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Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Medication. Show all posts
Showing posts with label Medication. Show all posts

Tuesday, September 5, 2023

How does marijuana affect the brain?

Heather Stringer
Monitor on Psychology
Vol. 54, No. 5, p. 20

Here is an excerpt:

Mixing marijuana with mental health issues

Psychologists also share a sense of urgency to clarify how cannabis affects people who suffer from preexisting mental health conditions. Many veterans who suffer from PTSD view cannabis as a safe alternative to other drugs to alleviate their symptoms (Wilkinson, S. T., et al., Psychiatric Quarterly, Vol. 87. No. 1, 2016). To investigate whether marijuana does in fact provide relief for PTSD symptoms, Jane Metrik, PhD, a professor of behavioral and social sciences at the Brown University School of Public Health and a core faculty member at the university’s Center for Alcohol and Addiction Studies, and colleagues followed more than 350 veterans for a year. They found that more frequent cannabis use worsened trauma-related intrusion symptoms—such as upsetting memories and nightmares—over time (Psychological Medicine, Vol. 52, No. 3, 2022). A PTSD diagnosis was also strongly linked with cannabis use disorder a year later. “Cannabis may give temporary relief from PTSD because there is a numbing feeling, but this fades and then people want to use again,” Metrik said. “Cannabis seems to worsen PTSD and lead to greater dependence on the drug.”

Metrik, who also works as a psychologist at the Providence VA Medical Center, has also been studying the effects of using cannabis and alcohol at the same time. “We need to understand whether cannabis can act as a substitute for alcohol or if it leads to heavier drinking,” she said. “What should we tell patients who are in treatment for problem drinking but are unwilling to stop using cannabis? Is some mild cannabis use OK? What types of cannabis formulations are helpful or harmful for people who have alcohol use disorder?”

Though there are still many unanswered questions, Metrik has seen cases that suggest adding cannabis to heavy drinking behavior is risky. Sometimes people can successfully quit drinking but are unable to stop using cannabis, which can also intensify depression and lead to cannabis hyperemesis syndrome—repeated and severe bouts of vomiting that can occur in heavy cannabis users, she said. Cannabis withdrawal symptoms such as irritability, anxiety, increased cravings, aggression, and restlessness usually subside after 1 to 2 weeks of abstinence, but insomnia tends to persist longer than the other symptoms, she said.

Cannabis may also interfere with pharmaceutical medications patients are taking to treat mental health issues. Cannabidiol (CBD) can inhibit the liver enzymes that metabolize medications such as antidepressants and antipsychotics, said Ryan Vandrey, PhD, a professor of psychiatry and behavioral sciences at Johns Hopkins University and president of APA’s Division 28 (Psychopharmacology and Substance Abuse). “This could lead to side effects because the medication is in the body longer and at higher concentrations,” he said. In a recent study, he found that a high dose of oral CBD also inhibited the metabolism of THC, so the impairment and the subjective “high” was significantly stronger and lasted for a longer time (JAMA Network Open, Vol. 6, No. 2, 2023). This contradicts the common conception that high levels of CBD reduce the effects of THC, he said. “This interaction could lead to more adverse events, such as people feeling sedated, dizzy, [or] nervous, or experiencing low blood pressure for longer periods of time,” Vandrey said.

The interactions between CBD, THC, and pharmaceutical medications also depend on the dosing and the route of administration (oral, topical, or inhalation). Vandrey is advocating for more accurate labeling to inform the public about the health risks and benefits of different products. “Cannabis is the only drug approved for therapeutic use through legislative measures rather than clinical trials,” he said. “It’s really challenging for patients and medical providers to know what dose and frequency will be effective for a specific condition.”

Sunday, July 3, 2022

Mental Illness Is Not in Your Head

Marco Ramos
Boston Review
Originally posted 17 MAY 22

Here are two excerpts:

In Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, Anne Harrington argues that the current crisis is just the latest in a long line of failures to discover the biology of mental illness over the last two centuries. In this sweeping study, the history of psychiatry undulates like the boom and bust of a speculative market. First a wave builds with enthusiastic promises of revolutionary breakthroughs that will change psychiatry as we know it. Then the wave collapses, as psychiatrists fail to deliver on those bold promises. Crisis ensues, and after the requisite finger-pointing, the next wave of psychiatric revolution begins to build. Rinse and repeat.

