Tag Archives: Medicine

Beware Mind Drugs

One in eight Americans take prescribed mind drugs, which probably hurt on average (vs. talking cures):

I first took a close look at treatments for mental illness 15 years ago while researching an article for Scientific American. At the time, sales of a new class of antidepressants, … SSRI’s, were booming. … Clinical trials told a different story. SSRI’s are no more effective than two older classes of antidepressants. … Antidepressants as a whole were not more effective than so-called talking cures. … According to some investigators, treatments for depression and other common ailments work—if they do work—by harnessing the placebo effect. …

In retrospect, my critique of modern psychiatry was probably too mild. According to Anatomy of an Epidemic … by … Robert Whitaker, psychiatry has not only failed to progress but may now be harming many of those it purports to help. …

As recently as the 1950s, Whitaker contends, the four major mental disorders—depression, anxiety disorder, bipolar disorder, and schizophrenia—often manifested as episodic and “self limiting”; that is, most people simply got better over time. Severe, chronic mental illness was viewed as relatively rare. But over the past few decades the proportion of Americans diagnosed with mental illness has skyrocketed. … One in eight Americans, including children and even toddlers, is now taking a psychotropic medication. …

Whitaker compiles anecdotal and clinical evidence that when patients stop taking SSRI’s, they often experience depression more severe than what drove them to seek treatment. A multination report by the World Health Organization in 1998 associated long-term antidepressant usage with a higher rather than a lower risk of long-term depression. …

Before the introduction of Thorazine in the 1950s, Whitaker asserts, almost two-thirds of the patients hospitalized for an initial episode of schizophrenia were released within a year, and most of this group did not require subsequent hospitalization. Over the past half-century, the rate of schizophrenia-related disability has grown by a factor of four, and schizophrenia has come to be seen as a largely chronic, degenerative disease. A decades-long study by the World Health Organization found that schizophrenic patients fared better in poor nations, such as Nigeria and India, where antipsychotics are sparingly prescribed. …

Beginning in the 1970s, Harrow tracked a group of 64 newly diagnosed schizophrenics. Forty percent of the nonmedicated patients recovered—meaning that they could become self-supporting—versus 5 percent of those who were medicated. … Electroconvulsive therapy … fell out of favor in the 1970s, in part because of its negative portrayal in the 1975 film One Flew Over the Cuckoo’s Nest, and yet about 100,000 Americans a year still receive ECT. … virtually everyone who receives electroconvulsive therapy relapses within a year without further treatment. (more)

Added 1p: I’ve blogged before on antidepressants as placebos.

Added 21Sept: Yvian has convinced me to doubt the claim above I had found most interesting, that schizophrenia changed from a temporary to a chronic condition. So now I doubt this author in general as a source.

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Downturn Cuts Exercise

It turns out that death rates fall during recessions. I posted in January on how some had speculated that people eat better during recessions, but in fact people seem to eat worse food. Now I can report that people also get less exercise during recessions:

Recreational exercise tends to increase as employment decreases. In addition, we also find that individuals substitute into television watching, sleeping, childcare, and housework. However, this increase in exercise as well as other activities does not compensate for the decrease in work-related exertion due to job-loss. Thus total physical exertion, which prior studies have not analyzed, declines. These behavioral effects are strongest among low-educated males. (more)

The healthy-recession puzzle deepens.

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Are Nations Tribes?

Ezra Klein:

During Monday’s debate, CNN’s Wolf Blitzer asked whether an uninsured 30-year-old who had chosen to go without insurance should be left to die if he falls unexpectedly ill. Ron Paul dodged the question. … If you collapse on a street, an ambulance will rush you to a hospital. If you get into a car accident, you’ll wake up in intensive care. … Whether you get billed or your family gets billed or society gets billed, someone will pay the bill. … Even the hardest of libertarians has always understood that there are places where your person ends and mine begins. Generally, we think of this in terms of violent intrusion or property transgressions. But in health care, it has to do with compassion. We are a decent society, and we do not want to look in people’s pockets for an insurance card when they fall to the floor with chest pains.

