Thursday, August 26, 2010

How to Use a Journal Article to Advertise Your Product

From this Month's JAMA (1) "Cognitive Behavioral Therapy vs Relaxation With Educational Support for Medication-Treated Adults With ADHD and Persistent Symptoms" by Safren et al.

In order to use an article to advertise your product, first you'll need to chose a topic about which people are fairly ignorant and make yourself an expert on it:

Approximately 4.4% of adults in the United States have attention-deficit/hyperactivity disorder (ADHD).”

Writing Style Recommendation: If you use the word “approximately,” which means “near or around,” then don’t use a number with a decimal. That’s too much precision. Just say “approximately 4% of adults.”

The lead author is Steven Safren, Ph.D., ABPP. In case you’re wondering, those initials mean people have to refer to him as “doctor” and believe that he actually knows what he is talking about. Although adult ADHD is rather amorphous, Safren et al. have extensively researched CBT with adult ADHD. This gives Safren et al. a posteriori authority on the topic.

Second, you'll need to concoct a reason why you're conducting research:

…Medications have been the primary treatment; however, many adults with ADHD cannot or will not take medications while others show a poor medication response. Furthermore, those considered responders to medications may continue to experience significant and impairing symptoms. Thus, there is a need for alternative and next step strategies.

Reader Advisory: Don’t be fooled by this “need.” It’s not a real need, it’s a constructed need (hey look at this huge hole in the ground I created! It needs to be filled!). These authors are using the construct of ADHD and the failure of medication (to treat an arbitrary construct) to accomplish their own goal.

You can read the results in the abstract here (1) as they are only of secondary importance.

Here is the real importance of this article: “Cognitive behavioral therapy was delivered consistent with our manuals.”

The authors of this article are also the authors of these two books (2, 3). This journal article will serve as a marketing device for these manuals.

It works like this: First, they will give “talks” touting the results of this research.

I am going to show you a bunch of statistics that have no real world relevance…

Second, they will conclude that pointless discussion with…

Our manual is available in the literature section located in the lobby.”

Unfortunately, those manuals don’t contain actual cognitive and behavioral material. Sure, they use the jargon, but it’s not actual CBT.

Writing Style Recommendation: Add words to mundane terms, thus making them appear more important than they actually are.

Sessions were designed specifically to meet the needs of ADHD patients and included things like starting and maintaining calendar and task list systems

Anybody can use a calendar or task list, but only “doctors” can provide instruction on how to use a calendar system or a task list system.

Here's a beauty...

The first module focused on psycho-education about ADHD…

What’s the difference between psycho-education and regular education you ask?

If you read an ADHD article on webMD, that’s “education.” When a psychologist prints out that webMD article and hands it to you, that’s “psycho-education.”

Study CBT protocol (i.e., the important one)

Study Relaxation protocol (i.e., the unimportant one)

Other cutting edge cognitive behavioral techniques include “setting priorities” and “breaking large tasks into manageable steps.” Oh snap!

I argue that this is not CBT but rather a collection of common sense solutions to everyday organizational needs. However, Safren et al. refer to this as a particular “type of cognitive behavioral therapy,” which was successfully documented to be useful “as a next-step strategy for patients with ADHD…”

So you better go buy those books!

Safren SA, Sprich S, Mimiaga MJ, Surman C, Knouse L, Groves M, & Otto MW (2010). Cognitive Behavioral Therapy vs Relaxation With Educational Support for Medication-Treated Adults With ADHD and Persistent Symptoms: A Randomized Controlled Trial. JAMA : the journal of the American Medical Association, 304 (8), 875-80 PMID: 20736471

Friday, May 28, 2010

Cerebellar Agenesis: Life without a Cerebellum

Many people are familiar with the famous patient H.M., the man who, in an attempt to control his intractable epilepsy, underwent surgical resection of both his medial temporal lobes.

There is another patient who is less famous, known the by initials H.C. He died in 1939 when H.M. was just entering adolescence. Unlike H.M., this patient did not undergo radical resection surgery. In fact, he never underwent brain surgery at all. His contribution to neurology did not begin until after his death at the age of 76.

In what was supposed to have been a routine autopsy, H.C. was discovered to have had no cerebellum (see pictured brain above). H.C. had a very rare neurological condition known as cerebellar agenesis. When I was in graduate school, I was taught that the neuroplasticity of the brain was so remarkable, that even a child born without his or her cerebellum could grow-up to have no deficits and live a normal life. As it turns out, that was only partly true. H.C. was in fact, not without deficits. His tale is recounted briefly in two articles from the March 2010 issue of Brain:
"It was clear that there were indeed clinical signs included right external strabismus (i.e., misaligned eyes), slow and slurred articulation and an unsteady gait." (1)
However, he did live a "normal life":
H.C. "had employment, that he was able to work in a manual job and that his working life was not curtailed by his cerebellar agenesis." (1)
What is interesting about H.C. compared to H.M., is that H.C.'s agenesis was discovered only after he died. Very little clinical history about his life exists, making this story a great neurological detective case. Most of what is known about H.C. comes from hospital notes during his last years of life, just before he developed dementia:
"The social history describes him as 'single.' The notes contained a record of his assessment by a neurologist, Dr. Jacobson, who described him as 'a simple man with some hearing loss and slow slurred speech; he has a fair memory for recent and remote events concerning himself, but with limited general knowledge. There is no hallucination or delusions nor emotional defect. He is clean in his habits and able to attend to his person. He is able to get around unassisted." (1)
The human brain is estimated to have approximately 85 billion neurons (2). The cerebellum, which is typically 1/4 the size of the rest of brain, contains a full 50% of all our neurons. If you pay close attention to the image above, you will notice that, in addition to not having a cerebellum, H.C. was also missing his pons, the bulbous structure that is typically adjacent to the cerebellum and is responsible for arousal and alertness.

