Meghna’s question, lightly distilled: Before your current posting, you were the president of St. Elizabeth’s Medical Center — the biggest hospital in the Steward Health Care System, which has been pretty aggressive in trying to reduce costs. Massachusetts has academic medical centers that are gems in terms of medical research and care, but those top-tier hospitals tend to say that their prices need to be higher to support research, or care for those who can’t pay. What do you tell them?

Polanowicz, excerpted:

We are one of the few states where we’re a little upside down in terms of where care is actually being sought. The vast majority of individuals in other states are not running to their academic medical centers for primary and secondary care. Absolutely going there for tertiary care and for some of the advances and frankly programs that we, as a Commonwealth, should be very proud of, that we have them here in Massachusetts.

…

I think that part of the issue is, and what I would say is, we have a lot of duplication of programs.  We have programs even within some systems, the same program almost across the street from each other…

I’ve said this to many of my former CEO colleagues: No one is going to want to pay us more for the things we are doing today, so we have to figure out ways to provide the care less expensively. Whether that’s through technologies, through reduction of testing, through reduction of waste.

…We need to figure out what businesses we need to be in and what not. Do we need five of these ultra-high -level services for the Commonwealth?

Meghna: Some would say that we do.

Some would say that we do. This is the interesting thing.  I heard it right after the Marathon. Frankly, we’ve all asked, do we need this many level one trauma [centers]…and on that day we did.  So if you need that capacity, the question is, if you can’t take it from there, then everything else you do has got to be run in a very fine way, in as most cost-efficient a way as possible.  Looking at how the organizations are structured, there are opportunities there.  It’s just, it’s hard to go after them.

You can find the full interview here.

“Ariadne is the myth of the Greek goddess who showed Theseus the way out of the labyrinth with a simple thread,” Gawande explained. “We’re in the simple-threads business to show our way out of the labyrinth of health care complexity.”

Gawande, a surgeon at Brigham and Women’s Hospital, has been named one of the world’s most influential thinkers. The surgical checklist he promotes has been gaining traction worldwide since 2008, when it’s use in a World Health Organization project reduced deaths during surgery by nearly 50 percent. The list is a set of questions everyone in an operating room answers, starting with: Do we have the correct patient? What operation are we performing? And is the site marked?

Now, Gawande is expanding his focus from surgery to two other big health care moments: childbirth and death.

“We think in the course of a person’s life that you will turn to the health system for a few high-risk, high-failure health care moments, and also some of the highest-cost moments in that system,” Gawande said. It starts with childbirth and surgery — the average person has seven operations in their lifetime — all the way to the end of life.

“We know that almost 90 percent of patients say they want to die at home, yet less than 50 percent do,” Dr. Rachelle Bernacki tells an audience gathered for the first research meeting on end-of-life care at Ariadne Labs’ new office.

Bernacki is testing a set of questions that aim to make sure doctors understand the wishes of patients who face a prognosis of death within six months. “We start all conversations with, ‘What’s your understanding of where you are with your illness now?’” Bernacki explained. She is analyzing patients’ responses to seven questions and training doctors to have these difficult conversations.

Some health care experts who’ve wrestled with the end-of-life issue for years – like Stuart Altman, who has worked on health care reform at the state and national level for 45 years —  are thrilled to hear Gawande’s lab is taking it on.

“Atul Gawande is a true find,” Altman said. “There are few people — no, as a matter of fact, I don’t know anybody who really has a better insight into how our system works and where it doesn’t work and how it could be better.”

But Gawande knows there are hurdles ahead. His lab is getting off the ground with donations from individuals, the Gates Foundation and some government grants. He has support from Brigham and Women’s and the Harvard School of Public Health. But Gawande isn’t certain about long term funding.

In another hurdle, he has to persuade doctors and nurses to buy into his proposed solutions. But he’s optimistic.

“Boston is a place where, if we are not leading this, I don’t know who is,” Gawande said. He expects to work with major hospitals and medical schools to expand work that other organizations have started, “out of a belief that Boston can be the Silicon Valley of health care innovation.”

He says the theme in all his work, whether it’s health care policy, surgery, or writing for The New Yorker, is finding simple solutions for messy problems.

Readers? Anything you’re most hoping they’ll take on? The Ariadne Labs Website is here.

As rules and guidelines and processes are developed to translate last year’s successful medical marijuana ballot measure into practice, the shape of the state’s coming “MM” order is beginning to emerge. State officials say it is a “Goldilocks” plan — (as in, just right) — balancing patients’ needs with concerns about abuse.

