Electroconvulsive Treatment: Hypotheses about Mechanisms of Action

No consensus has been reached on the mode of action of electroconvulsive treatment (ECT). We suggest that two features may aid in the delineation of the involved mechanisms. First, when effective, ECT would be likely to affect brain functions that are typically altered in its primary recipient group, people with severe depression. Central among these are the frontal and temporal lobes, the hypothalamus-pituitary-adrenal (HPA) stress axis, and the mesocorticolimbic dopamine system. Second, the involved mechanisms should be affected for a time period that matches the average endurance of clinical effects, which is indicated to be several days to a few weeks. To identify effects upon frontal and temporal lobe functioning we reviewed human studies using EEG, PET, SPECT, and fMRI. Effects upon the HPA axis and the dopamine system were assessed by reviewing both human and animal studies. The EEG studies indicate that ECT decelerates neural activity in the frontal and temporal lobes (increased delta and theta wave activity) for weeks to months. Comparable findings are reported from PET and SPECT studies, with reduced cerebral blood flow (functional deactivation) for weeks to months after treatment. The EEG deceleration and functional deactivation following ECT are statistically associated with reduced depression scores. FMRI studies indicate that ECT flattens the pattern of activation and deactivation that is associated with cognitive task performance and alters cortical functional connectivity in the ultra slow frequency range. A common finding from human and animal studies is that ECT acutely activates both the HPA axis and the dopamine system. In considering this evidence, we hypothesize that ECT affects the brain in a similar manner as severe stress or brain trauma which activates the HPA axis and the dopamine system and may compromise frontotemporal functions

Intersectoral Planning for Public Health: Dilemmas and Challenges

Abstract Background: Intersectoral action is often presented as essential in the promotion of population health and health equity. In Norway, national public health policies are based on the Health in All Policies (HiAP) approach that promotes whole-of-government responsibility. As part of the promotion of this intersectoral responsibility, planning is presented as a tool that every Norwegian municipality should use to integrate public health policies into their planning and management systems. Although research on implementing the HiAP approach is increasing, few studies apply a planning perspective. To address this gap in the literature, our study investigates how three Norwegian municipalities experience the use of planning as a tool when implementing the HiAP approach. Methods: To investigate planning practices in three Norwegian municipalities, we used a qualitative multiple case study design based on face-to-face interviews. When analysing and discussing the results, we used the dichotomy of instrumental and communicative planning approaches, in addition to a collaborative planning approach, as the theoretical framework. Results: The municipalities encounter several dilemmas when using planning as a tool for implementing the HiAP approach. Balancing the use of qualitative and quantitative knowledge and balancing the use of structural and processual procedures are two such dilemmas. Other dilemmas include balancing the use of power and balancing action and understanding in different municipal contexts. They are also faced with the dilemma of whether to place public health issues at the forefront or to present these issues in more general terms. Conclusion: We argue that the dilemmas experienced by the municipalities might be explained by the difficult task of combining instrumental and communicative planning approaches because the balance between them is seldom fixed

Impact of Psychotherapy in Psychosis: A Retrospective Case Control Study

Background: The need for psychological therapies for psychosis has become apparent since long-term antipsychotic drug treatment has a range of adverse side effects, with moderate therapeutic effects at best.Aims: To investigate whether the psychotherapeutic approach, dialogue therapy (DT) is associated with improvements of symptoms and functioning beyond standard psychiatric treatment (ST) in both schizophrenia and other psychosis.Methods: A retrospective case-control design, comparing 54 patients with different psychoses who received DT with 54 patients in a control group receiving ST was carried out. The groups were matched on diagnosis, age, sex, and treatment start. Outcome measures were Global assessment of functioning (GAF) scores, medications at follow up, and hospital stays after completed outpatient treatment.Results: Mean time in treatment from inclusion to follow-up was 3 years and 5 months. At follow-up, GAF functioning (GAF-F) and GAF symptom (GAF-S) scores both were significantly higher in the DT group than the ST group. Effect sizes (Cohen's d) were large; 1.8 for GAF-S and 2.1 for GAF-F. At follow-up, the use of psychoactive drugs was significantly reduced despite a shorter time in psychotherapy in the DT group compared to the ST group. Days of hospitalizations after end of treatment in the study period were significantly reduced in both groups compared to the period before start of treatment.Conclusions: The findings from this exploratory study are consistent with the possibility that dialogue therapy may lead to improvements in symptoms and functioning compared to standard treatment in psychosis