Many of the patients I have seen with cerebellar strokes typically have severe and irreversible deficits. While H.C. did have some cognitive and functional deficits, that he lived a full and functional life is nothing less than remarkable. His case is an example of how extraordinary the human brain actually is.

I encourage you to read more about the mysterious case of H.C. here.

Boyd, C. (2009). Cerebellar agenesis revisited Brain, 133 (3), 941-944 DOI: 10.1093/brain/awp265

Lemon, R., & Edgley, S. (2010). Life without a cerebellum Brain, 133 (3), 652-654 DOI: 10.1093/brain/awq030

Sunday, May 16, 2010

Detroit SWAT Team Kill 7 Year-Old Girl

There has to be a better way to do this....full story here.

UPDATE: As luck would have it, this particular raid was being filmed for a reality show known as "The First 48." Base on the footage, the family lawyer is alleging a cover up (1).

Friday, May 14, 2010

Draw Central Executives Day

May 20th has been declared "Everybody Draw Muhammad Day" (1). By now, many should be aware of the controversy surrounding South Park's 200th and 201st episodes.

Shortly after the airing of episode 200, a group known as Revolution Muslim posted the following message on their site:
"We have to warn Matt and Trey that what they are doing is stupid and they will probably wind up like Theo Van Gogh for airing this show...this is not a threat, but a warning of the reality of what will likely happen to them." (2).
Thereafter, the media got wind of this post and ran with it. All major news networks and outlets had something to say about this "controversy". A week later, the 201st episode aired. It was, against the wishes of Matt Stone and Trey Parker, heavily edited by the douche bags at Comedy Central/Viacom.

As a result of the ignorant and spineless actions by the douche bags at Comedy Central/Viacom, a self-proclaimed idiot (3) and artist, Molly Norris, declared May 20th to be "Everybody Draw Muhammad Day." She had created a poster showing many objects, such as a tea cup, claiming to be the likeness of Muhammad. She sent this poster to different media outlets, who took it seriously, and then it went viral.

Ms. Norris has since distanced her self from "Draw Muhammad Day" and suggested that we should draw Al Gore instead (4).

After reading and listening to the media, I decided to do some research. To me, all this "controversy" seemed a bit contrived. After all, this was nothing like the Danish cartoon hysteria. If you were paying attention at all, it appears that this "controversy" had fallen on deaf ears in the Muslim world (5).

The true extent of Muslim hysteria was this: one post, by one Islamic group, Revolution Muslim.

I read about the group on Wikipedia (6). It turned out to be an interesting read:
"The group of 5-10 by Yousef al-Khattab, born Joseph Cohen, an American Jew who converted to Islam in 2000 after living in Israel and attending an orthodox rabbinical school."
More about Joseph Cohen from :
"He was born and raised in the United States as a Jew, and holds both American and Israeli citizenship.   In the late eighties, Cohen embraced an ultra-orthodox interpretation of Judaism, and began attending a yeshiva (rabbinical school).  In 1998, Cohen hearkened to the Zionist call, and packed up his bags to relocate to the Israeli Occupied Territories where he became an Israeli settler.  As an ardent and extreme Zionist, Joseph Cohen fell in with the Jewish fundamentalist group Shas, an extreme right-wing political party that believes in flouting international law based on their religious beliefs.  Less than three years later, Cohen 'converted' to Islam, moved back to the United States, and founded the most radical Islamic group in the country." (7, 8)
A radical in one religion will be a radical in another religion.

Maybe, just maybe, it was not the Muslims who were over reacting, but rather, the American Media. Now many people across this country are angry, and on May 20th, people will take pencil to paper and draw the Prophet Muhammad.

Perhaps this anger is misplaced. After all, it was Comedy Central/Viacom that censored the cartoon. It was also Comedy Central/Viacom that censored people who criticized their spineless behavior (9). Perhaps the true enemies of free speech are the people responsible for actual censorship: the executives/lawyers at Comedy Central/Viacom.

Thursday, May 13, 2010

Woman Hospitalized Following Botched Raid

How many armed, anonymous, men does it take to give an old woman a heart attack? The answer:
"An elderly Polk County woman is hospitalized in critical condition after suffering a heart attack when drug agents swarm the wrong house. Machelle Holl tells WSB her 76-year-old mother, Helen Pruett, who lives alone, was at home when nearly a DOZEN local and federal agents swarmed her house, thinking they were about to arrest suspected drug dealers." (1)

Wednesday, May 5, 2010

There Are 40,000 of These Each Year

Here's what happened (1):
"SWAT team breaks into home, fires seven rounds at family's pit bull and corgi (?!) as a seven-year-old looks on.
They found a "small amount" of marijuana, enough for a misdemeanor charge. The parents were then charged with child endangerment.
So smoking pot = "child endangerment." Storming a home with guns, then firing bullets into the family pets as a child looks on = necessary police procedures to ensure everyone's safety.
Just so we're clear."

Transcranial Magnetic Stimulation: Does it Live Up to the Hype?

