The Demon Haunted World – A Survivalist Counterfactual

 

The Demon Haunted World – A Survivalist Counterfactual

 

I found myself watching survivalist videos last night.  I had just completed a blog post and was working on another (that is becoming a thesis rather than a blog) and decided to take a break.  I have dabbled in that literature on and off over the past 30 years and found that it does not add much. The end games are typically played out in popular movies and fiction. You either find yourself in an impregnable underground shelter or wandering semi-aimlessly over a barren and hostile landscape.  Both scenarios have their problems.

In the impregnable fortress there are the inevitable power struggles, equipment breakdowns, outside attacks, functional and dysfunctional alliances, and lack of planning.  Good recent examples include The Silo and Fallout.  In the wandering scenario there seem to be a plethora of hazards including violent psychopaths, cannibals, various zombies, diseases, natural disasters, and the ever-present lack of food and water.   Examples include The Road, The Walking Dead, and The Last of Us.

Survivalists are more realistically focused. The brief series that I watched emphasized escaping detection by any means.  The implication was that you were in a secure remote location with adequate food and water.  The assumption is that there are many people who were not prepared for when the shit hits the fan or WTSHTF for short.  Four days of starvation is enough to make most people desperate and at that point they cannot be trusted.  A corollary is that once they get skilled at taking what they need from others – you may be the next target.

The first video discussed the importance of smoke. A poorly constructed fire can lead to a smoke signal for people to see for miles.  That signal translates to shelter, warmth, food, and resources to any desperate person who sees it.  The author emphasized methods to minimize smoke production. Elaborate underground survival shelters not only minimize smoke but also heat signatures to avoid infrared detectors and missiles.

 The second avoidable signal to the post-apocalyptic miscreants is gunfire. You might be thinking hunting, but the emphasis was on interpersonal conflict rather than hunting.  There may be better ways to resolve a dispute and secondarily gunfire WTSHTF is not necessarily a red flag. It is a sign out there that somebody has food and resources they want to protect.   The zombie mindset is “even if you do not have a gun – you might be able to hang around in the darkness long enough to get what you want.”  No other ways were discussed about how to avoid gunfire.

The final avoidable signal was light.  Even as little as a candle represents somebody with enough resources that they can and want to see in the dark. It represents the last vestige of civilization.  For that reason, it must be blocked at all costs. Curtains were emphasized as a practical measure but black out screens were preferable.  It reminded me of the subtitle to Carl Sagan’s classic book The Demon Haunted World (TDHW).  That subtitle is: Science as a candle in the dark.  It seemed like a perfect metaphor for what is currently happening in the world. To anyone who has not read the book – the subtitle is from Thomas Ayd’s 1655 treatise on witchcraft A Candle In the Dark where he described witchhunts as a way to delude the people about what was otherwise unexplainable.  Sagan sums up the progress against witchmongering this way:

“Microbiology and meteorology now explain what only a few centuries ago was considered sufficient cause to burn women to death.” (p. 26).

The title is a metaphor for reason and truth in the context of dire superstition and this is captured by Sagan’s summation.

Many reviews of TDHW suggest that Sagan’s views are formulaic – a few rules about how to assess facts and be skeptical along with listing logical fallacies. That minimizes the context he provides about the founding fathers and how they were impacted by The Enlightenment and science. Sagan’s thesis is more complex. He is the first to acknowledge that science is not perfect but that the method of science encourages and produces self-correction. To capture reasoning that is strictly outside of formal science, Sagan suggests that all matter of human endeavor like politics, economics, and even specific policies can be subjected to scientific reasoning and scrutiny and it will result in better results and prevent primitive biases.    

Since the beginning of the COVID-19 pandemic there has been an almost continuous attack on science and scientific experts.  The first Trump administration attacked public health officials, physicians, scientists, and anyone affiliated with them.  They promoted ineffective and potentially harmful treatments for COVID, suggested vaccines were problematic, said that COVID-19 was no worse than the flu, and that case and death rates were overstated.  Several conspiracy theories were promoted suggesting that HIV was a planned bioweapon, that NIH officials were corrupt, and that the “planned” HIV epidemic was paralleled by the “planned” COVID epidemic.  If the COVID epidemic was not planned it was supposed to have originated from a lab leak in China despite all the evidence pointing against that.  The problem is not merely a lack of training in science and the scientific method.  The problem is that we have a large segment of the population that really does not care about their ignorance of science and a large segment who seem to happily take advantage of that on social media.

Sagan has a famous quote that is considered prophetic by many:

“…Science is more than a body of knowledge; it is a way of thinking.  I have a foreboding of an America in my children’s or grandchildren’s time – when the United States is a service and information economy; when nearly all the key manufacturing industries have slipped away to other countries; when awesome technological powers are in the hands of a few, and no one representing the public interest can even grasp the issues; when the people have lost the ability to set their own agendas or knowledgeably question those in authority; when, clutching our crystals and nervously consulting our horoscopes, our critical faculties in decline, unable to distinguish between what feels good and what’s true, we slide almost without noticing, back into darkness and superstition.”   (p. 25).   

Much has been made about manufacturing in the US and there is an active debate.  Specifically – is it a feasible solution for whatever economic problems you claim it will solve?  I have seen business experts interviewed who say it is not and others who have their own specialized supply chains within the country as being a solution. How will it be compounded by tariffs and an attempt to resuscitate the coal industry? The technological power is concentrated at the monopoly level according to several court decisions.  And what about artificial intelligence? There are daily predictions that AI will replace not only truck drivers and assembly line works but also doctors and teachers.  There are grandiose claims that AI will "cure all diseases" in less than the time I have been writing this blog.  Those aspects of Sagan’s prediction seem too uncertain to be useful.

The lack of knowledge in both the general population and at the highest levels of government is also on display.  Scientific knowledge and thinking is lacking and that it is not enough.  Any reasonable analysis of population wide policies needs to include a scientific dimension, a rational thinking dimension, and a moral/ethical dimension.  This is the real current failure.  As an example, the divisive rhetoric used around the COVID-19 issue.  There was a lot of uncertainty about the best way to stop the pandemic. As physicians and public health officials were learning about this and saving lives – the counter response was that no measures were necessary including vaccinations.  In the end public health officials were being blamed for lockdowns and school closings that could only have been done by local elected officials. That rapidly evolved to conspiracy theories that led to threats of physical harm and legal action against some of the top scientists.  The culmination of this rhetoric was recently evident when the Trump administration replaced a government webpage providing scientific information on COVID-19 with one that presents a combination of conspiracy theories and pseudoscience.  None of this sequence of activity included science, rationality, or ethics.

This is what Sagan is referring to in his quote. The current web page on COVID is emblematic of sliding into the modern version of darkness and superstition. Like the old version the new one is as out in the open and accepted by many. There is an army of celebrities, podcasters, media networks, social media bots, and writers supporting it. Some of the wealthiest people in the country claim they were “censored” because they opposed some suggested COVID measures or supported anti-science rhetoric – even though there was no formal censoring. The dark narrative is very present and it continues to take its toll in terms of cabinet appointees who promote it and some who seek vindication against scientists and officials who were making a good faith effort.

