Showing posts with label Nature. Show all posts
Showing posts with label Nature. Show all posts

Sunday, December 11, 2016

Brandolini’s Law





There was an informative editorial in Nature this week by Phil Williamson - a scientific expert on ocean acidification.  I like the concept of bullshit and have referred to Professor Harry Frankfurt's classic essay on it many times.  I was not familiar with Brandolini's Law until I read the essay.  Simply stated:

Brandolini’s Law: “The amount of energy needed to refute bullshit is an order of magnitude bigger than to produce it.”

It is also more simply known as the The Bullshit Asymmetry Principle.

Williamson uses a political example from a libertarian web site.  The central piece of that article was that ocean pH was not decreasing and that climate change would lead to reduced carbon dioxide in the oceans.   Because the climate is not changing there is no worry that the ocean pH would change.  The original publication denied Williamson's rebuttal.  An opinion piece in a professional journal led the author of libertarian piece to write online that his work should be "squashed like a slug".  Nothing like elite scientific dialogue is there?

In the UK there is apparently a press watchdog called UK Independent Press Standards Organization (IPSO).  Williamson filed a complaint with them about the factual accuracy of the piece and is awaiting their verdict.  He goes on to illustrate how Brandolini's Law comes in to play in this situation.  The original author these days can essentially be anyone from a journalist to a blogger.  He points out that online journalism "seems to be subject to few if any rules."  That leaves anyone in the position of responding to a factually inaccurate claim at a distinct disadvantage.  There may not be any formal complaint procedure and there is probably no editorial hierarchy.  Many web sites count on bloggers and writers to produce content that they can attach advertising to and this content seem to have very little oversight in terms of accuracy.  Much of this content on social web sites makes up what has been referred to as fake news.

Williamson's position is very clear.  He thinks that these inaccuracies need to be responded to and corrected.  He accurately points out that the audience for the correction is not the authors, but readers who are interested in accuracy and science.  I don't think that the division is that clear for a number of reasons.  A large number of people really don't care.  They are involved in the emotion generated by the issue and don't make decisions based on facts.  That general attitude is promulgated by the political process in most countries.  This is rarely a rational discussion of the main issues of the day.  I think this goes a lot deeper than generating rebuttals.  There needs to be education on the difference between science and everything else.  A good example is Creationist based rhetoric and the denial of evolution.  Creationist advocates do not seem to recognize that they are engaged in a process that is nothing like science and therefore cannot scientifically prove anything.  They fail to recognize the basic issue that science is a process and not an immutable collection of writings written by ancient prophets and subject to many interpretations.  That failure of recognition also leads to a failure to recognize that they are  completely outside the field of science. They fail to recognize where they are and that the best critics of a scientific theory are the scientists in the field.

This failure of recognition is much wider than Creationists.  Journalists produce many examples, not the least of which is a consistent bias against psychiatry.  That bias is present whether or not there is editorial oversight.  A great example is the journalistic tendency to propose what psychiatry is and then proceed to attack that straw man.  And interestingly these outsiders with no training in medicine or psychiatry are often joined by insiders pushing the same arguments.  In one case a prominent journal editor came out and endorsed an anti-psychiatry book, proclaiming legitimate criticism when in fact the book was rhetorical.  I would not presume that medical editors are without common biases.  There are many forces producing misinformation.

I diverge a bit with Williamson's approach on refuting the misinformation and hoping for the best.  I think that there are additional considerations.  One thing is very clear - the head-in-the-sand approach taken by physician professional organizations in response to misinformation is clearly not a good idea and is sure to lose in the current propaganda war of misinformation and political corruption.  If there is a lesson with the current Presidential campaign it is that there is a very small margin between a typical fact less campaign and one where anything at all can be said whether it is true of not - and nobody seems to care about it.

That is foreboding for all levels of public policy, especially when the political spoils includes being able to appoint agency heads with not only a lack of basic footing in science but also a lack of knowledge about what constitutes science.  For the country to run and maintain some standards in science, technology, and engineering there needs to be a basic understanding of these fields in all branches of government and at the highest levels.  There is currently no better example of what happens when the unscientific manage the store than what has happened to American medicine.  We are not only cursed by work rules that are made up as we go and have little to do with the practice of medicine, but we we have to live with pseudo-scientific management practices that affect our work flow and and detract from the lifelong task of learning the science of medicine.  A few strategies I can offer as a blogger follow.  I also have additional strategies that I am going to keep to myself until just the right time.

1.  Don't feel compelled to engage - Twitter is an excellent example of how this principle is applied. Suddenly you are being given the third degree by some poster. That turns into misinterpretations of your statements and positions and before you know it personal attacks.  But it doesn't stop there. A new account pops up and mysteriously continues the attack.  Call them trolls or whatever you like but recognize the tactic. They don't really care what you have to say and are quite happy to waste your time.  Don't engage. Twitter gives you the option to block them and that works the best.

2.  Present the facts but counter the rhetoric - It is important to recognize the common forms of rhetoric without being pedantic.  The best way to do that is by pointing out the erroneous aspects of the argument and the overall form without naming the fallacy.  This sounds easy and it should be - but physicians and psychiatrists seem to be spellbound at times by the simplest arguments.  One common example is anytime a business executive shows up and talks about "cost effectiveness" - everybody shuts down.  Nobody seems to understand that this is just business rhetoric.  It should be as obvious as the fact that with 30 years of intensive management and "cost effectiveness" - per capita health care costs are 40% higher than the country with the next highest per capita expenditures and health care is certainly no better.  In the case of treating mental illnesses and substance use disorders it is much worse.  Somebody needs to stand up and say: "We are doing our part - when are you going to start to do yours." or "Get out of the way and let us do our work." or "Give us the resources to provide the adequate service or shut it down."   Rationing is clearly a very ineffective and costly way to provide health care services.

