The Last Psychiatrist

What Happens If Pharmaceutical Marketing Disappears? Part 1

2008-08-27T14:51:57Z

Everyone (including me) thinks Pharma is too heavily involved with the practice of medicine. So we try to think of ways to stop this. Restrict gifts and consultant fees to doctors; decrease, or at least separate, industry funding from research; and, of course, no more reps in doctors' offices.

These all sound like great ideas, how could you even come up with an argument against any of them?

Here goes.

As a bonus, I even offer a practical long term solution.
]]> The core issue is that Pharma exposure represents a conflict of interest. Ok, let me ask you a question. What is the plural of conflict of interest?

a. conflicts of interest
b. conflict of interests
c. conflicts of interests

Not so easy to answer, because any of them could be correct. You have to target the individual conflict and weigh it against the individual interest. It may be a conflict of interest to take money from Merck while doing AIDS research, it might also be a conflict not to.

Ask The Question Differently:

Instead of asking what should be done to curb COIs (clever, huh?) ask: what would happen if we succeeded?

1. No more reps.

I don't know what goes on in other branches of medicine, but let me swear to you that if you get rid of reps-- and detailing, and "lunch and learns" and all that goes with them-- psychiatry will instantly grind to a halt, and people will die.

It is an indisputable point that reps know more about the medicines than the doctors do. Worse, doctors don't know much more than a patient on the Google. We can argue whether Lilly hid the diabetes risk of Zyprexa, but it took Pfizer to tell us about it. Don't tell me that we would have learned about it from the extensive journal articles about it in 2000 (three.) Doctors only recently discovered Vioxx had a cardiac risk, though Yahoo! News had an article about it in 1999. Abbott et al may have rammed Depakote down our throats, but it took Astra Zeneca to kill it.

2. No more Pharma education money.

People whine that there's $1B of Pharma money in CME. Is that just extra money? What's going to happen if you take it away? Then there's no more education. All of post graduate medical education is done by Pharma. The residency didn't buy the textbooks for the residents, Pharma did. Pharma sponsors all the short "throwaways" and supplements that at least get some readers, unlike the regular journals which get no readers. Pharma also pays for the CME.

Who's going to pay the CME lecturers? Who is going to pick the topics? The government?

Here's an anecdote: I'm talking to one nut, and he says, "these new drugs are no better than the old ones, we should go back to them." Is that a fact, commtard? You want to go back to Trilafon and Pamelor? If perphenazine is so great now, how come it wasn't when they called it Trilafon?

If you prescribe generics because they are generics-- I don't mean sertraline vs. Zoloft, I mean imipramine vs. Effexor-- you are much worse than the guy who prescribes Abilify because Pharma paid him.

3. No more Pharma research money.

Do you know how many clinical trials are done by Pharma? Lots. You know how many are done by NIH? Not lots. If there exists one person on the planet who can tell me what society got from the $68M tapayer dollars spent on CATIE, I'm listening.

Clinical research is performed for two reasons. Secondarily, it is to promote the science. Primarily, however, it is deficit spending. It gives jobs to people. Few clinical researchers end up studying their passion; they study what's being funded. If Depakote's paying, we're studying Depakote. You want a job at Harvard in 2004? Make sure you can spell Depakote. You want one in 2009? It's S-E-R-O-Q-U-E-L. Or generics.

If Pharma stops paying, then there will be much less research, even if it is biased. People are missing the hidden benefit of the "biased" Pharma trials: they are extra information. I know Depakote isn't a maintenance agent because of the failed trial. I know Zyprexa causes diabetes and weight gain because of Lilly's own data (and the data from comparator trials done by other Pharma companies.) I recognize Pharma spins the data, but it's hard to argue that the data is absent. (Though that is preposterously what was argued about Vioxx.)

If Pharma did not pay for these trials-- if we had to wait for the NIH to investigate Zyprexa's diabetes-- we'd wait a long time. And, per #1, without Pharma to inform us a study was even done, we simply wouldn't know.

4. No more Pharma building money.

You know that new wing of your university hospital? Who do you think paid for it? The New England Journal of Medicine? My favorite of all Pharma ironies is that a university will take $25M to build something, but will ban reps from interacting with their doctors.

5. No handouts to doctors.

Why do doctors get entangled with Pharma at all? Is it really just greed? Then why not just move to California and prescribe marijuana out of a shack?

I'm going to write something that so extraordinarily impolitic that no doctor will even admit to hearing this argument, let alone agreeing with it:

Doctors don't view this as extra money, they view this as money they are entitled to.

$120k may seem like a lot of money, but no academic doctor thinks that university salary is what he deserves. So he does extra things for Pharma, or gets some unrestricted grants from Pharma to free up time (so that he can do "other" things). His assumption is he is worth, say, $200k, the University only pays $120k, and he's going to make the rest up.

BTW, that's why the University gets away with paying you $120k.

The same is true for non-academic docs. They didn't imagine they'd be getting paid so little to do not exactly the job they thought they had signed up for. So they make up the difference.

I'm not justifying it, I am explaining it. If you completely ban all Pharma money going into doctors' pockets, they will demand it from somewhere else. They are not going to be satisfied with $120k. Or 15 minute med checks at $30 a pop. And you'll have a brain drain-- many docs will actually go work for Pharma. I can't tell you how many times I've been offered jobs at Pharma-- easy jobs, at 2-3x what I make now. Good students will think twice about medicine. Maybe they try biotech. Or law.

Do not email me "what ever happened to working for the common good?" The only people who say that are not working for anyone, let alone the common good. Doctors do have a nobler sense of purpose, but not at half price. Sorry. It's America.

Before you take that money away, makes sure you have a plan B.

Solution:

In order to solve the problem, you have to adequately explain the problem. Right off: patients are not the customers of Pharma. Doctors are. Pharma isn't making medicines that people want/need, they are making medicines that doctors want/need, i.e. that they will prescribe. So the way Pharma operates is to either identify what doctors will use, and market it, or they wil find a way to take an existing chemical and market it so that doctors will use it. Viagra, a drug "for" pulmonary hypertension, was decided to be marketed as a penis pump.

Like everything else in life, the solution is the demand side.

(Part II Friday.)

If You're Watching, It's For You

2008-08-20T17:17:42Z

On the Late, Late Show With Craig Ferguson, a joke about "man-ginas," a few drug/DUI references, a Kristy Ally fat joke ("uses her swimming pool to cook spaghetti") and a homosexual reference.

And I think about how TV has changed, things unimaginable 20 years ago are routine now.   I guess they'll do anything to get the coveted youth demographic.

And then I think, wait a second...

]]> II.

It's the easiest logic in the world to follow: racy humor targeting the youth; old people will either not get it or be outright offended, but it's worth it to get the young viewers.

Ok, but there are also going to be a group of older people, maybe in their forties, who are cool enough to get the humor, to like it, but, you know, most of other people their age will be offended, people like their parents.

But here's the sticking point: Ferguson, Conan, and Leno all have an average viewer age of 50. They're not getting the jokes in spite of their age-- the show is written for them.

And it makes sense: the humor isn't more edgy or racy, it's the same stuff we heard 20 years ago from Stern and others, so this isn't a case of targeting the young, it's actually targeting the old.

Example: they picked Jimmy Fallon to replace Leno, theoretically because he can target the youth viewer. But Fallon was funny on SNL a decade ago-- he's funny to people who were young a decade ago. And so he's going to be funny to those same people who are now a decade older. People don't step outside themselves and realize that everything that is being made by 30-50 year olds, which is nearly everything, is actually for 30-50 year olds, even though it appears like it's for 20 year olds.

Here's an example: Chris O'Donnell is Ferguson's first guest, and he comes out in jeans and a suitcoat. Because he's cool, he's younger than he actually is. Actually, no-- he's exactly as old as he is, because the only people who dress like that are people his age or older.

As if to solidify the point, the next guest is Henry Winkler-- the Fonz-- who also is wearing jeans and a sportcoat. That was cool to (actual) kids thirty years ago when Letterman dressed that way, and now those "kids" are old enough to dress themselves the way they always wanted. (Letterman doesn't anymore.)

III.

But this isn't just old people pretending to be young, an innocuous though silly behavior. This is a larger, social trend, a game, designed to promote a fiction.

The game is to pretend that all this media is for the young, so they're targeting the young by acting "young." But it's really for the old-- who still think they are young. They are calming the anxiety of a generation of older people who still think they are young. "Winkler is acting and dressing hip for the kids, and since I get it and dress like that, too, I must be young."   But Winkler is 60. And no one uses the word hip anymore. Get it?

