Slate Star Codex

In a mad world, all blogging is psychiatry blogging

A Series Of Unprincipled Exceptions

Meeting with a large group of effective altruists can be a philosophically disconcerting experience, and my recent meetup with Stanford Effective Altruist Club was no exception.

Buck forced me to pay attention to an argument I’ve been carefully avoiding. Most people intuitively believe that animals have non-zero moral value; it’s worse to torture a dog than to not do that. Most people also believe their moral value is some function of the animal’s complexity and intelligence which leaves them less morally important than humans but not infinitely less morally important than humans. Most people then conclude that probably the welfare of animals is moderately important in the same way the welfare of various other demographic groups like elderly people or Norwegians is moderately important – one more thing to plug into the moral calculus.

In reality it’s pretty hard to come up with way of valuing animals that makes this work. If it takes a thousand chickens to have the moral weight of one human, the importance of chicken suffering alone is at least equal to the importance of all human suffering. You would need to set your weights remarkably precisely for the values of global animal suffering and global human suffering to even be in the same ballpark. Barring that amazing coincidence, either you shouldn’t care about animals at all or they should totally swamp every other concern. Most of what would seem like otherwise reasonable premises suggest the “totally swamp every other concern” branch.

So if you’re actually an effective altruist, the sort of person who wants your do-gooding to do the most good per unit resource, you should be focusing entirely on animal-related charities and totally ignoring humans (except insofar as humans actions affect animals; worrying about x-risk is probably still okay).

I acknowledged the argument was very convincing, but told Buck that I waS basically going to safe-word out of that level of utilitarian reasoning, for the sake of my sanity.

Buck pointed out that this shouldn’t be too scary, given that many utilitarians have already had to go through a similar process. Peter Singer talks about widening circles of concern. First you move from total selfishness to an understanding that your friends and family are people just like you and need to be treated with respect and understanding. Then you go from just your friends and family to everyone in your community. Then you go from just your community to all humanity. Then you go from just humanity to all animals.

By the time most people figure out what they’re doing they already accept at least friends, family, and community. But going from “just my community” to “also foreigners” is a difficult step that’s kind of at the heart of the effective altruism movement. In the same way that allowing animals into the circle of concern totally pushes out the value of all humans, allowing starving Third World people into the circle of concern totally pushes out most First World charities like art museums and school music programs and holiday food drives. This is a scary discovery and most people shy away from it. Effective altruists are the people who are selected for not having shied away from it. So why shy away from doing the same with animals?

It’s a good question. After thinking about it for a while, I think my answer is that I never actually completed the process of widening my circles of concern and neither has anybody else, and because I’m thinking about this one in an abstract intellectual way I’m imagining actually completing it, which would be much scarier than the incomplete things I’ve done before.

Like, although I acknowledge my friends and family as important people whom I should try to help, in reality I don’t treat them as quite as important as myself. If my brother asked me for money, I’d lend it to him, but I wouldn’t give him exactly half my money no-strings-attached on the grounds that he is exactly as important to me as I am.

Likewise, although I acknowledge strangers as important people whom I should try to help, in reality I don’t treat them as quite as important as my friends. We all raised a lot of money to help Multi when she was in a bad situation, but there are thousands of other people in the same exact same bad situation and we’re not putting nearly as much effort into them.

You can try to justify this in terms of “well, I know myself better than I know my brother, and I know Multi better than I know strangers, so I’m more effective at helping me and Multi, so I’m just rationally doing the things that would have the most impact”. But I think if I bothered to dream up some thought experiment where that wasn’t true, I would prefer to help me and Multi to my brother and random strangers even after that factor had been controlled away.

This doesn’t come as a surprise to me and I’m not sorry. But…well…I guess my worry about the animal charity thing wasn’t that I was inconsistent, so much as that I was being meta-inconsistent; that is, I didn’t even have a consistent set of rules for deciding whether I was going to want to be consistent or not.

And now I think I might have a consistent policy of allowing some of my resources into each new circle of concern while also holding back the rest of it for the sake of my sanity. Thus my endorsement of GiveWell’s principle that you should donate at least 10% of your income to charity, but then feel okay about not donating more if you don’t want to. I am allowed to balance resources devoted to sanity versus morality and decide how much of what I have I want to send into each new circle of concern – without denying that the circle exists.

I think that armed with this idea I am willing to accept Buck’s argument about animal welfare being more important than human welfare, insofar as this means I should donate some resources to animal welfare without necessarily having to give up caring about human welfare completely. I don’t think I can make a principled defense of doing this. But I think I can claim I’m being unprincipled in a meta-consistent and effectively sanity-protecting way.