The first “revolution” in American psychiatry that Harrington tracks arrived in the nineteenth century. At the time, large lunatic asylums dominated the psychiatric landscape, such as the Blackwell’s Island hospital on what today is called Roosevelt Island in New York City. These institutions were designed to cure patients with mental disorders by placing them in the hospitable environment of the asylum architectural space. However, a series of journalistic exposés revealed that these asylums were overcrowded and underfunded with patients living in deplorable, instead of therapeutic, conditions. For example, in 1887, journalist Elizabeth Seaman, who wrote under the pen name Nellie Bly, went undercover as a patient in Blackwell’s Island Hospital and exposed horrible acts of brutality in her best-seller Ten Days in a Mad-House. Asylum psychiatry faced a crisis of public trust.

As Harrington explains, European neuroanatomists came to the rescue. Unlike asylum physicians, anatomists were pessimistic about the potential for a cure. Building on eugenic theories, they believed that asylum patients were “degenerates” who were biologically unfit to cope with the stresses of modern life. But they also believed that the mentally ill could provide a service to society after their deaths by offering their brains to science. The dissection of their pathological brains, the anatomists hoped, could reveal the biological causes of mental suffering.


But if the pharmaceutical industry has invested so heavily in psychiatry, why have there been no breakthroughs in drug treatment? A major reason is that the industry has spent billions of dollars more on advertising psychiatric medications than on research and development of novel drugs. As psychiatrist David Healy has shown, money earmarked for R&D is often not intended to produce genuine innovation. Almost all of the psychopharmaceuticals produced since 1990 have been “copycats” that mimic older, generic pharmaceuticals, with only minor chemical modifications. These (unfortunately named) “me-too” drugs work no better clinically than the drugs that came before them, but their slight biochemical novelty means that they can be patented, so that pharma can charge insurance companies’ top dollar.

Perhaps the worst news is that Big Pharma, having created and capitalized on psychiatric markets, is now jumping ship. Anthropologist Joe Dumit has shown that most psychiatric drugs will soon go off patent, so companies will be forced to charge less for them. With the market already saturated with pharmaceutical copycats and no significant scientific biological breakthroughs in sight, there is suddenly little room for growth. Almost all of the major pharmaceutical companies have decided to divest from psychiatric drug research and turn to more promising sectors, especially the development of “biologics” and other cancer drugs.

Tuesday, May 3, 2022

The Mystifying Rise of Child Suicide

Andrew Solomon
The New Yorker
Originally posted 4 APR 22

Here are two excerpts:

Every suicide creates a vacuum. Those left behind fill it with stories that aspire to rationalize their ultimately unfathomable plight. People may blame themselves or others, cling to small crumbs of comfort, or engage in pitiless self-laceration; many do all this and more. In a year of interviewing the people closest to Trevor, I saw all of these reactions and experienced some of them myself. I came to feel a love for Trevor, which I hadn’t felt when he was alive. The more I understood the depths of his vulnerability, the more I wished that I had encouraged my son, whose relationship with Trevor was often antagonistic, to befriend him. As I interviewed Trevor’s parents, my relationship with them changed. The need to write objectively without increasing their suffering made it more fraught—but it also became deeper and more loving. As the April 6th anniversary of Trevor’s death approached, I started to share their hope that this article would be a kind of memorial to him.

Angela was right that a larger issue is at stake. The average age of suicides has been falling for a long time while the rate of youth suicide has been rising. Between 1950 and 1988, the proportion of adolescents aged between fifteen and nineteen who killed themselves quadrupled. Between 2007 and 2017, the number of children aged ten to fourteen who did so more than doubled. It is extremely difficult to generalize about youth suicide, because the available data are so much sparser and more fragmentary than for adult mental illness, let alone in the broader field of developmental psychology. What studies there are have such varied parameters—of age range, sample size, and a host of demographic factors—as to make collating the information all but impossible. The blizzard of conflicting statistics points to our collective ignorance about an area in which more and better studies are urgently needed. Still, in 2020, according to the Centers for Disease Control and Prevention, in the United States suicide claimed the lives of more than five hundred children between the ages of ten and fourteen, and of six thousand young adults between fifteen and twenty-four. In the former group, it was the second leading cause of death (behind unintentional injury). This makes it as common a cause of death as car crashes.