Repetitive Transcranial Magnetic Stimulation (rTMS) is a treatment for depression that was approved by the FDA in October of 2008 (1). Repetitive TMS involves a device (pictured right), which is noninvasive, that excites the neurons in the brain. When this done over the left dorsolateral prefrontal cortex (an area of the brain supposedly less active in depressed patients), brain activity increases. The major selling point is that it has very few side-effects compared to standard antidepressant treatment (most common effects are headache and tingling at the stimulation site).

The FDA approval of this device has been controversial (2). The initial study submitted to the FDA was rejected. The folks at Neurostar (the manufacturers of the device) did a post-hoc analysis of that data. They discovered that patients, who failed to respond to only 1 antidepressant, subsequently responded to rTMS greater than sham (27.3% versus 10.5%). Based on this analysis, the FDA approved rTMS for the treatment of MDD in patients who have failed only 1 antidepressant trial.

In this month's Archives of General Psychiatry, is an article titled "Daily Left Prefrontal Transcranial Magnetic Stimulation Therapy for Major Depressive Disorder" (3). This study was funded by the NIMH and is the first nonindustry funded multisite study of rTMS (though some of the researchers are paid consultants of the TMS manufacturer). It involved 190 people.

What supposedly separates this study from all others, is the sham treatment. One major criticism of the previous TMS research is that the sham treatment was not convincing enough to prevent unblinding (for example, sham did not cause scalp irritation or facial twitching). The researchers went to great lengths to develop a sham treatment which produced the similar physical sensations of rTMS to prevent unblinding.
(Click to Enlarge)

Unfortunately, approximately 50% of the active treatment group correctly guessed which treatment condition they were in. A full 66% of placebo participants correctly guessed their condition. In truth, the level of unblinding is not a whole lot different from standard antidepressant drug trials (since placebos are inactive). The patients, on average, were similar to the patients in the Neurostar post-hoc analysis. The participants failed 1.51 antidepressant trials. 
The primary outcome was remission, defined as a score of 3 or less on the HAM-D or 2 consecutive HAM-D scores less than 10 during phase 1 of the study. Phase 1 was three weeks in duration. Patients received rTMS once a day for 50 minutes (5 days a week).
(Click to Enlarge)
Unfortunately, the results were negative. During the three week period (the right side of the chart) only 6 patients (11%) met criteria for remission. The average drop in HAM-D score for active treatment was only 5 points (26 to 21). The researchers then extended the the length of phase 1 by two weeks. The number of patients who went into remission during this extension phase was 13 (14%). By increasing the length of the phase 1, they obtained statical significance. Sounds fishy to me, but at least they provide all the data.
Similar to the Neurostar analysis, those who did remit were less treatment resistance (i.e., failed only 1 antidepressant trial). The number needed to treat (NNT) was 12. That means, 12 people will need to be treated with rTMS before another person, who otherwise would have not remitted without intervention, finally does remit. That's not very good. However, that number is not far off from standard antidepressant drug trials.
Does rTMS have any practical value as a future treatment for depression? Based on these results, one will need to attend a 50 minutes session everyday (excluding weekends) for 3-5 weeks to see some sort of result. That is in stark contrast to attending psychotherapy 1-2 times a week or visiting a psychiatrist once every 4-6 weeks. As Daniel Carlat points out in his monthly report (1), each treatment session would cost approximately $400. Insurance companies do not currently cover this treatment (and probably never will). Moreover, the group of patients who did remit (i.e., those who failed only 1 antidepressant trial) is not very marketable. Odds are they will try a second antidepressant instead. According to the Star-D results, the odds of improvement are 30% on a second antidepressant compared to 14% of rTMS. Presently, rTMS just does not make economic sense.

George MS, Lisanby SH, Avery D, McDonald WM, Durkalski V, Pavlicova M, Anderson B, Nahas Z, Bulow P, Zarkowski P, Holtzheimer PE 3rd, Schwartz T, & Sackeim HA (2010). Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Archives of general psychiatry, 67 (5), 507-16 PMID: 20439832

Tuesday, May 4, 2010

Psychosis Among Substance Users

Psychosis among drug users is quite common. Often, it is difficult to determine which came first, substance use or psychosis. Frequently, they co-occur. In cases where drugs are causally related (i.e., substance-induced psychosis), the condition is typically transient with a duration of 1 month or less. In rare cases, the length of psychosis can last longer. And in even rarer cases, symptoms such as hallucinations can be permanent.

Psychosis can be associated with the use many legal (e.g., alcohol) or illicit substance such as stimulants (amphetamines and cocaine), cannabis, and hallucinogens. An article by Thirthalli and Benegal (1) reviews the evidence that these drugs can cause psychosis in nonpsychotic persons. 

The neurochemical effects of alcohol are complex. "Common knowledge" states that alcohol acts in a similar fashion to other sedatives (e.g., diazepam). In other words, it is an agonist of GABA receptors. In reality, the alcohol molecule is very simple. It has the ability to cross cell membranes (e.g., blood-brain barrier) easily and can exert its effects on the brain within minutes. Alcohol also influences the phospholipid bilayer that make up cell membranes. This ability has a widespread impact on normal cell functions and also enables alcohol to modify the action of many neurotransmitter systems, such glutamate, dopamine, and norepinephrine in addition to GABA.

Alcohol-induced psychosis can occur during different drug states such intoxication or withdrawal (e.g., delirium tremens, alcoholic hallucinosis). In general, the risk of psychosis is two-fold greater than in the general adult population.

