Wednesday, 19 September 2012

Drug Buddy: Ecstasy to self-medicate depression?

This is not ecstasy, but it's better than cocaine.
and you know that I will miss you when you're gone
but I'm not equipped to play this game
The Czars (Drug)

by Majumder, White & Irvine (in press) Addictive Behaviours

Majumder et al look at the topical and fascinating notion that people with a pre-existing mood disturbance may be using ecstasy as a ‘self-medication’. Given recent media reports about possibly using of MDMA to treat depression and the Channel 4 TV show Drugs Live: The Ecstasy Trial ...although presented by the media as looking at MDMA for depression, it seems to be more traumatic memories (but we haven't seen the show yet!)
does this short report of Majumder et al get us rolling...?
What did Majumder et al do? They compared the immediate effects of ecstasy on mood in subjects divided into those with (WP) and without (NP) a predisposition to depression (as assessed using the Brief Symptom Inventory: BSI) before and after a 'party'.
65% of the NP group were females, whereas in the WP group the male to female ratio was 2:1 (χ2(1)=4.912, p=0.027). The authors say "Other demographic parameters were similar between the groups [and]...No significant differences were observed between groups for ecstasy use or recent use of other substances (though details are missing)
The Czars (Drug)


The baseline session was scheduled when participants were drug free (confirmed by a urine test) for at least 7 days prior. All subjects were asked to fill out three self-assessment questionnaires: the Brief Symptom Inventory (BSI), the Beck Depression Inventory (BDI) and the Profile of Mood States (POMS).

All participants were invited to attend a "party session" (and details about this are sketchy e.g. were they were all together - which could influence who does and doesn't decide to take the Es); and crucially, we assume they arrive with their own Es - however many?)

Participants were assigned to either the ecstasy or control group "based on their intention to consume a pill during the social gathering." The authors state "There was no encouragement to consume a pill for the purposes of the study. Subjects in the ecstasy group notified the investigator when they consumed a pill via text message, and 60min later the investigator administered the BDI and POMS by telephone and asked participants to provide a saliva sample in a plastic tube given to them prior to the party session."

The Lemonheads (My Drug Buddy)


(All variance measures are SE). During the social gathering, the NP group reported consuming average of 1.7±0.33 pills, and those in the WP group 1.4±0.22 pills (not significantly different).
The mean MDMA concentration in saliva was 896±132.1 ng/ml (n=17). Crucially, again some detail is missing - they don't give MDMA concentration for the two separate groups, but for whole group. Urine screening tests the following day confirmed exposure to MDMA of subjects in the ecstasy group and did not detect MDMA in any of the control group samples. Other substances consumed were alcohol, cannabis and tobacco, but no difference was observed between the groups.
As expected, when drug-free, the WP subjects show greater mood disturbance and depressive symptoms than the NP group (POMS: NP 5.85±1.63, WP 14.5±2.81, p<0.05, BDI: NP 4.9±0.86, WP 11.2±1.65, p<0.01). Turning to the main reuslts:
Beck Depression Inventory (BDI) The authors report that "During social gathering, WP subjects who consumed ecstasy reported a significant decrease in depressive symptoms (F(1,35)=5.47, p<0.05). We can see this reduction in bottom figure (b).
However, the authors fail to say anything about the top left figure (a) - where the No Predisposition group show far greater depression (BDI scores) than controls after taking ecstasy - this looks, if anything, a larger difference than the purported reduction (after E); and even a reduction in depression symptoms for the controls themselves who don't take E (which seems as quite large given the small SE bars) 
Profile of Mood States (POMS)
POMS: No significant effect of E on mood emerged. The authors state "No interaction or main effects of the drug group and predisposition to depression scores at the party session were observed."
This seems slightly odd given that every group showed a reduction of POMS scores (see Figure below) whether they had predispotion or not, took E or not!