As far as science goes, whether that is hard science or the dismal science of economics – we have a choice to stay in darkness and superstition or move toward the light of science and facts.   Not caring about the smoke is the difference between surviving and living.

 

 

George Dawson, MD, DFAPA

 

 

Graphics Credit:

Campfire in the forest by Crusier, CC license BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0&gt https://commons.wikimedia.org/wiki/File:Campfire_in_forest.jpg

References:

1:  Sagan Carl.  The Demon-Haunted World – Science as a Candle In The Dark.  Ballantine Books 1997.

2:  Ayd Thomas.  A Candle in the Dark.  Smithfield, London. 1655.

Science and Politics…..With A Lesson from Psychiatry

 

I started reading this week’s edition of Science and was surprised to find several editorials about the relationship between science and politics. In addition to the editorials, news items like “Will Trump upend public health?” and “Trump picks lawyer for EPA.” Were no less alarming.

Marcia McNutt, President of the National Academy of Sciences wrote the first essay (3).  She correctly discusses science as a rational neutral process that by its very nature is apolitical.  She describes the peril of citizens ignoring scientific reality by quoting a 26% increased mortality rate in areas of the US where political leaders dismissed the importance of the COVID-19 vaccine.  She makes the point that science must define the body of information that policy should be based on - but it should not actually dictate policy.  She advocates for a role of listening to the affected people and fighting the disinformation that affects them.  Unfortunately, the process of active listening will not do anything toward fighting misinformation – especially when things get to the wide dissemination and meme stage. 

H. Holden Thorp, Editor-in-Chief of Science journals wrote the second essay (4) and it was more specific to the current political situation.  After commenting on the win for Trump he provides the following qualifier:

“Although his success stems partly from a willingness to tap into xenophobia, racism, transphobia, nationalism, and disregard for the truth, his message resonates with a large part of the American populace who feel alienated from America’s governmental, social, and economic institutions.”

The first clause in this sentence is accurate – but there are problems with the second.  Are xenophobia, racism, transphobia, nationalism, and dishonesty really symptoms of an underlying problem or do they represent the real problem of an opportunistic politician successfully scapegoating a portion of the population to gain the support of the electorate with these biases?  That has immediate relevance for the author’s proposed solutions of decreasing scientific misconduct to enhance public trust.  He points out that an animated defense on X/Twitter by scientists was not successful (how could it be based on the platform’s structure, biases and conflicts of interest?). He ends by correctly predicting that the attacks on science and scientists will go on unabated into the future and would like to see a response by the scientific community that makes them less successful.

The essay by Jaffrey Mervis (2) highlights concerns that research advocates have for the Trump agenda that is described at one point as defunding research to reduce taxes.  Any analysis of the tax plan shows that the savings are disproportionately awarded to the top 1% of wage earners.  A research physicist points out that there is no good news for science in the Trump agenda and that also translates to no good news to the tech industry that depends on government funded research for innovation.  Three areas from the Biden administration that may suffer are the Chips and Science Act, climate change, and research collaboration with China. 

The essay by Jocelyn Kaiser (1) focuses on the possible impact on the National Institutes of Health (NIH).  In this essay there is clear focus on Robert F. Kennedy, Jr. as a danger to the NIH and health related basic science research.  That danger on the one hand describes him with the euphemism “vaccine skeptic” and on the other quotes former NIH Director Harold Varmus as saying: ”enormous risks especially if [Trump] placed someone as unhinged as [Kennedy] into a position of responsibility.”  There is a lot of room between skeptic and unhinged.  Trying to present an even-handed description in this case is a clear error when responding to RFK’s rhetoric. It is not a stretch to say that his rhetoric may replace science as the guiding principle behind the NIH.  That is a problem regarding the role of science advising policy makers and a boundary problem on the part of rhetoricians.  Simply put – if you are an administrator with no science background and you are making science up – stay in your lane.

Another clear example of potential problems with a Republican Congress is still based on the COVID-19 pandemic and insistence that the bat coronavirus research was the source of the pandemic virus.  This has reached meme status in the MAGA community fueled by rhetoric from both Trump and members of Congress who have directly attacked NIH scientists.  In some cases those verbal attacks have resulted in threats of violence to those same scientists. All of that happening even though the origins of SARS-CoV-2 are not settled science - but most recent reports suggest origins in the wild like practically all pandemic viruses. Some politicians want to reform the NIH and that is typically a code word for changing an institution to something more like the one they want.  In the case of the Trump administration that can include banning fetal tissue research and I would expect other issues related to women’s reproductive health that the religious right objects to.

The final essay by Rachel Vogel (5) is focused primarily on the implications of Trump’s threat to leave the World Health Organization (WHO). The author reminds us that Trump started this process in July 2020 based on the false claim that “WHO had helped China cover up the spread of the virus in the early days of the pandemic.”  The Biden administration came in and stopped that process.  WHO member states are bracing for a second withdrawal or a reduction in funding to key programs that many think would be catastrophic.  Cuts could also be made to the US Agency for International Development (USAID) that administers many of these programs and other agencies funded to research and treat tuberculosis, malaria, and AIDS.  Political and religious ideology may also be a factor.  A program for AIDS relief started by George W. Bush is a possible target for indirect support of abortions and the use of language that right wing religious groups consider offensive including “transgender people” and “sex workers”.  It is likely that a “gag rule” on the dissemination of abortion information will be reinstated and the penalty will be withdrawal of funding.  Like aspects of the other essays, the author is hopeful that there will be ways to compensate for the Trump worst case scenario. Reform of the NIH has been talked about in the past.  Europe and other countries could compensate for the lack of US support.  Competitive funding sources like the BRICS group (Brazil, Russia, India, China, and South Africa) could also come to the forefront.  The amount of funding available from BRICS and what those countries would require in return is speculation at this point.    

The 5 essays highlight real problems and given Trump’s current nominations for the Director of HHS and NIH probably minimize them.  Suggested solutions to the problem seem to be the time-honored stay out of politics, present the data, and take the high road.  This is really an inadequate plan.  How do I know this?  The valuable lesson is that this is what psychiatry has done for decades.  Ever since Thomas Szasz began his repetitive rhetoric that there was no such thing as mental illness, or that psychiatric diagnoses were like drapetomania (later modified to drapetomania was somehow a psychiatric diagnosis) we have had to tolerate nonsensical criticism while major physician and psychiatric groups were silent.  The many leaders in the field who did respond and had excellent responses were eventually ignored as the neo-Szaszians continue to repeat this nonsense decades later.  An experiment by Rosenhan that was exposed as fraudulent continues to serve as an anchor point for antipsychiatrists – even though what happened clearly did not impact the field (deinstitutionalization had already started and the neo-Kraepelinians were already at work on reliable and valid diagnostic criteria).  The result of this rhetoric is significant hangover on the field. It is difficult to make a direct connection but common sense dictates that psychiatric resources probably takes a hit from all the repetitive negative rhetoric. That is the risk to all of medicine, public health, and scientific research with the current MAGA rhetoric.