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California Meetups (Rererevised)

The following Slate Star Codex meetups are planned for the next week or so:

Berkeley, Sunday 3/1 at 2:00 PM at Indian Flavor Express, 2548 Bancroft Way, Berkeley

San Jose, Monday 3/2 at 7:30 PM at David Friedman’s house, 3806 Williams Rd, San Jose

Googleplex, Tuesday 3/3 at 1:00 PM at the picnic tables between CL2 and CL5, maybe. Googlers can get more information at go/ssc-meetup

Stanford, Tuesday 3/3 at 6:00 PM, at the picnic tables outside Tresidder Union, 459 Lagunita Dr, Stanford

across the street from Old Union, Room 200, 450 Serra Mall, Stanford, at the picnic tables outside Tresidder

EVERYONE is welcome to come to Berkeley and San Jose, even if you don’t read this much, don’t comment, whatever. Googleplex is limited to Google employees, unless you have another way to get in (NOT to be interpreted as a challenge!). Stanford is mostly intended for Stanford students, but if you’re in the area and really want to come I’m sure we can fit a few others in.

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Early Intervention: You *Might* Get What You Pay For

I find myself caught between the genetics community – which takes it as a given that childhood experiences and education have a very limited role in shaping life outcomes – and the psychiatric community, which takes it as a given that childhood experiences and education are crucial in shaping life outcomes. Both sides have their favorite studies to cite supporting their positions. I’ve already talked about the genetics studies, so I thought I’d bring up a recent particularly good study from the other side.

Dodge et al’s Impact Of Early Intervention On Psychopathology, Crime, And Well-Being At Age 25 is published in last month’s American Journal Of Psychiatry. Gratifyingly, it is a randomized controlled trial. Ten thousand kindergarteners in disadvantaged areas were screened for “conduct problems” until they found about 900 who looked like they were at high risk. 445 were randomly selected for the intervention. Another 446 stayed in the control group. The intervention was a bunch of extra classes and ‘enrichment programs’ from elementary school (age 5) all the way through high school (age 16). The study mentions “social skills friendship groups”, “guided parent child interaction sessions”, “tutoring in reading”, “parent-youth groups on topics of adolescent development, alcohol, tobacco, and drugs”, “youth forums on vocational opportunities”, and “Oysterman’s School-To-Job possible selves intervention aimed at examining emerging identity”.

All of these sound so pretentious that I would have loved to be able to report that they had no effect, but in fact the opposite was true. When they caught up with these kids at age 25, the intervention group was found to have an odds ratio of around 0.6 to 0.7 of having developed various psychiatric disorders the study was testing for, including antisocial personality disorder, ADHD, depression, or anxiety. They had odds ratios around 0.7 of developing drug and alcohol abuse problems by various measures. They reported less risky sexual behavior, less domestic abuse, and fewer violent crimes. All of this was significant at the p < 0.05 level, and some of it was significant at much higher levels like p = 0.001 or below. Subgroup analysis found the data were very similar when you restricted the analysis to various subgroups like boys, girls, whites, blacks, highest-risk, lowest-risk, and by study site (it was a multi-site study). As best I can tell there were not an equal number of anaylses they did that came up negative that they covered up.

The apparent conclusion is that intensive interventions can change children’s outcomes and personalities in important ways ten years down the road, even regarding things believed to be highly genetic like antisocial personality disorder.

A few weak attempts to rebut this. First, there were some things that study didn’t do that one might have expected it to. It didn’t change graduation rates or employment rates. The apparent decrease in domestic violence was mediated entirely by the intervention group being less likely to have relationships (!) – the rate of domestic violence among people in relationships was the same. There was no effect on health. There was no effect on self-reported satisfaction with their parents’ parenting. There were (nonsignificantly) higher death rates and incarceration rates in the intervention group than the control group.

So if I wanted to be maximally mean to the study, I could say that whatever it’s doing to violent crime and drug use has to be compatible with a (nonsignificantly) raised incarceration rate, and whatever it’s doing to drug use and risky sexual behavior and criminality has to be compatible with a (nonsignificantly) raised death rate. This suggests the possibility of an attack based on their endpoints being screwy, though I’m not sure what form such an attack could take. One could argue that since many of their outcomes were based on self-report surveys maybe the kids who had been through all of the enrichment programs had grown to like the study people and had a stronger demand effect to say that they were doing great. But a lot of the survey data was backed up by court records confirming fewer drug and violence convictions. So that doesn’t really work.

If you’re less interested in the pure science of individual differences and more interested in policy, one fact that I forgot to mention was that this program cost $60,000 per kid. The paper points out that this is the same cost as a year or two of incarceration, so if it really changes children’s life outcomes and makes tham less antisocial even that hefty price tag might be justified (although again, remember that it didn’t affect employment or incarceration when checked directly).