3.  Recognize bullshit no matter where it comes from -  Many of the arguments for health care reform are just plain erroneous.  And why wouldn't they be.  We now have a continuous supply of what are essentially blogposts on the front of our most respected medical journals.  How could anyone expect that 12 or 52 health care reform ideas each year for years would be worth anything?  All of the top posts that they have been implemented like the electronic health record, managed care as business intermediaries for government purchasers, pharmaceutical benefit managers, creating various financial incentives - have all been progressively worse ideas.  Sifting through the misinformation to correct what is false, what are lies, and what is bullshit is a tedious but necessary task.  As long as medical journals legitimize this constant stream of unscientific information - countering it will remain an onerous task.  The sources of bullshit go far beyond blogs and traditional journalism.

4.  Don't let anyone define you - A common strategy these days is that detractors tend to jump in and set the stage with false criticism.  It was easy to see this in political debates.  In medicine and psychiatry the same process happens and I have pointed out the dynamic on this blog.  I also posted a recent summary of how the release of the DSM-5 was a major source of misinformation, lies, and bullshit in 2015 but there are many more examples in psychiatry.

5.  Don't let the barbarians at the gate get you down - I tell aspiring physicians and aspiring psychiatrists the same thing - don't let the detractors or in these days trolls - get you down.  Psychiatry is a tough field because there will always be a lot of people blaming you for their problems.  This is where Brandolini's Law really applies.  There are numerous dialogues on web sites available where the game is to post as much misinformation, bullshit and lies about psychiatry in particular.  Entire web sites exist for that purpose.  Entering into that discussion and taking the opposite side of the argument can be more futile than the Law suggests.  It may take several orders of magnitude of effort and even then it may be futile.  The best approach is to just get the information out there in cyberspace in an independent forum where you know that it can be safely viewed.   That is one of the reasons that this  blog exists.

6.  The Internet is still the Wild West and that will probably never change in its current form - Williamson suggests that it may be possible to "harness the collective power of the Internet to improve its quality."  He suggests the global scientific community reviewing sites and rating them like film rating sites.  I am far less optimistic.  The first problem is the scope of that project.  The second would be consistency in ratings.  The third is that a rating in some sense is legitimizing.  It is a far better approach to ignore the ignorant.  The reality is that reputation protection web sites basically work by generating a lot of information designed to bury the obnoxious web site.  Most people find that if they contact a search engine about a web site that may be slandering them that they are met with a a relatively hostile response and a complete lack of interest in correcting anything.  That is true for even the largest search engines.  Google for example, clearly doesn't give a damn about your reputation.

7.  Brandolini's Law is a significant deterrent to keeping professionals engaged in educating the public - Physicians certainly find this out in a hurry if they decide to post a rebuttal in political or media forums that are populated by the ignorant, trolls, or those with a specific agenda.  That is more true of psychiatrists than any other specialty.  That has a dual effect of limiting feedback to those who might be interested and eliminating the most informed criticism.  It also has the added effect of adding professionals who may have legitimate criticism to antipsychiatry web sites where scientific criticism is clearly not the agenda.  It is a dangerous path of least resistance when legitimate professionals start posting on web sites dedicated to the destruction of the profession.

 These are just a few ideas about Brandolini's Law.  I did not write the most important one down and that is you can always just go off the grid.  Even then there are problems.  I talked with a psychiatrist about 10 years ago who was asked to give presentations at local churches on depression.  He eventually gave up because there were people in the audience who for various reasons were so disruptive that it prevented him from giving the interested people the information that they wanted.  Only psychiatrists could end up being heckled in church.  Bullshit can be presented in person just as easily as is can by typed online.

Williamson refers to a "rising tide of populism threatens the future of evidence-based government."  I don't think that we have ever had evidence based government in the US.  I see it as mostly a power dynamic here - influencing people by emotional ideas and shouting them down.

The only reason why that Brandolini's Law doesn't work in reality in the case of psychiatry is that at the end of the day, there are still people with severe mental illness - no matter who tries to deny it and a group of people called psychiatrists who are interested in helping them.  That is not necessarily enough to prevent the widespread demoralization of a profession.        


George Dawson, MD, DFAPA


Reference:

1:  Phil Williamson.  Take the time and effort to correct misinformation.  Nature 8 December 2016; 540: 171.


Supplementary 1:

My brother saw this post and commented that Brandolini's Law has "never been more true."

I reflected on that true statement and the continued widespread ignorance of science and came up with the following observation that might have been made by Casey Stengel:

"Good science cancels out bullshit and vice versa."

That probably captures why misinformation grows as exponentially as scientific information in any society.  It levels the playing field (to some degree) between the informed and the uniformed.


Sunday, March 20, 2016

The Screeners - Annotated: Psychiatric Lessons From A Short Science Fiction Story




I recommend reading the original version (preceding post) first before reading the annotated version.


What follows actually happened in the year 2066......

I could tell my brother needed help. We had been underground for too long. Whenever that happened he stopped sleeping regularly, he started to act crazy. This time he was looking for footprints - evidence that somebody was trying to get in through the hatch. I explained to him that the hatch was hydraulically locked from the inside. It was designed to take a direct hit from a grenade-launcher. But who could even hit it at that angle, flat against the two foot thick concrete roof of our bunker. This time he was sprinkling flour rations on the floor under the hatch. Anyone who came in had to step on that area and he would have their footprint in the flour.