Perhaps the most unsettling aspect of child suicide is its unpredictability. A recent study published in the Journal of Affective Disorders found that about a third of child suicides occur seemingly without warning and without any predictive signs, such as a mental-health diagnosis, though sometimes a retrospective analysis points to signs that were simply missed. Jimmy Potash, the chair of the psychiatry department at Johns Hopkins, told me that a boy who survived a suicide attempt described the suddenness of the impulse: seeing a knife in the kitchen, he thought, I could stab myself with that, and had done so before he had time to think about it. When I spoke to Christine Yu Moutier, who is the chief medical officer at the American Foundation for Suicide Prevention, she told me that, in children, “the moment of acute suicidal urge is very short-lived. It’s almost like the brain can’t keep up that rigid state of narrowed cognition for long.” This may explain why access to means is so important; children living in homes with guns have suicide rates more than four times higher than those of other children.

Sunday, May 1, 2022

Why So Many Middle-Aged Women Are on Antidepressants—Scientists are gaining a better understanding of women’s midlife depression

Andrea Petersen
The Wall Street Journal
Originally posted 2 APR 22

For years, middle-aged women have had some of the country’s highest rates of antidepressant use. Now, scientists are starting to better understand why—and to develop more targeted treatments for women’s midlife depression.

About one in five women ages 40 to 59 and nearly one in four women ages 60 and over used antidepressants in the last 30 days during 2015 to 2018, according to the latest data from the National Center for Health Statistics. 

Among women ages 18 to 39, the figure was about one in 10. 

Among men, 8.4% of those ages 40 to 59 and 12.8% of those 60 and older used antidepressants in the last 30 days, according to the NCHS data.

The figures are drawing increasing attention from scientists and doctors. Many are alarmed at how high depression rates were among midlife women even before the pandemic, now that the past two years have exacerbated mental-health issues for many Americans. 


Researchers at NIMH who have been following 90 women since 1988 have found that the incidence of women’s midlife depression is concentrated in the two years before and after the last menstrual period, says Dr. Schmidt. 

The quality of women’s midlife depression is distinct, too, Dr. Schmidt says, in that it often involves intense anxiety, irritability and sleep problems along with the more typical sadness and loss of pleasure in once-enjoyed activities.

Doctors speculate that antidepressant use among middle-aged women is being driven in part by the reluctance of women—and many of their physicians—in recent decades to use hormone-replacement therapy for menopausal symptoms. In 2002, a large study, the Women’s Health Initiative, was stopped after women taking hormone therapy had an increased risk of breast cancer, heart attacks and strokes. 

Later analyses found that the risks were largely concentrated among women who were older when they started hormone therapy. For women in their 50s, hormone therapy actually reduced the risk of heart disease and death from any cause. 

Hormone therapy, either estrogen alone or combined with a progestogen, is the most effective treatment for hot flashes and night sweats, according to the North American Menopause Society and the American College of Obstetricians and Gynecologists. 

Some research has found that it can also improve mood.

Wednesday, December 2, 2020

Do antidepressants work?

Jacob Stegenga
Originally published 5 Mar 19

Here is an excerpt:

To see this, consider an analogy. Imagine we are testing a drug for weight loss. For every 100 subjects in the drug group, three subjects lose one kilogramme and 97 subjects gain five kilos. For every 100 subjects in the placebo group, two lose four kilos and 98 subjects do not gain or lose any weight. How effective is the drug for weight loss? The odds ratio of weight loss is 1.5, and yet this number tells us nothing about how much weight people on average gain or lose – indeed, the number entirely conceals the real effects of the drug. Though this is an extreme analogy, it shows how cautious we must be when interpreting this celebrated meta-analysis. Unfortunately, however, in response to this work, many leading psychiatrists celebrated, and news headlines misleadingly claimed ‘The drugs do work.’ On the winding route from the hard work of these researchers to the news reports where you were most likely to hear about that study, a simple number became a lie.

