How do you define remission?

OBJECTIVE: To underscore the need to attain remission in the treatment of depression, taking into consideration the appropriate definitions of response and remission, as well as the impact of residual symptomatology. METHOD: A review of research pertaining to successful response and remission of depression following antidepressant intervention, as identified by a comprehensive MEDLINE search. RESULTS: Complete remission is both critical and attainable with appropriate antidepressant therapy. CONCLUSION: While adequate response to antidepressant medication is desired, the ultimate goal of therapy is remission, the achievement of an asymptomatic state characterized by complete functional recovery.     

How do researchers define self-injurious behavior?

Self-injurious behavior is commonly observed among persons with intellectual disabilities. However, a second parallel use of this term is used in the general mental health field for self-mutilation. The authors describe these two disorders and how they differ. Characteristics of what we refer to as repetitive self-injurious behavior among persons with intellectual disabilities and risk factors for these behaviors are discussed. We also describe different assessment/testing methods which aid in defining this phenomenon. The implications of these data for research and clinical practice are discussed.     

How much sleep do we need?

There is increasing concern for sleeplessness-related risks in modern society. Some recent epidemiological data seem to support the view that many segments of the adult population have chronically inadequate sleep. On the other hand, some experts have claimed that our core, basic amount of sleep is around 6 h per night, and that the rest of our sleep can be easily curtailed, being unnecessary to fulfill any sleep need. However, experimental data on the effects of both acute and cumulative partial sleep deprivation (PSD) consistently point out that sleep restriction has substantial negative effects on sleepiness, motor and cognitive performance and mood, as well as on some metabolic, hormonal and immunological variables. As chronic PSD may have serious long-term adverse health effects, it should be avoided in the general population. In the short-term, the effects of sleep curtailment seem to accumulate linearly, while the effects of long-term PSD should be further investigated, as the few available studies are flawed by methodological weaknesses. On the other hand, there is evidence that extending sleep by 2-3 h beyond the norm produces only marginal benefits for an average individual. Finally, it is underlined that, as large individual differences do exist in the need for sleep, the search for the sleep need may be vain. A somnotypology, taking into account age, gender and the position in both the sleep-alert and the morningness-eveningness continuum, should help in the search for the actual individual sleep need. 2001 Harcourt Publishers Ltd     

How well do we recognise non-motor symptoms in a British Parkinson's disease population?

Although awareness of non-motor symptoms in Parkinson??s disease (PD) has recently increased, little is known about their recognition and treatment in routine clinical practice. We therefore applied non-motor rating scales for dementia, depression, anxiety and excessive daytime sleepiness to a community-ascertained cohort of 202 PD patients. Hospital case notes were reviewed for evidence that the non-motor problems had been recognized and whether any action had been taken to ameliorate or assess these symptoms. The prevalence of each non-motor problem was as follows: dementia 25.3% (95% CI 19.0, 32.4), depression 37.3% (95% CI 30.6, 44.4), anxiety 31.3% (95% CI 25.0, 38.2), excessive daytime sleepiness 59.4% (95% CI 52.2, 66.3). However, these features were only recognised in 27.2, 38.7, 9.5, and 12.8%, respectively. We did not identify any specific factor that predicted under-recognition. Our study shows that when rating scales are applied to formally assess for non-motor symptoms a large clinical ??iceberg effect?? emerges with the majority of symptoms going unrecognised and untreated.     

How many assertive community treatment teams do we need?

OBJECTIVE: Assertive community treatment (ACT) reduces hospitalizations for persons with severe mental illness. However, not everyone who needs ACT receives it. Without empirical guidelines for ACT planning, communities are likely to underestimate or overestimate the number of teams they need; thus the capacity of the programs will not meet current needs. In this study, administrative data were used to develop empirical estimates for the number of required ACT teams. These estimates were then used to examine current conceptual guidelines for developing the number of ACT teams that communities need. METHODS: Administrative data from a large, urban county were used to enumerate all persons with a severe mental illness who had three or more hospitalizations within one year (ACT eligible). RESULTS: Fifty-one percent of persons with a severe mental illness were found to be eligible for ACT (743 of 1,453 persons). This figure represents 2.2 percent of the county's mental health users and .06 percent of its adult population. CONCLUSIONS: Communities should develop enough ACT teams to serve approximately 50 percent of their populations of persons with severe mental illness or roughly .06 percent of their adult populations.     

The challenge of multiple sclerosis: How do we cure a chronic heterogeneous disease?

Multiple sclerosis is (MS) a T‐cell autoimmune disease characterized by a relapsing‐remitting followed by a progressive phase. Relapses are driven by the adaptive immune system and involve waves of T helper cell 1 (Th1), Th17, and CD8 cells that infiltrate the nervous system and provoke a attack. These cells are modulated by regulatory T and B cells. Infiltration of T cells into the nervous system initiates a complex immunological cascade consisting of epitope spreading, which triggers new attacks, and activation of the innate immune system (microglia, dendritic cells, astrocytes, B cells), which leads to chronic inflammation. The secondary progressive phase is due to neurodegeneration triggered by inflammation and is driven by the innate immune system. Why a shift to the progressive stage occurs and how to prevent it is a central question in MS. Effective treatment of MS must affect multiple disease pathways: suppression of proinflammatory T cells, induction of regulatory T cells, altering traffic of cells into the nervous system, protecting axons and myelin, and controlling innate immune responses. Without biomarkers, the clinical and pathological heterogeneity of MS makes treatment difficult. Treatment is further hampered by untoward adverse effects caused by immune suppression. Nonetheless, major progress has been made in the understanding and treatment of MS. There are three definitions of cure as it applies to MS: (1) halt progression of disease, (2) reverse neurological deficits, and (3) prevent MS. Although the pathways to each of these cures are linked, each requires a unique strategy. Ann Neurol 2009;65:239–248     

What should we do with a discontinued shunt?