And that means learning from the 17 other states that have already legalized medical marijuana, they say. So, for example: The rules will emphasize that to prescribe marijuana, a doctor must be involved in a patient’s continuing care, thus avoiding the pot equivalent of “pill mills.” Signs will need to be low-key, not neon. Edible marijuana will be allowed, but cannot be marketed in candy-like forms alluring to children.

Those are a few of my takeaways from speaking to interim commissioner Cheryl Bartlett of the Department of Public Health. Our conversation is below, lightly edited, and for further details, the state has a medical marijuana FAQ here and more information here. To learn more, tune in to Radio Boston today at about 3 p.m. for a live interview with John Polanowicz, the state’s secretary of Health and Human Services — and if you have a particular question, the show will be taking call-ins at 800-423-8255.

So where are we at with medical marijuana?

The latest thing that happened is on Friday, we held a public hearing at the Department of Public health on fees. The ballot initiative requires that we develop a program of oversight, and that it be revenue-neutral to the state. So it authorized us to develop fees to cover the costs of this program. We took input and comments on that, and we’ll formulate the comments and get them up to Administration and Finance, which has the authority to establish fees.

When are they expected? 

We think in about a month.

We’re also in the midst of drafting what the application process will look like. There’s a two-phase review process to select the candidates for opening Registered Marijuana Dispensaries. There’s an initial phase to determine if an organization has the capacity to do this work in the way that we have outlined in our regulations, so we screen out those that wont meet the minimal requirements for eligibility. And we have a very thorough process to select candidates to be Registered Marijuana Dispensaries. The ballot initiative allows up to 35 across the state, with one in each country, so it’s a minimum of 14.

Judging by the experience of other states, do you expect many more applicants than there are slots?

Based on our best guesstimates, we’re hearing that there will be more applicants than the number of dispensaries. One number I’ve heard is that we might get around 80 applicants, but that is total hearsay from different informational sessions. Once people see the application, they’ll know better if they really have the ability to meet the specifications. We haven’t been accepting applications at this point, so we have no way of knowing who’s out there.

When will you start accepting them?

We believe in the fall we’ll be able to start accepting applications; I’d say September-ish is a reasonable timeframe.

And in the meanwhile, patients can make an interim arrangement?

Yes, the ballot measure says that until there are registered medical dispensaries, that patients can get a written recommendation from their physicians that says they qualify to use marijuana, and would most likely cultivate a limited supply for their personal use. That’s now in effect until there are registered dispensaries and we start registering patients.

Do you have an estimate of how many patients there will be?

We don’t. We’ve looked at Colorado to get a sense of how many they have, and they have about 2% of their population. We don’t think we’re going to get that many; our projections have been maybe about one half of one percent. But again, that’s really taking a stab in the dark based on what some other states have seen.

What else are you projecting from other states’ experience?

We took a very serious and responsible approach to our regulations that really considered the public safety concerns of communities balanced with compassionate access. We really have thought through how to make sure that people can use marijuana to help take care of themselves but at the same time we minimize the opportunity for diversion. We think that our regulations around hardship waivers and cultivation, and minimizing of caregivers growing for multiple patients, really minimize the opportunity for diversion.

What are those caregiver rules?

Caregivers are allowed to grow, and either to cultivate for a patient or go and receive the medical marijuana at a dispensary when the patient meets the hardship criteria — that they are immobile and unable to go and accept the products themselves, or grow their own, or can’t afford it.

We limited that so you can only have one caregiver who would cultivate for you, and each caregiver can only be a caregiver of one patient, whereas in some states, you can be a caregiver for more than one patient, which would allow you to cultuvate more marijuana based on the number of patients you had.

What else should we know about how this is going to go?

I think the expectation would be that we would hope to see some dispensaries in the beginning of next year. That would be dependent on their ability to either renovate or build whatever facility they have, so some of the timing is not exact at this point.

Physicians will be required by the end of Fiscal Year 2014 to get continuing medical education on this, if they want to be able to certify their patients. So to do it you’d have to have some knowledge about what anecdotal evidence about the use of marijuana there is, as well as unintended consequences — so use of marijuana, risks and benefits. We feel that will make physicians more comfortable in certifying patients, and that increases access to physicians who certify. There has been concern from doctors that they don’t get that knowledge in medical school because it’s not a federally approved medication that has gone through clinical trials. We felt it was really important to give more comfort to physicians to certify patients.