When analysed properly, the best evidence indicates that antidepressants are not clinically beneficial. The meta-analyses worth considering, such as the one above, involve attempts to gather evidence from all trials on antidepressants, including those that remain unpublished. Of course it is impossible to know that a meta-analysis includes all unpublished evidence, because publication bias is characterised by deception, either inadvertent or wilful. Nevertheless, these meta-analyses are serious attempts to address publication bias by finding as much data as possible. What, then, do they show?

In meta-analyses that include as much of the evidence as possible, the severity of depression among subjects who receive antidepressants goes down by approximately two points compared with subjects who receive a placebo. Two points. Remember, a depression score can go down by double that amount simply if a subject stops fidgeting. This result, found by both champions and critics of antidepressants, has been replicated year after year for more than a decade (see, for example, the meta-analyses led by Irving Kirsch in 2008, by J C Fournier in 2010, and by Janus Christian Jakobsen in 2017). The phenomena of blind-breaking, the placebo effect and unresolved publication bias could easily account for this trivial two-point reduction in severity scores.

Thursday, March 12, 2020

Business gets ready to trip

Jeffrey O'Brien
Forbes. com
Originally posted 17 Feb 20

Here is an excerpt:

The need for a change in approach is clear. “Mental illness” is an absurdly large grab bag of disorders, but taken as a whole, it exacts an astronomical toll on society. The National Institute of Mental Health says nearly one in five U.S. adults lives with some form of it. According to the World Health Organization, 300 million people worldwide have an anxiety disorder. And there’s a death by suicide every 40 seconds—that includes 20 veterans a day, according to the U.S. Department of Veterans Affairs. Almost 21 million Americans have at least one addiction, per the U.S. Surgeon General, and things are only getting worse. The Lancet Commission—a group of experts in psychiatry, public health, neuroscience, etc.—projects that the cost of mental disorders, currently on the rise in every country, will reach $16 trillion by 2030, including lost productivity. The current standard of care clearly benefits some. Antidepressant medication sales in 2017 surpassed $14 billion. But SSRI drugs—antidepressants that boost the level of serotonin in the brain—can take months to take hold; the first prescription is effective only about 30% of the time. Up to 15% of benzodiazepine users become addicted, and adults on antidepressants are 2.5 times as likely to attempt suicide.

Meanwhile, in various clinical trials, psychedelics are demonstrating both safety and efficacy across the terrain. Scientific papers have been popping up like, well, mushrooms after a good soaking, producing data to blow away conventional methods. Psilocybin, the psychoactive ingredient in magic mushrooms, has been shown to cause a rapid and sustained reduction in anxiety and depression in a group of patients with life-threatening cancer. When paired with counseling, it has improved the ability of some patients suffering from treatment-resistant depression to recognize and process emotion on people’s faces. That correlates to reducing anhedonia, or the inability to feel pleasure. The other psychedelic agent most commonly being studied, MDMA, commonly called ecstasy or molly, has in some scientific studies proved highly effective at treating patients with persistent PTSD. In one Phase II trial of 107 patients who’d had PTSD for an average of over 17 years, 56% no longer showed signs of the affliction after one session of MDMA-assisted therapy. Psychedelics are helping to break addictions, as well. A combination of psilocybin and cognitive therapy enabled 80% of one study’s participants to kick cigarettes for at least six months. Compare that with the 35% for the most effective available smoking-cessation drug, varenicline.

The info is here.

Monday, February 10, 2020

The medications that change who we are

Zaria Gorvett
Originally published 8 Jan 20

Here are two excerpts:

According to Golomb, this is typical – in her experience, most patients struggle to recognise their own behavioural changes, let alone connect them to their medication. In some instances, the realisation comes too late: the researcher was contacted by the families of a number of people, including an internationally renowned scientist and a former editor of a legal publication, who took their own lives.

We’re all familiar with the mind-bending properties of psychedelic drugs – but it turns out ordinary medications can be just as potent. From paracetamol (known as acetaminophen in the US) to antihistamines, statins, asthma medications and antidepressants, there’s emerging evidence that they can make us impulsive, angry, or restless, diminish our empathy for strangers, and even manipulate fundamental aspects of our personalities, such as how neurotic we are.