The authors conclude "A decrease in depressive symptoms was observed in subjects predisposed to depression. This antidepressant-like action of MDMA may contribute to its use, particularly among people with an existing or latent depressive disorder."
To me it seems a few questions remain:
1) Did the participants take E together? what are the consequences of social desirability and bravado?
2) Why was the MDMA concentration not given for separate groups (WP and NP) who took E? This is important information as we dont know what the WP and NP groups took
3) Did the BDI scores of controls decrease significantly in the NP condition?
4) In the NP condition, do the E users show significantly greater BDI scores than controls at the party?
5) If BDI does decrease, why is POMS left unaffected? or is it unaffected given all groups show a reduction, why is the main effect for before and after party not sigificant (possibly a lack of power?)

Monday, 10 September 2012

Come Sta La Luna: fingernails and depression


I saw it written and I saw it say
Pink moon is on it's way
And none of you stand so tall
Pink moon gonna get you all
It's a pink moon
Hey, it's a pink moon 
Nick Drake (Pink Moon)

Psychiatry Research has just published a somewhat leftfield paper about fingernails and depression by a group of Chinese scientists. The association between absent lunula and depression in depressive outpatients: A case-control study by Zhou et al (2012).  It concerns  the lunula (Latin Little Moon), which is the white, half-moon shape often visible on all fingers except the little finger.

File:Fingernail label (enwiki).jpg

Absent lunula are apparently associated with various systemic disorders including hypopituitarism, hypothyroidism, iron deficiency anaemia, arteriosclerosis, malnutrition, chronic renal failure, and even cancer (e.g. Cohen, 1996).

Zhou et al state that in "Traditional Chinese Medicine absent Lanula are associated with lower physiological response and bad microcircualtion" and then use this as leverage for hypothesising that absent lunula may be linked to depression.

 Present Lunula                                                                                 Absent Lunula

The authors examined fingernails in a large sample of 332 depressive outpatients (aged between 19 and 67) without cutaneous, congenital or other systemic diseases; and without application of drug and henna that might contribute to any change of lunula. They compared the patients with a similarly large sample of 367 healthy controls, who were drawn from ‘spouses of the patients’ or local residents. The two groups were well matched for age and sex.
Come Sta La Luna (by Can) - if feeling unwell, the cure is in the Can

The Zung Self rating Depression Scale (ZSDS: Zung, 1965) was used to measure the level of depression with scores of <50 =normal; 50–59=mild depression; 60–69=moderate depression; and 70=severe depression (Lin et al., 2009).

Then they simply observed for absence of luluna on right hand (as right and left tend to be identical in this respect). People were classified as having 1,2, 3 or no luluna (as noted the little finger is excluded having no lunula anyway)

Pink Moon (by Nick Drake) followed by the Black Dog

A large difference emerged with only 17.2% of depressed having all 4 lunula present compared to 68.1% of controls. At the other end, 23.7% of the depressed group and only 9.8 of controls had 4 missing (see Table 2)

Table 3 compares absent lunula in relation to depression severity within the depressed group. The table show no differences in sex and age composition between mild/moderate vs severely depressed but that 69% of severe depressed have >3 absent lunula while in the mild/moderate depressed this figure is 41.7%.

Conclusion - mechanism?
The authors state that
"Though the mechanism of absent lunula is still not clear and disputed, previous researches [sic] agreed that absent lunula reflects a variety of complex factors including metabolic changes in addition to anaemia (Dyachenko et al., 2007;Salem et al., 2008;Saray et al., 2004). Metabolic changes are also included in the mechanism of depression, such as the metabolic disorders of angiotensin-converting enzyme, serotonin, monoamine, cortisol, brain-derived neurotrophic factor, melatonin and so on (Akpinar et al., 2008; Annerbrink et al., 2010; Belmaker and Agam, 2008; Montag et al., 2010; Okuno et al., 2011; Wang et al., 2009). Therefore, it may be possible that absent lunula and depression have a common metabolic process leading to the co-occurrence of them."
While the explanation is somewhat speculative and opaque, it is an intriguing finding showing that a small visible finger detail (lunula) may provide information about inner mental state. Looking at my own fingers, my two hands are quite different - lateralised depression! Perhaps a link between mental health and the 'Moon' has some basis after all, but in a positive manner ...check for your good Moon rising...