Another thing for the public to know is that youth under 18 will have access to the use of medical marijuana, but will need two physicians to certify that the risks and benefits have been assessed and the benefits will outweigh the risks, one being a board-certified pediatrician. That was to address the concerns of the pediatric community about the developing brain and the impact of marijuana on it. We wanted to be clear that the benefits must outweigh the risks, and a parent or legal guardian must also approve the access.

And the child must be terminally ill?

Terminally ill — and the definition is that the prognosis is about a two-year life expectancy — or with other debilitating conditions as defined in the regulation. We also leave a lot of this up to the physician-patient relationship. We heard many comments from patients that they did not want us to provide just a set list of conditions, because there are some unusual and rare conditions that might benefit, so it would really be up to the doctor thinking there was no other conventional treatment that could alleviate this person’s symptoms.

Another aspect of public interest is that we really have put some guidelines around the signage of dispensaries, so they’re not neon signs, not recreational. They convey that this is a structure that is really a serious business.

We have allowed for local communities to use some of their own bylaws and regulations. A lot of towns have zoning regulations about signs.

Anything else in which you looked at what happened in other states and said, ‘Let’s not do that here’?

We really emphasize the bona-fide patient-physician relationship. In other states, I think they’ve experienced physicians that set up shop to certify patients and they might not have an ongoing relation to their care. And we want this to really be about care coordination, and a physician who really understands the needs of the patient.

So when a physician is certifying a patient they both have a series of questions they have to answer about what condition they’re being certified for, they have to attest to the fact that they’ve seen the patient in person, and they’ll have to certify the patients annually, so it won’t be ongoing once they’re certified. The longest a certification can last is one year, and the minimum is 15 days.

Much of the initial reaction to the regulations focused on the quantity limits: 10 ounces every 60 days. Some people thought that was quite a lot…

Again, we looked at what the 17 other states did, we reviewed the testimony from hundreds of patients and medical providers and we heard about the most common methods of use of marijuana. A lot of people only understand marijuana as a smoked product, so that seems like a lot in many people’s minds, but we heard that the most common methods are aerosolization and edible products, so it takes more product to get the same effect as smoking.

So 10 ounces seems like a lot for smoking but not for using other methods?

Correct. And we allow the physicians to determine a lot. We had a lot of patients actually advocate for 24 ounces, which is what Washington does — they felt they had the most evidence for that amount. We allowed the physician to certify for more if they can demonstrate that the 10 ounces were not adequate to alleviate the symptoms. Again, it’s the emphasis on the physician and the patient deciding what’s in their best interests.

One other highlight: The regulation prohibits the marijuana-infused edible products from resembling any form of commercially available candy. That’s been an important issue in other states, products looking like candy and younger kids ingesting it. We really want it to be clearly packaged as medicine. We don’t have an exact description but it can’t be flashy colors, like some tobacco products.

We’re also requiring tamper-resistant packaging. In other states there were problems when children have gotten their hands on it and become ill. And it will have to be labeled so we know the amount of the product in there, as part of the 10 ounces the patient has.

Readers, additional questions? Comments? Thoughts? For a fun look at potential applicants, check out today’s Boston Globe story: Three making plans for medical marijuana dispensaries.

Funny. Sure didn’t feel like love.

These days, laudable anti-bullying programs abound in the nation’s schools. But the anti-bullying movement seems to have an odd blind spot when it comes to bullying at home.

A new study just out in the journal “Pediatrics” addresses that gap, using findings from a national survey of children and their caregivers. It found that, just like bullying by peers, bullying by siblings causes significant mental distress and worsens the victims’ emotional health. Bottom line:

The authors concluded that parents, pediatricians and the public should treat sibling aggression as potentially harmful, and not dismiss it as normal, minor, or even beneficial, and this message should be included in parenting education.

Corinna Jenkins Tucker, associate professor of family studies at the University of New Hampshire and the paper’s lead author, suggests that it’s time for the new norms that condemn school bullying to stop making an exception for siblings.

Sibling aggression has “generally gone unrecognized and dismissed,” she said in a phone interview. “Our findings suggest that it should not be dismissed and it’s in fact not benign.”

What kind of aggression are we talking about? Here’s a useful explainer from the New York Times report on the study:

While normal rivalries with siblings can encourage healthy competition, the line between healthy relations and abuse is crossed when one child is consistently the victim of another and the aggression is intended to cause harm and humiliation, said John V. Caffaro, a clinical psychologist and the author of “Sibling Abuse Trauma.”

