The Therapist Will See You Now, via the Web

The New York Times
By Randall Stross

SEE a therapist without leaving your home?

In an article in the American Journal of Psychiatry, Dr. Thomas F. Dwyer, a Massachusetts psychiatrist, says he has practiced “telepsychiatry,” via video teleconferencing, for five years. Its “adoption by psychiatrists and patients,” he predicts, “will proceed quickly if the organizers cope with the irrational responses of some users.”

But wait: That article appeared almost 40 years ago. It told how microwave television signals were used to connect a satellite clinic to Massachusetts General Hospital in Boston.

Today, even with the rise of the Internet, virtual therapy hasn’t been widely adopted. But several start-up companies are trying to make Dr. Dwyer’s decades-old vision a workaday reality.

Therapy delivered over the Internet, says Lynn Bufka, a psychologist and staff member of the American Psychological Association, “may open access to those who might be reluctant to go to an office or to those who might be physically or psychologically unable to.”

Proponents of Internet-based therapy point to some research suggesting that it is effective for certain kinds of conditions, like depression and anxiety. Reporting in The Lancet in 2009, a team of researchers found that cognitive-behavioral therapy delivered remotely to depressed patients in Britain continued to show benefits eight months later.

But companies promoting online therapy must contend with uneven or absent support from insurance companies, Medicare and Medicaid. Most states don’t require insurers to pay for “telehealth” services (those not delivered in person). And any reimbursements can be less substantial than for in-person treatment. Medicare offers reimbursement only if providers are very scarce, as in rural areas.

One company that is trying to match patients to therapists online is Cope Today, based in Raleigh, N.C. Tania S. Malik, its chief executive, said the company, which began in 2010, worked with the North Carolina National Guard for a pilot test of its service. It has since opened its service to individuals, whom it attracts primarily with search ads that are keyed to phrases like “online counseling” or “treating anxiety.”

Cope Today lets prospective clients view a list of therapists and their availability for consultation via video, phone or online chat. It provides the first 10 minutes of a session free, then charges $35 for 15-minute increments.

The entire story can be read here.

Researchers Create The First Artificial Neural Network Out Of DNA

Medical News Today

Deborah Williams-Hedges

California Institute of Technology 

Artificial intelligence has been the inspiration for countless books and movies, as well as the aspiration of countless scientists and engineers. Researchers at the California Institute of Technology (Caltech) have now taken a major step toward creating artificial intelligence - not in a robot or a silicon chip, but in a test tube. The researchers are the first to have made an artificial neural network out of DNA, creating a circuit of interacting molecules that can recall memories based on incomplete patterns, just as a brain can.

"The brain is incredible," says Lulu Qian, a Caltech senior postdoctoral scholar in bioengineering and lead author on the paper describing this work, published in the July 21 issue of the journal Nature. "It allows us to recognize patterns of events, form memories, make decisions, and take actions. So we asked, instead of having a physically connected network of neural cells, can a soup of interacting molecules exhibit brainlike behavior?"

The answer, as the researchers show, is yes.

Consisting of four artificial neurons made from 112 distinct DNA strands, the researchers' neural network plays a mind-reading game in which it tries to identify a mystery scientist. The researchers "trained" the neural network to "know" four scientists, whose identities are each represented by a specific, unique set of answers to four yes-or-no questions, such as whether the scientist was British. 

After thinking of a scientist, a human player provides an incomplete subset of answers that partially identifies the scientist. The player then conveys those clues to the network by dropping DNA strands that correspond to those answers into the test tube. Communicating via fluorescent signals, the network then identifies which scientist the player has in mind. Or, the network can "say" that it has insufficient information to pick just one of the scientists in its memory or that the clues contradict what it has remembered. The researchers played this game with the network using 27 different ways of answering the questions (out of 81 total combinations), and it responded correctly each time.

This DNA-based neural network demonstrates the ability to take an incomplete pattern and figure out what it might represent - one of the brain's unique features. "What we are good at is recognizing things," says coauthor Jehoshua "Shuki" Bruck, the Gordon and Betty Moore Professor of Computation and Neural Systems and Electrical Engineering. "We can recognize things based on looking only at a subset of features." The DNA neural network does just that, albeit in a rudimentary way.

Biochemical systems with artificial intelligence - or at least some basic, decision-making capabilities - could have powerful applications in medicine, chemistry, and biological research, the researchers say. In the future, such systems could operate within cells, helping to answer fundamental biological questions or diagnose a disease. Biochemical processes that can intelligently respond to the presence of other molecules could allow engineers to produce increasingly complex chemicals or build new kinds of structures, molecule by molecule. 

Read the entire story here.