I'm not saying Ferguson isn't funny-- I watch him-- but I have no illusion that I get him despite my age. It's the foundation of televsion: if you're watching it, it was meant for you.

I couldn't have produced the show better myself to reinforce my point: the commercial break between O'Donnell and Winkler was-- please sit down-- Just For Men hair dye. The commercial showed news and concert footage from the sixties and seventies with a voice over, "The generation that said they'd never grow up-- didn't."

TV may say it wants younger viewers, but every commercial was for older viewers.

About twenty years ago I learned the marketing law that young people have all the disposable income-- because older people were saving-- and they spend the most, and you have to go after them. I don't believe that's true anymore. Hell, the fact that it was true 20 years ago means that those young people are older. They're still the consumerists they once were.

And so what we have here is semiotics, a redefining of terms. "Young" no longer means "ages 18-24." It means "old people who did not grow up."

Don't delude yourself that "40 is the new 30." It isn't, ask anyone who is 30. But that's your business how you want to be. The problem is that the actual youth have no idea what to make of aging. How long are they allowed to be adolescents? Pretty long, it appears. What's the reference point for being mature if your Dad isn't?

Clearly this attitude doesn't bode well for capitalism. Older people who are supposed to be more thrifty are spending their money on useless symbols of wealth. Yes, that includes (too big) houses. And the narcissism that I'm accused of seeing everywhere may, in fact, only exist in people over 30.   Twenty somethings are allowed to be quasi-narcissists, and it's also defensive: what do you expect from a teenager whose Dad, overweight, balding, drives a sportscar?   Emotional lockdown.

Patton Oswalt said he'll be the best parent ever by being boring, because their kids rebel. All the cool parents who smoked pot with their kids raised the kids who moved to the suburbs and put warning labels on record albums.

I believe kids demand of adults to be different than them. More stable, more future oriented, more careful with money. Not someone they want to emulate, but someone they want to go beyond. The adult serves as a foundation to build on. That desire to be a foundation-- not a support or a model or a goal-- is lacking in the older people. There's little thought given to multigenerational advancement, that the primary point of their existence is their kids', and their kids' kids, progress. Not a point, not also a point, but the primary point.

So I wonder if the conventional wisdom "we are a youth obsessed culture" is actually wrong.   It may be worse than that: youth obsessed and frankly delusional. They're not pretending to be young, they actually believe they are young. A "residual self image" in a person's mind of who he thinks he is, despite that image being 20 years younger. They picked an identity not supported by the facts. And has set up a media apparatus to reinforce the delusion, hide the reality.

So the actual young get squeezed out of their own demographic, into being even younger, or jumping over and becoming too old, too quick. If the kid is parentified, or grossly immature, you may want to consider that.

Ara Abrahamian Wins Award For Medal Toss, Saved By Passport

2008-08-15T04:30:46Z

Between 1am and 9am, a previous 2 paragraph version of this post managed to offend Swedes, Armenians, wrestlers, the Olympics, bronze medals and mats.

In the interest of completeness, I will this time include the French.

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Background: Ara Abrahamian, Swedish wrestler, wins the bronze/loses the gold. At the podium, he steps down, tosses the medal on the mat, and says, "this medal means nothing to me. I wanted gold."

That's Roget's antonym for sportsmanship. Because competitions are so clear--winner/loser-- you're supposed to reserve your emotions. I'm not saying you have to be the Charioteer of Delphi if you win, but tossing your medal on the mat when you lose is a definite no.

I am told that he was robbed, that the judges didn't make just a bad call, but purposely made a bad call. I believe you. You don't need to convince me that Olympic judges border on corrupt, are susceptible to bribes or even petty personality/nationality controversies.

But that fact makes his behavior worse, not understandable. That's the point of sportsmanship. We know you were robbed, tossing the medal doesn't support your case; Better if he quietly taken the bronze, noble in the eyes of the world.

Because if we didn't think you were robbed, we'd just think you were a jerk.

To illustrate this, imagine if this guy was American. The world would completely lose their marbles. "Did you see that fucking American!" would be all anyone would say about Beijing 2008-- and that would just be coming from the Americans!

The Swedish wrestler had to be restrained by team-mates earlier as a row erupted with judges over the decision...

Can you imagine what would have happened if an American wrestler went at the judges?

Which brings me to the French. Michael Phelps decided "eat, sleep, swim" would be his tagline, and without reading too much into it, maybe it signifies an individual devotion to self-improvement in the service of himself/team/country. But when the French choose, "we will bury the Americans"-- is that a bit broad? Even "we will bury Michael Phelps" makes more sense, since he actually is their enemy, but "the Americans" actually aren't.

Flip it: imagine Phelps had said, "I will bury the French." If he actually wins, people will just dismiss him as an arrogant American who should have drowned. And if he loses, how did saying that help him? It makes him look, well, French. And that's all anyone would talk about, those arrogant Americans.

You will observe that no one, anywhere, is writing that the French team were a bunch of arrogant losers who got, as they say, pwned. That's a double standard, yo.

So Abrahamian was saved by a Swedish passport. Because he's Swedish, he doesn't carry any other baggage-- his tantrum only reflects on him and the judges. An American wrestler who tosses a medal would be General Assembly level outrage.

Especially if the American wrestler was robbed. Somehow, people would see it as a sort of justice, yeah, he was robbed but see how he's acting? He doesn't deserve to win anyway, he doesn't represent the spirit of the games, those Americans think they can do and have whatever they want.

"It's all politics," said Swedish coach Leo Myllari.

You said it, brother. People working out their grievances in ways and in forums that have nothing to do with either the way or the forum, and so creating new grievances. The judges, I'm sure, thought they were righting some social/personal/political wrong through the medium of point deductions; the French were voicing the cultural hopes of the world; all under the unfortunate maxim of the powerless: there is no justice, get justice however you can get it.

Seroquel For Bipolar Maintenance

2008-08-14T18:21:10Z

A brief history of the past decade.
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I. Background

A mood stabilizer is a drug that prevents mania and/or depression. Depakote was the default mood stabilizer since 2000. Hundreds of papers promoted its use, though all relied on a single double blind, placebo controlled trial as support for its efficacy. Mentioned almost no where was that this trial did not show any superiority over placebo. However, Depakote enjoyed tremendous sales in the years 2000-2008, showing 10-20% growth per year.

II. But the bulk of the support, especially in journals, came from academics who believed in it, not Pharma?

Since the academics have no relationship with Abbott and are motivated only by clinical efficacy, we can expect their promotion of Depakote to continue even after it goes generic. Oh, wait, that happens in 2008.

III. The Sad, Quiet Story Of The Mainetance Trial That Wasn't

Here's a quick summary of the (only) Depakote vs. placebo for maintenance study: manic patients were enrolled, put on Depakote + any other necessary meds until they were stabilized. Then these patients were randomized to Depakote, lithium or placebo.

At the end of the study, all three groups had similar relapse rates. Putting them on Depakote was not better than placebo for maintenance. On this single, failed trial, an entire decade of psychiatry was premised.

However, there is one technical point that I have never, not once, in 8 years, seen written about, discussed, or even alluded to, and when you do bring it up people look at you blankly: the study patients were stabilized on meds, then randomized to drug or placebo. So those that were randomized to placebo had their stabilizing meds stopped. They were "taken off their meds." So actually, being on Depakote was not simply no better than placebo, it was no better than abruptly going off your meds. Take a long hard look at yourselves.

IV. Two Drugs Are Better Than One

Depakote continued to be grow, continued to be a "mood stabilizer" when it was really simply an acute antimanic. NB: it may be true that Depakote is a tremendous mood stabilizer; you can't condemn the drug on one study. But, importantly, in the decade of "Evidence Based Medicine" why was it at the top of every treatment algorithm and guideline? There's the rub.

But psychiatrists did not use it as a monotherapy mood stabilizer-- it was always "mood stabilizer" plus something else.   In fact, the major discussions in psychiatry 2001-2007 were whether/how additional medications would benefit when used with Depakote. No one asked whether Depakote itself was a mood stabilzier-- that was assumed. The question was whether adding antipsychotics to Depakote provided additional benefit. The answer was always "yes" as long as the question had the caveat, "notwithstanding details or generalizability."

Consider the study of Depakote alone, or Depakote + Risperdal, for the treatment of acute mania. Which is better?

The graph is clear: the combination is better than the single drug alone. BTW, every atypical antipsychotic has a similar study with nearly identical results.

Two sleights of hand:

1. This is a study of acute mania--3 weeks-- not maintenance. The study does not say that Depakote + Risperdal will provide better maintenance control over a year. Yet that is how the results were generalized-- psychiatrists left their patients on "whatever" broke their mania. You can see how, over time, doses and number of meds keep going up.