Parents who fail to intervene, play favorites or give their children labels that sow divisions — like “the smart one” and “the athlete” — can inadvertently encourage conflict. Nationwide, sibling violence is by far the most common form of family violence, occurring four to five times as frequently as spousal or parental child abuse, Dr. Caffaro said.

According to some studies, nearly half of all children have been punched, kicked or bitten by a sibling, and roughly 15 percent have been repeatedly attacked. But even the most severe incidents are underreported because families are loath to acknowledge them, dismissing slaps and punches as horseplay and bullying as boys just being boys, he said.

“Our society tends to minimize child-on-child violence in general,” he added. “We have these ideas that if you’re hurt by a child it’s less injurious than if you’re hurt by an adult, but the data don’t support that.”

The study did not compare the damage of sibling bullying to peer bullying. It found that either could cause mental distress. From the press release:

The researchers interviewed more than 3,500 children and youth aged 1 month to 17 years or their parents about various measures of aggression displayed by siblings and peers as part of the National Survey of Children’s Exposure to Violence. They assessed the range and extent of sibling aggression experienced by the respondents, looking at such measures as physical assault with and without a weapon or injury; stealing something from the child with or without force, or breaking siblings’ things on purpose; and saying things to make the child feel bad or scared or not wanted around.

The children’s mental health also was assessed. The results showed that sibling aggression in the past year was associated with significantly worse mental health for both children and adolescents. Distress was evident for children and adolescents who experienced both mild and severe forms of sibling aggression. The data also showed that when comparing sibling versus peer aggression, each uniquely predicted greater mental distress.

The study is unique, Corinna Jenkins Tucker said, because it used national-level data and looked at more than one age group.

“And we also have a comprehensive picture here, where it’s not just physical — we look at physical, property and psychological, and we look at more mild forms vs. more severe, and we also took the approach of, ‘Is it just experiencing one type vs. none, and that made a difference as well,” she said. “And the final thing that’s unique is that we controlled for other kinds of co-occurring victimization, such as experiencing Internet victimization or maltreatment, and these connections between sibling aggression and mental distress still showed up.”

I must say, I’ve sometimes thought that my brother’s aggression did help toughen me up. Tucker says that’s a common belief, that “this is one of the first places you learn how to fight. You’re able to try things out.”

But really, I’d gladly have forgone that toughening for more peace. Tucker says that for parents, sibling bullying should be “a real teaching opportunity, to teach about conflict resolution skills and constructive conflict.”

Readers, any old scores to settle? Will you be sending any siblings a long-belated ‘That was not okay’?

My inbox and voicemail were filled with gleeful messages from colleagues, friends, and family Thursday afternoon. My beloved friend Martha put it just right when she called me from Connecticut: “I’m happy for you, and me, too, and everyone else!”

In what may be the single most popular opinion of his Supreme Court career, Justice Clarence Thomas wrote the unanimous decision, released Thursday, that liberates scientists to perform research on and design tests for BRCA 1 and 2. These are the genetic mutations linked to an elevated risk of developing breast and ovarian cancer.

Some of us belong to families where grandmothers, mothers, aunts, and sisters don’t survive into middle age because they develop breast and ovarian cancer. Up until today, the only way we could find out if we’d be likely to share the fate of our doomed relatives was to give our cells to one company — Myriad Genetics.

Myriad claimed its patent prevented any other entity from providing this service, and it set the cost for testing so high that low-income, uninsured, and underinsured women weren’t able to unlock the riddle of their fate.  In addition, it made research into effective cures impossible.

In his decision, Justice Thomas explained that the Court had reasoned that Myriad can’t hold a patent on “naturally occurring phenomena.” Myriad didn’t invent the mutations. It didn’t even invent the process for removing the DNA from human cells. The company therefore can’t prevent others from sequencing or studying these mutations. (Here’s a good explanation of the case in layperson’s terms.)

There is concern among business experts that entrepreneurs in biotech fields will be less willing to invest time and money into research if they can’t patent their discoveries. I don’t believe it. If competition plays a role in market expansion, then I think — like my friend Martha — that we all have reason to be happy.

I am optimistic this evening that my kids will have better options than I do when they face the results of their own testing. I cherish hope that the Supreme Court’s decision guarantees that I will belong to the very last generation whose best option for survival is the loss of healthy ovaries and breasts.

Cathy Corman is a writer and multimedia producer who teaches American Studies at Umass Boston and keeps an occasional blog, “Bowl o’ Cherries.” She wrote previously about the Myriad patent issue here.

This is an admittedly heart-rending quandary. But it’s one that administrators of Boston’s One Fund for marathon bombing victims will have to resolve soon.