If you’re looking for an optimistic spin on that number, they freely admit they have no idea which part of their gigantic ten year intervention program produced the positive effects. It could be that all the youth forums and enrichment programs and friendship groups and so on had zero effect, and the entire benefit came from the “Oysterman’s School-To-Job possible selves intervention aimed at examining emerging identity”. And maybe that’s a piece of paper that can be copied on a copy machine for ten cents a sheet. All this suggests is that at least some part of the ten-year, $60,000 intervention did something.

If you’re looking for a pessimistic spin on that number, consider. Every so often I see things that claim to have completely shifted children from the most high-risk of high-risk groups to upstanding successful members of society by giving them a year or preschool, or a couple of after-school lessons, or something like that. And these studies always boast that they did it with only $1000 or $5000 or some number like that, so it’s nice and cost effective. So far, the studies I have seen like this have been wrong. And so far I have not been surprised, because we already spend between $100,000 to $200,000 per child on education and various social programs. If someone ever found a social program that really worked for $1,000, the first thing we would want to do is tar and feather everyone currently in our bureaucracy of social programs, for being so incompetent that changing their $200,000 in spending to $201,000 in spending (with the extra $1000 going to someone besides them) could completely revolutionize life outcomes.

This study seems more in line with everything else. By going from $200,000 to $260,000, we can slightly push a few things in a positive direction a little bit more, maybe. From a scientific view, it’s pretty interesting. From a policy view, it’s nothing to write home about.

OT15: Open Relationship

This is the semimonthly open thread. Post about anything you want, ask random questions, whatever. Also:

1. I’m off to California, so no blogging for a while. I’ll see some of you at Ruby and Miranda’s wedding on Saturday. Everyone else, I will have a post on meetup times up no later than this weekend. Yell at me if I forget.

2. Comments of the week: Douglas Knight explains heritability statistics, Gwern gives an economics answer to a statistics question, a health care economist discusses why it’s a weird market and how to improve it

3. I think I have room for another ad of about the same size and shape as the MealSquare one in around the same area. If anyone wants to pay for such, email me with an offer. For comparison, the MealSquares ad has gotten about 700 clicks a month.

Remember, no race and gender on the open thread. Ozy will put up a parallel open thread over at their place for you to talk about that.

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Links 2/15: Land of Linkin’

Sometimes called “the most astounding medical lecture ever”, the notorious Brindley lecture is a good example of why your announcements of ground-breaking urology discoveries should not include live demonstrations.

FAA: If you can get to the moon, nobody’s stopping you from claiming property there.

Normal weight woman gets a fecal transplant from overweight donor and suddenly gains a lot of weight, supporting theory that microbiome is involved in weight regulation.

A claim that humans naturally divide into a bimodal distribution of monogamous and promiscuous.

Preliminary research suggests that eating a diet rich in tryptophan might make people more charitable (news article, study)

Left-handed people differ from righties in various ways, including less likely to attend college, less likely to get good jobs, and earn an average of $1,300 less per year. Likely mechanism is that a lot of neonatal health issues that disrupt brain development can leave you left-handed. If you restrict your sample to people without any neonatal health issues, lefties and righties appear about equal.

Sounds like a dystopian horror story – in a lot of areas, it is illegal to live with your friends because zoning issues say that houses must be owned by “a family”.

There is a campaign going around to boycott Yale’s senior gift because of their shameful mental health policies. Those policies are that if a student at Yale develops a serious mental illness, they can sometimes be kicked out of school because of worries that if they committed suicide on campus it would be a public relations nightmare. Yale is far from the only college to do this, but I’ve talked to some people there who say they’re especially bad. I’m reluctant to signal-boost this because I don’t really like boycotts as a political tactic, but the article suggests the senior gift is already very politicized and so this wouldn’t be politicizing it any further. If you go to Yale, take a look and draw your own conclusions.

Some interesting discussion of the Crusades recently, sparked by an Obama remark. Here a historian explains that a lot of anti-Crusade tropes are myths. On the other hand, the trope that the Crusaders were bloody and killed lots of innocent people is totally true. There was a lot of outrage that Obama was trying to distract from ISIS with his clumsy remark that Christians had done some bad stuff too. The appropriate analogy to me seems to be “Down with ISIS” : “Christians do bad stuff too” :: “Black lives matter!” : “All lives matter!”. The second statement in each branch is 100% true, but brought up at a time when it can’t help but be seen as a somewhat insensitive distraction.