Purpose  

The reported rate is up to 10% of shunt disconnection or fracture, either ventriculoperitoneal or subduroperitoneal. However, not all of shunt discontinuity is associated with shunt malfunction. We analyzed the discontinuity of the shunt system and related factors and tried to present a follow-up policy.     

How many forensic assertive community treatment teams do we need?

Despite the growing interest in forensic assertive community treatment (FACT), there is no standardized definition of FACT eligibility and no guidelines for how many FACT teams communities may need. In this brief report a definition for FACT eligibility is proposed-severe and persistent mental illness and three jail detentions in a one-year period-and modeled by using 5.5 years of administrative data (July 1, 1993, through December 31, 1998) from a large, urban county in the western United States. Findings suggest that large, urban communities should develop enough FACT teams to serve approximately 44% of their populations of persons with severe mental illness, or roughly .05% of their adult populations. Developing standardized eligibility criteria for FACT is an important first step toward developing its evidence base.     

Why do we sleep?

Slow-wave sleep consists in slowly recurring waves that are associated with a large-scale spatio-temporal synchrony across neocortex. These slow-wave complexes alternate with brief episodes of fast oscillations, similar to the sustained fast oscillations that occur during the wake state. We propose that alternating fast and slow waves consolidate information acquired previously during wakefulness. Slow-wave sleep would thus begin with spindle oscillations that open molecular gates to plasticity, then proceed by iteratively 'recalling' and 'storing' information primed in neural assemblies. This scenario provides a biophysical mechanism consistent with the growing evidence that sleep serves to consolidate memories.     

From engagement to participation: How do we bridge the gap?

Supporting and developing choice has often been seen as an aim for community services, but is difficult to achieve for individuals with severe learning and communication difficulties. Measures of service quality have tended to look more at the activities which individuals engage in, although there is now an increasing emphasis on trying to access user views. The aims of the present study were to examine staff judgements about clients' responses to the daily routines organized for them and to examine the extent to which it appeared that service users were engaging in activities which they preferred. The results suggest that staff are able to ascribe meaning to the different behaviours of clients, but that they do not always agree amongst themselves as to what the behaviour means. They are also aware that service users do not enjoy all the activities in their daily routine. Service providers and commissioners need to make the development of choice and preferences for service users as much of a priority as engagement in activities.     

How do seizures stop?

Although often overshadowed by factors influencing seizure initiation, seizure termination is a critical step in the return to the interictal state. Understanding the mechanisms contributing to seizure termination could potentially identify novel targets for anticonvulsant drug development and may also highlight the pathophysiological processes contributing to seizure initiation. In this article, we review known physiological mechanisms contributing to seizure termination and discuss additional mechanisms that are likely to be relevant even though specific data are not yet available. This review is organized according to successively increasing "size scales"-from membranes to synapses to networks to circuits. We first discuss mechanisms of seizure termination acting at the shortest distances and affecting the excitable membranes of neurons in the seizure onset zone. Next we consider the contributions of ensembles of neurons and glia interacting at intermediate distances within the region of the seizure onset zone. Lastly, we consider the contribution of brain nuclei, such as the substantia nigra pars reticulata (SNR), that are capable of modulating seizures and exert their influence over the seizure onset zone (and neighboring areas) from a relatively great-in neuroanatomical terms-distance. It is our hope that the attention to the mechanisms contributing to seizure termination will stimulate novel avenues of epilepsy research and will contribute to improved patient care.     

Mesial temporal lobe epilepsy: How do we improve surgical outcome?

Surgery has become the standard of care for patients with intractable temporal lobe epilepsy, with anterior temporal lobe resection the most common operation performed for adults with hippocampal sclerosis. This procedure leads to significant improvement in the lives of the overwhelming majority of patients. Despite improved techniques in neuroimaging that have facilitated the identification of potential surgical candidates, the short-term and long-term success of epilepsy surgery has not changed substantially in recent decades. The basic surgical goal, removal of the amygdala, hippocampus, and parahippocampal gyrus, is based on the hypothesis that these structures represent a uniform and contiguous source of seizures in the mesial temporal lobe epilepsy (MTLE) syndrome. Recent observations from the histopathology of resected tissue, preoperative neuroimaging, and the basic science laboratory suggest that the syndrome is not always a uniform entity. Despite clinical similarity, not all patients become seizure-free. Improving surgical outcomes requires a re-examination of why patients fail surgery. This review examines recent findings from the clinic and laboratory. Historically, we have considered MTLE a single disorder, but it may be time to view it as a group of closely related syndromes with variable type and extent of histopathology. That recognition may lead to identifying the appropriate subgroups that will require different diagnostic and surgical approaches to improve surgical outcomes.