More treatment but no less depression:The treatment-prevalence paradox

Treatments for depression have improved, and their availability has markedly increased since the 1980s. Mysteriously the general population prevalence of depression has not decreased. This "treatment-prevalence paradox" (TPP) raises fundamental questions about the diagnosis and treatment of depression. We propose and evaluate seven explanations for the TPP. First, two explanations assume that improved and more widely available treatments have reduced prevalence, but that the reduction has been offset by an increase in: 1) misdiagnosing distress as depression, yielding more "false positive" diagnoses; or 2) an actual increase in depression incidence. Second, the remaining five explanations assume prevalence has not decreased, but suggest that: 3) treatments are less efficacious and 4) less enduring than the literature suggests; 5) trial efficacy doesn't generalize to real-world settings; 6) population-level treatment impact differs for chronic-recurrent versus non-recurrent cases; and 7) treatments have some iatrogenic consequences. Any of these seven explanations could undermine treatment impact on prevalence, thereby helping to explain the TPP. Our analysis reveals that there is little evidence that incidence or prevalence have increased as a result of error or fact (Explanations 1 and 2), and strong evidence that (a) the published literature overestimates short- and long-term treatment efficacy, (b) treatments are considerably less effective as deployed in "real world" settings, and (c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases. Collectively, these a-c explanations likely account for most of the TPP. Lastly, little research exists on iatrogenic effects of current treatments (Explanation 7), but further exploration is critical

When teleconferencing was the future: the 1970 'Medizin Interkontinental' transmission and West German medicine in the space age

In March 1970, the first ever medical teleconference connected U.S. aeromedical experts in Houston and San Antonio to an audience of 25,000 physicians in congress centres in West Germany, Austria, and Switzerland. As this article shows, the ‘Medizin Interkontinental’ transmission was a costly demonstration of the latest developments in satellite telecommunications and projection technology as well as a stage for space-age visions of the future of medicine in the aftermath of the moon landing. Audio-visual and space technology became, at one at the same time, the medium and the message of medical futurity. As I argue, the teleconference was an audio-visual techno-spectacle that marked the culmination of the German medical community’s infatuation with futurology at the end of the 1960s, but it was also contingent on the concrete interests of the parties involved, which included the German Medical Association, medical futurologists, nasa, the U.S. Air Force, and the Swiss pharmaceutical company Ciba. Decades before teleconferences and telemedicine entered day-to-day medicine, the convergence of new medical and media technology, changes in medical education, Cold War geopolitics, and pharmaceutical sponsorship created a brief glimpse of a technology-based future of medicine that fell apart once these constellations changed in the early 1970s

Rhetorics of pain: agency and regulation in the medical-industrial complex

This dissertation explores the rhetorical mechanisms of agency and regulation in the medical-industrial complex. It presents the results of over two years of ethnographic observation and interviews with a multidisciplinary pain management organization. Additionally, it interrogates two broader cases of agency and regulation in pain science: 1) the debate over the nature of the sinus headache and 2) the debate surrounding the legitimacy of the chronic pain condition fibromyalgia. Following recent theoretical work in rhetorical studies, this dissertation argues that the rhetoric of pain science corroborates recent theoretical suggestions that the exercise of both agency and regulation is predicated on structures of authority. Furthermore, the results of this study suggest that when clinicians seek change in medical science or healthcare regulation, they rely on authority provided to them by their disciplinary identity--an identity supported by the same structures they seek to change. Similarly, the exercise of regulation in the medical-industrial complex is often based on identical structures of authority. Finally, in exploring these issues, this dissertation also argues for more inquiry in the emerging subfield known as rhetoric of technoscience. The work of this dissertation demonstrates the methods and modes of inquiry for rhetoric of technoscience and reflects on how such modes of inquiry are different from rhetorics of science and technology, as traditionally conceived. Ultimately, this work argues for greater attention to issues of ontology and materiality as well as continued exploration into how those issues impact scientific and policy discourses

Re-awakening the brain: Forcing transitions in disorders of consciousness by external in silico perturbation