Adjunct Professors Demand That Their Pay Quintuple. I don’t have enough space to do justice to this issue in a links post, but I urge you to meditate on the claim mentioned in the article that adjuncts need their pay quintupled in order to get “the kind of upper-middle-class salary they think people with advanced degrees should be able to expect.”

Ramon Llull meets Weird Sun Twitter in @CloneOfSnow, which describes itself as “an attempt to robotically exhaust all pairs of memes.” Since popular memes are often created by combining two other memes, for example something like “Hello, gentlemen, all your snakes on a plane are belong to us”, if you just get a list of all memes and combine them exhaustively, some of the results should be interesting. And so they are.

The Chinese philosopher Mozi was one of the first pacifists and consequentialists – and his followers decided the greatest good was to train to become experts in siege warfare, then go around to places helping them resist invasions.

According to a survey, the public believe medicine to be the most scientific field. In your face, physics! As usual, Razib Khan has some good analysis. H/t Noahpinion.

WhoPays is a site where writers post how much they got writing for different media. Useful if you’ve just gotten an offer from someone and want to know if it’s competitive, or if you want to know where to send a piece. Linked because I keep getting for-profit news sites asking me to write for them for free if they promise to link back to my blog; I guess this probably works for some people but it annoys me and I want people to know their options.

Woman’s wedding to Charles Manson called off after it turns out she just planned to wait for him to die so she could turn his corpse into a tourist attraction. r/theredpill warned me about this kind of thing!

Everybody knows that gender stereotypes are so fluid and socially constructed that people used to associate pink with boys and blue with girls, right? According to a more recent paper, this is “a scientific urban legend”, and when you do a systematic search of old books, blue and pink always had their current gender associations (study). I find the paper’s claim that maybe these links are genetically based to be extremely bizarre and hard to swallow, which I guess means that there was no harm done – whether or not pink and blue actually reversed, it’s the sort of thing that probably could have happened. But if the new paper is true, there’s still a lesson to be learned about how easily any politically convenient story that supports nurturist ideas can turn into gospel.

The case for melancholia as a distinct type of depression.

Here’s a study I don’t believe at all, but can’t quite figure out how to debunk: The Lethal Effects Of Three Strikes Laws. Not only do three-strikes laws fail to decrease crime, but they “are associated with 10-12 percent more homicides in the short run and 23-29 percent in the long run”, possibly because “a few criminals, fearing the enhanced penalties, murder victims and witnesses to limit resistance and identification”. Are there really that many criminals hardened enough to consider killing witnesses an option who weren’t going to be getting these long sentences anyway? Are there really that many instances of witness-killing? Until this gets replicated, I defy the data.

A newer, bigger, more rigorous study once again finds that quality of parenting has no effect on whether a child becomes a criminal.

At this point I only really pay attention to results in economics when they go against the bias I expect the writer to have. In that spirit, here’s a study by Alex Tabarrok finding that increasing regulation is not to blame for the decline in American entrepreneurship.

The Man Who Tried To Redeem The World With Logic is an interesting biography of near-forgotten polymath and neuroscientist Walter Pitts. Related: a couple of posts ago, someone pooh-poohed me for saying von Neumann was a born genius, insisting it was just the effect of the high quality education his rich father gave him. Walter Pitts worked with von Neumann and was considered to have a similar level of genius – and he was the son of a poor laborer in Detroit who insisted he drop out of school to do real work. Pitts’ education consisted solely of reading library books on his own time, including Principia Mathematica – about which he sent a letter to Russell containing several corrections when he was only 12 years old.

Work Stress Found Not To Cause Cancer. The most interesting thing that could come out of this study would be an attack on the tradition that has sprung up from the Whitehall Study, which found that lower-ranking civil servants were more likely to get diseases than higher-ranking civil servants even after the usual confounders were adjusted away, and which is touted as proving that inequality directly causes poor health. This current study doesn’t directly contradict Whitehall since it limits itself to a few cancers and Whitehall mostly limited itself to cardiovascular disease and a different few cancers. But it will be interesting to see if someone tries to replicate the Whitehall results in light of this new study, and whether they hold up.

The greatest hits of legendary comments troll KenM: 1, 2.

The Promises And Pitfalls Of Genoeconomics. Most interesting result: male income appears to be heritable at a level of 0.6 or so (female income slightly lower). This isn’t just boring old “if your parents are rich you’ll be rich”, this is pure genetic “based on the difference between monozygotic twins and dizygotic twins” heritability. Applying this result to your favorite economic argument is full of potential pitfalls I should probably write a full post on sometime.

Why the medieval debate between geocentrism and heliocentrism was more complicated than that. Be sure to read also Jonathan Lee’s comment and Douglas Knight’s comment.