Tomorrow (Saturday) is the deadline for applications. Money will go out to victims on July 1, based on the fund total as of July 27. So between July 27 and July 31, One Fund administrator Ken Feinberg and his team will decide who gets how much. Feinberg has set the categories. The question is…how to divide the money?

This is a tragic calculation. As Feinberg has said, there is no way to meet all the victims’ needs. But how would you do it? How much more does the family of someone who died deserve as compared to a young woman who lost most of one leg or a man who kept both legs but suffered permanent damage?

We did some back-of-the-envelope math to get the conversation started, using the best numbers we’ve been able to gather thus far.

As of today, the One Fund has just about $48 million, and 155 people have applied.

The largest awards will go to victims who died, are double amputees or those with permanent brain damage. There were four deaths (three at the bombing site and Sergeant Sean Collier) and two double amputees. We don’t know how many survivors have a permanent brain injury. To be cautious, let’s say one. So the total in Category A would be 7. Let’s say we start with $2 million a piece, for a total of $14 million.

The second-highest award will go to survivors who lost one limb. We know of 14. If they get $1 million each, for a total of $14 million, the fund has $20 million left to distribute.

The third-highest award will go to people whose injury was bad enough to require an overnight hospitalization. There were at least 135 survivors in this category (after you subtract the single and double amputees). Let’s say they get $133,000 each. That leaves $2 million.

The fourth category is for patients who were treated and released without an overnight hospital stay. There were at least 125 such victims as of the last count. Let’s say they would get $16,000 each.

Some people who are eligible may not apply.

And yes, there will be more money by July 28. This is just a way to start thinking about balance, priorities and the decisions fund administrators will have to make.

They do not plan to consider a victim’s income, assets, life expectancy or any other factors.

What would you do?

Readers, we’ll be discussing this on Radio Boston today at 3 p.m.; any particular comments or questions to be mentioned on air? Please write them in the Comments below.

From the New York Times here:

Human genes may not be patented, the Supreme Court ruled on Thursday.

“A naturally occurring DNA segment is a product of nature and not patent eligible merely because it has been isolated,” Justice Clarence Thomas wrote for a unanimous court. But manipulating a gene to create something not found in nature is an invention eligible for patent protection.

The case concerned patents held by Myriad Genetics, a Utah company, on genes that correlate with increased risk of hereditary breast and ovarian cancer.

The central question for the justices in the case, Association for Molecular Pathology v. Myriad Genetics, No. 12-398, was whether isolated genes are “products of nature” that may not be patented or “human-made inventions” eligible for patent protection.

And its take on the implications:

The court’s ruling will shape the course of scientific research and medical testing, and it may alter the willingness of businesses to invest in the expensive work of isolating and understanding genetic material.

From The Wall Street Journal:

The court was handing down one of its most significant rulings in the age of molecular medicine, deciding who may own the fundamental building blocks of life.

The case involved Myriad Genetics Inc., MYGN +10.29%which holds patents related to two genes, known as BRCA1 and BRCA2, that can indicate whether a woman has a heightened risk of developing breast cancer or ovarian cancer.

Justice Clarence Thomas, writing for the court, said the genes Myriad isolated are products of nature, which aren’t eligible for patents.

“Myriad did not create anything,” Justice Thomas wrote in an 18-page opinion. “To be sure, it found an important and useful gene, but separating that gene from its surrounding genetic material is not an act of invention.”

Even if a discovery is brilliant or groundbreaking, that doesn’t necessarily mean it’s patentable, the court said.

However, the ruling wasn’t a complete loss for Myriad. The court said that DNA molecules synthesized in a laboratory were eligible for patent protection. Myriad’s shares soared after the court’s ruling.

Further reading: From CommonHealth: Opinion: Why Our Genes Should Not Be Patented.

From the Nation: What’s at stake in the Supreme Court decision in ‘AMP vs. Myriad Genetics’

The full Supreme Court decision is here.

Written by three Boston University professors – George J. Annas, J.D., M.P.H.; Sondra S. Crosby, M.D.; and Leonard H. Glantz, J.D. — it begins:

American physicians have not widely criticized medical policies at the Guantanamo Bay detainment camp that violate medical ethics. We believe they should. Actions violating medical ethics, taken on behalf of the government, devalue medical ethics for all physicians. The ongoing hunger strike at Guantanamo by as many as 100 of the 166 remaining prisoners presents a stark challenge to the U.S. Department of Defense (DOD) to resist the temptation to use military physicians to “break” the strike through force-feeding.