2. See the y-axis? It doesn't say "amount of improvement," it says "percent of patients." It doesn't say that each person got more better, it says more people responded to two drugs than responded to one drug. We assume the superiority was the result of the combination. But how do you know it wasn't due entirely to the Risperdal? If you give a room full of manics Depakote, 25% get better.    If you give a room full of manics Risperdal, 25% get better. If you gave both to everyone, then 50% would get better, but it's pretty clear that the Depakote responders didn't need Risperdal, and the Risperdal responders didn't need Depakote. Indeed, when you look at change of symptom severity, two meds was no better than more of one med.

This chart could simply be the result blasting patients with two drugs, hoping one works. So this doesn't say "if a drug fails, add a second." It says, "if a drug fails, switch to something else."

Which should have been so obvious as to never have necessitated a study.

V. So Then It's Agreed: Let's Change The Definitions So We Don't Get Caught

At some point, someone is going to notice that polypharmacy isn't working as promised; that it is not particularly safe; and that it certainly isn't worth the price.

And Depakote was going off patent. What to do?

What you do is write a completely unimpressive, pointless article (Effectiveness of Adjunct Antidepressant Treatment for Bipolar Depression) based on a multimillion dollar government finded study that tells us nothing we didn't already know for decades, in the most prestigious medical journal (NEJM) available, and in it sneakily and gigantically change the definitions of words to prepare for the next wave of psychopharmacology, granting plausible deniability.

Mood stabilizers were initially limited to lithium, valproate, the combination of lithium and valproate, or carbamazepine. In 2004, the protocol was amended to define mood stabilizers operationally as any FDA-approved antimanic agent.

Now, in two sentences, all the junk articles that used to apply only to Depakote can now be reused to apply to antipsychotics. "We've known since 2001 that mood stabilizers, for example Depakote or Seroquel or Abilify, are maintenance agents..."

VI. But How Can Antipsychotics Be Mood Stabilizers If They Are For Psychosis?

At first glance, the question seems reasonable, but for the fact that the none of the capitalized words above have any meaning at all, except those with three or less letters.

Seroquel for maintenance bipolar. Why not, a priori? Why would it be any worse than Depakote, a drug which didn't work anyway?

The problem, however, is that by pushing Depakote as a maintenance agent for so long, everything is reflexively considered second line, an add-on.

So because of the artifice, the semiotics, "bipolar requires mood stabilizers; Depakote is a mood stabilizer; bipolar needs Depakote" you can't do a Seroquel monotherapy study. It has to be done as an adjunct to Depakote or lithium. Therein lies the problem with the interpretation of the results.

The results are, indeed, impressive: people on both Seroquel and Depakote had fewer, and later, relapses than those on Depakote alone. This holds true whether you are looking at relapses into depression, mania, or all mood episodes.

So, for example, by 52 weeks, about 25% of Seroquel + mood stabilizer patients had relapsed, while 62% of mood stabilizer alone patients had relapsed. That's an NNT of roughly 2.5, i.e. you need to put 2.5 people on Seroquel to reliably know one person benefited. Lipitor's NNT for reducing heart attacks is 25.

Although you're not supposed to compare results from different studies, I feel completely comfortable saying that the Depakote curve here is about the same as it was the in other maintenance study, i.e. no better than placebo. (Stop using Depakote.)

VII. But Is It Measuring Prophylaxis Or Relapse?

Look back at the Depakote study for a hint.

Patients were all stabilized on Depakote/Li with Seroquel over 36 weeks, and then randomized to either continuing Depakote/Li + Seroquel, or to being taken off Seroquel and being left on Depakote/Li. Those left on Seroquel did well; those who had the Seroquel removed did not.

So on the one hand, you could say "the combination prevented relapse," or, you could say, "abruptly stopping your Seroquel results in a relapse." Do you see the difference?

With the Depakote study, stopping your Depakote had no adverse effect. For whatever reason, stopping your Seroquel apparently does result in prompt relapse.

You are being tricked (not on purpose) by the presence of the Depakote, thinking that this is providing you some degree of mood stabilization, and the Seroquel is adding to it. Wrong. The Depakote is providing you nothing. The Seroquel is the mood stabilizer. And "stopping your meds" is, after all, not a good idea.

VIII. What Dose?

There is one other important result of this study. The patients were not simply on Seroquel; they were on Seroquel at fluctuating doses, per the judgment of the doctor, 400mg to 800mg. That is key. Seroquel didn't prevent relapse; rather, raising the dose whenever they needed it, and possibly lowering it when they didn't, is what kept them stable. Maybe if they were on a fixed dose of Seroquel the whole time, no opportunity to raise the dose, people would have relapsed more frequently. But this way, at the first sign of trouble, you pre-empt it by increasing the dose.

In other words, Seroquel didn't prevent relapse; prompt intervention by the doctor as things developed (using Seroquel) prevented the relapse. This doesn't diminish the utility of Seroquel, but it also doesn't mean you can put everyone on 600mg and say, "see you in a year."

That is, perhaps, why Depakote failed: it relied on a steady dose, titrated to an imaginarily important blood level that it seems never to have occurred to anyone to ask why we target.

IX. The King Is Dead, Long Live The King

Just as Depakote was an overhyped drug that will thankfully die with its patent, it is more than likely that Seroquel for maintenance bipolar disorder represents some sort of top in the antipsychotic market. It will enjoy massive, and steady, use for several years, but I doubt if there is much growth left in it. Astra Zeneca thinks it has penetrated a market; but it has really opened the doors for all antipsychotics in the same market. You can prescribe Seroquel; don't invest in it.

Simultaneoulsy, just as I was a vocal advocate for the use of antipsychotics over the massive overuse of Depakote-- and I thus contributed to the rise of Seroquel (and others), my new target may be the overuse of antipsychotics.

The target is not Pharma or reps, but academic physicians who are politicians posing as scienticians. Completely absent is the pursuit of science or truth-- e.g, "we didn't expect this result, I guess we were wrong"-- but diversions and sleight of hand. The point is not the results; the point is the discussion. The message doesn't matter, the medium is the message. They have an allegiance to a given concept, and they defend it, promote it. No different than a PAC. And when their King dies, they celebrate as if they never believed in him at all.

But at least the rise of Seroquel will benefit humanity in two important ways. First, it brings evidentiary support to the not common enough practice of fluctuating the doses as needed, up and down, rather than relying on a set dose.

Second, it means the demise of polypharmacy (until they invent a new class of drugs), the drastic reduction of the number of medications patients will be prescribed, especially when coupled with the slow demise of SSRIs.

Drug Reps From Congress To Detail Doctors

2008-08-13T19:19:27Z

Oh, my God, I hope you're lying down for this.
]]> I get raped by an email that is not caught by my spam filter, it says that Congress is considering a bill that would create an academic detailing program-- sending in a team of doctors to visit other doctors and give them "unbiased" (scare quotes mine) information about prescription drugs.

I have some questions, of course:

1. This is going to be federally funded: how much will these doctors get paid?

2. Will they be allowed to take docs out to lunch and dinner? If not, is it because it's a waste of time (in which case why does it matter that Pharma does it) or because you don't want to unduly influence the doctors (in which case...?)

3. Where will you get these "academic detailers?" Are they academics? No possibility of bias there, right? Do you really think it was drug reps that made Depakote ubiquitous?

4. Where will this unbiased information come from? You're going to be using published data-- isn't that already free of bias?

5. Seriously, is anyone even a little bit horrified that doctors have so checked out of their own education that Congress has to send in tutors?

5b. Oh, you mean there's so much pressure from marketing that doctors are confused or even manipulated? Then we should probably set up some academic detailers to go teach nutrition to McDonalds customers. I mean, if doctors aren't smart enough to withstand marketing, what chance does anyone else have against a Britney Spears Pepsi ad?

5c. While we're at it, how about academic detailers to Congress? You know, unbiased information on the ethanol mandate and other special interest Kool-Aid they're drinking?

I'll add that for four years, I was hired by the state Medicaid (DHS) as just such an academic detailer. I went around to all the hospitals, especially the state hospitals, giving talks and meeting with docs, trying to reduce the polypharmacy and dosing problem (e.g. three antipsychotics at lower doses, or Haldol 20 + Seroquel 25, etc.)

You want the ironic part? They hired me because the assistant commissioner of DHS was at a Pharma sponsored dinner program I gave, and thought I my talk about the perils of polypharmacy was compelling-- and not Pharma biased.