This is an almost universal experience of family members directly observing their relatives with bipolar disorder.  They notice they become unpredictable sometimes to the point that they are frightening.  This is often manifested in their capacity for rational thought and personality changes.  In this case they observe paranoid behavior - defined as an unrealistic fear of harm or manipulation.  Family members are often at a loss in this situation because the person with the problem denies that there is anything wrong.  In many cases, the personality changes go on for months and lead to problems with employers and spouses.   

But the powder around the entrance was the least of our worries. His apartment was within a hundred feet of the hatch. He sat in his apartment looking out the window. He kept a plasma cutter nearby. It was for self defense, but he also told my son that if anyone did breach the hatch and they came for him - he knew exactly what to do. He would turn the plasma cutter on himself. He did not want to give the invaders a chance to torture and kill him. He would kill himself first. It would be over quickly.

This is a little known form of suicidal thinking that occurs in paranoid people.  They are so fearful of the unknown assailants that they are prepared to kill themselves - rather than be tortured or slowly killed.  In fact, they are not in danger at all.  This problem requires an intense effort to diagnose and treat - independent of any medications.

He had been getting worse for the past ten years. Long periods of laying in bed for days and weeks, barely eating and drinking. Not saying a word. That usually happened after weeks or months of being hyper, talkative and staying up all night. If you caught him at exactly the right time, he was interesting, funny, and you felt good talking with him. At the wrong time - it could be a nightmare. He could accuse you of trying to steal his American Gold Eagles. Everybody knew he had a tube of them somewhere in the bunker. Everybody knew because whenever he got hyper and started talking a lot, he would hold some of the coins in his hands and show everybody that he had them. During one of these episodes, he gave a couple of them away. Gold Eagles worth tens of thousands of dollars - just handed out to strangers at a watering hole.

Very typical behavior of untreated bipolar patients.  During periods of hyperactivity and euphoria they may give away large sums of money to casual acquaintances without being able to assess the consequences.  This can lead to financial duress or in the extreme, financial ruin. 

He had bipolar disorder, just like our mother. He has never seen a doctor, I just know from my experience with my mother. I remember going to see the doctor with her. She would see her every couple of months, unless she was having problems and then it would be more frequently. She liked that doctor and trusted her. She would always tell me that if she got too sick to make it to the doctor, my job was to call the doctor's office and let her know that she was not doing well. The doctor came over to our house one day to see my mother. Mom didn't say much, but the doctor knew what she needed and a short time later she was better. That went on like that for about ten years until I was ready to go to college. That was when the Supervolcano blew and we all had to go underground for three years. Mom was 60 by then. She couldn't adapt to living underground. She could not sleep underground in the phosphorescent lighting. She would stay up for weeks and get harder and harder to understand. She would start swearing and eventually made no sense at all. Then she would crash and not be able to eat. My wife and I would encourage her, but she would say: "Let me die....pick up that knife over there and kill me." We knew that she was not joking. Until the air finally cleared, there were no doctors and no medicines. She only had a month of medication when we went underground. Nobody could get more than a month at a time - even though everybody knew it was going to be a long time before we could come up for air.

Bipolar disorder definitely runs in families with what appears to be sporadic inheritance because of the polygenic nature of the disorder.  Bipolar disorder is sensitive to sleep and circadian rhythm disruptions and patients need to be counseled and constantly reminded about this.  Severe cognitive problems and catatonia can result and lead to severe disability. 

At about the one year mark - Mom died. She just got more and more confused. She stayed in bed and did not eat or drink anything for five days. The paramedic in our bunker said that she probably died from dehydration.

I don't think it is common knowledge that bipolar disorder can be a fatal condition.  At the turn of the 19th century, well before there were any useful medications - some forms of bipolar disorder were highly fatal.  Estimates from Boston Hospitals at around that time suggested that malignant catatonia resulted in about an 80% fatality rate.  Untreated mania in those days also resulted in a significant number of deaths from congestive heart failure due to constant agitation.  These facts are often ignored during an era where even episodic care during exacerbations of illness can prevent death.  Inpatient psychiatrists and consultation-liaison psychiatrists still find themselves in many life and death situations per year with hospitalized patients on the verge of dehydration and starvation due to severe psychiatric disorders.  In many situations, one of the best treatments available for this problem - electroconvulsive therapy is unavailable due to legal and political constraints.   

"Kevin is getting bad again" - my wife walked in. She was wearing standard desert camouflage hardened to withstand all of the fly ash. "I just saw him. He had melted a jar of peanut butter in the microwave and and he was throwing it all over the place. He has it splattered all over the walls. It looks like a Jackson Pollock painting." My wife was going to study art before the Supervolcano or "SV" as some call it now. Most people just talk about surviving it by using the phrase "when the air cleared." "We have to do something before he ends up like your mom or somebody takes advantage of him and gets his gold."

Highlights the familiy predicament of dealing with a family member who has had a transformation of their conscious state.  They are no longer predictable or rational.  Most emergency medical personnel confronted with this situation would ask the person a few questions and leave.  If the person became verbally aggressive, the outcome of the situation is highly dependent on the skill of the emergency personnel or involved law enforcement officers and there can be very adverse outcomes.

"More like hitting him over the head and taking it you mean. You would think that a guy who can be that paranoid would not put himself in those situations." I knew the words were meaningless as soon as they rolled off my lips. I had been watching bipolar people in my family for decades and they are unpredictable. Expect to see them in a certain situation and they disappear for weeks or months. "We have to try to get him to Minneapolis and see if they have scavenged any medication or if any new medical supplies have been flown in."