The original article in Nature is here.

Heart Warning Added to Label on Popular Antipsychotic Drug

The New York Times
by Duff Wilson

AstraZeneca is adding a new heart warning to the labels of Seroquel, its blockbuster antipsychotic drug, at the request of the Food and Drug Administration, company and agency officials said on Monday (July 18, 2011).

The revised label, posted without fanfare last week on the F.D.A. Web site, says Seroquel and extended-release Seroquel XR “should be avoided” in combination with at least 12 other medicines linked to a heart arrhythmia that can cause sudden cardiac arrest.

Sandy Walsh, a spokeswoman for the F.D.A., said the statement was only a precaution for doctors, and should not be considered a complete ban against prescribing Seroquel with the other drugs.

Ms. Walsh said the label was changed after the F.D.A. received new information about reports of arrhythmia in 17 people who took more than the recommended doses of Seroquel. Though it should not be a problem at a normal dosage, she said, it may still be good advice to avoid using the drugs together.

The arrhythmia, known as prolongation of the QT interval, referring to two waves of the heart’s electrical rhythm, is estimated to cause several thousand deaths a year in the United States.

As AstraZeneca prepares to report its second-quarter earnings at the end of this month, it faces additional scrutiny this week. The F.D.A. is considering the London-based company’s dapagliflozin, a proposed diabetes drug with Bristol-Myers Squibb, and is expected to decide soon on Brilinta, an anticoagulant. The company is facing the loss of patents for Seroquel next year and for the heartburn drug Nexium in 2014.

Seroquel is one of the top-selling drugs in the world, at $5.3 billion last year, including $3.7 billion in the United States. Introduced in 1997, it has been approved for schizophrenia, bipolar disorder and severe depression. Seroquel has caused legal problems for AstraZeneca, including a $520 million payment in 2009 to settle government charges of illegal marketing. Thousands of lawsuits are pending over side effects like diabetes.

The previous Seroquel labels had mentioned the risk of a prolonged QT interval, but had not identified other drugs to avoid, Stephanie Andrzejewski, a spokeswoman for AstraZeneca, said Monday. The new warning also is separated from other warnings and precautions on the label, she said, “to provide some additional guidance to physicians” treating patients ”who are already at risk of QT prolongation.”

The new warning will be added to printed labels as soon as possible, Ms. Andrzejewski said.

The new label lists the other drugs to avoid as antiarrhythmic drugs like quinidine, procainamide, amiodarone and sotalel; antipsychotic drugs like ziprasidone, chlorpromazine and thioridazine; antibiotics like gatifloxacin and moxifloxacin; the anti-infective drug pentamidine; and synthetic opioids like levomethadyl acetate and methadone. The label also raises caution about use by the aged and people with heart disease.

James J. Pepper, a lawyer in Pennsylvania who is involved in drug litigation, has been arguing for months in letters to government officials that Seroquel has a potentially deadly interaction with methadone in regard to the QT interval.

“This is a huge, huge step,” Mr. Pepper said of the label change, though he said he thought it should be stronger.

Ms. Walsh said the F.D.A. action was unrelated to Mr. Pepper’s arguments.

Three months ago, Dr. Janet Woodcock, director of the F.D.A. Center for Drug Evaluation and Research, rejected those arguments in a letter to the Project on Government Oversight, a nonprofit group in Washington, which had also raised the issues. Dr. Woodcock wrote that a thorough agency review had found it “exceedingly unlikely” that patients faced an unreasonable risk from the interaction between Seroquel and methadone. The review found only one death that was probably caused by the interaction, she wrote.

Dr. Woodcock concluded that the F.D.A. would take no action to change the label. Ms. Walsh said that conclusion was still correct, because the F.D.A. had found no biological basis for a problem or unusual numbers of deaths at normal dosages.

Methadone use and deaths have increased drastically in recent years as more doctors prescribe it for chronic pain. The number of methadone prescriptions for pain in the United States rose to 4.3 million in 2010 from 2.2 million in 2006, IMS Health, an industry data firm, said Monday. The use for pain has surpassed that for heroin withdrawal and maintenance.

Harvard Psychologist Resigns

The Chronicle of Higher Education
by Tom Bartlett

Marc Hauser, PhD

Marc D. Hauser, the Harvard psychologist found responsible for eight counts of scientific misconduct by the university, has resigned, ending speculation about whether the embattled professor would return to campus this fall.

In a letter dated July 7, Mr. Hauser wrote to Michael D. Smith, Harvard's dean of the Faculty of Arts and Sciences, that he was resigning effective August 1 because he had "some exciting opportunities in the private sector" and that he had been involved in some "extremely interesting and rewarding work focusing on the educational needs of at-risk teenagers."