Science typically considers itself above rhetoric and politics at least until the competition for grant funding heats up.  The editorials all fail to comment on this.  Instead, they suggest that leading by example, being available for consultation, and generally taking the higher ground will somehow correct corrosive politics.  That is both a naïve and losing strategy.  We currently have a party that has lied and misinformed the public repeatedly and at record levels.  It is supported by a large mainstream media organization with the same goals providing a constant diet of misinformation. It is funded by billionaires. The effects of all those dynamics are easily observed in attitudes toward real science and scientists.  Experts on autocracy and authoritarianism point out that the effect of constant lies on any group of citizens is that eventually they don’t believe anything – even if it happens to be the truth.  A standard authoritarian tactic is to attack expertise and pretend that it does not exist.   

At no recent point in history have legitimate scientists, physicians, and public health officials been threatened with violence by people who have no clear idea of what they do.  In many cases these professionals have been responsible for saving thousands of lives. That situation should be intolerable to any scientist or modern citizen who can evaluate the effects of science.  Furthermore, it should not be supported at any level by the government, but it currently is.  The same party that that supports lies also supports threats and violence at various levels up to an including an attempt to overthrow the US government. With the current election there is the expectation that attempt will be whitewashed as a protest further eroding the rule of law.

The curious aspect of this process is that it is right out there in the open. The repetitive lies are picked up by social media.  Proxies of that ideology begin to amplify them to the point that they become memes rapidly assimilated by true believers in the same ideology.  At that point they become part of that culture and resistant to change from rational arguments and additional information. There is no evidence that I am aware of that change is possible at that point and the most recent Presidential election is solid evidence.     

There is a semi rational basis to politics at best.  The current election illustrates this at many levels.  Major questions of character, intellect, and policy were ignored. The fact checking mode of the fourth estate was minimized.  Some media outlets were mere propaganda arms and provided no information for voters to make an informed decision. 

The only rational course is to continuously counter the repetitive propaganda being put out in social media.  There is no comprehensive strategy for doing this but it must be done.  It will take more than a few editors from Science journals.  A starting point may be a coalition of editors of science and medical journals with their own website dedicated to refuting misinformation and posting the real science. The time has come to stand up for what is science and what is not and protect people under attack for doing the right thing.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Kaiser J. Trump won. Is NIH in for a major shake-up? Science. 2024 Nov 15;386(6723):713-714. doi: 10.1126/science.adu5821. Epub 2024 Nov 14. PMID: 39541475.

2:  Mervis J. Research advocates see 'no good news for science'. Science. 2024 Nov 15;386(6723):712-713. doi: 10.1126/science.adu5820. Epub 2024 Nov 14. PMID: 39541473.

3:  McNutt M. Science is neither red nor blue. Science. 2024 Nov 15;386(6723):707. doi: 10.1126/science.adu4907. Epub 2024 Nov 14. PMID: 39541446.

4:  Thorp HH. Time to take stock. Science. 2024 Nov 15;386(6723):709. doi: 10.1126/science.adu4331. Epub 2024 Nov 7. PMID: 39508752.

5:  Vogel G. 'America first' could affect health worldwide. Science. 2024 Nov 15;386(6723):715. doi: 10.1126/science.adu5822. Epub 2024 Nov 14. PMID: 39541476.

Why “Reading” and “Doing Your Own Research” are not nearly enough….

 

 

Medical training is an exercise in repeatedly meeting people who know a lot more about the field than you do and hoping to learn something in the process.  It happens regularly – often several times a day.  It is a common occurrence to meet people with encyclopedic knowledge – not just of textbooks and papers but disease patterns and presentations as well as the best treatment approaches.  The knowledge can be obtained through straight didactics, informal seminars, bedside interactions, and direct observation.  It can be affiliative or adversarial. In other words, you might get the attending physician who asks you a series of questions until you run your knowledge base dry or you might get the attending who realizes that your life is difficult and details the pathophysiology while pointing you to the latest review to read.

All that dynamic learning happens in a certain time frame where everyone must focus on the problems of the day.  The recent COVID-19 epidemic is a striking case in point. During the years of my training and practice the pandemic of interest was the human immunodeficiency virus (HIV-1, HIV-2). I started to see those patients in residency training – typically for the neuropsychiatric manifestations. At the time there were full isolation precautions and we had to wear surgical gowns, caps, and masks to see the patients. There was also the concern about needlestick injuries and injuries sustained by during surgery on HIV positive patients – that was subsequently shown to be a rare occurrence.  

All primary care and specialty physicians need to have a knowledge of HIV/AIDS – because of the potential protean manifestations, the need to maintain medications, and for infection control purposes.  It is also useful to recall epidemiological and infectious disease concepts – the most relevant being that for a while the infectious agent of the disease was not known.  Early in the course it was characterized by epidemiological features. When the virus was eventually isolated – steady progress was made in the development of antivirals to the point where the virus can be suppressed and is no longer detectable.

Over the course of learning about the illness and its treatment – I observed a heavy toll on treatment providers. There were no effective treatments early on.  I had lunch every day with an infectious disease team who ran one of the early HIV/AIDS clinics. Providing care in that setting took an emotional toll on them.

Against that 40 year backdrop – Aaron Rodgers recent press conference stands in tragic contrast.  For a time, Rodgers assumed the role of inscrutable new age guru.  He refused to state his COVID vaccine status but talked in detail about the rejuvenative properties of ayahuasca.  But I want to focus on his 208-word commentary on HIV, COVID, and Dr. Fauci. The full video is linked above for viewing.  I will address his commentary on a subject-by-subject basis.

1:  There was a “game plan” in the 1980s to create a pandemic with a “virus that’s going wild.”

Multiple lines of evidence show that HIV resulted from cross species transmission of Simian Immunodeficiency Virus (SIV) existing in African primate species. The transmission occurred through infected blood or bodily fluid exposure from hunting (1).  The key concept is that many human pandemics originate from cross species transmission.  Further – there is ample evidence that the cross over to humans occurred decades before the first AIDS fatality occurred in the US in the 1980s.  The only "game plan" in place was evolution in nature - over millions of years.

2:  Dr. Fauci was given $350 million dollars to research this:

Dr. Fauci was appointed head of the National Institute of Allergy and Infectious Diseases (NIAID) in 1982. NIAID is one of 27 institutes and centers of the National Institute of Health (NIH).  The funding for AIDS research is available on several sites. In this paper Tables 4.2 and 4.3 give the research dollars as well as the distribution by institute. In 1982 for example – there was $3.6M in AIDS funding.  Looking at the 1990-1991 allocation NIAID got 53.1% of the research allocation. The detailed allocation of that grant money consists of intramural and extramural research funding as well as funding clinical centers of research with adequate patient numbers to advance the field. From that paper:

“The need for more—and more appropriate—facilities specifically for AIDS work was acutely apparent in early 1988 when NIH director James Wyngaarden and NIH AIDS coordinator Anthony Fauci testified before several congressional committees (U.S. Congress, 1988a:259, 1988c:331). Their concerns were echoed in the June 1988 report of the Presidential Commission on the HIV Epidemic. The commission noted that plans for AIDS office and lab space were seriously delayed, and recommended that intramural construction and instrumentation needs be assessed and made a high priority in future budget requests…”

When Dr. Fauci assumed control of NIAID, the total budget of that agency was $350M.  He described it as a relatively secondary institution, that he built up to a $6.3B agency over the next 38 years (3). 