Research into these effects couldn’t come at a better time. The world is in the midst of a crisis of over-medication, with the US alone buying up 49,000 tonnes of paracetamol every year – equivalent to about 298 paracetamol tablets per person – and the average American consuming $1,200 worth of prescription medications over the same period. And as the global population ages, our drug-lust is set to spiral even further out of control; in the UK, one in 10 people over the age of 65 already takes eight medications every week.

How are all these medications affecting our brains? And should there be warnings on packets?

The info is here.

Friday, December 6, 2019

The female problem: how male bias in medical trials ruined women's health

Gabrielle Jackson
The Guardian
Originally posted 13 Nov 19

Here is an excerpt:

The result of this male bias in research extends beyond clinical practice. Of the 10 prescription drugs taken off the market by the US Food and Drug Administration between 1997 and 2000 due to severe adverse effects, eight caused greater health risks in women. A 2018 study found this was a result of “serious male biases in basic, preclinical, and clinical research”.

The campaign had an effect in the US: in 1993, the FDA and the NIH mandated the inclusion of women in clinical trials. Between the 70s and 90s, these organisations and many other national and international regulators had a policy that ruled out women of so-called childbearing potential from early-stage drug trials.

The reasoning went like this: since women are born with all the eggs they will ever produce, they should be excluded from drug trials in case the drug proves toxic and impedes their ability to reproduce in the future.

The result was that all women were excluded from trials, regardless of their age, gender status, sexual orientation or wish or ability to bear children. Men, on the other hand, constantly reproduce their sperm, meaning they represent a reduced risk. It sounds like a sensible policy, except it treats all women like walking wombs and has introduced a huge bias into the health of the human race.

In their 1994 book Outrageous Practices, Leslie Laurence and Beth Weinhouse wrote: “It defies logic for researchers to acknowledge gender difference by claiming women’s hormones can affect study results – for instance, by affecting drug metabolism – but then to ignore these differences, study only men and extrapolate the results to women.”

The info is here.

Saturday, October 26, 2019

Treatments for the Prevention and Management of Suicide: A Systematic Review.

D'Anci KE, Uhl S, Giradi G, et al.
Ann Intern Med. 
doi: 10.7326/M19-0869


Suicide is a growing public health problem, with the national rate in the United States increasing by 30% from 2000 to 2016.

To assess the benefits and harms of nonpharmacologic and pharmacologic interventions to prevent suicide and reduce suicide behaviors in at-risk adults.

Both CBT and DBT showed modest benefit in reducing suicidal ideation compared with TAU or wait-list control, and CBT also reduced suicide attempts compared with TAU. Ketamine and lithium reduced the rate of suicide compared with placebo, but there was limited information on harms. Limited data are available to support the efficacy of other nonpharmacologic or pharmacologic interventions.


In this SR, we reviewed and synthesized evidence from 8 SRs and 15 RCTs of nonpharmacologic and pharmacologic interventions intended to prevent suicide in at-risk persons. These interventions are a subset of topics included in the updated VA/DoD 2019 CPG for assessment and management of patients at risk for suicide. The full final guideline is available from the VA Web site (www.healthquality.va.gov).

Nonpharmacologic interventions encompassed a range of approaches delivered either face-to-face or via the Internet or other technology. We found moderate-strength evidence supporting the use of face-to-face or Internet-delivered CBT in reducing suicide attempts, suicidal ideation, and hopelessness compared with TAU. We found low-strength evidence suggesting that CBT was not effective in reducing suicides. However, rates of suicide were generally low in the included studies, which limits our ability to draw firm conclusions about this outcome. Data from small studies provide low-strength evidence supporting the use of DBT over client-oriented therapy or control for reducing suicidal ideation. For other outcomes and other comparisons, we found no benefit of DBT. There was low-strength evidence supporting use of WHO-BIC to reduce suicide, CRP to reduce suicide attempts, and Window to Hope to reduce suicidal ideation and hopelessness.

Wednesday, July 24, 2019

Campuses Are Short on Mental-Health Counselors. But They’ve Got Plenty of Antidepressants.

Lily Jackson
The Chronicle of Higher Education
Originally posted June 28, 2019

Here is an excerpt:

A Potential for Lopsided Treatment

It is generally accepted that the most effective treatment for medium-to-severe depression is a mix of therapy and medication. But on most college campuses, it’s easier to get the latter than the former.