Oh, and in answer to #1: they paid me more than Pharma did. Tax dollars at work. I'm happy to take the money, of course, but I've previously given my solution for fixing drug costs while simultaneously improving clinical practice. All of this other stuff is useless politics.

A Trip You May Have Taken

2008-08-12T17:47:56Z

He pulls over at the curb. All the shades are pulled down, the house looks dead. The house-- shack-- is on the beach.

He gets out of the car.

"Tracy," he calls out, expecting nothing.

He walks to the screen door. It's locked, but the inside door is wide open. He smells pot, and something that is not pot, and something that is feces.   He has never seen this place, yet it is, somehow, exactly as he imagined it would be. It is also worse.
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"Tracy!"

Tracy appears in the front yard, behind him. "What are you doing here?" she shrieks. "You weren't supposed to come until Thursday!" She looks like a crack addict.

She runs in the back door, cursing.

A man who looks like anyone from Cops except the cops comes and unlocks the screen. "You're Tom, right? My name's Sam. Pleased to meet you, I've heard a lot of great things about you that for all intensive purposes I feel like I knows you." There is no geographic reason he should speak with a drawl, but there it is. Obviously, he is not wearing a shirt.

"Where's Tracy?" He walks past Sam. The house is filthy. There is broken glass from what could have been a crack pipe pushed to the corner of the floor, and what still is a crack pipe is sitting hopefully on the TV, waiting for someone to hold it.

Tracy comes back. "You can't just come by whenever you want! You can't force me to do anything, I told you I wanted to do this but not yet! Fuck! My girlfriend's boyfriend just got locked up, and she needs me--" She yells more words at him.

"Get your stuff, we're going."

"Son of a bitch!" she screams, slaps a beer bottle off the counter and it smashes into the sink, more glass. She walks off, screaming something about a car and a guy from Arkansas. With her, it is always more and more words.

"Tracy, let's go! Now!"

Sam intervenes. "Don't worry about it man, I'll go talk to her. I'm really glad you came, she really needs help right now.   Do you want a beer or something?" He has one ready, pops the tab and hands it to Tom, who takes it for no reason. Sam goes off to make things right, crunching some broken glass underneath his bare feet. His feet do not care enough to bleed.

There is more screaming.

A man knocks hard at the screen door; Tom instinctively locks it. The man looks like a ex-football player turned pro beer drinker. Big chest, bigger gut. No sleeves. He cups his hand over the screen to look in, then jumps back when he sees Tom standing there. "What's going on in there? Open this fucking door!"

Tom takes one step back, close to the kitchen cabinets.

"Who the fuck are you? Where's Tracy?!" He yanks at the screen door. "Open this goddamn fucking door or I'm going to fucking smash it--" and it bursts open.

Oh my God, Tom thinks. I'm going to have to kill this guy.

"Hold on, man," Tom says. "I'm her brother."

That was the only right answer. The sibling relationship is the only one respected in the streets. It's even, neutral. There's no assumption of ulterior motives. You're given credit for trying to do the right thing, and leeway because you're young enough to know the score.. If he was her father he'd be tossed. If he was her husband, he'd be dead.

"Oh, sorry man, that's cool. Things have been out of control here lately, people, crack, the cops, last week someone set fire to my--"

"I'm getting my sister out of here."

"Ok." He glares at Sam, who is peeking around a corner, and walks out. Tracy reappears. "Fucking--"

"Shut up. Get in the car."

Sam is overly helpful, he puts her bag in the car, goes inside, gets another bag and puts that in, too, then suddenly stops, reaches in, and grabs a bottle of pills. He looks back at Tom. "I don't know how you all are getting back home, but you know she's got an open warrant, right?"

"No, I didn't know that."

"It's not a warrant," she says, "the PO violated me because I had a hot urine, but she wasn't allowed to do that because I was already in treatment for it, so I spoke to her supervisor, a guy named Marins, or Marinis, Marins, something like that, I have his name inside with the other papers, and they told me that I had to get a doctor's note verifying that I am in treatment and that I am prescribed the Xanax for my anxiety, one four times a day. I never abuse my medications, I take it only as prescribed. My doctor knows that. That's why he trusts me with the Xanax. But I couldn't get to him because they don't allow walk ins, and the last prescription he wrote by mistake he wrote two times a day instead of four times a day, so the PO said that she had to technically violate me but since she knew that I was telling the truth about the Xanax I wouldn't be arrested. But then she got transferred, and she never changed the order--"

"Tracy," says Sam, "just get in the car. You're brother really cares about you, don't give him a hard time."

"Whatever."

Sam looks at him. "She really needs help. She's been diagnosed bipolar schizoaffective, she takes Seroquel but she's supposed to be on lots of other shit, but, you know, she doesn't take them. I always try to get her to take them, and I make sure she doesn't abuse them, and I makes sure she gets to her appointments. She's really lucky to have a brother like you, to come out and do this for her. " He pauses. "Do you want some beers? You know, for the road?"

"No, thanks." He shakes Sam's outstretched hand, but then Sam won't let go. "Look, could you do me a really big favor? It would really help me out a lot. I'm trying to get this apartment but the landlord needs me to verify that--"

Tom pulls his hand back. "Sorry, I can't help you."

"No, wait, hold up, it's really not a big deal, all I need is a letter--"

"Sorry."

Tom's face turns stern. "So that's it? After all the help I gave you here? I gave you my beer. I moved all this--"

"Dude, I'm not doing anything. I'm here to get my sister, and I'm leaving."

He takes both her bags out of the car and drops them in the yard. "Wait," she yells, "I need that bag, I have a pair of pants inside I have to return to--"

He gets in, starts the car. "Wait," she says, "I forgot my cigarettes-" He drives off.

Forty five minutes later, she says, "I need a beer. We need to stop somewhere."

Tom shakes his head in disbelief. "Yeah, sure."

"No, seriously, I'm going to have a seizure, I'm coming off it, I'm in withdrawal."

He looks for no reason, he wouldn't know what withdrawal looked like.

"Please, I'm not kidding here, I was taking like 12 Xanax a day, I'm going to have a fucking seizure--"

"Fine!"    He pulls into a gas station, parks, takes the keys. "Stay right here. Do not get out of the car." He goes in, buys a six pack of beer. Walks out, throws three of them away. Gives her the other three.

He can actually see her get calmer with every approaching step. "I need to pee." Christ. He's with a three year old. She takes the beers, takes her bag-- which he snatches back out of her hand. She glares, goes off to the bathroom.

As he waits, he notices his sunglasses case is missing. Not the glasses, just the case. He opens her bag, it is pushed to the bottom. He opens the case. Inside is the tire gauge he didn't even know was in the car.

Then he sees her.

The beers are not in her hand. What is in her hand, balanced on her head, is a 3x4 ft picture, in a steel frame.

"Open the trunk," she says.

"What the hell is the matter with you? Did you just steal that from the bathroom?"

"It's all right, don't worry about it. No one will need it."

"What are you talking about?!"

"Come on, I really like it, this is my favorite photo in the whole world. I love Marilyn Monroe, she inspires me, she inspires me to get clean, this photo always reminds me of--"

"Give me that fucking picture," he snarls, rips it more aggressively than necessary from her hands, and walks back to the gas station.

"What the hell is wrong with you?" she yells after him. "It's just a fucking picture!"

He walks into the gas station. The attendant sees him, sees the picture, and does not want to understand. "I'm calling the police," he says.

"Look, this picture fell off the wall, so I'm returning it to you. Here it is."

"You fucking--"

"Here it is, I'm sorry, I'm leaving."

He comes back to the car, she is smoking a cigarette. Where did she get cigarettes? Where did she get a lighter? "What's your problem, man?" she says. "You're acting like I stole a guy."

"Get in the car. Just get in the car, and don't talk, don't talk to me, just don't fucking talk to me until you're sober." He is suprised he can't pull the steering wheel off.

They drive silently for about ten cigarettes.

"When I get out," she says, looking out past the highway into her dreams, "I'm going to move back to the beach, and I think I'm going to get a job working with vets from Iraq who have, like, PTSD, people who are self-medicating." He says nothing. She eventually looks over at him, honestly perplexed.

"You don't even fucking care about the vets, do you? You voted for Bush, but you don't even--"

"Shut up," he says, "all the time."

"You don't know what it's like for us."

He actually slows the car down. "Us vets? Are you a vet now?"

She rolls her eyes, you just don't fucking get it, takes a drag from the cigarette and blows it out the window. "You know what your problem is? You don't fucking care about anything, or anyone. That's your problem."

They keep driving.

I'd like to say there's an ending to this story, but unfortunately there isn't.