But a great many ill, collapsed, etc. folks in the world are largely left to die, at least if curing them costs anything like a US hospital stay. Ezra argues above for “decent” national care, not global care. And even libertarians wouldn’t leave family members to die. So everyone agrees that we heroically help some, and leave others to die. We only disagree on who falls into which category.

I see key similarities between this and many responses to my recent posts, such as on 9/11, alien elites, or immigration. Such as: How can I not see that 9/11 deaths matter far more than most deaths, because this was them attacking our way of life? Or that alien elites secretly running our society, even running it well, must be exterminated though that would be unreasonable for human elites? Or that the richest big US county, Fairfax County, shouldn’t restrict immigration from poorer counties because we US folks are similar enough to each other?

Humans clearly evolved quite different mental modes for thinking about how to treat folks with our our local tribe, vs. how to treat distant strangers. Libertarians largely accept the usual ideas about how to treat both groups. Where they disagree is who counts as a stranger.

Libertarians limit “my tribe” to close family and small chosen communities, much as did our forager ancestors, who were free to change bands at any time. Farmer culture taught farmers to think of distant strangers as “my tribe”, as long as “our elites” said so, or if “we” fought wars together. And nation-states have worked hard over the last few centuries to transfer this feeling to nations. Libertarians mostly just don’t accept this. And though I’m not strictly libertarian, on this I agree – it is far from obvious that nations must be our tribes.

Now people usually try to be nicer to their tribe than to distant strangers. From this one might conclude that libertarians, who see more folks as strangers, are not as nice people. But not only are folks who see their tribe as smaller usually nicer to such insiders, libertarians also tend to be more accepting of mutually beneficial interactions with strangers. And economists make a pretty strong case that libertarian policies such as free immigration would greatly improve overall welfare.

As with Ezra’s comments above, most critiques of libertarian policy seem to miss this central point, by invoking standard ways to classify folks into “us” and “them.” To criticize libertarians effectively, you need to make clear why exactly “we” are a nation, rather than the entire world, or close family and friends. Alas, few critics even try to argue this point.

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The Poor Are Not Fat

In both the popular press and academic research, there is the argument that the growth of fast food and energy-dense food has been an important cause of the overweight epidemic in the U.S. and that this has disproportionately affected poor people. [Some] argue that limited economic resources may shift dietary choices toward a diet that provides maximum calories at the least cost. An implication of this line of research is that the poor cannot afford healthy diets. (more; ungated)

In fact, however, the poor are on average not fatter than the rich:

Contrary to conventional wisdom, … the poor have never had a statistically significant higher prevalence of overweight status at any time in the last 35 years. Despite this empirical evidence, the view that the poor are less healthy in terms of excess accumulation of fat persists.

A new paper manages to find a relation between poverty and fat – both the very fattest and the very thinnest people tend to be poor:

Distribution-sensitive measures of overweight … [show] that the severity of overweight has been higher for the poor than the nonpoor throughout the last 35 years. … The strongest relationship between income and BMI is observed at the tails of the distribution. … For those at the tails of the BMI distribution, increases in income are correlated with healthier BMI values.

OK, but this hardly supports a general story that the poor can’t afford healthy diets. It fits much better with there being a small fraction of “broken” folks who tend both to have low abilities to earn money, and to have an unhealthy weight, both too high and too low.

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Expats Like Cryonics

At the end of that ABC Good Morning America segment on cryonics, they pointed viewers to a poll on “Would you have your body cryonically frozen after death?”  Out of 15,335 answers so far, 78% said “No, that’s too weird!”, 14% “I’m not sure”, and 8% “Yes, I believe in the science.” Of course these are mostly made up opinions; far less than 8% of the show’s 4.6 million viewers of the show will actually sign up. (Over forty years, only two thousand have signed up worldwide.)