A student experiencing symptoms of depression who wants to see a counselor may have to wait weeks. The average wait for a first-time appointment among all college counseling centers is about seven business days, according to a report by the Association for University and College Counseling Center Directors. And nearly two-thirds of counseling directors whose centers offer psychiatric services say they need “more hours of psychiatric services than they currently have to meet student needs,” according to the same report.

On many campuses, the path to a prescription is simpler. A student can walk into a campus clinic where a medical employee can administer an evaluation called the PHQ-9, a nine-question rubric, commonly used across medicine, that assesses the patient's well-being with questions like, “Have you been feeling blue for the last two weeks?” and “Have you experienced thoughts of suicide?”

Based on the student’s evaluation score, psychologists can direct them toward medication or therapy, or both, based on the severity of their symptoms. Some students are seeking mental health resources with a driving force of “instant relief,” said Gregory Eells, executive director of Counseling and Psychological Services at the University of Pennsylvania and the president-elect of Aucccd.

So they tell their physician what they want, Eells said, rather than inquiring about what they need.

It’s common, experts say, for a patient to leave the first visit with a prescription for an antidepressant.

“Most students come in knowing one thing: They want help,” said William E. Neighbor, clinical professor of family medicine at the University of Washington Hall Health Center. “They are interested in medications because most have friends who have been on them.”

The info is here.

Friday, November 2, 2018

Companies Tout Psychiatric Pharmacogenomic Testing, But Is It Ready for a Store Near You?

Jennifer Abbasi
JAMA Network
Originally posted October 3, 2018

Here is an excerpt:

According to Dan Dowd, PharmD, vice president of medical affairs at Genomind, pharmacists in participating stores can inform customers about the Genecept Assay if they notice a history of psychotropic drug switching or drug-related adverse effects. If the test is administered, a physician’s order is required for the company’s laboratory to process it.

“This certainly is a recipe for selling a whole lot more tests,” Potash said of the approach, adding that patients often feel “desperate” to find a successful treatment. “What percentage of the time selling these tests will result in better patient outcomes remains to be seen.”

Biernacka also had reservations about the in-store model. “Generally, it could be helpful for a pharmacist to tell a patient or their provider that perhaps the patient could benefit from pharmacogenetic testing,” she said. “[B]ut until the tests are more thoroughly assessed, the decision to pursue such an option (and with which test) should be left more to the treating clinician and patient.”

Some physicians said they’ve found pharmacogenomic testing to be useful. Aron Fast, MD, a family physician in Hesston, Kansas, uses GeneSight for patients with depression or anxiety who haven’t improved after trying 2 or 3 antidepressants. Each time, he said, his patients were less depressed or anxious after switching to a new drug based on their genotyping results.

Part of their improvements may stem from expecting the test to help, he acknowledged. The testing “raises confidence in the medication to be prescribed,” Müller explained, which might contribute to a placebo effect. However, Müller emphasized that the placebo effect alone is unlikely to explain lasting improvements in patients with moderate to severe depression. In his psychiatric consulting practice, pharmacogenomic-guided drug changes have led to improvements in patients “sometimes even up to the point where they’re completely remitted,” he said.

The info is here.

Friday, May 25, 2018

The $3-Million Research Breakdown

Jodi Cohen
Originally published April 26, 2018

Here is an excerpt:

In December, the university quietly paid a severe penalty for Pavuluri’s misconduct and its own lax oversight, after the National Institute of Mental Health demanded weeks earlier that the public institution — which has struggled with declining state funding — repay all $3.1 million it had received for Pavuluri’s study.

In issuing the rare rebuke, federal officials concluded that Pavuluri’s “serious and continuing noncompliance” with rules to protect human subjects violated the terms of the grant. NIMH said she had “increased risk to the study subjects” and made any outcomes scientifically meaningless, according to documents obtained by ProPublica Illinois.

Pavuluri’s research is also under investigation by two offices in the U.S. Department of Health and Human Services: the inspector general’s office, which examines waste, fraud and abuse in government programs, according to subpoenas obtained by ProPublica Illinois, and the Office of Research Integrity, according to university officials.

The article is here.