We had been to Minneapolis a couple of times since the air cleared. The trip is not too bad - 300 miles by a skimmer across the fly ash. So far nothing was growing up through the fly ash. We make good time with a skimmer and the metal composite tires make that trip many times before they need to be replaced. It just takes 20 minutes to recharge the batteries and we are back home the same day. The medical infrastructure was slowly being rebuilt. Practically all of the health care administration in the state was in Minneapolis and many of these bureaucrats survived the near extinction event. Surgical services and Cardiology had been restored. Last year they began doing heart, lung, liver and pancreas transplants at what used to be University Hospital.

There is a long history of discrimination against psychiatric and addiction services, despite the fact that they are routinely assessed as being in the top 10 disabling conditions world wide.  The discrimination is well documented on this blog and it occurs at all levels.  The so-called critics of psychiatry do not mention this phenomenon because it is inconsistent with their view that psychiatry is the source of all problems and not the selective rationing.

Treatment for mental disorders was always a problem. As people started coming out of their bunkers and heading back into the city general medical care was available in many places. The only treatment for mental disorders occurred in the same clinics where people went to get treated for infections and lung problems from the fly ash. People still got cancer and heart disease. People still got involved in accidents and injured themselves. Doctors with various skills were still around even though training programs were just restarting. Doctors tended to be old or really young.

In this piece, collaborative care and its ultimate goal of eliminating psychiatry rules the day.  An interesting proposition is who all of the critics will blame when psychiatrists are gone.  The obvious choice would be the next batch of prescribers, but in my story they became history as well.  There is clear history of mismanagement in medicine - rationalized by "cost effectiveness".  The most cost effective approach is to marginalize all professionals and pretend to replace them with checklists or artificial intelligence

My wife and I did some fast talking, convinced Kevin it would be an exciting trip, loaded him in the skimmer and took off. Within 4 hours we were standing in line in a large warehouse that had been converted to a medical clinic. Half an hour later we were face to face with a triage person:

"Nature of the problem?" he said matter of factly.
"My brother has bipolar disorder and he needs treatment." I replied.
"We don't see a lot of that here, are you sure about the diagnosis?" The triage person seemed a little impatient.
"My mother had it and she told me that her grandfather had it. He does a lot of what she used to do. His whole personality changes at times and he has problems taking care of himself. She used to see a doctor who treated bipolar disorder. Do you have a doctor like that?"
"Not anymore...but we do have screeners."

You don't have to live in the year 2066 to experience the above dialogue.  It is occurring right now in hundreds of clinics across America.  No access to psychiatrists or mental health professionals who could be very useful in treating the problems that they were trained to treat. 

We walked to the west side of the warehouse and entered a small room. There were a few people there. We got in to see the screener in a about 20 minutes. He looked like a clone of the triage person right down to the American Health Care pin on his lapel. He listened to me describe the problem for about two or three minutes, reached in a drawer and pulled out a piece of paper. It had three questions on it. After every question there was a line that varied from "None" to "Most of the time." Kevin made three checkmarks - one on each line at about the 75% mark.

This is a standard approach being used right now.  A checklist will be made right out of the DSM criteria.  Then it will be pared down to 3 or even 1 question rating scales.  Without the presence of a diagnostician, the checklist score and cutoff becomes the default diagnosis.  The interesting aspect of a screening instrument for bipolar disorder is that in many cases the affected person will not endorse any problems on the scale even when they are quite symptomatic.  

"Well he qualifies for treatment." the screener remarked. "The Army just brought in a shipment of medication for mood problems."
"My mother used to take Phosphotide 23, before the volcano blew. It worked pretty well."
"No ... all I have is this stuff.   It is taking a while to get drug manufacturing up and running again. Only the west coast facilities were untouched and they have shifted all of their production to what people really need...you know antibiotics, heart meds, asthma medication. But I have plenty of this medication. Give it a try. Take two of these tablets every night".

There are widespread complaints about Big Pharma and medication prices.  I have written several pieces on this blog myself.  Medication expenditures have created a large number of medications and a significant surplus, but they are ironically rationed by Pharmacy Benefit Managers and managed care companies, even to the point that generics drugs require a negotiation.  In this case the patient is being given a medication that is probably not indicated for his condition and may make him worse.  Similar problems can occur with treatment based on screening tests.   

He handed me a large bottle of medication. The darkened label on the bottle read: "amitriptyline 25 mg tabs". The expiration date was July 20, 2025. I looked back at the screener and asked: "Is there anybody he can talk to about some of his problems? He goes off on a tangent and my wife and I don't know what to say to him."

This is a current problem in the business oriented behavioral health system.  Psychotherapy is rationed and in many case therapists have productivity expectations that they cannot sustain and that leads them to quit.  Contrary to popular myths people with severe mental illnesses benefit greatly from talking with their psychiatrists and are often reluctant to see other therapists or physicians.  In many systems of care today patients with severe mental illness see a "prescriber" for 15-20 minutes - 2 - 4 times a year. 

"No I'm afraid not. At American Health Care we do screening. My understanding is that the new government and the remaining businesses got together and decided that was the most cost-effective approach."

"Cost-effective" is a buzzword that is unevenly applied.  That should be evident from comparing psychiatric services (or behavioral health services) to every other medical specialty in any health care system.  There is a sharp contrast between what this concerned family member knows about bipolar disorder (disabling and killing his mother and disabling his brother and making him unpredictable) and how the health care system responds to his concerns.  It is as if  he is talking about a trivial condition.