Stimulants (click to enlarge picture; 2)
Cocaine and Amphetamines are widely known to lead to psychosis. The psychosis produced by both cocaine and amphetamines is similar to schizophrenia. The risk of psychosis from amphetamine use is quite high; greater than 70% in chronic users. Users who develop first episode psychosis use an average of 20 times years. Psychosis typically lasts for the duration the drug is in the system. However, it can last more than a month in more severe cases.

For cocaine, typically 50% of chronic users experience paranoia and hallucinations. Cocaine-induced psychosis has a stereotypical form; Users believe that their drug use is being watched and that they are being followed. This paranoia is typically accompanied by hallucinations. Cocaine-induced psychosis also shows sensitization; that is, psychosis becomes more severe and occurs more rapidly with continued use. Unlike amphetamine-induced psychosis, cocaine induced-persistent psychosis is very rare.

Cocaine has the highest affinity and binds most strongly to the serotonin (5HT)reuptake pump, followed by the dopamine (DA) reuptake pump, then the norepinephrine (NE) reuptake pump (FYI-Effexor is cocaine with a PG-rating; effexor's affinities are for serotonin, then NE, and then DA). Contrary to popular belief, amphetamines do not act by blocking the dopamine reuptake pump. Amphetamines are indirect agnonist of the catecholaminergic systems (i.e., dopamine and norepinephrine). First, amphetamines go inside the neuron and release both DA and NE from their vesicles into the cell cytoplasm (i.e., catecholamins are released inside the neurone). Second, The catecholamines are subsequently transported outside of the neuron by a reversal of the reuptake pumps. This results in a MASSIVE increase in synaptic DA and NE. Lastly, at higher doses, amphetamines inhibit catecholamine metabolism, leading to even higher concentrations in the synapse. 

There has been a boom in the current research of cannabis and psychosis. There appears to be a temporal correlation between early cannabis use and onset of schizophrenia. This association is stronger than for any other substance. Why the association exists is unclear. In general, cannabis has the same risk of inducing psychosis as alcohol (i.e., two-fold).

There are two cannabinoid receptors in the human body: CB1 and CB2. The CB2 receptor is not expressed in the brain, and is primarily found in the immune system. The CB1 receptor is typically found in the basal ganglia, cerebellum, hippocampus, and the cortex. CB1 receptors exist on the axon terminal instead of the post-synaptic cell. In others words, CB1 receptors are autoreceptors that can inhibit the release of many different neurotransmitters.

Many different drugs fall under this category: mushrooms, peyote buttons, and LSD, for example. Many hallucinogenic drugs are either synthesized by plants or are based on plant-derived compounds. The main active compound in peyote is mescaline, while psilocin in found mushrooms. LSD is actually a synthetic compound, but is based on a fungal alkaloid taken from ergot.

Hallucinogenic compounds have a catecholamine-like structure (most are similar in shape to serotonin). Hallucinogens are primarily 5-HT2a receptor agonists. While these drugs do not lead to dependence, withdrawal, or cravings, they still can lead to serious problems for some users. Some people experience acute anxiety or panic attacks in responses to the drugs' hallucinogenic effects. There is a disorder known as hallucinogen persisting perception disorder (HPPD), which is the fancy name for "flashbacks." The most severe reactions, of course, are psychotic breakdowns. However, similar to the above mentioned drugs, psychosis is typically transient. Most prolonged episodes of hallucinogen-induced psychosis involve individuals who have already been diagnosed with a psychotic disorder or who have manifested prepsychotic (e.g., prodromal) symptoms before taking these drugs.

In most cases, substance induced psychosis does not need medical treatment per se. It usually disappears when the drug's affects are gone. However, there are cases when treatment is necessary. Alcohol dependent individuals in withdrawal do need medical treatment because alcohol withdrawal can be lethal. Typically, sedatives (benzodiazepines) are the drugs of choice. For either cocaine or amphetamine induced psychosis, first or second generation antipsychotics are the drugs of choice because of their potent D2 receptor antagonism. In general, it is common for anyone presenting with psychotic symptoms to be prescribed antipsychotics. Occasionally, patients who are addicted to amphetamines will be prescribed antipsychotics in hopes that they will reduce the risk of subsequent psychosis or reduce euphoria, making the drug less reinforcing. Drugs that antagonize the 5HT2a receptor such as risperidone (or any second generation antipsychotic), ketanserin, and ritanserin have been shown to reverse hallucinogenic-induced psychosis.

In rare cases when psychosis persists, there are a few things to consider, such as, is their another cause for the psychosis? For example, does the person have schizophrenia or is there a physical cause for the psychosis (e.g., tumor, metabolic, etc)? Often times, doctors not knowing what to do, will double down on the antipsychotics. This is unlikely to work because the mechanism of action (D2 or 5HT2a blockade) does not necessarily increase with the addition of a second drug. Simply upping the does of the current drug should suffice. Side effects, however, are always additive. Antipsychotics with higher affinities for both D2 and 5HT2a receptors are preferable (e.g., risperidone).

Risk Factors
The risk factors for substance-induced psychosis are similar across all substances. Pre-morbid psychiatric history or a family history of schizophrenia put an individual at risk. Also, the longer a substance is consumed and the larger the quantities consumed are also risk factors. Polysubstance use or consuming drugs that contain other compounds increases the risk of psychosis too. Unfortunately, the research into the neurobiological and genetic underpinnings is substance-related psychosis are quite poor. A useful theory for substance-related psychosis which could lead to better acute treatment is lacking.