3:  The only drug they came up with was AZT:

 Azidothymidine (AZT) was developed in 1964 by the National Cancer Institute (NCI) as a potential anti-cancer therapy.  It was ineffective but was included in screening as an HIV treatment where it stopped viral replication without damaging normal cells.  It was the first FDA approved drug to treat AIDS in 1987. Advancing Clinical Therapeutics Globally for HIV/AIDS and Other Infections (ACTG) was founded at that time along with other networks though NIAID to conduct clinical trials in therapeutics for AIDS. Subsequent trials established more safe and effective doses as well as demonstrating a delayed onset of AIDS in HIV infected persons with AZT making it the first effective HIV treatment.

NIAID funded research for combination therapy, triple drug therapy and novel agents to the point where there are now 30 anti-retroviral drugs and new classes of therapeutic agents.  During Dr. Fauci’s tenure at NIAID, research has gone from antiretroviral treatment (ART) based remission to clinical trials looking at strategies for potential ART-free remission of HIV or cure (4).  That goal has not been realized but there is no question that the research work on HIV has been productive resulting in reduced transmission and mortality.

 4:  An “environment” was created where only one drug worked

The environment was a research environment looking for treatments at a time where there were so many AIDS related deaths that it led to public outcry and activism. AZT was discovered as effective in a standard screening protocol, but additional clinical trials were necessary to establish doses, safety, and efficacy for FDA approval.

5:  Just like HIV – only remdesivir worked for COVID until there was a vaccine

Just like HIV – additional therapies became available for COVID (SARS-CoV-2) including nirmatrelvir-ritonavir (Paxlovid), simnotrelvir-ritonavir, and high titer convalescent plasma.  A recent review of the issue of vaccine versus pills for COVID concludes that it is a false dilemma and that they may have complementary roles (5). There is active research continuing in SARS-CoV-2 antivirals and no reason to expect that there will not be many additional medications.

6:  Dr. Fauci had a conflict of interest because of a “stake in the Moderna vaccine.”

Dr. Fauci has no stock in Pharma companies. The “stake” in vaccines are royalty payments that researchers are obligated to take, the majority occurring before the COVID pandemic. That standard and the average payments have been documented in the medical literature where Dr. Fauci is on record as having donated payments to charity (6).  Without having a detailed list of royalty payments, what they were for, and the outcomes it is difficult to make any additional comments except to say that there was no violation of NIH policy – in fact not accepting the payments was a violation. Royalties are based on discoveries and not getting products to market, FDA approval, or sales.  My further speculation is that the royalties are a small fraction of actual sales and company profits and the original NIH policy was probably designed to retain talented researchers who would otherwise be lost to private industry. Major universities and research institutes generally allow their faculty to accept consulting and royalty fees. I have worked in several settings where those arrangements were spelled out in the initial employment contract, including intellectual property ownership.

7:  Pfizer is also “criminally corrupt” based on a fine that was paid.

Large fines against pharmaceutical companies are the rule rather than the exception.  In looking at this list of the largest settlements most of the fines are based on regulatory laws having to do with off label promotion of drugs beyond what is indicated in the FDA package insert. Practically all of the penalties have to do with marketing rather than research or production. It has been well known for decades that Pharma companies aggressively market their products to physicians, hospitals, clinics, and now direct-to-consumer advertising to potential patients. You could look at a list like this and decide against using a company’s product – but it might mean not taking a potentially safe and effective drug.  The same type of enforcement actions are taken against companies in other fields such as information technology.

8:  People who can “do their own research” and “read” are commonly vilified for that if they question authority

There is a basic difference between authority and expertise. The only vilification that I have noticed is of experts. Dr. Fauci is an extreme example but during COVID it extended to many local public health officials. It was a direct product of the minimization of COVID by President Trump and many of his officials as well as the MAGA movement.  Further it has led to political violence that includes threats of physical harm to Dr. Fauci and many other public health officials.  These threats are unprecedented and have been attributed to right wing political rhetoric.

9:  Why should science be trusted if it can’t be questioned.

Science is continuously questioned and this is probably the most significant public misunderstanding.  Science is a process where results are continuously challenged and updated. The politization of the COVID pandemic illustrates what happens when people who are not trained in the scientific method get involved. Suddenly each scientific modification means that somebody was wrong or lying. Scientists are treated like politicians and the politicians feel free to say anything that is not grounded in science. 

That is not how science works. It takes actual observations over time to test hypotheses.  As one example – I have collected about 200 hypotheses on the pathophysiology of depression over the past 40 years and to date – there are not sufficient observations to prove or disprove them and get to the level of a theory of depression. An equivalent scenario is the endless speculation of the lab leak hypotheses versus the cross-species transmission hypothesis of COVID origins.  Although the probability lies in the direction of cross species transmission – there are insufficient direct observations to prove one versus the other and ample discussions of the lab leak hypothesis by people with a complete lack of expertise.

Finally, with the errors in Rodger’s statement – I would be remiss if I did not mention Brandolini’s Law. Simply stated:

“The amount of energy needed to refute bullshit is an order of magnitude bigger than to produce it.”

This is true – especially when the false argument does not have to be based on facts, process, or rigorous standards. The politization of COVID and many other health issues by the extreme right wing should be a lesson that is not forgotten.  This video clip is a case in point.

 

George Dawson, MD, DFAPA

Supplementary 1:  The NIH policy on royalty payments to inventors can be viewed at this link.  The abbreviation IC stands for the Institutes and Centers of the NIH.  More detailed information can be found at this link.  The NIH also has conflict of interest policy (see conflict of interest in Appendix 1).

 Supplementary 2:  A few relevant titles from my library - note dates. 

 

References:

1:  Sharp PM, Hahn BH. Origins of HIV and the AIDS pandemic. Cold Spring Harb Perspect Med. 2011 Sep;1(1):a006841. doi: 10.1101/cshperspect.a006841. PMID: 22229120; PMCID: PMC3234451.

2:  Institute of Medicine (US) Committee to Study the AIDS Research Program of the National Institutes of Health. The AIDS Research Program of the National Institutes of Health. Washington (DC): National Academies Press (US); 1991. 4, Supporting the NIH AIDS Research Program. Available from: https://www.ncbi.nlm.nih.gov/books/NBK234085/

3:  Anthony Fauci: a scientific adviser's role from HIV to COVID-19. Bull World Health Organ. 2023 Jan 1;101(1):8-9. doi: 10.2471/BLT.23.030123. PMID: 36593776; PMCID: PMC9795384.

4:  Schou MD, Søgaard OS, Rasmussen TA. Clinical trials aimed at HIV cure or remission: new pathways and lessons learned. Expert Rev Anti Infect Ther. 2023 Jul-Dec;21(11):1227-1243. doi: 10.1080/14787210.2023.2273919. Epub 2023 Nov 8. PMID: 37856845.