The full piece is here, and The Guardian newspaper quotes the lead author, ethicist George Annas, here:

In an interview, Dr Annas said the force-feeding went against international standards of medical ethics. He said that a hunger strike was a legitimate form of protest – not an attempt to commit suicide – and that the portrayal of doctors at Guantánamo as ethically intervening to preserve life was wrong. “That is at the core of this. These people are not trying to commit suicide. They are risking death to make a political point,” he said.

That is backed up by the World Medical Association, which has declared that force-feeding hunger strikers is “never ethically acceptable”.

Readers?

But a new government-funded study suggests there may soon be a way to decide by looking at brain scans.

If the part of the brain called the insula is overactive, the patient should be prescribed medication, the study indicates; if the insula is underactive, than cognitive behavioral therapy, a type of talk therapy, may be better.

This power to predict, if confirmed by other research, will help avoid months of trial and error treatment, and – though brain scans are costly – might save money in the end, by getting the patient effective care much faster, said Diego Pizzagalli, director of the Neuroimaging Center and the Center for Depression, Anxiety and Stress Research at McLean Hospital. He was not involved in the study.

Published in today’s issue of JAMA Psychiatry, the study also reinforces the idea that depression is not one condition, as it’s currently defined in the “bible” of psychiatry – the newly published edition of the Diagnostic and Statistical Manual.

Instead, Pizzagalli said, it’s a wide-ranging set of symptoms that experts have decided should be called depression. Psychiatrists are currently debating whether such symptoms – or the underlying biology – should be used to define psychiatric conditions.

“What we are learning through our work is that basically the diagnosis of depression does not map one to one to biology,” said Pizzagalli, also an associate professor of psychiatry at Harvard Medical School. “Using neuroimaging we can differentiate between subgroups of patients in important ways.”

Pizzagalli said he is optimistic that imaging, along with hormones in the blood that indicate stress or markers that show inflammation, will eventually allow psychiatrists to do a much better job of diagnosing and treating people with mental health challenges. “We are getting closer to the day when we will be able to guide treatment selection using more objective markers,” the neuroscientist said.

The new study, led by Dr. Helen Mayberg at Emory University in Atlanta, looked at PET scans from 63 depressed, untreated patients, and then divided them randomly into two groups, with half receiving cognitive behavioral therapy and half the anti-depressant escitalopram (brand name Lexapro) for 12 weeks. Activity in the insula, which is involved in emotional states and perceiving bodily sensations, predicted which treatment they would fare better on, the study showed.

From the press release:

“For the treatment of mental disorders, brain imaging remains primarily a research tool, yet these results demonstrate how it may be on the cusp of aiding in clinical decision-making,” said NIMH Director Thomas R. Insel, M.D.

Currently, determining whether a particular patient with depression would best respond to psychotherapy or medication is based on trial and error. In the absence of any objective guidance that could predict improvement, clinicians typically try a treatment that they, or the patient, prefer for a month or two to see if it works. Consequently, only about 40 percent of patients achieve remission following initial treatment. This is costly in terms of human suffering as well as health care spending.

Mayberg’s team hoped to identify a biomarker that could predict which type of treatment a patient would benefit from based on the state of his or her brain. Using a positron emission tomography (PET) scanner, they imaged pre-treatment resting brain activity in 63 depressed patients. PET pinpoints what parts of the brain are active at any given moment by tracing the destinations of a radioactively-tagged form of glucose, the sugar that fuels its metabolism.
They compared brain circuit activity of patients who achieved remission following treatment with those who did not improve.

Activity in one specific brain area emerged as a pivotal predictor of outcomes from two standard forms of depression treatment: cognitive behavior therapy (CBT) or escitalopram, a serotonin specific reuptake inhibitor (SSRI) antidepressant. If a patient’s pre-treatment resting brain activity was low in the front part of an area called the insula, on the right side of the brain, it signaled a significantly higher likelihood of remission with CBT and a poor response to escitalopram. Conversely, hyperactivity in the insula predicted remission with escitalopram and a poor response to CBT.

Among several sites of brain activity related to outcome, activity in the anterior insula best predicted response and non-response to both treatments. The anterior insula is known to be important in regulating emotional states, self-awareness, decision-making and other thinking tasks. Changes in insula activity have been observed in studies of various depression treatments, including medication, mindfulness training, vagal nerve stimulation and deep brain stimulation.

So when will this be coming to a clinic near you? Unclear. “Of course studies will be needed to replicate this finding,” Pizzagalli says.