Thirthalli, J & Benegal, V. (2006). Psychosis Among Substance Users Current Opinion in Psychiatry

Monday, May 3, 2010

"Anatomy of an Epidemic" or The Same Story Told Over and Over Again

On, there is an interview with Robert Whitaker, the author of Mad in America, about his new book titled "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America."

The article/interview at Salon is devoid of any context:
"In the past few months, the perennial controversy over psychiatric drug use has been growing considerably more heated. A January study showed a negligible difference between antidepressants and placebos in treating all but the severest cases of depression. The study became the subject of a Newsweek cover story, and the value of psychiatric drugs has recently been debated in the pages of the New Yorker, the New York Times and Salon...The timing of Robert Whitaker’s "Anatomy of an Epidemic," a comprehensive and highly readable history of psychiatry in the United States, couldn’t be better."
That study in JAMA is hardly a first (1, 2, 3), nor is Mr. Whitaker's book a first (4, 5, 6, and anything written by Peter Breggin). Timing couldn't be better? Sure, if by timing you mean, when can one cash in on anti-psychiatry sentiment.

I have not read this book. I did read his previous book, Mad in America, which surveyed the history of the treatment of mental illness in American and the rise of psychiatric drugs. Based on that book, which was sensationalistic and misrepresented research, I think I know what to expect in his new book. My focus, instead, will be on his interview. Comments in red.
"Psychiatric drug use is a notoriously tough subject for writers, because of all the contradictory research. Why wade into it? In 1998, I was writing a series for the Boston Globe on abuse of psychiatric patients in research settings. I came across the World Health Organization’s outcomes study for schizophrenia patients, and found that outcomes were better for poor countries of the world -- like India, Colombia, Nigeria -- than for the rich countries. And I was startled to find that only a small percentage of patients in those countries were medicated. I also discovered that the number of people on disability for mental illness in this country has tripled over the last 20 years..."
 He doesn't provide an actual number for "only a small percentage of patients." However, according to the Worldwide-Schizophrenia Outpatient Health Outcomes (W-SOHO;7), which surveyed Europe, Asia, Africa, and Latin America, it revealed that a not so small 40% of patients where on antipsychotic medications. The real differences between rich and poor counties is that patients in developing countries were primarily on first generation antipsychotics (60%) and on monotherapy (75%). The reasons for outcome differences are many.
"...If our psychiatric drugs are effective at preventing mental illness, I thought, why are we getting so many people unable to work?"
I don't think anyone of real importance claimed that psychiatric drugs were aimed at "preventing mental illness." Again, there is no context. For example, one explanation for the increase of those on disability is that entitlement programs have increased their coverage over the years to include those with mental illnesses.
"What's so risky about Ritalin? For one, a significant percentage -- between 10 and 25 percent -- of kids prescribed medication for ADHD will have a manic episode or psychotic episode and deteriorate in such a way that they’re diagnosed with bipolar disorder..."
He is misrepresenting the data. That study (8), examined the comorbidity of ADHD and mania, not the association of stimulant medication use and risk of mania. It's quite possible that those who eventually develop bipolar disorder have an ADHD appearance during childhood.
"But if these studies are so groundbreaking, why have they gone unreported in the media? Because the NIMH didn’t announce it. Just as they didn’t announce the 2007 outcome study for schizophrenia patients. In that study, the recovery rate was 40 percent for those off meds, but only 5 percent for those on meds. I checked all the NIMH press releases for 2007, and found no release on this study. I found no announcement of it in any American Psychiatric Association publication or textbook. Not a single newspaper published an account of the study. And that’s because the psychiatric establishment -- the NIMH, the APA, even the National Alliance on Mental Illness, an advocacy organization -- did not put out any press release about it or try to alert the media in any way."
Either he's lying or had a lobotomy. I have reviewed that study as well as it's follow-up (9). Here is what the researchers actually discovered :
"Looking at it from a different viewpoint, the data suggests that schizophrenia patients with good prognostic features, with better premorbid developmental achievements and with more favorable personality characteristics are the subgroup more likely to stay off antipsychotics for a prolonged period"
That's why the NIMH, APA, and NAMI didn't sound the alarm about that supposed discovery. Here's another way to highlight the absurdity of his conclusion: Two women have been diagnosed with breast cancer. One has a strong family history of breast cancer and tested positive for the BRCA gene (i.e., she has a poor prognosis). The other woman has no family history nor the BRCA gene. Both were treated with chemo. One recovered quickly stopped treatment. The other woman, while still being treated, died. The chemotherapy killed her, right?

 I could continue, but what's the point. His book has one intended audience: People who already hate psychiatry. If one cares to fully fact check the entire interview, you'll find one misleading statement after another. Whitaker is biased and has no scruples about misrepresenting facts and data to suit his narrative.

He is no different than the very industry that he is attacking.  

Tuesday, April 27, 2010

R-Rated Movies Aren't Bad for Your Kids...R They?

In the May issue of the Journal of Studies on Alcohol and Drugs is an article titled "Parental R-Rated Movie Restriction and Early-Onset Alcohol Use." (1) Without reading the study, one can guess the reported result : the more R-rated movies that youths watch, the higher the frequency of early-onset alcohol use.