Thing #8603238450 that correlates with obesity and is neither calories in nor calories out: timing and intensity of light exposure.

Another boring article on political correctness which I am linking not for the sake of the article itself but for the sake of a short throwaway argument it makes: private colleges are companies in the free market, so if they want to ban offensive ideas, then students won’t go to them unless they like offensive ideas being banned, which means the market works – ie a Patchwork/exit/Archipelago type picture. Anyone want to agree or disagree?

MIRI: Three common misconceptions of people who say they’re not worried about AI risk.

Extreme Obesity In Children Tied To Low IQ, independent of obvious genetic diseases. At least three possible interpretations. Number one, low IQ kids have poor impulse control/understanding of consequences so they have poorer health. Number two, bad diet impedes brain development. Number three, there are non-obvious genetic diseases which affect both metabolism and IQ; this would work especially well in the context of a mutational load argument.

The Nazis had a bright idea. They didn’t like Jews. A lot of Arabs didn’t like Jews. Why not dislike Jews together? Thus begins the facepalm-inspiring history of attempts to translate Mein Kampf into Arabic, which basically consisted of the smarter Nazis saying “This might catch on if we remove the parts about Arabs being subhuman scum” versus Hitler saying “But I really like those parts!”

I didn’t think it was possible to make a graph about US inequality I’d never seen before, but the second graph in this article is genuinely pretty neat. And worrying.

EXPECTO PATRONUM!

Relevant to my interests: how a bunch of different measures of different kinds of intelligence relate to college majors.

Melanie’s Marvelous Measles is an anti-vax propaganda book aimed at children ages 4-10 about getting measles is actually really fun, and also how really vaccination causes the measles (why yes, those two forms of propaganda do seem to be mutually self-defeating). You probably shouldn’t read it. But you should definitely read the Amazon reviews.

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Pharma Virumque

Going around the psychiatry blogosphere recently: this segment by John Oliver about doctors who take pharmaceutical company money:

I will resist the urge to geek out about its minor medical errors1 in favor of clarifying something more important.

The impression you’re supposed to get from this piece is a shady looking man handing you a briefcase full of cash and whispering “Hey, here’s $10,000 for you if you prescribe unnecessary medication.” The implication is the doctors who do this are awful and if you were in medicine you would have no trouble resisting this temptation.

In reality, pharma companies have figured out that some people have ethical qualms – “evil cannot possibly understand good” only works in movies – and adjusted their strategies accordingly.

We’ll start with a simple one. Imagine you’re a doctor, and your staff are complaining because the staff at every other doctor’s office has been getting these incredible free lunches every day – the video says drug companies aren’t supposed to give, like, Zagat-rated steakhouse lunches, but there’s still a lot of room between “Zagat-rated” and “Way better than the peanut butter and jelly sandwich you bring from home”. The nurses are grumbling and threatening to revolt and asking if you really appreciate them.

A drug company representative offers to provide your office with free lunches a couple of times a week.

You say “It would be really annoying to actually use the phrase ‘there’s no such thing as a free lunch’ here, so I will just ask what the catch is.”

They say “No catch. We don’t require you to ever prescribe any of our drugs. We don’t require you to listen to our presentation. We don’t even require you to read our promotional literature. Just accept our offer.”

You say “Why are you doing this?”

They say “Because every time you eat one of our lunches, you’ll associate the ice cold taste of Coca-Cola and the sweet warm chewy chocolate chip cookies with our company, and you’ll get positive feelings about it, and maybe those positive feelings will influence your prescription habits.”

You say “I think I’m a good enough doctor not to prescribe a drug solely because I get lunch from their company.”

They say “Look. We all know that most antidepressants are about equally effective. Sure, we split hairs and talk about how one has more anticholinergic side effects so it’s bad for patients with cholinergic sensitivity, and another has more chance of weird visual disturbances, but how often does someone come into your office and announce ‘Hey, I’m depressed, and also I have cholinergic sensitivity, but I LOVE weird visual disturbances!’? Although there are a few cases where one drug’s clearly a better choice than another, most of the time you’re about equally balanced between two or three options, and you just pick one at random. So maybe instead of picking one at random, you’ll pick the one you associate with delicious food. And if you do, so what? Nobody’s harmed. You would have just flipped a coin anyway.”

You say “I’d rather flip a coin than feel like I’m being pressured by what I had for lunch.”

They say “Look, you secretly worry anyway that you sometimes prescribe Effexor because the name makes it sound effective, or Paxil because the name makes it sound peaceful.”

You say “Wait, you can read my thoughts?”

They say “We’re a pharmaceutical company. Of course we can read your thoughts. Look. You already know that the mostly-meaningless choice of which of several equally effective drugs you prescribe is influenced by a bunch of silly marketing factors beyond your control. Why not add one more?”