The letter states that he may return to teaching and research "in the years to come." It does not mention the scandal that damaged his once-stellar reputation and stunned his colleagues in the field.

Last August, The Boston Globe reported that a university investigation had found Mr. Hauser guilty of misconduct, though the nature of that misconduct remained murky. The picture became somewhat clearer after Mr. Smith, the Harvard dean, sent a letter to faculty members saying that Mr. Hauser was "solely responsible" for eight instances of wrongdoing involving three published and five unpublished studies.

An internal document provided last August to The Chronicle by a former research assistant in Mr. Hauser's laboratory revealed how members of the lab believed Mr. Hauser was reporting faulty data and included e-mails demonstrating how he had pushed back when they had brought problems to his attention. Several lab members alerted the university's ombudsman, setting in motion an investigation that would lead to the seizure of computers and documents from Mr. Hauser's laboratory in the fall of 2007.

Read the entire article here.

Facebook friend request from a patient?

The Lancet, Volume 377, Issue 9772, Pages 1141 - 1142, 2 April 2011

doi:10.1016/S0140-6736(11)60449-2

Sharmila Devi

Widespread use of new technologies such as social networking sites are creating ethical problems for physicians that some doctors' organisations are beginning to address. Sharmila Devi reports.

Social networking sites such as Facebook and the ubiquity of search engines such as Google are creating new medical ethical dilemmas as physicians around the world grapple with how to responsibly include new technologies in their professional lives.

In the USA, birthplace of most of these technological advances, various associations of health-care professionals are starting to issue codes of conduct when dealing with new digital media. Other countries, such as the UK, Canada, and Australia, are also debating what rules should be set. But some doctors believe such codes will have to evolve and adapt as younger generations, used to living an online life from an early age, start to dominate health care and to teach subsequent waves of professionals.

Websites such as Facebook allow individuals to post messages, photos, and videos and share them with an online group of friends. They can also be used to reach out professionally to a wider range of people than was possible with some traditional marketing methods. But used unwisely, such sites can blur the lines between the personal and professional and cause embarrassment.

“Older generations will moralise and say it's unethical and unprofessional [to be friends with clients on sites such as Facebook]”, says Ofer Zur, an Israeli psychologist based in California, USA, who offers online courses in digital medical ethics. “Younger generations have less of a sense of hierarchy and see the internet as an equaliser that opens doors. I am typical of the older generation because I sometimes cringe at the things my daughter posts online.”

Although it would seem obvious for many professionals to maintain as strict a boundary between them and clients in the online world as in the physical world, Zur said online interactions should be looked at on a case-by-case basis. For example, a physician in a small community might find that Facebook simply replicated the flow of information that already took place amid existing close relationships, he says.

Cases where health-care professionals have taken things too far are rare but well publicised. In February, a physician assistant working at a medical centre in New York state was found to have posted photos on Facebook showing him holding a syringe at a man's neck. He said: “When you can't start a line in a junkie's arm…go for the neck”, reported The Journal News, a local newspaper.

Such behaviour is unanimously condemned as inappropriate. More difficult to answer are questions such as whether health-care professionals should be allowed to research a client's background on the search engine Google? Does a blog's informative value outweigh any possible breach of confidentiality? Should medical students post online any personal information about themselves for fear of jeopardising relations with future clients and employers? “Questions about the internet are becoming a common inquiry among our members who want to take advantage of it, especially younger members and students, and the number one concern is confidentiality and how to preserve it”, says Erin Martz, manager of ethics and professional standards at the American Counselling Association. “We actually just received our first ethical complaint that's Facebook-connected and technically-driven. I do think Facebook can be quite dangerous.”

The rest of the article is here and can be accessed through psycnet.apa.org/psycinfo with your APA log in.

Bullying and Suicide: Detection and Intervention

By Anat Brunstein Klomek, PhD, Andre Sourander, MD and 
Madelyn S. Gould, PhD, MPH

Psychiatric Times

Bullying is recognized as a major public health problem in the Western world, and it appears to have devastating consequences. Cyberbullying has become an increasing public concern in light of recent cases associated with youth suicides that have been reported in the mass media.

Most of the studies that have examined the association between bullying and suicidality have been cross-sectional. Those studies show that bullying behavior in youth is associated with depression, suicidal ideation, and suicide attempts. These associations have been found in elementary school, middle school, and high school students. Moreover, victims of bullying consistently exhibit more depressive symptoms than nonvictims; they have high levels of suicidal ideation and are more likely to attempt suicide than nonvictims.