This study was funded by the National Cancer Institute and National Institute on Alcohol Abuse and Alcoholism. Remember what the Last Psychiatrist says: What do researchers want to be true?

First comes the filter that will aid our interpretation of the results:
"TODAY’S YOUTH HAVE UNPRECEDENTED ACCESS to entertainment media (Roberts et al., 2005), and longitudinal research has linked various forms of entertainment media with aggressive behavior (Bushman and Anderson, 2001), sexual behavior (Collins et al., 2004), and tobacco use (Sargent, 2005). Indeed, the available research evidence has led the National Cancer Institute (2008) to declare a causal relation between exposure to movie smoking and youth smoking initiation."
In the words of Mr. Mackey, "Mm..R-rated movies are bad...mmkay."

The study was done by survey. 3,577 youths where chosen out of 4,655 (grades 5-8) because they reported to never have drunken alcohol without the knowledge of their parents. Also at baseline assessment the youths rated how restrictive their parents were in allowing them to view R-rate movies.

Statistics 101: Very boring, but very important to interpret these results.

This study is correlational. This results are known as the standardized coefficient. This can vary from +1 (indicating a perfect positive relationship), to zero (indicating no relationship), all the way down to -1 (indicating a perfect negative relationship, that is, when the frequency of a factor goes up, the other factor goes down). As a rule of thumb, standardized coefficients between .00 and .30 are considered weak, between .30 and .70 are moderate, and between .70 and 1.00 are considered strong.

The primary meaning of standardized coefficients lies in the amount of variation in one variable that is accounted for by the variable with which it is correlated. To obtain this information, you square the standardized coefficient (e.g., .30 x.30). This number is called the coefficient of determination. Then you multiply the coefficient by determination 100. This proportion of variance indicates the percentage of variance. The coefficient of determination is the primary information measure. Correlation coefficients of .30 account for about 10 percent of the variance (.30x.30 =.90x100= 9%).

Here are the results as reported in the abstract, that is, the information they want you to know:
"The sample included 2,406 baseline never-drinkers who were surveyed at follow-up, of whom 14.8% had initiated alcohol use. At baseline, 20% reported never being allowed to watch R movies, and 21% reported being allowed all the time. Adolescents allowed to watch R-rated movies had higher rates of alcohol initiation (2.9% initiation among never allowed, 12.5% once in a while, 18.8% sometimes, and 24.4% all the time). Controlling for sociodemographics, personality characteristics, and authoritative parenting style, the adjusted odds ratios for initiating alcohol use were 3.0 (95% CI [1.7-5.1]) for those once in a while allowed, 3.3 [1.9, 5.6] for those sometimes allowed, and 3.5 [2.0, 6.0] for those always allowed to watch R-rated movies. Alcohol initiation was more likely if R-rated movie restriction relaxed over time; tightening of restriction had a protective effect (p < .001)."
With odds-ratios, 1.0 represent the prevalence of something (e.g., drinking behavior) that already exists in the population. Anything above that represents an increase in prevalence. For example, in the study, it's reported that youths who have peers who drink have an OR of 5.7, meaning that there is over a 400% increase in the incidence of early on-set drinking when one's peers start drinking early (peer pressure). Kids allowed to view R-rated content once in a while showed a 200% increase, those allowed sometimes saw a 230% increase, and those allowed all the time saw a 250% increase.

While these numbers are quite high, this tells us nothing about the relationship strength. Remember multiple variables can lead to this result. Here is a graph of the correlation coefficients:
Exposure to R-rate movies has a standardized coefficient of 0.10. This relationship is weak. Using the formula above, the amount of variance in behavior attributed to viewing R-rated content is only 1%. 

So why are youths, who are exposed to R-rated content, 2 times more likely to try alcohol at an earlier age?

Here is how the authors explain it:
"Youth who say that their parents allow them to watch R movies see more R movies and, therefore, more depictions of alcohol use...thus, the mechanism could be social influence via modeling of positive depictions of alcohol use."

Exposure to R-rated movies various with onset of early alcohol use by 1%. That means 99% of the variance is explained by other reasons (e.g., peer pressure!) While it is true that this tiny relationship is statistically significant, it has no practical significance what so ever.

But who cares about the actual science, politicians and other nanny state advocates have their sound bite,
"The research to date suggests that keeping kids from R-rated movies can help keep them from drinking, smoking and doing a lot of other things that parents don't want them to do, Sargent said." (2)
If only it were that simple.

This post was chosen as an Editor's Selection for

Tanski SE, Cin SD, Stoolmiller M, & Sargent JD (2010). Parental R-rated movie restriction and early-onset alcohol use. Journal of studies on alcohol and drugs, 71 (3), 452-9 PMID: 20409440

Thursday, April 22, 2010

Do Antidepressants Enhance Stroke Recovery?

A few months ago, in the February issue of Archives of General Psychiatry appeared this study (1) title, "Escitalopram and Enhancement of Cognitive Recovery Following Stroke."

The design was simple: a placebo group, an escitalopram group, and a problem solving therapy group (a manual based therapy to treat depression in the medically ill). No patients in this group met diagnostic criteria for Major Depression (so why the PST group?) according to the Hamilton Scale for Depression (HAM-D). Patients were administered the following neuropsychological tests at baseline and post-treatment:

"-The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). This 25- to 30-minute battery assesses functioning in 5 domains (immediate memory, visuospatial/constructional, language, attention, and delayed memory). These domains are evaluated by 12 individual subtests, including List Learning, List Recall, List Recognition, Story Memory, Story Recall, Figure Copy, Figure Recall, Line Orientation, Picture Naming, Semantic Fluency, Digit Span, and Coding. This battery provides age-corrected norms for overall performance (total scale score) and scores in each domain."