“But -”

“Come to the Dark Side! We literally have cookies!”

Still not tempting enough for you?

Okay, imagine this. You’re a doctor and one of your patients comes in with incurable chronic pain that’s ruining their life. You try the normal medications on it and nothing works very well. There’s a high-tech next-generation medication available that you think is a good fit for your patient’s disease, but it’s not covered by their insurance and there’s no way the patient can afford it. You have to tell this guy that there’s nothing you can do for him.

Then a drug company representative comes to you bearing a big box of free samples. By “free samples” I mean hundreds of pills, enough to help the patient for the better part of a year – and maybe at the end of that time you’ll get another box of free samples. The drug rep doesn’t want you to sign your life away. She’s giving them for free, no obligation, maybe just listen to a sixty second speech on how to prescribe them safely and effectively (she wouldn’t want to give them to someone who won’t prescribe them effectively!) Are you really so fundamentalist in your approach to medical ethics that you won’t listen to a drug rep for sixty seconds in order to save a patient’s quality of life?

Most doctors – even the ethical ones who would refuse the briefcase full of cash – take the offer. This practice has come under increasing scrutiny recently. Some of the complaints are kind of dumb, but one very valid one is that a lot of the times what happens is you start off by giving the patient 100 days of free sample or something, then the free sample runs out, they’re fixated on that particular medication because it’s the one that worked for them, and they find some costly way to continue the (more expensive new) medication – instead of the two of you working harder to find some older less expensive medication that works equally well. A few drug companies have “fixed” this by giving out cards for “prescription programs” that solve some of the problems with free samples. These are even harder to resist, and they’re also given out by attractive drug reps who just want to tell you a few important facts about the drug before giving it to you.

Still not tempting enough for you?

Fine, then imagine this. You’re a doctor who really believes in a particular drug and is trying to convince the medical community to use more of it. For example, a couple weeks ago I wrote an article on suboxone saying it was one of the best medications for opiate abuse and I wish the medical community would pay more attention and prescribe it more often.

I wrote that article for free as a public service because I think that drug saves lives. But imagine that the company that makes suboxone approached me afterwards and said “Hey, you seem to have an important message to spread. Why don’t we sponsor you to go around the country for a week or two telling it to other doctors at medical conferences? We’ll get you first-class flights, put you up in five-star hotels, and give you a $10,000 stipend.”

I say “Wait a second, that sounds like taking pharmaceutical company money, and taking pharmaceutical company money is evil.”

They say “Look. You were trying to promote suboxone to people already. You were just doing a bad job because you were limited to one little blog. The more suboxone-promoting you do, the more doctors know about this drug – which you yourself have said is life-saving – and so the more lives get saved. If you’re willing to promote suboxone ineffectively for free, why not promote suboxone effectively for $10,000 plus nice hotels?”

I say “I’m still kind of uncomfortable with this.”

They say “Okay, well, it’s not our fault if hundreds of people die of drug overdoses because their doctors didn’t know suboxone was an option.”

You’re probably going to ask if I’ve ever accepted any of these offers. The boring truth is that I haven’t had to consider them because I’m a resident and residents are lower than dirt and the pharmaceutical companies know this and they don’t waste time trying to cozy up to us.

I have tasted the forbidden fruit only once, and it was my attending’s fault. She told us that there was a big dinner being planned for the entire psychiatric community of our city. The goal was to get doctors to meet nurses to meet therapists to meet social workers in one place so we could all get to know each other and talk about changes we could make to the system. It was very important that we attend, or else the nurses and therapists and social workers would think that the doctors were too snooty to interact with them and didn’t care about changing the system. Oh, and by the way the dinner was sponsored by PANEXA (here used in place of the real drug because I don’t want to get in trouble for calling them out) but there wouldn’t be any promotional material or pressure to prescribe PANEXA, honest, no sirree.

This was a tempting offer precisely because it was such a good idea. Everyone in the local psychiatric community deals with each other frequently, but we’d mostly never met before. I know them as the voice on the other side of the phone saying “No, no beds are available in our facility” or as the person who refuses to fax me my patient’s past medical history because the patient is too catatonic to sign a consent form. None of us are ever entirely sure what the others are doing, sometimes there are bad feelings, and it was reasonable to hope that maybe if we all met each other and socialized things would get a little smoother.

So we all meet at this restaurant, and immediately World War III breaks out. It’s like “Hi, I’m Mary, the clerk at Blue Sky Mental Health.” “MARY?! YOU’RE THE ONE WHO DIDN’T FAX ME THOSE RECORDS I NEEDED TWO MONTHS AGO! MY PATIENT WENT A WEEK ON THE WRONG DRUGS BECAUSE OF THAT!”