Within thirty minutes we were back in the skimmer, moving at good speed across the fly ash. I glanced over at my wife. Her large blue mirrored-out glacier glasses did not conceal her worry. I looked at the plume we were kicking up in my rearview screen and thought:

"I hope this works."

Our concerned family member here is hopeful, but it is highly unlikely that the medication he picked up will be effective and it may make the situation worse.  The patient and family would have benefited by a detailed risk-benefit and monitoring discussion, as well as a follow-up plan.  In a typical screening procedure that occurs today, a person may leave the office with one or more month-long prescriptions and no clear plan for monitoring or contingencies if the medication does not work or it is not tolerated.  Follow up periods are frequently too long to make much of a difference and many people either discard the medication immediately, don't get it refilled, or get side effects - don't report them and discard the medication.  More frequent meetings for psychotherapy or closer monitoring are the exception rather than the rule.  

The more I thought about this near apocalyptic science fiction story, the more I realized that this is the type of care that many (if not most) people get right now and it is the type of care that is being promoted over seeing psychiatrists.



George Dawson, MD, DLFAPA


Supplementary:

I tried to write this science fiction piece in the spirit of the one page sci-fi stories that are always on the last page of the journal Nature under their heading Futures Science Fiction go.nature.com/mtoodm

From the perspective of a psychiatrist (and a family member) of course.

This is a pure fiction and it contains no references to any real people or corporations. Any resemblance is purely coincidental.


Attribution:

The picture at the top of this file was uploaded from Wikimedia Commons.  This attribution is from their side and when the file was accessed on March 19, 2016, the link in this reference did not work:  Work of the Bureau of Land Management, a U.S. Government Agency. Taken from the BLM website: http://www.blm.gov/style/medialib/blm/wy/rsfo/recpics.Par.0272.Image.640.427.1.gif  No photo credit is given.




Saturday, March 19, 2016

The Screeners





What follows actually happened in the year 2066......

I could tell my brother needed help.  We had been underground for too long.  Whenever that happened he stopped sleeping regularly.  He started to act crazy.  This time he was looking for footprints - evidence that somebody was trying to get in through the hatch.  I explained to him that the hatch was hydraulically locked from the inside.  It was designed to take a direct hit from a grenade-launcher.  But who could even hit it at that angle, flat against the two foot thick concrete roof of our bunker.  This time he was sprinkling flour rations on the floor under the hatch.  Anyone who came in had to step on that area and he would have their footprint in the flour.

But the powder around the entrance was the least of our worries.  His apartment was within a hundred feet of the hatch.  He sat in his apartment looking out the window.  He kept a plasma cutter nearby.  It was for self defense, but he also told my son that if anyone did breach the hatch and they came for him - he knew exactly what to do.  He would turn the plasma cutter on himself.  He did not want to give the invaders a chance to torture and kill him.  He would kill himself first.  It would be over quickly.

He had been getting worse for the past ten years.  Long periods of laying in bed for days and weeks, barely eating and drinking.  Not saying a word.  That usually happened after weeks or months of being hyper, talkative and staying up all night.  If you caught him at exactly the right time, he was interesting, funny, and you felt good talking with him.  At the wrong time - it could be a nightmare.  He could accuse you of trying to steal his American Gold Eagles.  Everybody knew he had a tube of them somewhere in the bunker.  Everybody knew because whenever he got hyper and started talking a lot, he would hold some of the coins in his hands and show everybody that he had them.  During one of these episodes, he gave a couple of them away.  Gold Eagles worth tens of thousands of dollars - just handed out to strangers at a watering hole.

He had bipolar disorder, just like our mother.  He has never seen a doctor, I just know from my experience with my mother.  I remember going to see the doctor with her.  She would see her every couple of months, unless she was having problems and then it would be more frequently.  She liked that doctor and trusted her.  She would always tell me that if she got too sick to make it to the doctor, my job was to call the doctor's office and let her know that she was not doing well.  The doctor came over to our house one day to see my mother.  Mom didn't say much, but the doctor knew what she needed and a short time later she was better.  That went on like that for about ten years until I was ready to go to college.  That was when the Supervolcano blew and we all had to go underground for three years.  Mom was 60 by then.  She couldn't adapt to living underground.  She could not sleep underground in the phosphorescent lighting.  She would stay up for weeks and get harder and harder to understand.  She would start swearing and eventually made no sense at all.  Then she would crash and not be able to eat.  My wife and I would encourage her, but she would say: "Let me die....pick up that knife over there and kill me."  We knew that she was not joking.  Until the air finally cleared, there were no doctors and no medicines.  She only had a month of medication when we went underground.  Nobody could get more than a month at a time - even though everybody knew it was going to be a long time before we could come up for air.

At about the one year mark - Mom died.  She just got more and more confused.  She stayed in bed and did not eat or drink anything for five days.  The paramedic in our bunker said that she probably died from dehydration.

"Kevin is getting bad again" - my wife walked in.  She was wearing standard desert camouflage hardened to withstand all of the fly ash.  "I just saw him.  He had melted a jar of peanut butter in the microwave and and he was throwing it all over the place.  He has it splattered all over the walls.  It looks like a Jackson Pollock painting."  My wife was going to study art before the Supervolcano or "SV" as some call it now.  Most people just talk about surviving it by using the phrase "when the air cleared."  "We have to do something before he ends up like your mom or somebody takes advantage of him and gets his gold."