(Number of Subjects in Each Treatment Group)

Here is what the researchers discovered: "We found a difference among the 3 treatment groups in change in RBANS total score (P<.01) and RBANS delayed memory score (P<.01)." They also found a significant result for immediate memory too, but for reasons beyond my knowledge (crack-cocaine?) they neglected to report this result. Test scores are below.

(Click to Enlarge)

The authors then engaged in a trite discussion about how escitalopram led to an improvement in memory and how serotonin theoretically affects memory, and blah, blah, blah.

On the surface, it does appear that escitalopram led to better outcomes: For the Total Score (a global measure of cognition) the escitalopram improved by 9.1 points compared to 5.7 for placebo; for delayed memory the escitalopram group improved by 12.4 points versus 5.9 for placebo, and for immediate memory (i.e., learning) the escitalopram group improved by 11.7 points versus 7.4 versus placebo.

However, look at the post-treatment final scores for both groups: total score: 89.8 (escitalopram) versus 91 (placebo); delayed memory 96.6 (escitalopram) versus 94.2 (placebo); and immediate memory 95.1 (escitalopram) versus 98.5 (placebo). Essentially, both groups post-treatment performance was nearly identical. The reason why the escitalopram group showed a larger magnitude in change was because that group had lower baseline scores.

The authors did point out that there was not statistical different between any of the baseline scores; however, that's irrelevant. Neuropsychological test performance scores are classified as either average, low average, mild deficit, moderate deficit, or severe deficit. Many of the escitalopram group baseline scores where in the mild-deficit range while the placebo group scores were in the low-average range. Functionally, that kind of difference is significant*.

Another factor not discussed is the rate of recovery in stroke patients. There is a pretty well delineated recovery curve for patients with mild-to-moderate strokes. Most recovery occurs in the first 6 months, followed by a slower recovery over the next 1-2 years. Those with more severe deficits will show greater initial recovery and then plateau at a level similar to the less sever group. This is why the groups matched on post-treatment assessment scores.

*It's actually more complicated than that. Scores actually fall within a certain range. So a person could perform in the mild-deficit range at point then in the low-average range at another point. So it's quite possible that these results reflect the error in the psychological instrument rather than a benefit from escitalopram.

Either way, I'm skeptical that escitalopram actually helped these people.

Jorge RE, Acion L, Moser D, Adams HP Jr, & Robinson RG (2010). Escitalopram and enhancement of cognitive recovery following stroke. Archives of general psychiatry, 67 (2), 187-96 PMID: 20124118

Wednesday, April 21, 2010

Health Care the Squeakquel: A Requiem in Two Parts

An interesting read over at the New York Times
"In a new report, the Congressional Research Service says the law may have significant unintended consequences for the 'personal health insurance coverage' of senators, representatives and their staff members. For example, it says, the law may 'remove members of Congress and Congressional staff' from their current coverage, in the Federal Employees Health Benefits Program, before any alternatives are available."  (1)

I guess that's the problem when you "pass the bill so that you can find out what is in it" (2).
"The confusion raises the inevitable question: If they did not know exactly what they were doing to themselves, did lawmakers who wrote and passed the bill fully grasp the details of how it would influence the lives of other Americans?"
As Ted Stevens likes to yell "NO!" (3)

One major selling point of the new health care bill was that it will reduce the deficit by $138 billion over the 2010–2019 period (4). That estimate was made by the nonpartisan Congressional Budget Office (CBO). The problem, however, is in how the CBO makes their estimates: they assume every provision in the bill will be carried out (e.g., cuts to medicare). In reality, congress never follows through with anything. For example, cuts to medicare have been delayed 5 times over the last 10 years (3 times by Republicans and 2 times by Democrats). A former CBO director wrote an article that details some of ways that this bill could contribute to the deficit rather than reduce it (5).

Last point about the deficit: if the debt is currently $12, 875, 520, 291, 623, 42 (6), what percentage is $138 billion? I tried to put that into my calculator, and all I got was this "60 2 4377".

Remember when Obama said this during the campaign: "One thing we have not done is raise income taxes on families making less than $250,000. That's another promise we've kept." (7).

Actually, that is what he said during his most recent radio address. Here is what he said during the campaign "I can make a firm pledge: Under my plan, no family making less than $250,000 will see their taxes increase—not your income taxes, not your payroll taxes, not your capital gains taxes, not any of your taxes." (8)

Needless to say, he's broken that promise more times than Tiger Woods cheated on his wife.  According to Americans for Tax Reform (ATR), you can add 7 more tax hikes for that below $250,000 tax group (9), four of which affect income, thus also nullifying his revised statement about income tax increases. Here is a list of more taxes being implemented as well (10). The upshot of this is that congress will be taxed too, though, through their own stupidity (11).

In an earlier post (12), I lamented that this was a health insurance bill, not a health care bill. I might have been wrong with that assertion, since it is quite possible that actual health care will be affected. You see, we have a microcosm that can act as a crystal ball to see our future. It's the state of Massachusetts. When that Moron Mormon Mitt Romney was governor of Massachusetts, he passed a health care reform bill for the state. It was the model after which the Democrats constructed their health care bill.