The emergence of lean construction in the Norwegian AEC industry

publishedVersio

Forbedring av arbeid på byggeplass ved operasjonsanalyse og Lean Construction

Byggebransjen har stort forbedringspotensial på flere viktige områder, blant annet produktivitet, kvalitet, læring av feil og andelen tid som brukes til verdiskapende arbeid. Disse forholdene kan knyttes til gjennomføringsmodellen og den grunnleggende tenke- og væremåten i prosjektene. Lean Construction, byggebransjens svar på Lean Production en alternativ tilnærming til bygge-prosjekter og har sitt opphav fra Toyota. For å overleve i en presset japansk bilbransje på midten av 1900-tallet skapte Toyota et svært suksessfullt produksjonssystem nesten fritt for sløsing (lean er slank på norsk). Lean var likevel ikke et sett med regler, men en dyptgripende tenke- og væremåte; en filosofi. Man har lenge ønsket å få liknende effektivitet som Toyota i byggsammenheng, men å implementere Lean har vist seg å være tid- og ressurskrevende grunnet en konservativ bransje.Denne masteroppgaven undersøker i hvor stor grad arbeidsoperasjoner kan forbedres med operasjonsanalyse og tiltak basert på Lean-Construction-prinsipper. I en case studie implementeres Lean Construction kun på én operasjon (ett arbeidslags arbeid), som analyseres med analyseverktøy og mulige forbedringer foreslås av fagarbeiderne i laget. Forslag med rot i Lean Construction-teori inkluderes i en revidert utgave av operasjonen som testes i case studiens siste uke. Tidsbruken ble redusert med 47,4% fra 71,25 til 37,5 timer og kostnadene med 20% fra 150 til 120 timeverk per produserte etasje. I tillegg ble akkordbeløpet redusert ved å fjerne unødvendige oppgaver og bevegelser. Fagarbeiderne vil likevel tjene mer siden de produserer mer per tidsenhet enn opprinnelig. Noe kvalitative forbedringer var bedre ergonomi, jevnere fremdrift på de enkelte oppgaver og mer klarhet i forhold til andre fag ved fysisk visualisering av arbeidsområde.Oppgavens hensikt er at fremgangsmåten fra case studien skal inngå i Skanskas standardiserings-arbeid. Man vil bruke kartleggingen fra analysene av den standardiserte operasjonen som basis for samarbeid mellom arbeidslag ved andre prosjekter og regioner for å etablere en god felles praksis og deretter bruke hverandres kompetanse til å stadig forbedre denne standard praksisen

Elektrokonvulsiv behandling ved alvorlig depresjon – i konflikt med den hippokratiske eden?

Electroconvulsive treatment (ECT) often is described as particularly effective with severe depression. We argue that available placebo-controlled evidence does not support this contention, instead showing marginal effects of ECT at treatment end and the absence of positive long term effects. In contrast, the literature on neuropsychological effects suggests that ECT weakens cognitive functions, in particular memory, for weeks or months in most participants. Neurophysiologically, ECT lowers the regional activation level and slows down neural firing in the frontal and temporal lobes (deceleration). ECT also blocks long term potentiation necessary for memory formation, and it activates the hypothalamus-pituitary-adrenal stress axis. The frontotemporal deceleration following ECT empirically is associated with changes in the patients’ behavior viewed as «therapeutic response» by clinicians, such as improved appetite and sleep. Increased «doses» of ECT are associated with a stronger «therapeutic response» as well as with gradually increased neurophysiological deficits and memory problems. It may appear that the response to ECT seen in the clinic reflects the neurophysiological deficits that the treatment incurs, indicating a violation of the Hippocratic oath – first, do no harm

Quantifying auditory impressions in dreams in order to assess the relevance of dreaming as a model for psychosis.