“Hi, I’m Dr. Alexander, I work at the inpatient unit in Our Lady Of An Undisclosed Location Hospital…” “WE HAD A PATIENT COME FROM THERE TWO WEEKS AGO AND HE ASSAULTED A STAFF MEMBER. IF YOU’RE A REAL HOSPITAL WHY CAN’T YOU DO PROPER VIOLENCE ASSESSMENTS?”

It turned out that the nurses hated the social workers for making them wait on the phone forever in order to get a straight answer. The social workers hated the nurses for always calling them up when they were busy about things and expecting an answer RIGHT NOW. The social workers hated the doctors for giving patients one measly prescription, then handing the case over to them to fix all of the impossible problems in the patient’s life. The doctors hated the social workers, because when we give patients one measly prescription and then hand the case over to the social workers to fix all of the patient’s impossible problems, sometimes the impossible problems don’t get fixed.

Anyway, in the midst of all of this, there was one guy who was staying completely calm, talking nicely to everybody, helping people see each other’s sides of the issue, just a really serene well-adjusted guy. I escaped over to his table and asked him who he was and why he was here.

“Oh,” he said “I’m a paranoid schizophrenic currently on PANEXA.”

Of course he was.

Then we all broke off into our own groups and got some incredible Italian food.2

What I’m saying is, pharmaceutical companies are sneaky.

Footnotes

1: By which I mean “succumb to the urge to geek out about its minor medical errors, but in the footnotes”.

The video says that a “horrifying example” of pharmaceutical company overreach was how AstraZeneca took Seroquel, “an antipsychotic with dangerous side effects” and marketed it to doctors for depression, sleep, and dementia, adding “You can’t just give people dangerous drugs and see what happens!”

But actually, lots of studies have shown Seroquel is effective for depression, lots of guidelines suggest Seroquel as a backup depression treatment, and doctors have been (correctly) prescribing it for such for a long time. Doctors also very commonly prescribe it for sleep and dementia; I think is less evidence-based, but it’d be a lie to say it wasn’t common as dirt or that it didn’t work for these things (safety is the problem).

So what was happening was that AstraZeneca was promoting Seroquel for the things it was actually being used for, as opposed to the thing the FDA said it was supposed to be used for. Doctors are allowed to use drugs for whatever they want based on their own analysis and their best judgment, but pharmaceutical companies are only allowed to promote it for the FDA-approved indication, which at that point was psychosis and bipolar depression.

The reason the FDA hadn’t approved Seroquel for depression wasn’t because it was a bad idea. It was because in order to get the FDA to approve anything for anything, you must perform the appropriate ritual of putting a zillion dollars into a big pile, then burning it as a sacrifice to the Bureaucracy Gods. AstraZeneca had performed the ritual for bipolar and psychosis, but was still in the process of performing it a third time for depression. Once they finished, the FDA approved it as an adjunctive medication for depression, but also fined them hundreds of millions of dollars because they had advertised it for depression – merely based on evidence and clinical practice – before the FDA had told them they were allowed to.

This is still not the whole story, because best clinical practice says to only use Seroquel as a third- or fourth-line antidepressant after some others have failed, and in conjunction with another medication. If AstraZeneca was advocating to use it for depression first-line on its own, this would have been a genuine overstep and something to get upset about.

(research and clinical practice say to use it for sleep and dementia approximately never, but there is enough wiggle room in that “approximately” for doctors to drive a bus through, and they do.)

This is still not the whole story, because The Last Psychiatrist thinks the way the FDA’s handled the Seroquel indication, and the subsequent culture of prescribing that grew up based on that indication, is stupid.

The other minor medical error in the video is much simpler. Oliver mocks Wellbutrin’s claim to be “the happy, healthy skinny drug” saying that “the only happy, healthy, skinny drug is amphetamine”. But Wellbutrin is actually amphetamine-based – its full chemical name is 3-chloro-N-tert-butyl-β-ketoamphetamine – and it shares a mechanism of action with amphetamines, which is why some of its effects are similar as well. So Oliver’s joke was a lot more accurate and a lot less funny then he thought.

2: Then later, and contrary to the promises I received, they gave us a presentation on PANEXA anyway.

The schizophrenic guy worked for one of the local psychiatric community services groups doing community outreach. I never did figure out whether he was there as a coincidence or whether the pharmaceutical company had arranged to have him there. I suspect the latter but I have no proof.

Did Falling Testosterone Affect Falling Crime?