Tuesday, March 20, 2018

The Psychology of Clinical Decision Making: Implications for Medication Use

Jerry Avorn
February 22, 2018
N Engl J Med 2018; 378:689-691

Here is an excerpt:

The key problem is medicine’s ongoing assumption that clinicians and patients are, in general, rational decision makers. In reality, we are all influenced by seemingly irrational preferences in making choices about reward, risk, time, and trade-offs that are quite different from what would be predicted by bloodless, if precise, quantitative calculations. Although we physicians sometimes resist the syllogism, if all humans are prone to irrational decision making, and all clinicians are human, then these insights must have important implications for patient care and health policy. There have been some isolated innovative applications of that understanding in medicine, but despite a growing number of publications about the psychology of decision making, most medical care — at the bedside and the systems level — is still based on a “rational actor” understanding of how we make decisions.

The choices we make about prescription drugs provide one example of how much further medicine could go in taking advantage of a more nuanced understanding of decision making under conditions of uncertainty — a description that could define the profession itself. We persist in assuming that clinicians can obtain comprehensive information about the comparative worth (clinical as well as economic) of alternative drug choices for a given condition, assimilate and evaluate all the findings, and synthesize them to make the best drug choices for our patients. Leaving aside the access problem — the necessary comparative effectiveness research often doesn’t exist — actual drug-utilization data make it clear that real-world prescribing choices are in fact based heavily on various “irrational” biases, many of which have been described by behavioral economists and other decision theorists.

The article is here.

Wednesday, November 29, 2017

The Hype of Virtual Medicine

Ezekiel J. Emanuel
The Wall Street Journal
Originally posted Nov. 10, 2017

Here is an excerpt:

But none of this will have much of an effect on the big and unsolved challenge for American medicine: how to change the behavior of patients. According to the Centers for Disease Control and Prevention, fully 86% of all health care spending in the U.S. is for patients with chronic illness—emphysema, arthritis and the like. How are we to make real inroads against these problems? Patients must do far more to monitor their diseases, take their medications consistently and engage with their primary-care physicians and nurses. In the longer term, we need to lower the number of Americans who suffer from these diseases by getting them to change their habits and eat healthier diets, exercise more and avoid smoking.

There is no reason to think that virtual medicine will succeed in inducing most patients to cooperate more with their own care, no matter how ingenious the latest gizmos. Many studies that have tried some high-tech intervention to improve patients’ health have failed.

Consider the problem of patients who do not take their medication properly, leading to higher rates of complications, hospitalization and even mortality. Researchers at Harvard, in collaboration with CVS, published a study in JAMA Internal Medicine in May comparing different low-cost devices for encouraging patients to take their medication as prescribed. The more than 50,000 participants were randomly assigned to one of three options: high-tech pill bottles with digital timer caps, pillboxes with daily compartments or standard plastic pillboxes. The high-tech pill bottles did nothing to increase compliance.

Other efforts have produced similar failures.

The article is here.

Sunday, November 19, 2017

Rigorous Study Finds Antidepressants Worsen Long-Term Outcomes

Peter Simons
Originally posted

Here is an excerpt:

These results add to a body of research that indicates that antidepressants worsen long-term outcomes. In an article published in 1994, the psychiatrist Giovanni Fava wrote that “Psychotropic drugs actually worsen, at least in some cases, the progression of the illness which they are supposed to treat.” In a 2003 article, he wrote: “A statistical trend suggested that the longer the drug treatment, the higher the likelihood of relapse.”

Previous research has also found that antidepressants are no more effective than placebo for mild-to-moderate depression, and other studies have questioned whether such medications are effective even for severe depression. Concerns have also been raised about the health risks of taking antidepressants—such as a recent study which found that taking antidepressants increases one’s risk of death by 33% (see MIA report).

In fact, studies have demonstrated that as many as 85% of people recover spontaneously from depression. In a recent example, researchers found that only 35% of people who experienced depression had a second episode within 15 years. That means that 65% of people who have a bout of depression are likely never to experience it again.

Critics of previous findings have argued that it is not fair to compare those receiving antidepressants with those who do not. They argue that initial depression severity confounds the results—those with more severe symptoms may be more likely to be treated with antidepressants. Thus, according to some researchers, even if antidepressants worked as well as psychotherapy or receiving no treatment, those treated with antidepressants would still show worse outcomes—because they had more severe symptoms in the first place.