A long noted hypothesis is that mechanisms of dreaming play a role in psychotic hallucinations. One challenge for this hypothesis is that while psychotic hallucinations primarily are auditory, dreaming most characteristically is visual. At the same time, previous studies have not explicitly examined auditory impressions in dreaming. Here, we mapped the prevalence and characteristics of auditory impressions in 130 dreams reported after spontaneous awakenings from sleep in 13 normal, healthy people. We instructed participants to report any dream they could recall and to pay particular attention to possible auditory impressions. The participants reported auditory impressions in 93.9% of their dreams on average. The most prevalent auditory type was other people speaking (83.9% of participants' dreams), followed by the dreamer speaking (60.0%), and other types of sounds (e.g. music, 33.1%). Of altogether 407 instances of auditory impressions in the 130 dreams, auditory quality was judged comparable to waking in 46.4%, indeterminate in 50.6%, and absent or only thought-like in 2.9%. The results suggest that also internally generated auditory (verbal) sensations are a central component of dreaming, typically occurring several times every night in normal, healthy people

Electroconvulsive treatment: hypotheses about mechanisms of action

No consensus has been reached on the mode of action of electroconvulsive treatment (ECT). We suggest that two features may aid in the delineation of the involved mechanisms. First, when effective, ECT would be likely to affect brain functions that are typically altered in its primary recipient group, people with severe depression. Central among these are the frontal and temporal lobes, the hypothalamus-pituitary-adrenal (HPA) stress axis, and the mesocorticolimbic dopamine system. Second, the involved mechanisms should be affected for a time period that matches the average endurance of clinical effects, which is indicated to be several days to a few weeks. To identify effects upon frontal and temporal lobe functioning we reviewed human studies using EEG, PET, SPECT, and fMRI. Effects upon the HPA axis and the dopamine system were assessed by reviewing both human and animal studies. The EEG studies indicate that ECT decelerates neural activity in the frontal and temporal lobes (increased delta and theta wave activity) for weeks to months. Comparable findings are reported from PET and SPECT studies, with reduced cerebral blood flow (functional deactivation) for weeks to months after treatment. The EEG deceleration and functional deactivation following ECT are statistically associated with reduced depression scores. FMRI studies indicate that ECT flattens the pattern of activation and deactivation that is associated with cognitive task performance and alters cortical functional connectivity in the ultra slow frequency range. A common finding from human and animal studies is that ECT acutely activates both the HPA axis and the dopamine system. In considering this evidence, we hypothesize that ECT affects the brain in a similar manner as severe stress or brain trauma which activates the HPA axis and the dopamine system and may compromise frontotemporal functions

Basal exposure therapy: A new approach for treatment resistant patients with severe and comorbid mental disorders

New treatment approaches are needed for patients with severe and composite mental disorders who appear resistant to conventional treatments. Such treatment resistant patients often have diagnoses of psychotic or bipolar disorders or severe personality disorders and comorbid conditions. Here we evaluate Basal Exposure Therapy (BET), a novel ward-integrated psychotherapeutic approach for these patients. Central to BET is the conceptualization of undifferentiated existential fear as basic to the patients’ problem, exposure to this fear, and the therapeutic platform Complementary External Regulation (CER) which integrates and governs the totality of interventions throughout the treatment process. BET is administered at a locked-door ward with six patient beds and 13.5 full time employees, including a psychiatrist and two psychologists. Thirty-eight patients who had completed BET were included, all but two being female, mean age 29.9 years. Fourteen patients had a diagnosis of schizophrenia or schizoaffective disorder (F20/25), eight had bipolar disorder or recurrent depressive disorder (F31/33), eight had diagnoses in the F40-49 domain (anxiety, stress, dissociation), five were diagnosed with emotionally unstable personality disorder (F60.3), and three patients had other diagnoses. Twenty of the patients (53%) had more than one ICD-10 diagnosis. Average treatment time in BET was 13 months, ranging from 2 to 72 months. Time-series data show significant improvements in symptoms and functioning from enrolment to discharge, with effect sizes at 0.76 for the Dissociation Experience Scale, 0.93 for the Brief Symptom Inventory, 1.47 for the Avoidance and Action Questionnaire, and 1.42 and 1.56, respectively for the functioning and symptom subscales of the Global Assessment of Functioning Scale. In addition, the patients used significantly less antiepileptic, antipsychotic, anxiolytic and antidepressant medications at discharge than at treatment enrolment. Patient improvement across treatment was associated with each of the successful completions of the exposure component of BET, with positive changes in psychological flexibility as measured with the Avoidance and Action Questionnaire, with high symptom levels and low levels of functioning at treatment start, and with the duration of time in BET. The findings indicate that BET may be a promising inpatient psychotherapeutic approach for previously treatment resistant patients with severe and comorbid conditions