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 ResearchBlogging.org

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.