The Hidden Zero Effect

2008-08-11T18:16:22Z

Choose:

$5 today or $10 in a year.

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Picking $5 is called temporal discounting-- you pick a sooner-but-smaller outcome simply because it is sooner.

But it's more than a preference based on how soon you get paid. If the question is changed:

$5 in 7 years, or $10 in 8 years

Then you can feel the pull to choose the $10-- even though the $5 is still one year earlier than the $10. So it's not simply people prefer sooner over later. It's also how far away the payoffs are. How soon is sooner? At some point in the future, your choices flip.

In fact, this is predictable (reliably so in animals)-- and follows a hyperbolic function:

Imagine there is a smaller-sooner reward at time T3, and a larger- later one at a time T4. At a very distant, early time T1, you prefer the solid line (the larger-later reward), because they are both far enough away that the time delay seems insignificant.

But if you choose at a close time T2, the choice has flipped and you prefer the smaller reward, because it seems sooner. The closer "soon" is, the more you're willing to settle. Hyperbolically.

II.

Why does this happen?

It's behaviorism. The effect of rewards are temporally dependent. Try it on your kid.

How this phenomenon is described is important, and it is frequently backwards. You don't prefer sooner choices that are smaller, but if they are both far enough away you'll choose the larger choice; you choose the larger choice all the time except if the choice is asked of you close to payoff.

If you intuitively know your future is long, and real, you don't succumb to it as much. But if the future is an abstraction, then you begin to discount your choices.

The future is real only if you are real, i.e. your identity is fixed. If your identity is in flux-- whether from personality disorder, bipolar, being a teenager, going through a divorce-- if there are different "yous" all the time, you cannot make decisions based on the future. If "you" aren't going to be the same in the future, how can you make decisions about it?

In other words, temporal discounting is not exactly an error; it is an accurate reading of the likelihood of change of one's identity.

III.

So how do you resist this?

One way is to make explicit the hidden zero:

Choose $5 today and $0 in a year, or $10 in a year and $0 today.

That hidden zero seems obvious, and it is obvious cognitively, but not instinctively. These habits and "errors" are hard wired in us because they are protective-- eat while you can, jackals are coming.

But they don't help when you're opting into a 401(k): "Choose $13,000 today and $0 at retirement, or $0 today and $13,000 at retirement."

When you make the hidden zero explicit, people choose differently-- less impulsively:

Whether it's real or hypothetical money, people choose sooner-but-smaller less often when they are told about the $0.

When dealing with impulsive people, or people whose identity is in flux, it is important to make explicit all parts of a choice, because time has little meaning.

IV.

But what caught my attention about this is the difference between real and hypothetical money. Why does making it real money significantly reduce the number of sooner-but-smaller choices, whether or not the zero is explicit? If anything, seeing the money on the table might drive them to choose the sooner (but smaller) choice-- the instinct becomes real ("eat now.")

The experiment was to ask subjects 15 questions of the form "$X today, or $Y in a month." But a second group of people, the "Real Money" group, were told that one of these hypothetical choices would randomly be used to pay them real money at the end of the questionnaire.

Do you see the problem? The subject isn't making a choice between a sooner payoff vs. a later payoff, but between sooner payoffs vs. all the other sooner payoffs, and later payoffs vs. all the other later payoffs.

Immediate rewards ranged from $2 to $8, delayed rewards ranged from $5.40 to $8.70, and delays ranged from 7 to 140 days.

In effect, this stops becoming a temporal discounting problem and becomes a game theory problem. He's maximizing the sooner payoffs, the later payoffs, and then also temporally discounting. E.g.,

$6 now, or $12 in a month----- he chooses $6.
$8 now vs. $10 in four days---- he chooses $10.

But now he's told one of these choices, randomly, will be paid to him. So instead he picks:

$6 now vs. $12 in a month--- he chooses $12
$8 now vs. $10 in four days-- he chooses $10

Because in the first pair, he would have been paid either $6 now or $10 in four days. "No way, I'm not risking losing $10 in four days just to get $6 now. In order to risk losing $10 in four days, I need a bigger payment down the road. The only choice available to me is $12, so I'll take it." Get it?

Aggregate 15 such choices and it's no surprise people pick larger-later payoffs more often. The real way to do this would be to offer the people real money for every single choice they made, but that didn't happen here.

Unfortunately, it doesn't happen in real life, either. Most of the time, people make decisions based on hypothetical scenarios, with a faint expectation that perhaps one of these decisions will result in an actual payoff. When people with identity issues are presented with a series of binary choices, we expect them to consider them independently, and we often marvel at how bad their choices seem to be. But they may be taking a series of binary choices and inappropriately pooling them to maximize an overall outcome.

That's why we get frustrated with their choices. We can't understand why they made that choice because the reason has to do with an entirely different decision that should be unrelated but to them is linked.

And so it becomes important to restate things into independent, binary choices. Certainly life choices are affected by other life choices, but for those floundering in their own identities, things need to become more concrete, not less.

Craig Ferguson, The Jonas Brothers, and Katy Perry

2008-08-08T14:26:58Z

This is what 46 year old Scottish late night TV host Craig Ferguson said Tuesday night:

The Jonas Brothers... I'm sure they're fine young kids, and their music's not for me, it's for young people, I understand that, but my point is-- they're kind of too clean. With the purity rings, symbolizing that you're saving yourself for marriage. Now, I'm thinking-- what kind of a rock star is this? What kind of a rock star is this?...

It makes me a little uncomfortable, it's a little sinister to me, when the teenage rebellion is controlled and sanitized by a big corporation. There has to be some rebellion, or else it's not rock and roll.

]]>

Ferguson was in a Scottish punk band, was a drug addict, almost suicided and is now clean-- and strong enough to make nightly jokes about using drugs and still not relapse. Rock and roll cred established.

What's he saying? He defines rock and roll as rebellion; now, and now laments is a genre.

You might say that actually, the Jonas Brothers are rebellion because they are rebelling against the established credo of rock and roll (sex, drugs, etc), but that's a ruse as well, they aren't the ones rebelling; they were selected by an industry that is trying to change it's image.

To illustrate this, take a look at the other promise ring wearer, Katy Perry, whose song, "I Kissed A Girl" has disturbed me for a long time, disturbed me because it is so not disturbing.

In case you don't have kids or contracted rubella as a fetus, here's the chorus:

I kissed the girl and I liked it

The taste of her cherry chapstick

I kissed a girl just to try it

Hope my boyfriend don't mind it

It felt so wrong
It felt so right
Don't mean I'm in love tonight
I kissed a girl and I liked it
I liked it

That's as raunchy as it gets. Anyone who lived through the bicurious 90s knows that this kind of "kissing the girl" is about boys. It's about being sexy for boys, even if the boy doesn't know you did it, you still feel you are even more attractive to them. But this is by no means cutting edge material.

I will grant you that the song is technically, and artistically, more brilliant than anything by Coldplay. Ok, you got me there.

Yet the song is everywhere, not just pop song everywhere, but everywhere everywhere. Here are three news media outlets that have no business writing about music, writing about her. And always the topic is sexuality, as if she's opening (or closing) doors or something.

I had a huge argument with a friend about that song. My position was that such a benign song-- this is old news-- has a popularity that cannot be explained by the seemingly relevant topic of kissing a girl, there must be something else to it. Why would the music industry choose to push this specific song, so much?

His position was that it was MTV et al, targeting the older people, the ex-MTV generation-- e.g. me-- trying to entice them back with songs that play on their (unfulfilled) fantasies. "Why else would they be in lingerie? Young guys don't care about lingerie, unless it's a thong. They're programming to the older crowd."

Maybe, but why this song? Why not a million other more risque songs?

So here is this not at all provocative video, completely old news to anyone 21-45, yet it is everywhere. Go ahead and watch it, tell me why. No nudity. She's pretty, but come on, she's no Taylor Swift. Song is catchy, but again...

I call your attention to the last five seconds of the video. In the final scene, she wakes up next to her sleeping boyfriend. Ooohh-- is he going to find out how naughty she is? Will he be jealous or turned on? Is it fantasy or real?

Here's the thing. Her boyfriend in the video is black.

If that realization doesn't have any impact on you at all, you are my point. You may be so progressive that you don't even notice race, but I can assure you race is still a gigantic issue, for both races.

We have a scenario where two maybe-sort-of taboos are present in a video, but one is highlighted as a real taboo, and the other as completely and utterly ordinary, meriting no comment or explanation. I'm pretty sure depending where you live in America, you'll either agree or disagree with her hierarchy.

