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“If you think of the brain as an orchestra, the thalamus is the
conductor. The players are in the cortex. When the conductor makes a move, the players follow. The conductor then hears their sounds and makes new moves, resulting in a continuous dialogue.” —Dr. Rodolfo Llinás, Colombian-American neurologist
Guest editorial: ACP guidelines provoke thought
in the development of practice guidelines over the last several decades. Although guidelines have existed for the care of patients for centuries it is only in the last several decades that evidence-based guidelines have been developed.1 in Qaseem, et al, reasonable practice guidelines and recommendations specifically related to the comparative effectiveness of treatment for second-generation antidepressants (SgA) versus non-pharmacological treatments for major depressive disorder (MDD) in adults have been developed based on systematic review of published, english lanDr. Rosenbluth guage, randomized, controlled trials from 1990 through to Sept. 2015. in an interesting conclusion, the American College of Physicians (ACP) recommends that clinicians select between either cognitive behaviour therapy (Cbt) or SgAs to treat patients with MDD after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient. they refer to this as based on moderate quality evidence indicating that there was no significant difference in response when comparing SgAs (fluoxetine, fluvoxamine, paroxetine, and sertraline) with Cbt in patients with MDD after eight to 52 weeks of treatment. they also make other recommendations vis-a-vis different kinds of therapies, as well as complementary and alternative medicines. the remaining recommendations are based on what they term low quality evidence as they note Here HAS beeN A rAPiD iNCreASe
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ABOUT THE AUTHOR Dr. Michael Rosenbluth is the chief, Department of Psychiatry, Toronto East General Hospital and psychotherapy supervisor at Sunnybrook Health Science Centre’s Department of Psychiatry. He is an associate professor in the Department of Psychiatry, University of Toronto. He is the Section Head of the 2012 Canadian CANMAT Task Force Recommendations on the Management of Comorbid Mood and Personality Disorders (published 2012) and a contributor to the 2016 CANMAT Guidelines for the Treatment of Affective Disorders (in press).
for most comparison studies, low quality evidence showed no difference in effectiveness of adverse effects between first line intervention using pharmacological (SgAs) or nonpharmacological (CAM, or exercise monotherapies, or accommodation therapies) in patients with MDD. Perhaps for many clinicians a particularly interesting finding in what they refer to as low quality evidence shows no difference when comparing monotherapy using SgAs with combination therapy using SgAs plus Cbt. this is a clinically important observation—does combining Cbt with pharmacotherapy work better than monotherapy with SgAs, or not? these guidelines are interesting and especially thought-provoking when they differ from other conclusions such as the CANMAt guidelines. (full disclosure, i am a contributor to the CANMAt guidelines). the CANMAt guidelines indicated most SgAs were first-line treatments for patients with MDD of moderate or greater severity. this was in the 2009 guidelines; and this recommendation remains unchanged in the 2016 guidelines to be released this year. Psychoeducation, self-management, and psychological treatment approaches are suggested as first-line treatments for individuals with mild severity. the CANMAt guidelines conclude pragmatically that although there is data indicating that the severity of depression does not differentially predict outcomes of treatment with antidepressants and Cbt, the time course of improvement is typically faster with pharmacological treatment; and thus, pharmacotherapy may still be preferred as the initial treatment in severe and high risk cases. CANMAt emphasizes that in moderately severe and low risk cases, the choice of initial treatment between psychological treatment and antidepressants may be determined by a balance of patient preferences and the availability of each treatment modality. they note that several meta-analyses have indicated that Cbt is as effective as antidepressants and the combination of Cbt and an antidepressant is more effective than either alone. As noted, this contrasts with the current ACP guidelines, which indicates no difference when comparing monotherapy using SgAs with combination therapy using SgAs plus Cbt.2,3 As is not unusual in modern psychiatry, there is not —Continued on page 12
The Chronicle of Neurology & Psychiatry is published six times annually by the proprietor, Chronicle Information Resources Ltd., with offices at 555 Burnhamthorpe Rd., Ste. 306, Toronto, Ont. M9C 2Y3 Canada. Telephone: 416.916.2476; Fax. 416.352.6199. E-mail: health@chronicle.org. Contents © Chronicle Information Resources Ltd., 2016, except where noted. All rights reserved worldwide. The Publisher prohibits reproduction in any form, including print, broadcast, and electronic, without written permissions. Printed in Canada. Mail subscriptions: $72 per year in Canada, $125 per year in all other countries. Single copies: $12 per issue (plus 13% HST) Canada Post Canadian Publications Mail Sales Product Agreement Number 40016917 The Publisher certifies that advertising placed in this publication meets Revenue Canada requirements for tax deductibility. Volume 19, Number 3, published June 2016 ISSN 1209-0565
Research
n Most (81.9%) of pediatric concus-
sion cases at the Children’s Hospital of Philadelphia had their first concussion-related health care visit through primary care, not the emergency department, suggesting estimates of pediatric concussion based primarily on emergency department visits underestimate concussion incidence in this population, according to findings published online ahead of print in JAMA Pediatrics (May 31, 2016). —Find more info at http://ow.ly/zbK93016cNJ
n Children with attention deficit hyper-
activity disorder adjust their behaviour less to changing reinforcement than typically developing children do when reinforcement is intermittent and the link between action and consequences is less certain, according to a paper published online ahead of print in the Journal of Child Psychology and Psychiatry (April 15, 2016). This may explain why these children have difficulty adapting their behaviour to new situations. —Read more at http://ow.ly/GStQ300Yy7G
n Alexithymia—an impairment in one’s
ability to identify one’s own emotions—is more associated with atypical interoception—the perception of the internal state of one’s body—than autism spectrum disorder is, researchers report in Cortex (Aug. 2016; 81:215-220). These findings suggest that interoceptive impairments should not be considered a feature of ASD, the authors concluded. —More information at http://ow.ly/bB3Y300YDIf
n Atrophy of subcortical grey matter
(thalamus, caudate, and putamen) volumes at early stages of multiple sclerosis has been found to be associated with subsequent changes in disability measures, according to a study published in the Journal of Neurological Sciences (July 15, 2016; 366:229233). —Discover more info at http://ow.ly/Pigm301dyd2 June 2016 n 3