5:  Papadakos SP, Mazonakis N, Papadakis M, Tsioutis C, Spernovasilis N. Pill versus vaccine for COVID-19: Is there a genuine dilemma? Ethics Med Public Health. 2022 Apr;21:100741. doi: 10.1016/j.jemep.2021.100741. Epub 2021 Nov 23. PMID: 34841029; PMCID: PMC8608621.

6:  Tanne JH. Royalty payments to staff researchers cause new NIH troubles. BMJ. 2005 Jan 22;330(7484):162. doi: 10.1136/bmj.330.7484.162-a. PMID: 15661767; PMCID: PMC545012.

7:  Mehellou Y, De Clercq E. Twenty-six years of anti-HIV drug discovery: where do we stand and where do we go? J Med Chem. 2010 Jan 28;53(2):521-38. doi: 10.1021/jm900492g. PMID: 19785437.

8:  Burke RV, Distler AS, McCall TC, Hunter E, Dhapodkar S, Chiari-Keith L, Alford AA. A qualitative analysis of public health officials' experience in California during COVID-19: priorities and recommendations. Front Public Health. 2023 Sep 13;11:1175661. doi: 10.3389/fpubh.2023.1175661. PMID: 37771831; PMCID: PMC10525347.

9:  Ward JA, Stone EM, Mui P, Resnick B. Pandemic-Related Workplace Violence and Its Impact on Public Health Officials, March 2020‒January 2021. Am J Public Health. 2022 May;112(5):736-746. doi: 10.2105/AJPH.2021.306649. Epub 2022 Mar 17. PMID: 35298237; PMCID: PMC9010912.

 10:  Royster J, Meyer JA, Cunningham MC, Hall K, Patel K, McCall TC, Alford AA. Local public health under threat: Harassment faced by local health department leaders during the COVID-19 pandemic. Public Health Pract (Oxf). 2024 Jan 24;7:100468. doi: 10.1016/j.puhip.2024.100468. PMID: 38328527; PMCID: PMC10847788.

 

Rosenhan Uncovered

I have been on record for many years regarding the Rosenhan experiment. To briefly recap, that was a paper published in Science in 1973 (1). In the paper the author described how eight pseudopatients were admitted to psychiatric hospitals and the treatment they received. He describes their varied backgrounds. He says that they were admitted to 12 hospitals in five states on the East and West Coast. The hospitals also varied from research institutions to institutions with much fewer resources. Most importantly he describes the script that each pseudo-patient is supposed to adhere to in order to get admitted and how they are supposed to behave post admission. 

Specifically:

“After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said "empty," "hollow," and "thud." The voices were unfamiliar and were of the same sex as the pseudopatient. The choice of these symptoms was occasioned by their apparent similarity to existential symptoms.” (p. 251)

Apart from the false symptoms, false name, false vocation, and false employment the social history provided by the pseudopatients was supposed to be identical to their real social history. After gaining admission so patient was supposed to “cease simulating any symptoms of abnormality.”

From the purported data, Rosenhan pointed out that none of the pseudo-patients were discovered, they were hospitalized for varying lengths of time, they were given medications that they may have been trained to not take and spit out, and they made a number of observations inside the hospital. Rosenhan concluded that “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals”.  He also uses at least half of the article for highly speculative observations on powerlessness, depersonalization, and labeling none of which really pertain to the study.

I just finished reading Susannah Cahalan’s new book The Great Pretender. It is about Rosenhan’s study and Rosenhan himself.  She has quite a lot to say about him including how this paper changed the face of psychiatric care and was a major factor in closing down psychiatric institutions.

Let me start by describing what I experienced at that time. In 1973, I was just finishing an undergraduate degree and although I was a science major - heard nothing about this paper. I was reading Science and Nature at the time. I did medical school and residency training between the years 1978 and 1986 and again heard nothing about Rosenhan - even during psychiatry rotations and seminars. That was a controversial time in psychiatry because of the tension between biological psychiatry and psychotherapy. The controversy seemed to be largely from the psychotherapy side of the equation. Psychiatry residents were pulled to one side or the other. It was always clear to me that both modalities were critical. I got what I consider to be good psychotherapy training at two different Midwest residency programs.

A unique aspect of my training happened at the University Wisconsin training program. Community Psychiatry was a mandatory six-month rotation that consisted of an outpatient clinic, crisis intervention training, and an active seminar every week. One of the leaders of that seminar was Len Stein MD. Dr. Stein was a major force and originator of Assertive Community Treatment (ACT) and other forms of community treatment that were focused on maintaining people with severe mental illness in the community. To this day I can recall a slide from one of his presentations that showed a gymnasium sized room at the local state mental hospital. In that room were cots arranged edge to edge across the entire floor. Rows and rows of these cots covering the entire floor. The men who slept on those cots were standing in the foreground. They were all wearing the same pajamas. After showing that slide, Dr. Stein would point out that this was one of the motivators that led him to help people get out of hospitals into their own apartments.  His goal at the time of Rosenhan’s paper, was to develop a way to help people with severe mental illnesses live independently in the community.  He was not only successful at it – he trained psychiatry residents how to do it. After completing my training, I went to a community mental health center and helped run an ACT team for three years.  We were highly successful at maintaining people outside of the hospital and helping them function independently.

My introduction here is to illustrate that one of the main theses of The Great Pretender, namely that Rosenhan’s experiment was one of the main forces in deinstitutionalization and closing down psychiatric hospitals is something that I disagree with. It seems to be a good theory if you want to suggest that psychiatry only changes from the outside and the change happens by people who are not psychiatrists. You can probably make that argument if you don’t know psychiatrists like Len Stein and all of the other community psychiatrists out there who were highly motivated to maintain people outside of state hospitals because it was the right thing to do. It was the right thing to do because states ration resources to the mentally ill. They always have and they always will.  Politicians don't really care about anyone with severe mental illness. Community psychiatrists know that. They know the only way to provide good treatment to those patients is to make sure that public funds follow the individual patient.

In her book Susannah Cahalan, spends a lot of time describing how seminal the Rosenhan study was. She has numerous testimonials from important psychiatrists at the time. There is even a suggestion that Robert Spitzer, MD used the study politically to advance his own agenda in writing more precise diagnostic criteria for the DSM-III. I can state unequivocally that I had not heard of this experiment until I started encountering anti-psychiatrists. That didn’t happen much until I started this blog in 2012.

What did I like about the book? I was impressed with the investigative aspects of the book. She carefully details how Rosenhan’s original description in Science does not accurately reflect what actually happened. There is not enough information available to verify whether or not the entire pseudoexperiment was completed as written. In addition to that research, she has detailed impressions of Rosenhan from fellow faculty members, coworkers, friends, and family members who knew him well. Many of these people had reservations about him and his work. Many believed that there were problems with the original paper. Many had concerns about his character that are clearly described in this book. In brief, there is plenty of circumstantial evidence in addition to the direct evidence that something was wrong with this paper.  I take this circumstantial and character evidence with a grain of salt. In any clinical or academic settings, there are always plenty of personality conflicts and politics. There is one scene in the book where Rosenhan is throwing a party and tells a colleague that he had a wig made for the pseudopatient role (Rosenhan was bald). Cahalan confirms by photo and the attending psychiatrist’s notes that he was bald and not wearing a wig during the hospitalization. I also do not consider that to be a big deal. He was described as a raconteur who liked to hear himself talk. Making up stories at parties to keep people engaged is what raconteurs and extroverts do.  