"More like hitting him over the head and taking it you mean.  You would think that a guy who can be that paranoid would not put himself in those situations."  I knew the words were meaningless as soon as they rolled off my lips.  I had been watching bipolar people in my family for decades and they are unpredictable.  Expect to see them in a certain situation and they disappear for weeks or months.  "We have to try to get him to Minneapolis and see if they have scavenged any medication or if any new medical supplies have been flown in."

We had been to Minneapolis a couple of times since the air cleared.  The trip is not too bad - 300 miles by a skimmer across the fly ash.  So far nothing was growing up through the fly ash.  We make good time with a skimmer and the metal composite tires make that trip many times before they need to be replaced.  It just takes 20 minutes to recharge the batteries and we are back home the same day.  The medical infrastructure was slowly being rebuilt.  Practically all of the health care administration in the state was in Minneapolis and many of these bureaucrats survived the near extinction event.  Surgical services and Cardiology had been restored.  Last year they began doing heart, lung, liver and pancreas transplants at what used to be University Hospital.

Treatment for mental disorders was always a problem.  As people started coming out of their bunkers and heading back into the city general medical care was available in many places.  The only treatment for mental disorders occurred in the same clinics where people went to get treated for infections and lung problems from the fly ash.  People still got cancer and heart disease.  People still got involved in accidents and injured themselves.  Doctors with various skills were still around even though training programs were just restarting.  Doctors tended to be old or really young.

My wife and I did some fast talking, convinced Kevin it would be an exciting trip, loaded him in the skimmer and took off.  Within 4 hours we were standing in line in a large warehouse that had been converted to a medical clinic.  Half an hour later we were face to face with a triage person:

"Nature of the problem?"  he said matter of factly.
"My brother has bipolar disorder and he needs treatment." I replied.
"We don't see a lot of that here, are you sure about the diagnosis?"  The triage person seemed a little impatient.
"My mother had it and she told me that her grandfather had it.  He does a lot of what she used to do.  His  whole personality changes at times and he has problems taking care of himself.  She used to see a doctor who treated bipolar disorder.  Do you have a doctor like that?"
"Not anymore...but we do have screeners."

We walked to the west side of the warehouse and entered a small room.  There were a few people there.  We got in to see the screener in about 20 minutes.  He looked like a clone of the triage person right  down to the American Health Care pin on his lapel.  He listened to me describe the problem for about two or three minutes,  reached in a drawer and pulled out a piece of paper.  It had three questions on it.  After every question there was a line that varied from "None"  to "Most of the time."  Kevin made three checkmarks - one on each line at about the 75% mark.

"Well he qualifies for treatment." the screener remarked.  "The Army just brought in a shipment of medication for mood problems."
"My mother used to take Phosphotide 23, before the volcano blew.  It worked pretty well."
"No ... all I have is this stuff.  It is taking a while to get drug manufacturing up and running again.  Only the west coast facilities were untouched and they have shifted all of their production to what people really need...you know antibiotics, heart meds, asthma medication.  But I have plenty of this medication.  Give it a try.  Take two of these tablets every night".

He handed me a large bottle of medication.  The darkened label on the bottle read: "amitriptyline 25 mg tabs".  The expiration date was July 20, 2025.  I looked back at the screener and asked: "Is there anybody he can talk to about some of his problems?  He goes off on a tangent and my wife and I don't know what to say to him."
"No I'm afraid not.  At American Health Care we do screening.  My understanding is that the new government and the remaining businesses got together and decided that was the most cost-effective approach."

Within thirty minutes we were back in the skimmer, moving at good speed across the fly ash.  I glanced over at my wife.  Her large blue mirrored-out glacier glasses did not conceal her worry.  I looked at the plume we were kicking up in my rearview screen and thought:

"I hope this works."          



George Dawson, MD, DLFAPA


If you read this far, you might be interested in the annotated version with notes on the psychiatric implications of this fictional account.


Supplementary:

I tried to write this science fiction piece in the spirit of the one page sci-fi stories that are always on the last page of the journal Nature under their heading Futures Science Fiction go.nature.com/mtoodm

From the perspective of a psychiatrist (and a family member) of course.

This is pure fiction and it contains no references to any real people or corporations.  Any resemblance is purely coincidental.


Attribution:

The picture at the top of this file was uploaded from Wikimedia Commons.  This attribution is from their side and when the file was accessed on March 19, 2016, the link in this reference did not work:  Work of the Bureau of Land Management, a U.S. Government Agency. Taken from the BLM website: http://www.blm.gov/style/medialib/blm/wy/rsfo/recpics.Par.0272.Image.640.427.1.gif  No photo credit is given.



            





Sunday, March 2, 2014

Cognitive Enhancement IS Cheating

One of my colleagues posted a recent commentary from Nature on how the idea of the smart pill has been oversold.  The basic theme of the commentary is that there is no good evidence that treatment of ADHD with stimulants improves academic outcomes.  The author reviews a few long term studies and contends that differences between the medication and placebo seem to wash out over time and therefore there is no detectable difference.  Her overall conclusions seem inconsistent with her view that:  "For most people with ADHD, these medications — typically formulations of methylphenidate or amphetamine — quickly calm them down and increase their ability to concentrate. Although these behavioural changes make the drugs useful, a growing body of evidence suggests that the benefits mainly stop there..."

A question for any cognitive psychologists out there - is it possible to improve your concentration and have that not improve learning?  I can't imagine how that happens.  If you go from not being able to read 2 pages at a time to suddenly reading chapters at a time, how is that not enhanced cognitive performance?  If you go from staring out the window all day and daydreaming to being able to focus on what the teacher is saying how will that not lead to an improved outcome?  The idea that improved attention - a central factor in human cognition will not affect anything over time suggests to me that the measures being used for follow up are not very robust or that this is a skewed sample of opinion.   