In all the Katy Perry discussions, blogs, and articles, no one noticed the race issue, no one thought to mention it, nothing. What they went all Manchurian Candidate about was that she kissed a girl.

"Well, maybe that's what she believes." She doesn't have anything to do with it. She didn't make a video, then go Jet Li the MTV program director's office door, slap him in the face with the reel, and say, "This is f-ing awesome, play this!" "oh-oh-oh right away Mrs. Perry! Right away!"

The video was directed, manufactured. The guy in her bed isn't random, they selected an actor. It wasn't accidental he was black, they picked him because he was black. Indeed, he's DJ Skeet Skeet, a friend of her real life black rapper/boyfriend Travis McCoy. Nothing here is random; even her name, Katy Perry, was selected because her real name, Katy Hudson, risked confusing her with Kate Hudson. She changed her name to differentiate herself from someone else. They are constructing an image, they are telling you a story.

So what's happening here is that MTV isn't saying, "wow, this is so shockingly sexy, she kissed a girl." MTV is actually resetting the culture, it is telling you, telling a generation of kids, that kissing a girl is shocking and sexy.

"But it isn't shocking, you can't simply declare that it is. Much more shocking porn is everywhere." Actually, that's the genius of this. Reconstruct adolescent sexuality to the old days of maybe you catch a glimpse of a worn and melted Playboy down by the creek. Online porn saturates, overloads, it stops becoming arousing and starts getting frustrating, "where the hell is the exact pic I need to get off?"

MTV can't compete with that. Music can't compete with that. In your face, up yours, all that. Those vibes are now elsewhere.

So it's recreating a niche by recreating a culture. Clean, sober, and hip-hop light.

So that when you turn the amp up just a little, it catches everyone's attention. "Holy crap! She kissed a girl!"

I'm not sure if I should be appalled that sexuality has been commandeered by MTV et al, or I should just be relieved they're pushing popcorn not penetration.

Back to the Craig Ferguson. The music industry has to make good boys cool because there's a glut of bad boys everywhere else, and MTV and the music industry can't compete. Sex is no longer cool. What's cool now? Status. Narcissism. Rich is the new porn.

But poor Craig Ferguson. He makes the point that rock and roll is supposed to be about rebellion-- theoretically getting a big inaudible cheer from the teenagers-- "this guy may be old, but at least he gets it!" But he doesn't. That cheer came from his viewers-- who have an average age of 50. He's talking to a bunch of old guys, people who still think Smoke on The Water meant something.

A Little Bird Told Me

2008-08-06T20:29:32Z

1. McCain may drop out of the race-- running mate Romney to continue?

2. Oil prices were pushed higher (Iran/Israel tensions, etc) by a concerted government effort to generate oil revenues for Iraq, promote greater stability so as to allow partial withdrawal of troops before election; and a subsequent reduction of oil prices to erase them as a campaign issue. Both Iran and Israel were in on the plan.

Tin foil hat stuff, but thought I'd put it out there.

Social Welfare Is A Red Herring: The Return Of Feudalism

2008-07-30T18:39:39Z

The policies sound good, and perhaps they would be, if not for the malignant intentions that motivate them.
]]> I.

I recently received a form letter from Marcia Angell's socialist federation, "Physicians For A National Health Program," looking for support for government sponsored universal health care. It cited the usual reasons:

As physicians, we have seen the numbers of uninsured and underinsured soar, costs skyrocket, and quality deteriorate. Meanwhile, doctors drown in a sea of bureaucracy.

Etc. Ok, valid if not hyperbolic points. But that's not why she wants single payer insurance.

Only single payer would eliminate the high corporate overhead, profits, and enormous inefficiencies...

The stated reasons include reducing corporate profits. That's not a byproduct, or a necessary result, it is a reason for doing it.

II.

Another example I've used before. NPR was interviewing someone over a year ago about the high price of oil (ha!) and she asked the guy how to reduce the price, and he said he actually hoped the price would go higher, because it would curb use, decrease carbon emissions, force alternative energies to be explored, etc. Great. Her response, however was: oh, ok, and decreasing demand would be another way to hit oil companies where it hurts.

Get it? That's where she was standing, lowering prices might be good for the consumer but she didn't bother to say that. What was on the tip of her tongue was the need to punish oil companies. This woman is not stupid, she's not unaware of the complexities of energy policy-- but where her mind went immediately was how we can hurt oil companies. It wasn't incidental, it was absolutely vital that this happen.

III.

In the British Times Higher Education is an article by a Harvard professor lamenting the decline of the American student. Here's the table of contents blurb:

The banality and sense of entitlement of rich students at Harvard left John H. Summers feeling his teaching had been degraded to little more than a service to prepare clients for monied careers.

It laments the student privilege, grade inflation, consumerist attitudes, and the like. But that turns out to be only a minor gripe. What really got him:

Most of the students I encountered had already embraced the perspectives of the rich, the powerful and the unalienated, and they seemed to have done so with appalling ease.

He goes on to describe and deride this perspective, but when he chooses to cite an example-- you expect him to say something like "they urinated on homeless people" or "voted for Bush"-- he chooses this:

One of my less affluent students, the son of a postman, asked me once for advice about a financial investment.... I told him what I thought about this recommendation; but only later, when I learnt how little he had to invest ($2,000 was his total savings), did I allow myself to think I understood the significance of his question. No amount of money may be permitted to lie idle if something may be got for nothing.

This Harvard professor is angry that the guy wanted to invest. Period. "Something for nothing." Do you understand?

IV.

I suppose I shouldn't be surprised-- this nut was also angry that Harvard wouldn't let him teach a class he named, "Anarchist cultural criticism in America"-- but the main point is that this guy, the NPR interviewer, and Marcia Angell are certainly not the underprivileged. Their resentment against the system isn't supposed to be this visceral.

That's why the social welfare angle is a red herring. It's not that they want better services for the underprivileged and hurting the rich is the byproduct; it's the opposite, hurting the rich is the emotional, primary motivator, and the rest is an intellectual posture that rationalizes this resentment. This is why it's dangerous. That's why you can't side with them even if you agree with their policies. Intention matters.

Ex-Marcia these three may not be rich, but this amount of public hate and open vitriol are not expected in a properly functioning classless society.

Which simply means it's not properly functioning. Nothing new there, except for this: it is properly functioning. What's not working is the perception.

Summers is angry because he doesn't feel he could plug into the capitalist system, even though, obviously, he could if he tried-- the postman's son certainly is, with far less money or knowledge than the professor. So it's not the reality, it's the perception, but perception, confidence, is what this society is based on. Consequently, the system is failing.

The analogy is a bank run. As long as people think the bank is solvent, then it actually is. But if enough people think it isn't, then it actually becomes insolvent.

V.

So the question that needs to be answered is, "what went wrong that ordinary Americans hate people they perceive to not be in their class?"

First, education. From grade zero through college, you are told you belong to a class. Let's use the simple example of money: if you're an engineering student they'll tell you how to be an engineer, but no one anywhere tells you how to be a rich engineer. No one even tells you it is possible. If you go into the humanities, the expectation is you'll be "poor." Your future is defined by its limitations, not possibilities. "You won't starve, but you certainly aren't going to be rich." Really? Are we still in America? It seems to occur to no one to try to teach humanities students how not to be poor.

You're choosing a major and a lifetime social class. There's no fluidity-- they teach you, day one, pick your life slot. Good luck changing your mind in twenty years.

I'm not saying they should explicitly teach you how to be rich-- I'm saying they shouldn't teach you to expect to be in a slot.

Worse-- and I have seen no one anywhere make this observation, the most important one of all-- there is no generational perspective on advancement. At no point in K-16 is there even the subtlest suggestion that you should make something of yourself so that your kids can go further than you. Not as a byproduct, but as the actual purpose of all this education. No: the whole thing is about you.

Certainly people want their kids to do well, they put them in violin lessons, but what is missing is this explicit mantra: they need to go further than me. If you're a doctor reading this, answer honestly: you've mused about whether you want your kid to become a doctor or not, but do you expect them to be more than that? Not equivalent-- e.g. lawyer-- but more? Are you raising them for more, or the same?

Here's a word you will never hear taught as a goal: dynasty. No. What they teach you is feudalism: here's your fief, bring me homage.

It's not totally the parents' fault: the entire system, education and onwards, has grossly diminished expectations of its people and encourages, necessitates a self-focused, ahistoric worldview. They want you to plug into the Matrix, and then die. When you do, return all your stuff, someone else will use it.