Gordon Brown's hands
Whose nails are they ...was he depressed? Not mine! (but belong to someone well-known at least to UK public)


Thursday, 6 September 2012

Strange Fruit: Is Racism a Mental Illness?

The weakest link in every chain
I always want to find it
The strongest words in each belief
Find out what's behind it
Politics is pride too
Vagaries of science
She left because she understood
The value of defiance
Scritti Politti (The Sweetest Girl)

Recently I came across a, sadly, all too common newspaper article about racism in the UK - the story concerned a man (Mr Swift) found guilty of racially abusing staff at his local shop. The 32 year-old man racially abused two staff, made Nazi salutes, called a woman in the shop a "black ****" and said "go back to your country you bitch".

What made this story marginally more interesting was that the man's defendant Paul Morris said "Swift suffers from schizophrenia and part of his behaviour in recent years has been a direct result of the illness" - he claimed, or at least implied (given the way that Lawyers use language), that the racism was somehow linked to his schizophrenia

On reading the article, I tweeted “Astonishing – Defence claims schizophrenia caused man to be aggressive racist twat.” And within a couple of hours, I received a tweet from @JonesNev linking me to her interesting Ruminations on Madness blog, where she articulated a thought-provoking (albeit ambivalent) retort to my tweet - it is called 'Culture and Delusions'

In the blog, Nev says:
Although I’m not entirely comfortable with my apparent self-appointed role as apologist for (schizophrenic) mass shooters and racists, it seems necessary to underscore the extent to which severe psychosis in fact can and often does lead otherwise liberal, kind, non-racist people to become glaringly, bluntly racist, sexist, phobic, nymphomanic, hostile, anti-Semitic and so on. I struggle to articulate this in a way that does not directly equate psychosis with pathology, but it seems relatively unambiguous that, at least in some cases, the dynamic “re-mixing” of (emotionally charged) cultural motifs with personal (conscious and/or unconscious) fears and insecurities, profound experiential changes in the boundaries between self and other, disorganization and slippage of thought and memory, sometimes bizarre and frightening voices and visions, often very unsurprisingly leads to a kind of unwitting and strangely cultural “performance” of otherwise more broadly salient sociopolitical conflicts. (And what, of course, is more culturally salient than race?) One might also speculate that implicit racism (which virtually all of us tacitly endorse, as social psychologists have repeatedly demonstrated) simply boils to the surface in the cauldron of psychosis."

Could racism result from delusional thinking?
Nev's response got me thinking - could schizophrenia or a delusional state really cause a person, who was hitherto not racist... to become a violent or abusive racist?

Psychosis is associated with increased odds of violence (estimated at 49%–68%  in the meta-analysis of 204 studies by Douglas et al 2009); and other meta-analyses confirm that the key predisposing factor is comorbid substance abuse (Fazel et al 2009).

But I have worked for 20+ years with many deluded individuals - some claiming to be John Lennon, the Queen's son, or even Green Gartside, but unlike Nev I have yet to meet one who changed from being a non-racist to an aggressive racist following their 'illness'. I have, of course, encountered some expressing politically incorrect views, but none who radically changed! While psychosis can produce dramatic transformations large enough to impact personal identity, as far as I can determine empirical data are sadly lacking on radical transformation of sociopolitical beliefs in psychosis.

Jacques Derrida is in love with Green Gartside

Are we all racists under the surface?
What about the notion that racism is implicitly bubbling under the surface in most or all of us? Evidence used to underpin this idea comes from the Implicit Association Test - but I don't think it holds much water. I don't doubt that the IAT (test yourself here) reveals some associations may occur faster than others - what I object to is the notion that such associations signify racism (implicit or otherwise). Little or no evidence exists to document a link between IAT performance and overt discrimination. And a recent meta-analysis (Greenwald et al. 2009) found a very small association between performance on the Race (black-white) IAT and explicit (self-report) measures in 27 studies (with an r=.11). The bottom line is little or no evidence for a link between the IAT with overt racism; and of course, if most of use show implicit racism, why do only a fraction become overt racist? If only we could cure racism with propranolol...