She also builds a careful case of additional red flags along the way. Rosenhan apparently achieved celebrity status for brief period of time. When that occurs he got a book deal and was advanced substantial sum of money. He also wrote several chapters that were read by Cahalan. He never finished the book even when he was sued by the publisher.  He never did any further research on the subject of pseudopatients getting into psychiatric hospitals or psychiatric hospitals at all. He had an active correspondence with Spitzer and one point recruited psychiatrists to convince Spitzer not to publish criticisms of his paper. Spitzer was very content with his criticism, but Cahalan points out that he may have had direct information at the time to refute the paper entirely. Rosenhan clearly broke the protocol that he described as evidenced by the medical record. The treating psychiatrist apparently sent Spitzer a copy of those records showing that as the original pseudo-patient, Rosenhan broke protocol. In addition to describing vague auditory hallucinations he added historical data that would have resulted in him being hospitalized anywhere.  Excerpts from the exact medical record are included in the book on pages 184 and 190. The author concludes (and any reader can do the same) that the facts were intentionally distorted by Rosenhan primarily with more elaborate delusional material and suicidal thoughts including the statement “everyone would be better off if he were not around.” What is recorded in the actual medical record is a person feigning a much more serious mental illness than “existential symptoms.”

Cahalan was able to locate two more pseudopatients, but one of them was not included in the study. Cahalan was unable to locate any of the other six pseudo-patients described in the Science paper despite an intensive effort.  Rosenhan also removed the data from the ninth pseudo-patient. The data from the ninth pseudo-patient was inconsistent with the others in that this patient liked his experience in the psychiatric hospital and in fact found to be very positive. He liked it so much that he published that positive experience in Professional Psychology in February 1976 (2) including the following conclusion “He recommends stressing the positive aspects of existing institutions in future research.” (p 213).

Cahalan approached Science directly. She asked them directly why they published this article in the first place given the concerns she outlined in her book. They refused to discuss their editorial process. A psychologist speculated that the submission to Science would be less rigorously reviewed because they probably did not have the top peer reviewers in the field. Although Cahalan uses a fair amount of anti-psychiatry rhetoric in her book, and seems to talk authoritatively about that field, there is no speculation that bias against psychiatry may have been involved in publishing this article.  Given what we know about general bias against psychiatry, that would seem to be a real possibility to me.

I am already on record saying that there is enough information in this book to retract the original article. I admit I don’t know the criteria for retractions or whether there is any time limit. Having been a Science subscriber for decades I know that it certainly does not meet their typical standards. I will happily go back and read articles from medicine and psychiatry in their 1973 editions to illustrate that fact if there is a shot at retraction.

Retraction would certainly create a furor in the anti-psychiatry community. Their arguments rest almost entirely on false premises and pseudoscience. As I noted in my post from seven years ago, anyone can walk into a medical facility and lie about a condition for any number of motives. In my current field, I have talked with hundreds of people who tell me they asked for a second or third opioid prescription when they did not need it for pain. They were taking it to get high. Before that I did consults in a general hospital, we were often asked to see people with factitious disorders who are feigning some medical illness. We also saw significant numbers of people who had medical symptoms but were not consciously feigning illness. The author mentions some of this but is usually quick to make it seem like psychiatry is the wildcard relative to the rest of medicine. 

I have had several people ask me if they should buy this book. I have also been asked to write a book review for newsletter.  My response is consistently, buy the book if you want to see the clear evidence that the Rosenhan experiment was more than seriously flawed – the protocol was violated by the author himself and the evidence is there black on white. A second protocol violation occurred when the Rosenhan decided to eliminate the experience of the pseudopatient who enjoyed being in the hospital and found it to be useful. I will say again that I am not an expert in retractions but believe that papers are retracted today for violations of data integrity.

Don’t buy this book if you are expecting to read a valentine to psychiatry. The author's previous book was about her episode of inflammatory encephalitis that was misdiagnosed as a psychiatric disorder. She mentions it several times to point out her credibility as a person who has experienced severe psychiatric symptomatology. At one point in the book she undergoes a SCID (Structured Clinical Interview for DSM-IV) evaluation by a psychiatrist who had a lot of input into DSM-5. After a tedious exchange he tells her that his going charge for the exam is $550. When I read that, I asked myself why would this psychiatrist go along with a SCID when he knew it was irrelevant to Cahalan’s diagnosis? Several other prominent psychiatrists are quoted in the book in a way that fits Cahalan’s thesis that psychiatry is in fact a weak link in medicine and even though Rosenhan’s pseudoexperiment was grossly flawed there is a still some valuable lesson there.

I would suggest that is really not the case. I don’t know why anyone would want to try to resuscitate this work and I sure don’t know why Science wants to keep it in a reputable journal.  The original responses over 40 years ago pointed that out. I would highly recommend reading the  original responses by Spitzer.

George Dawson, MD, DFAPA

References:

1: Rosenhan DL. On being sane in insane places. Science. 1973 Jan 19;179(4070):250-8. PubMed PMID: 4683124.

2: Lando H. On being sane in insane places: a supplemental report. Professional Psychology, February 1976: 47-52.

Additional Reference posted on July 17, 2021:

Justman, Stewart, "Below the Line: Misrepresented Sources in the Rosenhan Hoax" (2021). Global Humanities and Religions Faculty Publications. 13. https://scholarworks.umt.edu/libstudies_pubs/13

This author fact checks Rosenhan's references and footnotes and finds they do not support his points.

Basic Models

In order to bring some clarity into the discussion of why neuroscience is important for psychiatrists, I thought I would get back to the basics.  I have three models in the above graphic that I think represent the basic conceptualizations of the brain in my lifetime.  They are very basic models, but I think reasonable jumping off points for further discussion.  They also serve to make my point about the importance of neuroscience.  I realize that there is a natural human tendency to be argumentative.  When I mention neuroscience or even science it seems that many psychiatrists and interestingly their detractors both get irritated.  I can understand why the detractors are irritated since many of them are at the level of Black Box thinking in the above diagram.  I will elaborate further, but many of them seem to consider the brain an amalgam of various qualities that either defy understanding or are unnecessary to understand because the brain may be involved at the very periphery of human behavior if at all.  But I don't understand any attitude on the part of brain professionals like psychiatrists that doubt the importance of neuroscience. With that let me proceed with the three levels of thought about the brain in the above diagram.

