Tuesday, March 30, 2010

Health Care: A Requiem In Two Parts

I need to take a drug holiday from my usual concoction of Valium, Restoril, Ambien CR, and Benadryl to sleep at night. Apparently, I slept through an important change in human ethical thought. No longer does society have a moral obligation to provide health care, but rather, it's health insurance which we have the "moral imperative" to provide (1).

I find that really odd, since insurance, as I've come to know it, is defined as the "equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium, and can be thought of as a guaranteed and known small loss to prevent a large, possibly devastating loss" (2). Perhaps all that moral imperative stuff is found in the new revelation of Jesus Christ found in the Book of Moron Mormon. I'll have to look into that...

With health insurance, the "risk" that is being transferred is that of incurring medical expenses. As it turns out, there are a lot people in this country who do not have health insurance and therefore, are at risk for incurring medical expenses. The oft quoted (and inflated) statistic of people who do not have health insurance is 47 million (3). Even after the bill's passage, some 23 million still will not be covered.

But, who is to blame to for this high number?

"It's the insurance companies dummy!" was the implied message I got from one reader, who opined:
"I have no idea why everyone is defending the insurance companies who have been raping consumers' wallets for years and padding the pockets of politicians to keep antitrust laws from applying to them (thankfully, no more)."
Wow. Those companies sound really awful. I love my wallet. I would never let any harm come to it, sexual or otherwise. I guess a big "Thank You Mr. President Obama" is in order (and if you come into the oval office, a nice sloppy blow job too).

Obama sure screwed those wallet raping insurance companies (4): no more excluding people with pre-existing conditions, and no more setting rates based on a person's health status.
In addition, a weak economy is causing younger, healthier individuals to drop their insurance. As healthy people forego health insurance, the rates for those Americans who need coverage increases. That is why going into 2009 we advocated for robust insurance market reforms, including guaranteed coverage with no pre-existing condition exclusions or health status rating paired with an effective personal coverage requirement to get everyone covered." (5)
The above quote is not from an Obama speech. It's from America’s Health Insurance Plans (AHIP) President and CEO Karen Ignagni (i.e., the evil insurance lobby, dun, dun, dun...).

If the insurance industry actually supports those provisions in the bill, how exactly did Obama screw them?

The real question to ask is why the insurance industry supports those provisions. The answer: national health insurance mandate (i.e., "personal coverage requirement"). The health insurance industry is happy to drop those practices as long as they have a nice pool of  "younger, healthier individuals" to be conscripted. Since unhealthy individuals can no longer be charged higher premiums, it's healthier individuals who will see their premiums go up by as little as 10-13% or as high as 27-30%, depending on varying sets of circumstances (6).

We never learn from our mistakes. Many states have experimented with banning certain insurance practices such as the exclusion practice. This essentially kills any incentive to obtain insurance until you're actually sick. This ends up costing insurance providers a lot of money. The federal government's solution? Coerce their citizens to buy insurance. That's it, problem solved right?

Not exactly. Even with the mandate, there is still no incentive for healthy people to buy insurance. The average cost for an individual policy is $5,500 (7). The fine for not purchasing insurance ranges from $95 (1% of income) the first year to $695 (or 2% of income) after that. Would you rather pay $700 or $5000? Even if you're eligible for federal subsidies, $2,300 is still more expensive than $700. It's for this reason, the health insurance industry does not support this bill. The fines are too small (and currently, not enforceable).

We can predict what will happen next. It's known as a "death spiral." When premiums rise for those healthy people who already have policies (since unhealthy people can no longer be charged higher rates), more and more healthy people will drop their insurance. This will create an insurance pool of primarily of high cost, sick people (8). Many insurance companies will not be able to stay in business under these sets of circumstances. More and more health care dollars will become the responsibility of the government, which of course, is funded by taxing it citizens.

So in this sense, Obama has screwed the insurance companies. And us along with them.

(FYI: Those pesky anti-trust laws still don't apply to the health insurance companies).

(Coming soon: Will the health care bill reduce the deficit?)

Tuesday, March 23, 2010

The Dumbest Study I've Ever Read

This study has nothing to do with drugs, psychotherapy, or even neuroscience. It's about Jesus' head; more specifically, it's about Jesus' head in relation to the size of the main course in 52 different depictions of the Last Supper.