Interestingly, the poll website shows a graphic that breaks votes down by location, and the 274 who live outside the US, probably expats, like cryonics the most – 18% say yes and 19% not sure. Arizona, where the cryonics provider Alcor is located, is second at, 13% yes, 14% not sure, out of 146. (I ignore Rhode Island, with only 26 votes.) Are people more comfortable with moving to foreign lands also more comfortable with moving to the future?!

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Me On Good Morning America

Tomorrow morning at 8a EST I’ll appear on ABC’s Good Morning America, talking about cryonics. [Added:] The part on cryonics is at minutes 28:30-33:45 here; I’m at 31:50-32:50. Just my episode can be found here:

Some quotes are here. The show has 4.6 million viewers! So I had about as many TV viewers today as I’ve had blog post visits ever.

Added: Britney Spears is apparently a new cryonics customer.

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The Oregon Health Insurance Experiment

Two weeks ago the first paper was released reporting results from a new important medical study, the Oregon Health Insurance Experiment. Many are comparing it favorably to the RAND Health Insurance Experiment, which I call our best medical data ever. These new results are officially here, ungated here, and commentary is here, here, and here. I’ve now had time to read the new paper, talk to one of its authors, and ponder.

This new data is possible because for a short time Oregon assigned a limited number of available Medicaid slots by lottery. 89,824 people signed up for the lottery, about 70,000 of whom were plausible eligible. 35,169 of these folks won the lottery, and of those 8,704 (~30%) were enrolled in Medicaid medical insurance.

As Oregon ended the lottery within two years, we will at most see two years worth of data. This is probably too little data to see anything but implausibly large mortality effects, but they have been collecting many direct health measures like blood pressure. In this first paper, however, all we have are the results of surveys, which include self-reported health.

The big news is that lottery winners had substantially and significantly better self-reported health. The overall health difference is significant at a 10-4 level. Lottery winners reported, for example, being healthy (= unimpaired) an average of a half day more per month. If one assumes that being a lottery winner influences health mainly via giving health insurance, then health insurance gives people 1.6 more healthy days per month.

Sounds like solid proof that medicine is healthy, right? Not so fast. First, over two thirds of the health gains that appeared on the one-year-later survey also appeared on the very first survey, done before lottery winners got additional medical treatment. So clearly at least two thirds of the health gains here are due to the comfort of knowing one has insurance. (And since they’ll only directly measure health once per person, we may never get the timing data to see if any gains in direct measures also appeared right from the start.)

Second, the folks in this study aren’t remotely comparable to the folks in the RAND experiment. The RAND experiment was mainly on random people, though it over-sampled from people with the lowest 20% of income. The Oregon experiment, in contrast, is on very sick and poor folks. For example, “healthy days per month” above refers to to how people answered a survey question on the number of days in the last 30 that poor physical or mental health impaired their usual activity. On average people in this study were impaired for ten days per month! 28% of them have asthma, 30% high blood pressure, and 56% depression.

They are also very poor, with an average yearly income of $11,790. 67% have a high school education or less, and 55% are unemployed. While only 13-17% of Americans spend less that the federal poverty income level, 70% of these folks spend below that level, and 40% of them spend less than half that level. Just how poor, sick, and just plain dysfunctional these folks are is shown by the fact that only 30% of lottery winners actually managed to get insurance. For example, “only about 60 percent of those selected sent back applications.”

But if medicine is good for the poor and sick, can’t we presume it is good for everyone? No, because the most significant overall health result found in the RAND experiment was that medicine hurt the poor and healthy! The main pre-determined health measure in the RAND experiment was a “general health index” and they reported on how getting free medical insurance influenced four different groups: people were split by income, low (= lowest 20%) vs high, and by initial health, low (= lowest 20%) vs. high. At about a 6% significance level the RAND experiment found that poor but initially-well people got sicker when given free insurance (see Table 6.12, Page 210 of Free for All?).

My interpretation: such folks went wild getting stuff checked out that they’d been ignoring, and all that extra treatment of symptoms they could have ignored for longer led to lots of false positives on tests and over-treatment, making them worse on average.