The Black Box embodies what people have thought about the brain since the beginning of time.  The brain is a mystery on the one hand and immutable on the other.  The reality of that situation could not be denied for long.  It was obvious that people with clear brain damage who survived the initial insult could have a number of changes in cognition, personality, and social behavior.  The black box view eventually gave way to mind-body dualism that held there were a number of mental phenomenon that could not be explained  by physical properties alone.  That is really the last refuge of the Black Box and that is that the conscious human state has not been explained in terms of how it arises from the neural correlates of consciousness.  It is an active area of research in the Clear Box area today.  It is always interesting in terms of who adheres to Black Box thinking these days.  I can't think of any legitimate science that occurs using this model.  Pre-modern and modern neuroscience if anything has clearly dispelled black box and most mind-body duality.  Some philosophers and antipsychiatrists are at this level.

In the Grey Box Box things got clearer.  The transition from Black to Grey to Clear is not a well defined boundary.  The best example that I can think of is German neuropsychiatry at the beginning of the 20th century.  Much of that movement was focused in asylums.  There is a famous picture of giants in the field like Kraepelin. Alzheimer, Nissl, Binswanger and others who were active at the time.  These psychiatrists made good phenomenological observations but they were also focused on gross neuroanatomy.  In the case of some illnesses like Alzheimer disease some observations could be made at autopsy.  In the case of schizophrenia and bipolar disorder, gross anatomical changes were not evident.  Although that is a negative finding. it is a finding that propelled a century of more sophisticated neuroanatomy, neurophysiology and the beginnings of a much more sophisticated molecular  biological approach to functional mental illnesses or illnesses with no gross anatomical or physiological markers.

While neuroscience was moving forward at a slow pace, there was some slight progress on the fronts of diagnosis and treatment.  The DSM is always a controversial document, largely because there is never any shortage of self-proclaimed experts in psychiatry.  Psychiatrists know the limitations, what can be tested for, what physical illnesses are important to rule out, and what states can be cause by drug or alcohol intoxication, chronic use and withdrawal.  These medical and intoxicant induced states are all clear medical illnesses by any definition as well as the associated syndromes.  There is a disclaimer in the DSM about who should be using it.  Training is required to conduct the appropriate evaluations and make the appropriate diagnosis.  Further training is required to assure that patients can be safely treated.  Associated medical conditions need to be recognized and diagnosed.  All of this came about as a result of a medical focus that was reemphasized with the advent of the DSM.  Prior to that there was an overemphasis on psychoanalysis and psychodynamic psychotherapy.  A darker Grey Box consisted of a brain full of psychoanalytic constructs and the diagnosis and treatment was overly dependent on this model.

DSM technology was a required step in refocusing psychiatry on medicine and the brain as an organ.  But that occurred 40 years ago.  During that time, psychiatrists diagnoses and treat people based on clinical experience and general patterns that they recognize in the course of their training and practice.  In some cases the DSM has very clear criteria that are very helpful - like the definition of a manic episode.  In other cases - like the difference between anxiety and depression there are problems.  The same patients can endorse predominately anxious symptoms one week and predominately depressive symptoms the next.  The severity of the illness can typically lead to a clearer diagnosis and that is most likely due to the fact that the boundary between a clinical case and normal is arbitrarily defined as impairment in functioning.  More impairment should lead to clearer diagnosis.  Better markers to classify illness and hopefully predict treatment response are needed.  The search for these markers is an active area of investigation.  Psychiatry will remain in the Grey Box without these markers and more clear-cut treatments that address the underlying biological changes.

A lot of pharmacological research was done during the DSM era.  There was a lot of discussion about neurotransmitter and receptor pharmacology and the implications for scientific treatment.  Like all science, receptor pharmacology and post synaptic cell signalling mechanisms do not stand still.  There are many theories of receptor and drug pharmacology that have stood the test of time.  With a focus on the pathological nobody could hope that drugs that were often accidentally discovered would lead to highly effective treatments or a more comprehensive theory of mental illness or normal brain  function.  Clinical trials of psychiatric drugs and studies of pharmacology and physiology are are also limited by research subject heterogeneity.  That is a problem with research on any complex polygenic illness.  In the case of pure mental  illness where any medical cause has been ruled out, the DSM criteria alone are a poor filter for selecting homogeneous populations for research.

Drug and psychotherapy research in the Grey Box have both suffered from treatments being applied to heterogeneous populations.  There is no researcher that I know who thinks that any two people with a DSM diagnosis are similar to the point that drug or medication response would be high or necessarily reproducible.  Apart from the diagnostic problem, the DSM suggests homogeneity in a context where any seasoned clinician knows differently.

The Clear Box is the goal here.  The knowledge needed to get to this box is much more comprehensive.  It recognizes brain complexity and the importance of the conscious state rather than just a collection of DSM descriptors. Despite the fact that many of the basic mechanisms were elucidated over 40 years ago neuroscience has detractors just like psychiatry.  A common strategy of neuroscience detractors is to take either a research finding or a media quote and "debunk" it with fanfare in the popular media.  Ulterior motives are often suggested for connecting neuroscience primarily with psychiatric disorders.  Many of these detractors depend on their own characterization of the original research and the cultural phenomenon of piling on with negative criticism to score what appears to be a victory with the vocal and like minded.  They use the same strategy in claiming that mental illness or addictions are "not diseases" like "real" diseases - despite the fact that the general population considers them to be equivalent.  I find nothing compelling about critiques of ongoing science and medicine by the unqualified.  The main problem is that the people truly qualified to produce the criticism are ignored in favor of what amounts to unscientific criticism.  There is a secondary problem with the proliferation of journals, especially opinion pieces rather than scientific papers.  
                                   
Another interesting thought that I had about the Clear Box is that many people have no difficulty at all in recognizing that machine intelligence is improving and that at some point it might exceed human intelligence.  They don't seem to have any problem in figuring out whether a computer may have negotiated the Turing Test and seem indistinguishable from another human being.  Many people seem to have difficulty recognizing the computational capacity of the human brain and the result of that complexity.  Despite some philosophical arguments - that is a possible reason for not seeing the Clear Box as the preferred state of brain knowledge.

I have tried to point out many times that one key element of the  mischaracterization of neuroscience in psychiatry is a basic lack of understanding of science.  Science is a process and a dialogue.  Medical science is more of a process and a dialogue than physical science - the processes involved are more complicated and the experiments involve proportionally fewer relevant variables.  There are no differential equations based on a few variables that explain how the brain works.  Entire blocks of research can end up partially true or a dead end.  That does not mean there is some grand conspiracy - that just means it is time to move on to a new paradigm.  

George Dawson, MD, DFAPA



Quotation Credit:

"The brain is the most complex object in the known universe" is a quote from Christof Koch, Chief Scientific Officer of the Allen Institute for Brain Science and well-known consciousness researcher.


Tip For The Better Graphic:

The graphic at the top is rendered with Visio.  Blogger makes it blurry and ill defined.  Click on it for the sharp Visio version.

The Medicaid Emergency Department Study

There is an important study on the emergency department (ED) and health care policy in the January 17 edition of the journal Science. It looks at the question of whether not health insurance increases or decreases ED use.  This has been a political football for years.  The debate has been that increased insurance enrollment would prevent excessive ED utilization but the evidence has been sparse.  Some surveys have shown that the uninsured view the high cost of ED services and the financial repercussions are a deterrent.  On the increased utilization side is the economic argument that prepaid services lower the cost and therefore increase the use of all medical services across the board.  Another variable is the overall economy.  In an economic downturn, people use less goods and services including medical services.