Defining delusions
Could racist behaviour qualify as delusional? According to the DSM-IV-TR, a delusion is:
A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture.

Does racism meet the criteria for being a delusion? Yes...racism could be a false belief based on incorrect inference about external reality and one that is not one ordinarily accepted by other members of the person's culture.

In the case of Mr Swift, I think the correspondence may lack when we consider "firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary" Interestingly, in interview, Swift told police officers he remembered swearing and telling the shopkeepers to get out of his country, but he was not racist. Now, without being too picky (and leaving absurd "some of my best friends are black' reverse psychology nonsense), some might argue that his denial of being a racist undermines the claim about it being delusional. If only we could get deluded individuals to so readily give up their delusions (as perhaps a legal defence team), then I suspect we might dispense far less medication or psychological therapy!

As an aside, the person who thought they were Green Gartside looked nothing like him, being much heavier, shorter and with red hair  - when I pointed out the inconsistency, he informed me that the hospital had cut parts of his legs away and given him chemicals to change his hair colour and make him partly bald - invention and resistance are key to the survival of delusion!

If music could cure racists (a memory from my youth 30/4/1978)

Racism as a form of mental illness: Alvin Poussaint
Some within psychiatry, notably Harvard University psychiatrist Alvin Poussaint have argued that racism itself should be recognised as a mental illness. In a New York Times article entitled "They Hate. They Kill. Are they Insane?" in 1999, he argued that:
It is time for the American Psychiatric Association to designate extreme racism as a mental health problem. Clinicians need guidelines for recognizing delusional racism in all its stages so that they can provide treatment. Otherwise, racists will continue to fall through the cracks of the mental health system, and we can expect more of them to act out their deadly delusions
In another article entitled 'Is extreme racism a mental illness" Poussaint argues that:
To continue perceiving extreme racism as normative and not pathologic is to lend it legitimacy. Clearly, anyone who scapegoats a whole group of people and seeks to eliminate them to resolve his or her internal conflicts meets criteria for a delusional disorder, a major psychiatric illness
However, he also claims that common or garden varieties of racism are treatable:
"...sometimes even lesser forms of racism are treatable because they have psychodynamics to them...They don't exist as a social problem, they … exist as psychological problems inside the individual."
In a piece in the Western Journal of Medicine Poussaint proposes specific modifications to the DSM’s diagnostic criteria for delusional disorder, suggesting the prejudice subtype:
A delusion whose theme is that a group of individuals, who share a defining characteristic, in one’s environment have a particular and unusual significance. These delusions are usually of a negative or pejorative nature, but also may be grandiose in content. When these delusions are extreme, the person may act out by attempting to harm, and even murder, members of the despised group(s).
Poussaint makes some valid arguments, but the dilemma we are faced with is...arent most violent hate crimes largely committed by people who are bad, not mad?

You needn't take it any further, sir. You've proved to me that all this ultraviolence and killing is wrong, wrong, and terribly wrong. I've learned me lesson, sir. I've seen now what I've never seen before. I'm cured! Praise Bog! I'm cured!
Alex (Clockwork Orange)
Despite some reservations, I do think this is an area requiring far greater empirical investigation. Future studies might also examine if the reverse occurs - could a racist become liberal-minded following psychosis? After all, why should any change inevitably run in a negative direction? Might we then also extend the notion to those who express other obnoxious views: sexists, homophobes (Oh... the irony of homophobes being mentally ill) and so on - could they be classified as forms of mental illness or delusional thinking and treatable?


Douglas, K., Guy, L., & Hart, S. (2009). Psychosis as a risk factor for violence to others: A meta analysis. Psychological Bulletin, 135, 679–706.

Fazel S, Gulati G, Linsell L, Geddes JR, Grann M (2009) Schizophrenia and violence: systematic review and metaanalysis. PLoS Med 6(8):1–15

Greenwald, A. G., Poehlman, T. A., Uhlmann, E. L., & Banaji, M. R. (2009). Understanding and using the Implicit Association Test: III. Meta–analysis of predictive validity. Journal of Personality and Social Psychology, 1, 17–41.