Bottom line: So far, the new Oregon Health Insurance Experiment shows that for very poor and sick folks who go out of their way to request medical insurance, giving them such insurance makes them report feeling healthier. Two-thirds of this effect appears immediately on granting their request, and before they actually got more medical treatment. It remains to be seen if these healthy feelings will be reflected in more direct health measures, though that seems plausible, and we’ll probably never see mortality effects. The main results of the RAND experiment, which looked at all sorts of people, suggests doubts about presuming that if medicine helps the very poor and sick, it on average helps everyone.

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New Is Not Better

“As a non-American, I don’t completely understand it, but there is a phenomenon in the U.S., the latest and the greatest. … There was a patient demand to get these implants on the misconception that the latest was the best.” …“The vast majority of the ‘innovations’ on which we have spent money with respect to orthopedics over the past two decades have not resulted in improved patient outcomes.” (more; HT Tyler)

Assuming no side-effects, if users gain from innovations then innovators must gain less than the social value of their innovations, which risks their having insufficient incentives to innovate. This effect can be countered, however, by giving extra social status to the creators and users of innovative products, services, and behaviors.

United States culture gives such extra status to creators and users of innovations, and so probably deserves some credit for encouraging innovation. But alas much of this is wasted via merely rewarding things things that are new, rather than innovative. And if your reaction to reading that was “what is the difference?,” that just shows the depth of the problem.

Innovative things must be new, but new things need not be innovative. To be usefully innovative is to be better some how. Innovators try many new things, most of which are not better, but a few of which are. On average new things are w0rse, but those that are eventually retained are hopefully on average better. And with the right incentives, the retained better things are so much better that they pay for all the other new worse things.

If our culture waited until it was clear which new things were actually better, and gave more status to the creators and early adopters of those things, culture would promote innovation. But alas culture instead mainly showers status on those who merely create and use new things, regardless of whether they are better. While in small amounts even this status effect can promote innovation, in larger amounts it can hurt. After all, when there is too little added reward for creating or using something that is both new and better, relative to something that is just new, people will mainly focus on the new part.

The problem comes from an excess focus on current behavior, relative to past track records. In enforcing social status norms, it is relatively easy to just see that someone is today affiliated with with something that is new today, and give that person credit for their newness. It is much harder to remember that a person was once affiliated with something that was then new, and which later turned out to actually be better. A mechanism that made it easier to collect and view such track records could be of great social value, at least if combined with new matching social norms on who deserves social credit for being “innovative.”

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First Cryonics Hour

Me two years ago:

I hereby offer to talk for one hour on any subject to anyone who can show me they’ve newly signed up for cryonics. You can record the conversation, publish it, and can sell your time to someone else.

Stuart Armstrong has signed up for cryonics, and then redeemed my offer. Congrats Stuart! We talked for an hour, and he recorded the conversation. If he does something with that recording, I’ll post a link here.

Any other takers?

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Promises Signal

Promises can both 1) help others predict and rely on our future behavior, and 2) signal our current feelings to others. The signaling function seems to dominate:

People who had the most positive relationship feelings and who were most motivated to be responsive to the partner’s needs made bigger promises than did other people but were not any better at keeping them. Instead, promisers’ self-regulation skills, such as trait conscientiousness, predicted the extent to which promises were kept or broken. … Participants who were [caused to] focused on their feelings for their partner promised more, whereas participants who generated a plan of self-regulation followed through more on their promises. …

When people make promises to address a point of contention with their partner, they seem to get swept up in what they want to do for their partner. A promise situation might appear as an opportunity to be responsive to a partner’s needs and demonstrate the loving feelings they experience for the other person, and it is these feelings they are thinking of when they make promises. … If promised behaviors can be completed immediately after promising rather than be sustained over a longer period of time, then the link between positive relationship feelings and extent of followthrough reemerges. (more)

If relationship promises mainly function to signal our current feelings, that makes it more plausible that paying and pushing for medicine for our associates serves a similar function of showing that we care. We humans apparently do relatively little checking later of whether promises were kept, or if medicine helped.

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