For the purpose of cognitive enhancement, the typical users are students trying to gain an edge by increasing their study time.  Anyone who has experienced college and professional school realizes that here is a large amount of information to be mastered and it is not presented in an efficient way.  I can never recall a professor who advised us of the important guideposts along the way or gave us any shortcuts.  The usual message is study all of this material in depth every day or you will fall behind.  That approach in general is consistent with gaps in the ability to study either through the normal course of life or the competition for intellectual resources by 3 or 4 other professors who regard their courses as important.  That typically results in a pattern of cramming for specific key exams.  Although I have not seen any specific studies, stimulant medications are generally used for this purpose and in many cases the use is widespread.  There is a literature on the number of college students who may be feigning ADHD symptoms in order to get a prescription and that number could be as high as 50% (4,5). 

What  about the issue of stimulants acting as a smart pill in people who don't have ADHD?  In the most comprehensive review I could find on the subject (6) the authors review laboratory studies and conclude that in those settings stimulants enhance consolidation of declarative learning to varying degrees, had mixed effects on working memory, and mixed effects on cognitive control.  On 8 additional tests of executive function, the authors found that stimulant medication enhance performance on two of those tests - non-verbal fluency and non-verbal intelligence.  They have the interesting observation that small effects could be important in a competitive environment.  Their review also provides an excellent overview of the epidemiology of stimulant use on campuses that suggests that the overall prevalence is high and the pattern of use is consistent with cramming for exams.  They cite a reference that I could not find (7) that was a reanalysis of NSDUH data suggesting that as many as 1 in 20 stimulant users may have a problem with excessive use and dependence.     

Getting back to the theme of the Nature commentary, it is ironic that the smart pill theme is being called into question when it was the subject of a Nature article years earlier advocating for the use of cognitive enhancement.  In that article Greely, et al come to the somewhat astounding conclusion: 

"Based on our consideration, we call for a presumption that mentally competent adults should be able to engage in cognitive enhancement using drugs."

They arrive at that conclusion by rejecting three arguments against this practice.  Those arguments include that it is cheating, it is not natural and it is drug abuse.  Their rejection of the cheating argument is interesting because they accept the idea that performance enhancing drugs (PEDS) in sports is cheating.  They reject that in cognitive enhancement claiming that there would need to be a set of rules outlining what forms of enhancement would be outlawed and what would not (e.g. drugs versus tutors).  To me that seems like a stretch.  I think that sports bodies select performance enhancing drugs as a specific target because it clearly alters body physiology in a way that cannot be altered by any other means.  There is also plenty of evidence that the types of PEDS are dangerous to the health of athletes and associated with deaths.  Their conclusion about drug abuse: "But drugs are regulated on a scale that subjectively judges the potential for harm from the very dangerous (heroin) to the relatively harmless (caffeine).  Given such regulation the mere fact that cognitive enhancers are drugs is no reason to outlaw them."   That is a serious misread of the potential addictive properties of stimulants and the previous epidemics that occurred when the drugs were FDA  approved for weight loss, the epidemic of street use in the 1970s and the current and ongoing epidemic of meth labs and methamphetamine use throughout much of the USA.

These authors go on to outline four policy mechanisms that they believe would "support fairness, protect individuals from coercion, and minimize enhancement related socioeconomic disparities."  At first glance these lofty goals might seem reasonable if society had not already had in depth experience with the drugs in question.  The clearest example was the FDA approved indication of amphetamines for weight loss.  What could be a more equitable application than providing amphetamines to any American who wanted to use them for weight loss?  The resulting epidemic and reversal of the FDA decision is history.  A similarly equitable decision to liberalize opioids in the treatment of chronic pain had resulted in another epidemic of higher lethality due to differences in the toxicology of opioids and amphetamines. 

The contrast between these two commentaries in Nature also highlight a couple of the issues about the way medical problems and treatment is portrayed in the media.  This first is that you can't have it both ways.  Quoting a researcher or two out of context does not constitute an accurate assessment of the science involved.   Some of the authors in the first commentary are highly respected researchers in cognitive science and they clearly believe that cognitive enhancement occurs and it should be widely applied.  Nature or any other journal cannot have it both ways.  A more realistic appraisal of the problem is addressed in reference 6.   The second issue is that in both cases the authors seem blind to the addictive properties of stimulants and they are ignorant of what happens when there is more access as exemplified by the FDA misstep of approving stimulants for weight loss.  Do we really need a new epidemic to demonstrate this phenomenon again?  Thirdly, all of this comes paying lip service to non - medication strategies for cognitive enhancement.  We can talk about the importance of adequate sleep - a known cause of ADHD like symptoms and if we are running universities and workplaces in a manner that creates sleep deprived states, the next step is reaching for pills to balance an unbalanced lifestyle.  The new rules for residency training are a better step in the right direction.  Fourth, college is a peak time for alcohol and substance use in the lives of most Americans.  These substances in general can lead to a syndrome that looks like ADHD.  It is highly problematic to make that diagnosis and provide a medication that can be used in an addictive manner.  It is also highly problematic to think that treating an addicted person with a stimulant will cure them of the addiction and yet it happens all of the time.

There is plenty of evidence to suggest that cognitive enhancement is cheating.   Much of my career has been spent correcting the American tendency of trying to balance one medication against another and using medications to tolerate a toxic lifestyle or workplace.  It does not work and the current group of medications that are being put forward as cognitive enhancers are generally old drugs with bad side effect profiles particularly with respect to the potential for addiction.