I know what you're all thinking, it's barely past noon, and I've hit the scotch too hard this time. From the International Journal of Obesity:
"Portion sizes of foods have been noticably increasing in recent years, but when did this trend begin? If art imitates life and if food portions have been generally increasing with time, we might expect this trend to be reflected in paintings that depict food. Perhaps the most commonly painted meal has been that of Jesus Christ's Last Supper, chronicled in the New Testament of the Bible. A CAD–CAM analysis of the relative food-to-head ratio in 52 representative paintings of the Last Supper showed that the relative sizes of the main dish, bread, and plates have linearly increased over the past millennium."
First, it's spelled noticeably, not noticably. No need to thank me, I'm just here to help.

Lead author, Brian Wansink, proudly displayed his virginity by saying, "I think people assume that increased serving sizes, or ‘portion distortion,’ is a recent phenomenon, but this research indicates that it’s a general trend for at least the last millennium."

His brother Craig Wansink, proving that mental illness does run in their family added, "As the most famously depicted dinner of all time, the Last Supper is ideally suited for review."

Here is a graph showing some of the data that will one day lead to a vaccination for jock itch.   
I am posting another graph below because I hate all of you.

  What they found was that "the main courses depicted in the paintings grew by 69%, plate size by 66%, and bread size by 23%" over the course of 1000 years.

 I've lost precious minutes from my life. I've created this post to waste your time as well.
Be careful everyone. Stupid can kill...


B Wansink and C S Wansink (2010). The largest Last Supper: depictions of food portions and plate size increased over the millennium International Journal of Obesity, 37

UPDATE: It just got worse...

"54% of Voters Oppose the Health Care Plan"

So why are these people so fucking proud of themselves?
I don't care what people or other media say (1), this is not a "health care reform bill," it's a (really expensive) health insurance bill. It doesn't matter whether you have medicare or private coverage. Insurance does not equal actual health care (Nor quality of care either).

Update: Reader comment:
"Anonymous said...
You claim to have some background in psychology and science, yet your title is a rather emphatic and dubious conclusion based on a source that provides absolutely no information regarding the methodology employed. There is nothing easier in the world than to obtain a skewed polling result based simply upon the wording of a question. Yet, we do not know what questions were asked, the order in which they were asked, etc. From what I can see from their site Rasmussen is about as objective as Fox News and leans in the same direction."
(Click to Enlarge)
From realclearpolitics (1). You'll notice ALL of the polls show lack of support. Douche.

Update Too:
"a source that provides absolutely no information regarding the methodology employed. There is nothing easier in the world than to obtain a skewed polling result based simply upon the wording of a question. Yet, we do not know what questions were asked, the order in which they were asked, etc. From what I can see from their site Rasmussen is about as objective as Fox News and leans in the same direction."
 Methodology located at the bottom of the article page (2) "This national telephone survey of 1,000 Likely Voters was conducted by Rasmussen Reports March 19-20, 2010. The margin of sampling error for the survey is +/- 3 percentage points with a 95% level of confidence (see methodology)."

Amazingly, this right-wing whack job website also lists the questions and the order in which they were asked too (3).

Monday, March 15, 2010

WARNING: Chantix Causes Suicide, Herpes, and Nocturnal Vaginal Itch Syndrome

Here is a brief tale of an American dream deferred...
"Tina Hurst is a suburban mother and a manager at a Fortune 500 company. Her life was great, but she had one dark secret...'I was a closet smoker,' Hurst said."  
Here is where the plot thickens...
"Her doctor prescribed a drug called Chantix to help her quit. Seven million Americans have taken it. Hurst says she took Chantix for two months and it worked great."
Then, tragedy struck...
"But when she stopped, 'I totally went off the deep end,' she said. Hurst says she started walking around the house in circles, crying and hallucinating. 'I thought somebody died. And I was freaked out,' Hurst said." 
But, it wasn't over just yet...
"An ambulance rushed Hurst to a hospital where records indicate she was very agitated and had to be restrained. She spent four days in a psych unit. Prior to this, Hurst said she never had a history of anxiety, depression or any mental problems. She thinks it was caused by Chantix. Her doctor's diagnosis? "Substance-induced psychotic disorder." (1
No, this isn't the plot of Gothika (2), this is an account of a woman who claims that she was adversely affected by Pfizer's anti-smoking drug Chantix (varenicline). Stories like this are common place now. Since the drug has come to market, it has racked up some 10,102 reports in the FDA's adverse events database (3).

Normally, I'm all for psychoactive drugs causing harm to people. However, I think a skeptical approach should be taken when it comes to this drug.