Here is the current state of things is Massachusetts:
"People seeking to buy health insurance for the first time, or customers looking to change policies, found they could not do so." (13)
The state rejected of 235 of 274 proposed health insurance rate increases. That decision will cost insurance companies a lot of money (rendering them profitless). A judge ruled that the companies must comply with those rate rejections (14). That decision lead some insurers to do this:
"Health insurers are starting to sell policies that largely bar consumers from receiving medical care at popular but expensive hospitals such as Massachusetts General and Brigham and Women’s — a once radical idea that is gaining traction as a way to control soaring health care costs." (15)
Even the Massachusetts Treasurer (a recently former Democrat) has warned us of the things to come
"The Massachusetts treasurer said Tuesday that Congress will 'threaten to wipe out the American economy within four years' if it adopts a health-care overhaul modeled after the Bay State’s. " (16)
I think history is about to repeat itself. In the Senate:
"Fearing that health insurance premiums may shoot up in the next few years...Mr. Harkin praised a bill introduced by Senator Dianne Feinstein, Democrat of California, that would give the secretary of health and human services the power to review premiums and block 'any rate increase found to be unreasonable.' Under the bill, the federal government could regulate rates in states where state officials did not have 'sufficient authority and capability' to do so." (17
We're fucked.

UPDATE: Oops! Heath Care bill costs $251 billion more than originally thought (that's larger than $138 billion right?). From the Obama Administration's Health and Human Services Administration Department (pdf; 18).
"Medicare cuts could drive about 15 percent of hospitals and other institutional providers into the red, 'possibly jeopardizing access' to care for seniors."(19).
UPDATE: Double oops! "CBO: Medicare Payment 'Doc Fix' Is More Expensive Than Expected." (20)

UPDATE: The Health Insurance Trade-Off Game (22)

UPDATE: It just keeps going up, up, up. New CBO report say that an additional $115 billion in discretionary spending will be needed (23)

FYI: To all you conservatives out there, don't think the Republicans are going to "repeal the bill" either. (21)

And please, do not nominate this guy...

(part 1 here)

Thursday, April 1, 2010

Sexual Addiction or It's Not My Fault That My Penis Fell Into Her Vagina

David Duchovny, Tiger Woods, Steve Phillips, and now Jesse James. All men, all self-diagnosed sex addicts, and all victims of their disorder. Well, that's how they want to be betrayed in the media. To most people, sexual addiction appears to be a "get out of jail free" card for sleazy douche bags. So this begs the question, is it a real disorder?

Like any other complex human behavior, it all depends on who you ask.

There appear to be four main camps: those who liken the condition to a chemical dependency disorder, those who view it as a disorder similar to obsessive-compulsive disorder, and those who believe it to be an impulse control disorder. The fourth group believes that the other three groups are full of shit.

Even though many people are diagnosed with, and treated for sexual addiction every year (estimated 3-6% of US population), there is no actual disorder in any of the previous versions of the DSM. A new disorder is being considered for the DSM-V, which is termed "Hypersexual Disorder."

Here of some examples of proposed diagnostic criteria:
1) A maladaptive pattern of behavior, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

A) tolerance, as defined by either of the following:
-a need for markedly increased amount or intensity of the behavior to achieve the desired effect
-markedly diminished effect with continued involvement in the behavior at the same level or intensity

B) withdrawal, as manifested by either of the following:
-characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the behavior
-the same (or a closely related) behavior is engaged in to relieve or avoid withdrawal symptoms
-the behavior is often engaged in over a longer period, in greater quantity, or at a higher intensity than was intended

C) there is a persistent desire or unsuccessful efforts to cut down or control the behavior
D) a great deal of time spent in activities necessary to prepare for the behavior, to engage in the behavior, or to recover from its effects
E) important social, occupational, or recreational activities are given up or reduced because of the behavior
F) the behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behavior

I'd argue that these criteria adhere too closely to the substance dependence model and fail the capture the essence of human sexual behavior. Moreover, I don't know think "blue balls" would technically count as a withdrawal symptom.

From the DSM-V
A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:(1) A great deal of time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior.
(2) Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).
(3) Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events.
(4) Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior.
(5) Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. B. There is clinically significant personal distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior.
C. These sexual fantasies, urges, and behavior are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication).

There are some similarities between substance dependence, OCD, and impulse control disorders: impulsivity, obsessions, and compulsions.

Impulsive behaviors are by done without any forethought, spur of the moment.
Obsessions are intrusive thoughts that an individual does not want to have, but has them anyway.
Compulsive behaviors are behaviors that people do, but they do not want to do them.

There is another feature that ties all these disorders together: the addiction, obsession, or compulsion is the central organizing principle of that individual's life. The crack addict lives his life around obtaining and using crack, the patient with OCD is so fearful of contamination that she washes her hands so many times that she has blisters, someone with trichotillomania is completely bald because they cannot stop pulling their hair out. These people do not live happy lives. Their disorder rules their life; they are disabled. These people are doing something that they most certainly do not want to do.

Jesse James had an 11 month affair and Tiger Woods had a 2 year affair (plus other alleged affairs). David Duckovny banged his tennis partner. Steven Phillips is a misogynist. Sounds more like these were guys who got caught cheating and are now doing major damage control.

One more thought. If true addicts cannot use the substance to which they were addicted, are sex addicts not allowed to have sex anymore? If Jesse James porks Sandra again, did he relapse?

Discuss amongst yourselves.

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?)