Second, of course, is psychiatry. If you think of psychiatry as Zoloft, you're missing its scope. Psychiatry and culture are the same. It backs it, it supports it, it helps set expectations and values. It was more obvious with Darwinism or Freudianism because those were clearly articulated theories you could put in a book; psychiatry is more nebulous, but it is no less powerful a cultural force. Here's its mission statement: "you are different. And we will try hard to get you back up to the level of almost normal, but, state of the art, that's about as good as we can get."

But psychiatry doesn't just reduce expectations for humanity, it diverts attention away from real expectations, onto a pointless biologic outcome. If it really wanted to help, say, foster kids, it would say, "what are the ways we can actually change their lives? Options: we can send them to big orphanages with skill immersion programs; or we can spend a trillion dollars and give them all individual tutors/case managers to follow them every day, etc--" But since it can't have this complex debate, because it requires way too much money, it shifts the expectations to "managing symptoms."

The classic counterargument to my position is: you may be right, but psychiatry is better than nothing.

Yeah, so was your first husband. "Better than nothing" is almost always worse than "nothing." Defaulting to psychiatry legitimizes not pursuing actual solutions.

The patient is bleeding, your solution is to mop up the bloody floor so it doesn't look as bad. How long will this work? At what point do you become so deluded by the system that you think the "real" solution is better mops?

Fifty Percent of Foster Kids Are On Psychiatric Medications

2008-07-28T18:17:41Z

That's right. The single most best predictor of mental illness-- better than family history, better than genetics, better than symptomatology-- is being a foster child.

Texas data: 2004, 40% of the 32,000 foster kids were on psychotropics. 2005 it was, by age:

0-5: 12.4%
6-12: 55%
13-17: 66.5%

Do you understand the significance of this? If you tell me every single person in your family, including your identical twin, has schizophrenia, I will not be able to tell you if you have it-- but if you tell me simply that you are a foster child...

I'm sure someone has an explanation that deals with 5HT-2a receptors, or the amygdala, or genes on chromosome 12, but:

"When two-thirds of foster care adolescents receive treatment for emotional and behavioral problems, far in excess of the proportion in the non- foster care population, we should have assurances that the youth are benefiting from such treatment," said Dr. Zito.

Damn right. But as I said in my Esmin Green article that failed to convince anyone, this will never really be explored because society doesn't have any other options. If you don't call 16,000 Texas kids "early onset bipolar," does the system have a Plan B? Jail, I guess.

Psychiatry is the pressure valve of society

2008-07-23T14:02:55Z

In case you doubted, here is today's front page of USAToday: Economy's stuck, but business is booming at therapists' offices.

If that was the end of the story-- if people had social troubles and turned to psychiatry for help because of those troubles, it would be a good thing. Get help where you can.

But the larger problem is that in going to psychiatry, their socioeconomic issues get demoted to "factors" and the feelings become pathologized. Psychiatry doesn't explain, it identifies. You're not depressed because you lost your house; you have depression, and one of the triggers is losing your house. See the difference?

You'll say this doesn't happen all the time, maybe not even the majority of the time. But even if it doesn't happen to a specific individual, it still happens to enough people that it bolsters psychiatry's role as the necessary player in managing suffering of any kind.

A 20% increase in therapy visits will be interpreted by psychiatry as a 20% increase in depression and anxiety. It will say depression has a prevalence of X, it will say it is underdiagnosed and undertreated, etc. And it will creep into the social consciousness that these are pre-existing diseases with triggers, not the consequences of external events.

Society needs that illusion, it needs that lie, because it has created unrealistic expectations in people and no way of fulfilling them. Here's what a society looks like under the similar economic conditions, but without psychiatry:

The absence of hope
Today's popular frustrations over flat-lining living standards have been building for years. The recent boom, felt only by the already well-off, has done little to change that discontent. Labor unrest has been growing for months; violent protests erupted... corporate taxes will be raised and gasoline subsidies cut... The move was designed to take the steam out of boiling anti-government sentiment.

The above article, also from USAToday, has a slightly different title: Egypt's economy soars; so does misery.

Being The Main Character In Your Own TV Show Is Sort Of A Delusion

2008-07-22T04:20:38Z

Two psychiatrists, believe they have discovered a new, YouTube generation, delusion: believing you are in a secret reality TV show.

The article describes cases of people who believe they are secretly being filmed.

"I realized that I was and am the centre, the focus of attention by millions and millions of people," explained one patient, an army veteran who came from an upper-middle-class upbringing."My family and everyone I knew were and are actors in a script, a charade whose entire purpose is to make me the focus of the world's attention."

The belief that they are being filmed certainly gives the person a sense of importance, or worth independent of and beyond the mundane life he lives in. In other words, it allows for an inflation of identity without actually having to do anything. Call it grandiosity

The patient added that he planned to climb to the top of the Statue of Liberty, and if his true love were waiting for him, the puppeteer strings would be cut. If she failed to show up, he would jump to his death.

Grandiosity is one explanation, but I submit that the important part of this delusion isn't the filming, but the "puppeteer." The delusion isn't about self-importance, but rather an explanation for powerlessness. I am being manipulated by the outside. There's nothing I can do.

Consider that a delusion which enhances your importance might not be one you'd want terminated; but these cases have the termination of the delusion built in.

In "reality" (ha!) such cases are cognitive metaphors for maturity. Only when you gain sufficient self-awareness and autonomy can you break away from the artificial, manipulated reality of adolescence.

"But these guys are 30 years old!" Exactly. Real adolescents don't need a delusion to tell them they're powerless. But a 30 year old should be dealing with intimacy vs. isolation, but instead they're stuck back at identity vs. role confusion.

The delusion is the protection, not the empowerment. It says, "don't worry, you haven't accomplished anything because the producers haven't put that into the script yet." Ultimately, this YouTube delusion is the result of a fleeting awareness that you cannot choose your identity unless you back it up with actions-- that actions are identity.

When a narcissist has this awareness, he has two choices. He can retreat into a protective delusion, such as this one; or he can convince-- read: force-- someone else to accept his identity even in the absence of actions. "I am a tough cop! Well, maybe not actually a cop, but if something went down in this mall, I could be like a cop, and that's just as good!"

You do not want to be the person the narcissist tries to convince.
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Academics Hide Drug Company Payments

2008-07-21T03:57:21Z

And with good reason.
]]> The Independent asserts Dr. Joseph Biederman, Harvard guru of ADHD and child bipolar, received over $1M in consultant fees and didn't report it to Harvard; it then implies this is why kids are overmedicated, etc.

Wrong. A thousand times wrong. It could not be more wrong, it is dangerously wrong.

Believe me, I am no friend of Biederman's. But the money is a red herring. If you want to be angry about the specific ethics of a psychiatrist receiving Pharma money, fine, but I am telling you it is not worth the Senate time, not worth press space.

The real money, the real problem that goes unmentioned is the money that goes to universities, in the form of research grants. Biederman may have pocketed $1M, but I'm sure he was awarded much, much more for clinical trials-- money which he didn't get any of, which went to Harvard.

We aren't overmedicating kids because Biederman told us to; we're doing it because Harvard told us to. And Harvard told us to because that is what they are getting money to study. Biederman is just the nanobot that does it.

If Biederman never existed, nothing would be different. You read his resume, you think, wow, he's a big player. You don't realize that if he didn't exist there would be some other person in his exact position, who would also have become a Distinguished Professor, won awards, written 450 publications, etc. The machine was already in place, his slot was going to get filled; his mind didn't discover anything, those results were coming no matter what, those publications were already going to be written.

The money isn't corrupting him into thinking childhood bipolar is underdiagnosed-- he truly believes it. The reason he believes it is his entire professional existence-- his whole identity-- is predicated on believing it. He's not a scientist, he's a priest.

He starts out as a young academic. He lands a spot in a research group that studies X, so he studies X, later he branches out into X+Y, or goes to Z, etc, eventually he finds himself a niche. And he believes in that niche, he believes in his data, no matter what it says. You can't convince him he's wrong because it isn't science and it isn't even a bias-- it's identity.

That's how an entire nation of psychiatrists could have been deluded into prescribing Depakote for maintenance when the data itself says not to do it. It's belief, not money, "we believe bipolar is a kindled disorder..." Hell, if Harvard believes it, what chance do the rest of us have?

What he doesn't see because he is too small to see it is that that niche exists only because there is grant money for it. That's the real bias. He internalizes an artificial system because it gives him identity and identity is more important than money.

It's not just Pharma-- NIH is worse. If NIMH wants to study the biological causes for childhood bipolar, then we will all agree that these causes exist "we just haven't found them yet." But if NIMH decides to study the social causes of childhood bipolar, then those causes exist, and the biological ones don't. The question is how does NIMH decide what to study? Culture. When a culture decides to study something, the results don't matter-- the decision to study it affirms it a priori.