A fundamental challenge in neuroscience is accurately defining brain states and predicting how and where to perturb the brain to force a transition. Here, we investigated resting-state fMRI data of patients suffering from disorders of consciousness (DoC) after coma (minimally conscious and unresponsive wakefulness states) and healthy controls. We applied model-free and model-based approaches to help elucidate the underlying brain mechanisms of patients with DoC. The model-free approach allowed us to characterize brain states in DoC and healthy controls as a probabilistic metastable substate (PMS) space. The PMS of each group was defined by a repertoire of unique patterns (i.e., metastable substates) with different probabilities of occurrence. In the model-based approach, we adjusted the PMS of each DoC group to a causal whole-brain model. This allowed us to explore optimal strategies for promoting transitions by applying off-line in silico probing. Furthermore, this approach enabled us to evaluate the impact of local perturbations in terms of their global effects and sensitivity to stimulation, which is a model-based biomarker providing a deeper understanding of the mechanisms underlying DoC. Our results show that transitions were obtained in a synchronous protocol, in which the somatomotor network, thalamus, precuneus and insula were the most sensitive areas to perturbation. This motivates further work to continue understanding brain function and treatments of disorders of consciousness

What is psychiatry? Co-producing complexity in mental health

What is psychiatry? Such a question is increasingly important to engage with in light of the development of new diagnostic frameworks that have wide-ranging and international clinical and societal implications. I suggest in this reflective essay that ‘psychiatry' is not a singular entity that enjoins consistent forms of critique along familiar axes; rather, it is a heterogeneous assemblage of interacting material and symbolic elements (some of which endure, and some of which are subject to innovation). In underscoring the diversity of psychiatry, I seek to move towards further sociological purchase on what remains a contested and influential set of discourses and practices. This approach foregrounds the relationships between scientific knowledge, biomedical institutions, social action and subjective experience; these articulations co-produce both psychiatry and each other. One corollary of this emphasis on multiplicity and incoherence within psychiatric theory, research and practice, is that critiques which elide this complexity are rendered problematic. Engagements with psychiatry are, I argue, best furthered by recognising its multifaceted nature

Green Care: a Conceptual Framework. A Report of the Working Group on the Health Benefits of Green Care

‘Green Care’ is a range of activities that promotes physical and mental health and well-being through contact with nature. It utilises farms, gardens and other outdoor spaces as a therapeutic intervention for vulnerable adults and children. Green care includes care farming, therapeutic horticulture, animal assisted therapy and other nature-based approaches. These are now the subject of investigation by researchers from many different countries across the world

Functional MRI correlates of emotion regulation in major depressive disorder related to depressive disease load measured over nine years

Major Depressive Disorder (MDD) often is a recurrent and chronic disorder. We investigated the neurocognitive underpinnings of the incremental risk for poor disease course by exploring relations between enduring depression and brain functioning during regulation of negative and positive emotions using cognitive reappraisal. We used fMRI-data from the longitudinal Netherlands Study of Depression and Anxiety acquired during an emotion regulation task in 77 individuals with MDD. Task-related brain activity was related to disease load, calculated from presence and severity of depression in the preceding nine years. Additionally, we explored task related brain-connectivity. Brain functioning in individuals with MDD was further compared to 35 controls to explore overlap between load-effects and general effects related to MDD history/presence. Disease load was not associated with changes in affect or with brain activity, but with connectivity between areas essential for processing, integrating and regulating emotional information during downregulation of negative emotions. Results did not overlap with general MDD-effects. Instead, MDD was generally associated with lower parietal activity during downregulation of negative emotions. During upregulation of positive emotions, disease load was related to connectivity between limbic regions (although driven by symptomatic state), and connectivity between frontal, insular and thalamic regions was lower in MDD (vs controls). Results suggest that previous depressive load relates to brain connectivity in relevant networks during downregulation of negative emotions. These abnormalities do not overlap with disease-general abnormalities and could foster an incremental vulnerability to recurrence or chronicity of MDD. Therefore, optimizing emotion regulation is a promising therapeutic target for improving long-term MDD course.</p