Mapped onto the ED utilization problem is the EMTLA law or The Emergency Medical Treatment and Labor Act.  This law states that no person requiring medical stabilization can be turned away from an ED based on ability to pay.  A variety of mechanisms shifts the cost of care to the facility and physicians providing the care.  In the case of psychiatric services, EDs are obligated to find an open bed to transfer the patient.  In most states the majority of hospitals with EDs do not have psychiatric units, and that can result in patients being held for long periods of time until a bed opens up or transfer to beds across the state.  More radical solutions to that problem have included discharging a person untreated back out to the street or discharging them after a certain time interval if a bed could not be identified.

The scope of the problem of psychiatric services in the ED has not been well studied.  Some of the large studies suffer from an inadequate look at diagnoses, crisis care, patient flow and disposition and outcomes.  Before this study, I could not find any studies with adequate detail about diagnoses.  The other consideration is selection bias.  In most metropolitan areas, emergency services brings patients with psychiatric crises to identified hospitals with the largest psychiatric services.  These services typically have large capacity and become catchment areas for large areas of the states they are located in.  They can also be overwhelmed due to various factors that affect patient flow.  Most of these factors are directly related to the closure and rationing of psychiatric services in acute care but also residential facilities, clinics and community support services for the severely disabled.

The design of this study is interesting because it is randomized based on a political initiative.  In 2008, Oregon started a limited expansion of Medicaid.  They drew 30,000 names from a pool of 90,000 people.  There were 8 drawings between March and September 2008.  Previous studies on outcomes by the same authors showed that Medicaid assignment led to reduce depression and improved general health but it did not impact several general measures of general health, employment, or earnings.  In this study they looked at 12 hospitals that are the catchment area for Portland and surrounding suburbs.  These hospitals have half of the annual admissions in the state.  The study ran for 18 months, and was an intent-to-treat analysis of the randomly selected Medicaid enrollees and the non-selected matched on demographic variables.

The primary result of the study showed that Medicaid enrollment was associated with a significant use in ED services.  The increase was 41% relative to the control group.  There was no difference in the number of visits resulting in admission but increases in most other types of visits, including those that would be treatable in an outpatient clinic.  For some reason these differences were detected in administrative but not self reported data.  The authors look at three potential reasons for those differences.  The discussion of study limitations focuses primarily on the fact that the low income population studied may differ significantly from other low income populations and limit its generalizability.  The author's also comment on how establishing primary care can logically increase the likelihood of ED utilization.  The commonest scenario there is a patient with with either risk factors or chronic illnesses that calls their primary care clinic and is advised to go to the ED because of the anticipated length or complexity of the required evaluation.   That factor could not be studied with the available data.  In the case of psychiatric services that is typically a change in mental status, suicide risk , aggressive behavior or need for intoxication or detoxification.

One of the features of this study of interest to psychiatrists is the supplementary data.  Table S10 lists "Select Conditions (control sample only)" for a total of 17,498 ED visits separated by category.  A total of 1346 or 8.4% of all visits were for "Substance abuse and mental health issues."  Of that sample, 3% were mood disorders, 2% alcohol related disorders, 1.5 % anxiety disorders, 0.9% schizophrenia and psychotic disorders, and 0.8% substance related disorders.  In looking at visits per condition increased ED utilization occurred for injuries, headaches, and chronic conditions but not mood disorders or substance use or mental health disorders.  It is not possible to see the distribution of ED visits by hospital and with what is known about these distributions on metro areas it is likely that a few of the 12 hospitals had most of these visits.

In the weeks to come, I anticipate that there will be an active debate on the economic and political implications of this study.  From a psychiatric perspective it does not really capture the scope of the problem of how we got to the current predicament of discharging people with psychiatric and substance use problems untreated from emergency departments.  Nobody seems to consider that the ED problem exists as a result of rationing at multiple levels and a physician productivity model that values a stereotypical low to moderate complexity visit.  Most clinics and even urgent care settings have limited flexibility to assess some of the suggested ED problems like new chest pain even though in this study 93.1% of the chest pain assessed was nonspecific and 3.5% represented an acute myocardial infarction.  A few conclusions that I come to:

1.  This study is well done, unique and seems to have a highly significant finding that increased insurance to a low income population leads to increased ED utilization rather than less.  Caution is needed in the interpretation of that data.  A major weakness of any study like this is the fact that it is all of the data is administrative rather than clinical.  This is a major weakness of practically every data set used to establish health care policy in the past starting with the RAND studies on overutilization of hospitalizations and procedures relative to what was determined by the PROs of the 1990s.  These studies showed that when the data was reviewed by non-biased reviewers with no conflict of interest, there was minimal to no overutilization.  It is probably time to consider that we need better data.

2.  All elements in the system are not equivalent - no 2 EDs are the same.  In any state you can walk into an ED attached to a Level 1 trauma center and burn unit or one that is staffed by moonlighting physicians or residents who may not be emergency medicine specialists.  That will naturally affect referral patterns and overcrowding phenomenon.  Detailed patient flow pattern in and out of the busiest EDs with enough granular data about that phenomena is probably more important in addressing the problem than a look at a single global insurance decision.  Data in this study and others suggests that the increased ED use is based on rational decision making about medical conditions and previous surveys on wanting to avert a financial catastrophe.

3.  Targeted interventions to reduce ED use is specific populations are highly effective.  Assertive Community Treatment (ACT) teams for people with chronic mental illness are a good example.  In these interventions teams have their own crisis programs independent of EDs as well as medical staff who are available to the patients 24/7.  Their goal is also to avoid psychiatric hospitalizations and they are very good at that.  As clinics are acquired and consolidated under various managed care organizations the likelihood of consulting with a person from your primary care clinic after hours decreases significantly and that probably means more contact with the ED.

4.  Urgent Care facilities are a logical extension of primary care clinics after hours and there is currently no psychiatric equivalent.  A clinic with adequate multidisciplinary mental health staff would seem like a better options than being seen in an ED.  There currently do not appear to be any facilities like this for mental health other than county government based crisis lines that vary considerably form county to county.

Despite all of the considerations I have listed above and more, I do not expect a more sophisticated look at this issue.  Our politicians are incapable of it and the conflicts of interest related to the business side of medicine will typically carry the day.  There will be some ideological arguments about economic theory but in the end, what is good for business will carry the day.

Increased utilization of the ED is looking better and better for business every day.    

 

George Dawson, MD, DFAPA



1: Taubman SL, Allen HL, Wright BJ, Baicker K, Finkelstein AN. Medicaid increases emergency-department use: evidence from Oregon's Health Insurance Experiment. Science. 2014 Jan 17;343(6168):263-8. doi: 10.1126/science.1246183. Epub 2014 Jan 2. PubMed PMID: 24385603.

2: Fisman R. Health care policy. Straining emergency rooms by expanding health insurance. Science. 2014 Jan 17;343(6168):252-3. doi: 10.1126/science.1249341.  Epub 2014 Jan 2. PubMed PMID: 24385605.