Do you think that all those psychoanalysts from 1899-1974 were all retarded? No understanding of biology, a bunch of clowns, morons? They were brilliant, but that was the time, that was the culture, no matter what data you had to the contrary you were still going to be wrong and they right. Get it? People blame psychoanalysis, but the specific problem is paradigms, which are agreed upon because they have serve some other purpose-- not science, not truth-- and change only when that other purpose disappears, or the paradigm fails it.

If we just want to punish a few high ranking psychiatrists-- and for what? hiding money from Harvard so it doesn't take a 20% cut?-- it will do nothing to stop the anti-humanism zamboni that's trying to smooth out all the kinks in society.

Data are irrelevant, here's the paradigm: child bipolar is underdiagnosed because society needs it to be.

There is still massive wealth inequality, racism, resentment, unrealistic expectations of life and a gross sense of entitlement-- in short, narcisissm-- that we have no solutions for except to hastily pathologize it all and hand it to the psychiatrists. They can keep us all confused for a decade or two until we have another world war, discover cold fusion, or the aliens come.

The problem isn't that money influenced Biederman; the problem is that even money won't be able to influence him.

Do you know why Biederman hid the money from Harvard? Because he can't believe he's being paid so much money for something he would have done for free. Until you change that groupthink, that blind faith, nothing else will change.

When CGI Porn Looks Real: Is Anyone Thinking About The Children?

2008-07-17T04:51:24Z

Making the internet rounds is a post written by Debbie Nathan, (Pornography: A Groundwork Guide and Satan's Silence: Ritual Abuse and the Making of a Modern American Witch Hunt) on what the government is going to do when computer generated child porn becomes indistinguishable from actual photos.

Other than freak out.

]]> I.

Traci Lords makes several porn movies until 1986 when it is "discovered" that she was underage. So they go after the distributor, X-Citement Video.

Open and shut case-- they have her on film being underage and naked, so...

But on appeal, the 9th Circuit reverses the conviction. They say that the law is unconsitutional. It goes up to the Supreme Court, who reverse the reversal, and, more importantly, decide that the law is not unconstitutional. It is a great day for democracy, and for decency, but for the simple fact that they were wrong.

See if you can spot why that is:

Protection of Children Against Sexual Exploitation Act of 1977 (18 U.S.C. §§ 2252)

(a) Any person who -
          (1) knowingly transports or ships in interstate or foreign commerce by any means including by computer or mails, any visual depiction, if -
               (A) the producing of such visual depiction involves the use of a minor engaging in sexually explicit conduct; and
               (B) such visual depiction is of such conduct

The key word is knowingly. Knowingly what? Knowingly transports an object which [turns out to be] child porn. Not: transports an object knowing that it is child porn. Get it? Following this reading, the UPS guy is guilty of transporting child porn.

The Court acknowledged that that is the "most natural reading" of the law, but since it could lead to "absurd" results, they decide to interpret it differently, the more "logical way"-- instead of disposing of the law and forcing a new one.

"Well, duh, everyone knows what was really meant by the law." Really? One can easily imagine a time (say, now) when we all decide to read it differently, where the government looks for ways and laws to catch anyone it deems undesirable. Right? That could happen? I'm not just a paranoid, right? Such laws become, for example, deterrents on actually protected speech. For example, in this case it could be used to slow down all pornography.

Oh, wait, that turns out to have been precisely why the law was written that way in the first place:

In fact it seems to me that the dominant (if not entirely uncontradicted) view expressed in the legislative history is that set forth in the statement of the Carter Administration Justice Department which introduced the original bill: "[T]he defendant's knowledge of the age of the child is not an element of the offense but . . . the bill is not intended to apply to innocent transportation with no knowledge of the nature or character of the material involved." S. Rep. No. 95-438, p. 29 (1977). As applied to the final bill, this would mean that the scienter requirement applies to the element of the crime that the depiction be of "sexually explicit conduct," but not to the element that the depiction "involv[e] the use of a minor engaging" in such conduct.

So the intent wasn't to get the UPS guy, but it also expressly didn't want to make knowing the girl's age part of the offense, just that you know it's porn. The idea was to scare everyone down the pornography chain-- producers, distributors, etc-- to force them all to be more attentive to the possibility that their porn is child porn. Or not to make porn at all.

The real question brought up in the dissent was why the law even needed scienter (knowledge) of minority. Does forcing cinematographers to make sure everyone is over 18 really dampen free speech? To even debate the scienter requirement is to give it legitimacy that it doesn't have in these situations. This is pornography, not art-- why not force everyone to make very sure that the participants aren't minors? Otherwise it's perfectly legal to distribute child porn from Thailand ("there's no way for me to check, we don't even know who the actors are, and they told me they're all adults.") In other words, instead of debating where the word "knowingly" goes, get a law that doesn't have it in there at all: if you' can't show that everyone is over 18, you can't distribute it.

You may be surprised-- or not-- to learn that the dissenter in this case Antonin Scalia. Certainly he is not pro-pornography. But a) you can't have laws like this, vague and poorly constructed, talking around the issue, so that any government can choose to implement it any way it wants, and b) you can't allow the Supreme Court to basically re-write it, to suit their particular inclinations. You want a better law? Go ask Congress.

The Court today saves a single conviction by putting in place a relatively toothless child pornography law that Congress did not enact, and by rendering congressional strengthening of that new law more difficult.

II.

Back in the 1997(?) Patrick Naughton, an executive at Infoseek (where?), gets on dad&daughtersex and chats up a 13 year old girl named KrisLA, and agrees to meet in her home state. Surprise! She's a 40 year old guy who works at the FBI.

Naughton says he really "knew" she was an adult woman, and anyway all the pics found on his computer are computer generated. He's found guilty of possession, all other counts result in a hung jury. (All men voted not guilty, all women voted guilty. Does that beg the question: jury of your peers?)

Less than two days later, the 9th Circuit Court independently decides Child Pornography Prevention Act of 1996 is unconstitutionally broad. He is released.

The Child Pornography Prevention Act of 1996 (CPPA) 18 USC 2256, says, awesomely:

(8) "child pornography" means any visual depiction, including any photograph, film, video, picture, or computer or computer-generated image or picture, whether made or produced by electronic, mechanical, or other means, of sexually explicit conduct, where--

(A) the production of such visual depiction involves the use of a minor engaging in sexually explicit conduct;

(B) such visual depiction is a digital image, computer image, or computer-generated image that is, or is indistinguishable from, that of a minor engaging in sexually explicit conduct
...(D) such visual depiction is advertised, promoted, presented, described, or distributed in such a manner that conveys the impression that the material is or contains a visual depiction of a minor engaging in sexually explicit conduct

which, means not just CGI porn of kids, but any real girl over 18 who is pretending to be under 18 would be illegal. This is what lawyers would tongue-in-cheek call "overbroad"-- it applies to images that might be neither obscene nor actually involving real kids. The law is unconstitutional, so says SCOTUS in Ashcroft v. Free Speech Coalition.

III.

And so we're left wondering, what next? When the CGI gets so good that it is actually indistinguishable from real porn, what then? Should it be illegal, or not?

The new law, Child Obscenity and Pornography Prevention Act (COPPA), pertains to anything "virtually indistinguishable from that of a minor engaging in sexually explicit conduct." I think the use of the word virtually is ironic. Or stupid, your choice.

It seems to me that when the CGI gets that good, that easy to make, then people won't be choosing to find real or CGI porn, they will be making their own porn by themselves. The question is what this will mean for the rest of us.

IV.

I go through all this so that you can see that the general spirit may be to protect children, but the intention of the law is to stop child pornography. The two aren't the same, unfortunately. The person who molests and photographs kids will not molest them less if the photography is illegal; the question is whether CGI child porn increases the molestation of non-CGI kids.

We can take a hint from regular online porn in the early 1990s, easily accessible by everyone. I was pretty sure all that porn would turn a generation of twenty somethings into sluts, but, unfortunately, no such luck. (It did make men start to shave their bodies, which is further proof of the Law of Unintended Consequences.)

Similarly, Grand Theft Auto I-XIV hasn't increased the rates of car thefts or prostitute murders. What it has done, and what porn has done, is made their rare occurrence less shocking. In other words, we're not less moral-- we're more jaded. It's Seinfeld syndrome: "meh."

Child porn, real or CGI, should be considered on its merits (i.e. none) and not on the effect it has on actual molestation, because there appears to be very little connection between the two. If you want to ban it, the reason can't be "it promotes pedophilia" because if it is shown not to do that, then the whole law disappers.