The results pertaining to bullies are less consistent. Some studies show an association with depression, while others do not. The prevalence of suicidal ideation is higher in bullies than in persons not involved in bullying behavior. Studies among middle school and high school students show an increased risk of suicidal behavior among bullies and victims. Both perpetrators and victims are at the highest risk for suicidal ideation and behavior.

Suicide risk by sex

Cross-sectional studies of the differential impact of school bullying by sex on the risk of depression and suicidal ideation have shown significant associations, but the results are not consistent. Some researchers have found stronger associations among girls.

Kim and colleagues¹ reported that girls who were involved with school bullying (as either victim or perpetrator) were at significantly greater risk for suicidal ideation. Roland² found that girls who were bullies had more suicidal thoughts. Van der Wal and colleagues³ found a strong association between being bullied and depression and suicidal ideation in girls, and Luukkonen and colleagues⁴ found that being bullied and bullying others are both potential risk factors for suicidal behavior in girls.

On the other hand, Rigby and Slee⁵ found that the association between being a bully and suicidal ideation applied only to boys. McMahon and colleagues6 recently reported that boys who had been bullied at school were more depressed and had a higher risk of thoughts about harming themselves and self-harming behavior than boys who had not been bullied. Kaltiala-Heino and colleagues⁷ reported that among girls, severe suicidal ideation was associated with frequently being bullied or being a bully and for boys it was associated with being a bully. No association was found between boys and girls for depressive symptoms.⁸

Our earlier work tried to explain the differences in the risks of depression and suicidality between girls and boys; we suggested that there is a difference in the threshold for depression and suicide between the sexes.⁹ Girls who bullied others were at risk for depression, suicidal ideation, and suicide attempts even when the bullying was infrequent. However, only frequent bullying was associated with depression, suicidal ideation, and suicide attempts among boys.

There may be a different sex threshold in victimization as well. Among girls, victimization at any frequency increased the risk of depression, suicidal ideation, and suicide attempts. On the other hand, only frequent victimization increased the risk of depression and suicidal ideation in boys, although infrequent victimization was associated with an increased risk of suicide attempts.

The rest of the article can be found here.  The reader can sign up for Psychiatric Times (free) or google the title of this blog for the entire story.

Judge grants The Oregonian's request to release mental health evaluation

By Stuart Tomlinson, The Oregonian
Published June 22, 2011

A Columbia County Circuit Court judge has granted The Oregonian’s May request to release the mental health evaluation of Daniel Butts, officials said today.

Columbia County District Attorney Steve Atchison said Columbia County Judge Ted Grove will allow the release of the Butts’ mental health evaluation on July 15, one week before a scheduled hearing to determine if Butts can aid and assist in his defense.

Atchison said the mental health evaluation of Butts, 21, who is accused of shooting of Rainier Police Chief Ralph Painter on Jan. 5, was completed in mid-April. The evaluation was done by an Oregon doctor who traveled twice to the Columbia County Jail in St. Helens to assess Butts’ mental state.
It will be up to Grove to determine, based on the report, if Butts can assist in his defense. Atchison said the judge could rule that Butts can aid in his defense or is unable to aid in his defense. The judge could also ask for additional evaluations.

Under Oregon law, an aid and assist hearing is held, according to the statute, “if the court has reason to doubt defendant’s fitness.”

It can order an examination to determine if the defendant is incapacitated by mental illness; if he can understand the nature of the proceedings; assist and cooperate with his attorneys; and participate in his own defense.

After a hearing in February, Atchison emphasized that the evaluation and any treatment for mental illness is to make sure Butts can aid in his defense.

The entire story can be read here.

The Menace Within: The Stanford Prison Experiment

What happened in the basement of the psych building 40 years ago shocked the world. How do the guards, prisoners and researchers in the Stanford Prison Experiment feel about it now?

By Romesh ratnesar

It began with an ad in the classifieds.

Male college students needed for psychological study of prison life. $15 per day for 1-2 weeks. More than 70 people volunteered to take part in the study, to be conducted in a fake prison housed inside Jordan Hall, on Stanford's Main Quad. The leader of the study was 38-year-old psychology professor Philip Zimbardo. He and his fellow researchers selected 24 applicants and randomly assigned each to be a prisoner or a guard.

Zimbardo encouraged the guards to think of themselves as actual guards in a real prison. He made clear that prisoners could not be physically harmed, but said the guards should try to create an atmosphere in which the prisoners felt "powerless."

The study began on Sunday, August 17, 1971. But no one knew what, exactly, they were getting into.

