 5-6 times over the coming week.

To have an experience that we can use as a practice of acting mindfully, we very slowly eat a sweet. (I pick up a piece of fudge that’s stuck to another piece of fudge-yuusssss). The activity’s a chance to really focus on the sensation of eating. Our instructor makes the analogy of how many young children act when they eat an ice cream-poring over its texture and appearance as they enjoy it. Probably not something we do every day if we’re in the habit of “grazing”. I know I often nosh a sandwich at my desk while in the midst of swearing at the desktop screen.

Back home, at my first attempt at doing a body scan by myself I have a false start when a funny thought makes me laugh too much. The next few attempts I avoid laughter, but it’s definitely difficult to avoid daydreaming when doing the body scan. As suggested in the classes, I try to picture a spotlight shining on the different parts of my body as I move from the toes upwards.

WEEK 2: At the class we describe the steps and sensations involved in making a cup of tea. With our eyes closed, we take turns in describing a different step involved in the whole process. Must say that I’m tempted to shout out something silly like “and then I make the tea and drink the tea and then go for a walk with my granny”, but maintain my composure. The avoiding judgment thing is probably even harder when other people are involved in one’s mindfulness-I can’t help but think some people are jumping too far ahead in the tea-making process to allow the rest of the group enough material to work on. I'd like to bring more maturity to my mindfulness, but then again, I should withhold judging myself too harshly. 

After a whopping 7-8 days, my initial enthusiasm for homework practice wanes slightly. With a lot going on at work I'm not doing quite as much mindfulness practice as I did before. So much for not judging myself as well! 

WEEK 3: At the classes we are expressing frustration about need being able to sustain attention to the present when we do things like body scan, but the instructor reminds us that what is key is our intention to become more mindful, and our the adaptation of a non-judgemental approach to our own thoughts (including judgement about whether or not they are "mindful enough").

We're starting into mindful yoga, a gentle form of yoga. Essentially it involves gentle stretching of the limbs. Like the body scan, you try to keep the attention on your body and its sensations.

Outside class, toothache strikes, bringing my attention forcefully back to my present bodily sensations on a regular basis. With my the rest of my body bringing the brain’s attention to it, as opposed to my brain deciding to focus on the rest of my body, I’m reminded to do the mindful yoga most days.  

As I'm getting more into watching the recommended videos, I'm learning about non-striving, an attitude related to not trying to get anything out of one's awareness of the current moment (perhaps tricky when most people want to get something out of mindfulness).

WEEK 4: One thing I note one or two other people at the class saying is that they want to have an “emptier” mind when doing meditation. I don’t think that’s really what mindfulness is about. Your attention still has content, it’s simply that you adopt a different attitude towards it.

A 4-day weekend knocks my mindfulness schedule off somewhat, although I work some body scan into moments between awakening and getting out of bed. I also do more of the “informal practice”. Part of our informal practice is to note unpleasant experiences. One particular moment was an email I received that induced a mix of annoyance at myself and the person sending it. My heart rate probably increased, although with hindsight I doubt I noticed as much when it actually happened, wrapped up as I was in the possible implications of what was being said to me. However, after the initial wave of negative feeling I decided to focus on how I felt at that moment, and then what I could do step-by-step to respond. Whether or not my thoughts were “mindful enough”, a little bit of focus on the actual present killed of the perils of an imaginary future.

Stay tuned next month for the second half of my Mindfulness Odyssey!

For an intro to the ideas behind mindfulness-based stress reduction, you could check out the following resource: 

http://palousemindfulness.com/selfguidedMBSR.html

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Conference review: CINP Thematic Meeting 2015

Early June. I am back where I first studied psychology, Trinity College Dublin. Crossing the historical front square for the unapologetically brutalist architecture of the Arts Block. It’s the International College of Neuropsychopharmacology (CINP)’s thematic meeting, and the theme of the meeting is stress, inflammation and depression.

The charm of a thematic meeting is that one knows that there’s going to be a lot of work that’s of interest to you. I make no secret of the fact that I’m not a big fan of enormous, “GloboConference” type meetings. I can recall a least one occasion when I was presenting in a session where the theme was clearly “a bunch of studies that have nothing to do with each other, but couldn’t be matched up with anything else on this day”. Ah well, maybe I’m just bitter because a 1,000-strong poster session can confront you with your own insignificance as a little researcher star in the vast galaxies of Science.

When I heard my poster number was to be P001 I was nervous that this meeting would have the opposite problem: a lack of other posters. However, these nerves were unjustified. There’s an active session of over 100 posters, with topics of interest to me such as depression, ketamine and probiotics being covered.  

With a keen focus to the meeting there is a risk of repetition at the talks. However, although some introductions do cover some common ground, this is a complex enough topic for there to be plenty to cover, and each researcher brings something different to the party. NB: they also (generally) skip through stuff that previous speakers have covered already in their earlier intros-let that be a warning not to spend an entire conference prior to your own talk locked in your hotel room practicing your PowerPoint! The speakers often differ in their presentation style, but all are accomplished researchers with plenty to show.

A highlight is getting a chance to meet and hear from Ron Duman, an influential figure in the idea that neurotrophic factors in the brain might be implicated in depression. At his talk he discusses new pathways linking inflammation to depression that he is interested in. Like most researchers at the event he turns out to be a very approachable person too, as we find out at the social evening in Temple Bar. (The touristy trad band at the venue wind up some of the indigenous crew, but what are you gonna do? Better that than the wave of Weatherspoon’s about to descend upon our poor capital.)

Another talk of interest is by Phil Burnet of Oxford. He discusses recent findings that prebiotics (fibres that help the growth of friendly bacteria) can lead to a reduction in cortisol output, as well as changes in processing of emotional stimuli. These findings chime nicely with some results that Timothy Dinan presents, indicating that probiotics can lead to a subtle reductions in stress. Speaking of senior figures from our group, the mighty John Cryan also gives a highly engaging talk covering broad ground, taking in stress as well as hunger-related hormone ghrelin.

Future thematic meetings from CINP will be worth watching out for people interesting in neuropsychology and mental disorder, although be warned that the talks can have a heavy focus on molecular pathways and preclinical work. If you want the "globo" equivalent, than check out next year's World Congress. 


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