If you want safe cognitive enhancers that can be made widely available, they have not been invented yet.  

George Dawson, MD, DFAPA




References:

1: Sharpe K. Medication: the smart-pill oversell. Nature. 2014 Feb 13;506(7487):146-8. doi: 10.1038/506146a. PubMed PMID: 24522583.

2: Greely H, Sahakian B, Harris J, Kessler RC, Gazzaniga M, Campbell P, Farah MJ.
Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008 Dec 11;456(7223):702-5. doi: 10.1038/456702a. Erratum in: Nature. 2008 Dec 18;456(7224):872. PubMed PMID: 19060880.

3: Feldman HM, Reiff MI. Clinical practice. Attention deficit-hyperactivity disorder in children and adolescents. N Engl J Med. 2014 Feb 27;370(9):838-46. doi: 10.1056/NEJMcp1307215. PubMed PMID: 24571756.  

4: Green P, Lees-Haley PR, Allen LM., III The word memory test and the validity of neuropsychological test scores. J Forensic Neuropsychol. 2002;2:97–124. doi: 10.1300/J151v02n03_05

5: Suhr J, Hammers D, Dobbins-Buckland K, Zimak E, Hughes C.  The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation.  Arch Clin Neuropsychol. 2008 Sep; 23(5):521-30.

6: Smith ME, Farah MJ. Are prescription stimulants "smart pills"? The epidemiology and cognitive neuroscience of prescription stimulant use by normal healthy individuals. Psychol Bull. 2011 Sep;137(5):717-41. doi: 10.1037/a0023825. Review. PubMed PMID: 21859174 

7: Kroutil LA, Van Brunt DL, Herman-Stahl MA, Heller DC, Bray BM, Penne MA. Nonmedical use of prescription stimulants in the United States. Drug and Alcohol Dependence. 2006; 84:135–143.10.1016/j.drugalcdep.2005.12.011 [PubMed: 16480836]


Wednesday, May 1, 2013

Nature Takes A Shot at DSM5 – Spectrums Only Get You So Far

"The Catholic Church changes its pope more often than the APA publishes a new DSM." (reference 1)


I was disappointed to see another shot at the DSM, this time on my Nature Facebook feed.  I suppose with the impending release it is a chance to jump on the publicity bandwagon.  I will jump over numerous errors in the first paragraph (David Kupfer – modern day heretic?!) and get to the main argument.  The author in this case makes it seem like seeing psychopathological traits on a spectrum is somehow earth shaking news and yet another reason to trash a modest diagnostic manual designed by psychiatrists to be used as a part of psychiatric diagnostic process. 

In evaluating this article the first question is the whole notion of continuums.    The idea has been there for a long time and this is nothing new.  Just looking at some DSM-IV major category criteria like major depression, dysthymia, and mania and just counting symptoms using combinatorics you get the following possibilities:

Major depression - 20 C 5 = 15,504

Manic episode - 15 C 3 = 455

Dysthymia - 2 C 10 = 45

Mixed - 20 C 5 + 15 C 3 = 15,959

That means if you are following the DSM classification and looking just at the suggested diagnostic combinations you will be seeing something like 16,004 combinations of mood symptoms just based on a categorical classification.  Superimposed reality can expand that number by several factors right up to the point that you have a patient who cannot be categorically diagnosed. If you add all Axis II conditions with mood sx - there is another large expansion in the number of combinations.  The sheer number of combinations possible should suggest at some point that the discrete categories give way to a frequency distribution.  The only problem of course (and this is lost or ignored by all managed care and political systems) the clinician is treating an individual patient with certain problems and not addressing the entire spectrum of possibilities.  The other reality is that if you put a point anywhere on the spectrum including the Nature blog's  mental retardation-autism-schizophrenia-schizoaffective disorder-bipolar and unipolar disorder spectrum - you essentially have a categorical diagnosis.

In a recent article, Borsboom, et al use a graphing approach to show the relationship between the 522 criteria (simplified to 439 symptoms) of 201 distinct disorders in the DSM-IV.  The authors demonstrate that these symptoms are highly clustered relative to a random graph and go on to suggest that their network model currently account for the variance in genetics, neuroscience, and etiology in the study of mental disorders.  Their figure below is reproduced in accordance with the Creative Commons 3.0 license. (click to enlarge).





 For the example given by the author’s example – schizophrenia with obsessive traits, we still need to make that characterization in order to proceed with treatment.   The diagnostic categories “schizophrenia” and “obsessive compulsive disorder” and “obsessive compulsive personality disorder” are still operative.  What does saying that there is a “continuum” or “spectrum disorder” add?   In initial evaluations psychiatrists are still all looking for markers of all of the major diagnostic categories and listing everything that they find.  The treatment plan needs to be a cooperative effort between the psychiatrist and patient to treat the problems that are affecting function and leading to impairment.  The idea that there will be a magical genetic and brain imaging test that will result in a “proper clinical assessment” at this point is a pipe dream rather than a potential product of a diagnostic manual.  The limitations of the spectrum approach are also evident in this article that points out the failed field trials attempting to use a dimensional approach for personality disorders.

George Dawson, MD, DFAPA

1.  Adam D. Mental health: On the spectrum. Nature. 2013 Apr 25;496(7446):416-8. doi: 10.1038/496416a. PubMed PMID: 23619674

2.  Borsboom D, Cramer AO, Schmittmann VD, Epskamp S, Waldorp LJ. The small world of psychopathology. PLoS One. 2011;6(11):e27407. doi: 10.1371/journal.pone.0027407. Epub 2011 Nov 17. PubMed PMID: 22114671