The most widely heard side-effect of Chantix is that it causes suicidality. For the sake of argument, let's forget that suicidality is a very complex and multifaceted human condition; we're going to pretend that this little pill can lead an otherwise normal and healthy person to want to kill himself (4).

First, let's examine the neurobiological reasons why this might happen...oh, wait a minute, there are no widely accepted (or proposed?) mechanisms of how this happens, just like there is no proposed mechanism for the supposed anti-depressant induced mania phenomenon (5) or the anti-depressant induced suicidality phenomenon.

What we do have is a temporal association (6). That is, event B happens around, near by, within some sort of proximity of event A. Once that happens, our minds automatically link events A and B together, and we have causation! No need for scientific investigation. Just turn on your computer, sign onto word press and start blogging about how "Chantix Causes Traffic Accident, Passengers Almost Die."

Here's why I am skeptical of the Chantix-suicidality link: smoking is associated with psychiatric illness (8, 9, 10). Specifically, individuals who smoke and have a comorbid psychiatric (i.e., Axis I or II) disorder make up 7% of the population, yet they consume 34% of all cigarettes smoked in the United States. Moreover, cigarette use is associated with most major psychiatric disorders. This means that 7% of 45 million smokers are mentally ill. That's a lot of people who are already at risk for suicide, regardless of whether they use Chantix or not.

Here is another interesting piece of research:
"This study examined the relation between smoking and suicide, controlling for various confounders...We found a positive, dose-related association between smoking and suicide among White men. Although inference about causality is not justified, our findings indicate that the smoking-suicide connection is not entirely due to the greater tendency among smokers to be unmarried, to be sedentary, to drink heavily, or to develop cancers." (11
I almost forgot about this study:
RESULTS: Current daily smoking, but not past smoking, predicted the subsequent occurrence of suicidal thoughts or attempt, independent of prior depression and substance use disorders (adjusted odds ratio, 1.82; 95% confidence interval, 1.22-2.69). Additionally, current daily smoking, but not past smoking, predicted the subsequent occurrence of suicidal thoughts or attempt, adjusting for suicidal predisposition, indicated by prior suicidality, and controlling for prior psychiatric disorders (adjusted odds ratio, 1.74; 95% confidence interval, 1.17-2.54).  (12)
Anybody ever abruptly stop their anti-depressant medication? Bad stuff happens, right? Here is a pretty picture from a study in the September 2003 issues of PENIS er, PNAS (13).

Here is a comparison of a smoker and nonsmoker and the amount of monoamine oxidase throughout their bodies. Smoking lowers the amount of this enzyme, which breaks down the catecholamines (5HT, DA, NE). Without this enzyme, the levels of these neurotransmitters rises. This is how the class of anti-depressants known as monoamine oxidase inhibitors are supposed to work.

Here are the instructions for how a patient is supposed to use Chantix:

 That is, they quit smoking one week after starting Chantix. Since Chantix is a partial-nicotinic agonist and not an MAOI, this could have the same effect as abruptly stopping your anti-depressant medication.

What if the instructions read like this instead. "Patients should be instructed to set a date to quit smoking and to stop their antidepressant medication and to initiate CHANTIX treatment one week before the quit date." Would you still take it?

Earlier, I mentioned the FDA's adverse events database. This is a system, where if an adverse reaction to a drug is suspected, it can be reported.

Here is a link (14) to the FDA's adverse events database on those who quit smoking cold turkey.

You'll notice that there is no real link because there is no actual database for this. The data that is collected by the FDA's actual database is biased, there are too many confounds that are not accounted for.

What about actual research? If you search PubMed for the terms "varenicline" and "suicide" you get 19 hits. Only three are actual prospective studies that looked at the matter (15, 16). The first study only had 1 suicide, but the patent's psychiatric background is unknown since the study is not complete. In the second study,
"There was no evidence that varenicline was associated with an increased risk of depression or suicidal thoughts."
The third study uses an adverse events reporting paradigm (17):
"All patients with suicidal events either had a past medical history of psychiatric illness prior to starting varenicline and/or a precipitating factor for the event. Clinicians should closely monitor patients with pre-existing psychiatric illness who are taking varenicline."
I'm not defending Chantix or Pfizer; over 10,000 reported adverse events for a drug that has been on the market for less that 4 years is a lot. Also, I have no explanation for how seemingly normal people such as Ms. Hurst have such horrible reactions. But, let's not always play the "drug companies are evil" card either. Chantix is the most effective smoking cessation drug on the market. It actually has helped 2 or 3 people.

Just remember, things are not always as they seem; do your own research; and don't trust the shit you read on blogs!