Forty years later, the Stanford Prison Experiment remains among the most notable—and notorious—research projects ever carried out at the University. For six days, half the study's participants endured cruel and dehumanizing abuse at the hands of their peers. At various times, they were taunted, stripped naked, deprived of sleep and forced to use plastic buckets as toilets. Some of them rebelled violently; others became hysterical or withdrew into despair. As the situation descended into chaos, the researchers stood by and watched—until one of their colleagues finally spoke out.

The public's fascination with the SPE and its implications—the notion, as Zimbardo says, "that these ordinary college students could do such terrible things when caught in that situation" —brought Zimbardo international renown. It also provoked criticism from other researchers, who questioned the ethics of subjecting student volunteers to such extreme emotional trauma. The study had been approved by Stanford's Human Subjects Research Committee, and Zimbardo says that "neither they nor we could have imagined" that the guards would treat the prisoners so inhumanely.

In 1973, an investigation by the American Psychological Association concluded that the prison study had satisfied the profession's existing ethical standards. But in subsequent years, those guidelines were revised to prohibit human-subject simulations modeled on the SPE. "No behavioral research that puts people in that kind of setting can ever be done again in America," Zimbardo says.

The Stanford Prison Experiment became the subject of numerous books and documentaries, a feature film and the name of at least one punk band. In the last decade, after the revelations of abuses committed by U.S. military and intelligence personnel at prisons in Iraq and Afghanistan, the SPE provided lessons in how good people placed in adverse conditions can act barbarically.

The experiment is still a source of controversy and contention—even among those who took part in it. Here, in their own words, some of the key players in the drama reflect on their roles and how those six days in August changed their lives.

     *          *          *          *          *

The entire article can be here.  The article brings up a host of ethical issues related to research.

Upcoming Article: Is Coming Out Always a 'Good Thing'?

*Social Psychological and Personality Science* has scheduled an article for publication in a future issue of the journal: "Is Coming Out Always a 'Good Thing'? Exploring the Relations of Autonomy Support, Outness, and Wellness for Lesbian, Gay, and Bisexual Individuals."

The authors are Nicole Legate, Richard M. Ryan, and Netta Weinstein.

Disclosing a lesbian, gay, and bisexual (LGB) identity to others, or ''coming out,'' has been shown in past research to be associated with mental health benefits (e.g., Ragins, 2004).

Yet, in a world that can be unaccepting of nonheterosexual orientations, coming out also involves risk. LGB individuals may anticipate stigmatization, negative judgments, or rejection feelings that deter them from self-disclosing their sexual identity.

Recent legislation like Don't Ask Don't Tell provides a clear example of this risk: those who came out as LGB in the military were discharged from service. Indeed, some research suggests that coming out can result in other negative consequences such as costs to well-being (D'Augelli, 2006).

It is thus the case that many LGB individuals are selective, varying from context to context in how much they disclose their sexual identity to others.

In the present article, we explore this within-person variability in disclosure using a self-determination theory framework (SDT; Deci & Ryan, 1985, 2000; Ryan & Deci, 2000). SDT (Ryan & Deci, 2000) is a theory of personality and motivation that concerns how social contexts impact motivation and well-being.

According to SDT, social contexts vary in their levels of autonomy support, defined as interpersonal acceptance and support for authentic self-expression (Lynch, La Guardia, & Ryan, 2009; Ryan, La Guardia, Solky-Butzel, Chirkov, & Kim, 2005).

In environments high in autonomy support, people feel accepted for who they are, are free to act and express themselves, and are more open to rely on others. In contrast, in controlling environments, people feel pressured to appear, behave, or perform a certain way (Deci & Ryan, 1985), and they exhibit less openness and more defensiveness (Hodgins et al., 2010).

It is thus likely that autonomy supportive environments reduce perceived risks for coming out, whereas in environments perceived as controlling individuals may be less likely to express a potentially stigmatized part of themselves that could incur censure.

In addition, we argue that the autonomy supportiveness of an environment influences the well-being experienced in that environment as a result of disclosure. Specifically, we expect that LGB individuals who disclose in environments low in autonomy support will not experience the typical boost to wellness from coming out reported in the literature.

Here's how the article ends:

"This research has implications for practitioners providing treatment to LGB individuals because it suggests that people experience greater wellness when they come out in certain contexts, but certainly not all contexts. This research also has implications for workplaces. Providing autonomy support is beneficial for all employees (Baard et al., 2004), but may be especially important for LGB employees' wellness and productivity. Future research should look at disclosing in workplaces that foster self-expression versus controlling work environments and compare wellness and productivity of employees of different sexual orientations. More generally the findings may speak to factors that can facilitate greater openness and wellness in individuals who face stigma, as well as to the costs of controlling social contexts and the self-concealment they often foster."

Thanks to Ken Pope for this information.