The article is here.

The target article is here.

Monday, July 25, 2016

Consciousness: The Mind Messing With the Mind

By George Johnson
The New York Times
Originally published July 4, 2016

Here is an excerpt:

Michael Graziano, a neuroscientist at Princeton University, suggested to the audience that consciousness is a kind of con game the brain plays with itself. The brain is a computer that evolved to simulate the outside world. Among its internal models is a simulation of itself — a crude approximation of its own neurological processes.

The result is an illusion. Instead of neurons and synapses, we sense a ghostly presence — a self — inside the head. But it’s all just data processing.

“The machine mistakenly thinks it has magic inside it,” Dr. Graziano said. And it calls the magic consciousness.

It’s not the existence of this inner voice he finds mysterious. “The phenomenon to explain,” he said, “is why the brain, as a machine, insists it has this property that is nonphysical.”

The article is here.

Friday, March 11, 2016

Notes From Psychiatry’s Battle Lines

By George Makari
The New York Times - Opinionator
February 23, 2016

Here is an excerpt:

Consider this: Like most clinicians, I am eager for scientific progress, something new that will yield more clarity and provide my patients with faster or deeper relief. However, as I take stock of a new “neuroenhancer,” or the latest genetic correlation that may point to the cause of an illness, or a suddenly popular diagnosis, the historian in me senses ghosts beginning to stir.

Historians have shown that psychiatry has long suffered from the adoption of scientific-sounding theories and cures that turned out to be dogma. Perhaps the clearest example of such “scientism” was psychiatry’s embrace, in the early 19th century, of Franz Joseph Gall’s phrenology, in which all mental attributes and deficiencies were assigned to specific brain locales, evidence be damned. During much of the 20th century, psychoanalysis proposed far more conclusive answers than it could support, and today, the same could be said for some incautious neurobiological researchers.

The article is here.

Wednesday, September 2, 2015

Antidepressants Make it Harder to Empathize, Harder to Climax, and Harder to Cry

Big Think
Published on Apr 7, 2015

Dr. Julie Holland argues that women are designed by nature to be dynamic and sensitive – women are moody and that is a good thing. Yet millions of women are medicating away their emotions because we are out of sync with our own bodies and we are told that moodiness is a problem to be fixed. One in four women takes a psychiatric drug. If you add sleeping pills to the mix the statistics become higher. Overprescribed medications can have far-reaching consequences for women in many areas of our lives: sex, relationships, sleep, eating, focus, balance, and aging. Dr. Holland's newest book is titled Moody Bitches: The Truth About the Drugs You’re Taking, the Sleep You’re Missing, the Sex You’re Not Having and What’s Really Making You Crazy.

Tuesday, July 28, 2015

Parkinson’s and depression drugs can alter moral judgment

By Hannah Devlin
The Guardian
Originally posted July 2, 2015

Common drugs for depression and Parkinson’s can sway people’s moral judgments about harming others, according to research that raises ethical questions about the use of the drugs.

The study found that when healthy people were given a one-off dose of a serotonin-boosting drug widely used to treat depression they became more protective of others, paying almost twice as much to prevent them receiving an electric shock in a laboratory experiment. They also became more reluctant to expose themselves to pain.

The scientists also found that the dopamine-enhancing Parkinson’s drug, levodopa, made healthy people more selfish, wiping out the normal tendency to prefer to receive an electric shock themselves, while sparing those around them.

The entire article is here.

Monday, January 19, 2015

Early Death for Severe Mental Illness?

By Allen Frances
The Huffington Post Blog
Originally published December 30, 2014

People diagnosed with serious mental illness -- schizophrenia, bipolar disorder, or severe depression -- die 20 years early, on average, because of a combination of lousy medical care, smoking, lack of exercise, complications of medication, suicide, and accidents. They are the most discriminated-against and neglected group in the U.S., which has become probably the worst place in the developed world to be mentally ill.

In many previous blog posts I have bemoaned the shameful state of psychiatric care and housing for people with severe mental illness. My conclusion was that the United States has become the worst place, and now the worst time ever, to have a severe mental illness. Hundreds of thousands of the severely ill languish inappropriately in prisons. Additional hundreds of thousands are homeless on the street.

The entire blog post is here.