There are already too many proposed causes for the secular decline in crime, but I can’t resist suggesting one more. A couple of months ago Nydwracu asked me whether it could be related to the secular decline in testosterone. The answer turns out to be “Maybe”.

This secular decline in testosterone is pretty dramatic. Our best source is A Population-Level Decline In Serum Testosterone Levels In American Men, which finds that from 1987 to 2004, average testosterone declined from 501 ng/dl to 391 ng/dl, with an even more dramatic decline in bioavailable levels of the hormone. That’s about minus 1% per year.

No one knows exactly why this is happening. Some people blame increasing obesity and decreasing tobacco use (wait? Smoking increases testosterone levels? THOSE TV COWBOYS WERE RIGHT ALL ALONG!). Other people have tried to adjust for these and found they don’t explain the entire effect, leading to a host of other theories. Recent scrutiny has focused on the role of feminizing chemicals in the water supply, probably a combination of industrial pollutants and discarded medications; the worst-affected areas are marked by an epidemic of transsexual fish (really).

(A quick aside – since these chemicals are gender-bending fish, frogs, and various other animals, could they be responsible for transgender in humans? This theory seems to still be in crackpot territory, but I don’t know why. Research shows that male-assigned-at-birth children exposed to diethylstilbestrol in the womb are more likely to become transgender than the general population. Other than that, there just seems to be one unpublished paper on the subject. Get to work, scientists!)

Annnnnyway, testosterone has been found to correlate a bit with violent crime. In a study of 692 male criminals, Dabbs et al found that those in prison for more violent crimes had higher testosterone than those in prison for nonviolent offenses. It’s hard to say exactly how much higher because they report their testosterone in a different way that doesn’t correlate to anyone else’s – I think part of it is that it’s salivary rather than serum testosterone but it’s still confusing even after I adjust for that. If we use relative rather than absolute, they do mention that 66% of inmates in the upper third of testosterone levels committed violent crimes compared to 46% in the lower third. High-T inmates were twice as likely to be in for murder as low-T inmates. Interestingly, testosterone was the highest risk factor for sex crimes, such as child molestation and (especially) rape – high-T inmates were four times as likely to be in for rape as low-T inmates. On the other hand, low-T inmates were about twice as likely to be in prison for drug offenses.

This “which criminals are worse” study is obviously not as good as an “are high-T people more likely to be criminals at all” study, but I can’t fin any of those with a good sample size. You can read a review of the research here.

According to the population decline study, testosterone levels declined about 110 ng/dL in 15 years. They don’t give me a standard deviation, but from this site I get one a bit less than 200. So testosterone declines by one standard deviation about 25 years? That means that a person in the top third of testosterone levels today would have been in the bottom third fifty years ago. Which – and I realize I’m doing all sorts of horrible things here to cover up my lack of actually useful data – if we extrapolate wildly from the results of these studies, we could sort of justify murder halving in about fifty years by falling testosterone alone.

The first problem with this is that we can’t really use data on prison inmates as representative of the population.

The second problem is that murder has halved in way less than fifty years. It seems to have halved between 1994 and 2004.

The third problem is that crime didn’t start falling until the early 1990s, but testosterone was falling since at least 1987 and probably earlier. This site, which doesn’t cite sources, says testosterone was higher in the 1940s, though they might be confusing that with “in men born in the 1940s, as studied in the 1980s”, which is of uncertain significance. Sperm count has been declining since the 30s, according to an article called Sperm Quality & Quantity Declining, Mounting Evidence Suggests

(it looks like somebody was not quite as virtuous as this Twitter user).

The fourth problem is that there’s contradictory evidence about whether testosterone is even falling at all, according to a a study that looked at the faces of Major League Baseball players of the past 120 years. This sort of makes sense – face width-height ratio is affected by testosterone (one reason women’s faces look different than men’s) and baseball players had standardized photographs taken of them for that time period. They find that, at least based on the face ratios, testosterone was increasing during that period, which would be interesting if it didn’t contradict everybody else. As it is, I suspect it just means baseball players were differently representative of the general population. For example, if baseball requires high testosterone, and scouts became better at selecting the highest-testosterone people over that period, that’d do it. Or if the nature of baseball changed to more of a “power game” rather than a “finesse game” (I think some people have said this) that’d do it too. Or if all baseball players suddenly started taking powerful testosterone-analogue chemicals at some point…hmmmmmmmmm…On the other hand – literally on the hand – we have the digit ratios of Lithuanians over 120 years. Someone in 1880 measured the length of Lithuanians’ fingers – which can be a proxy for testosterone levels – and then the experiment was repeated recently and the results compared. It did find the expected increase in testosterone, though no word on whether that was throughout the entire period or just concentrated in the past couple of years. So this sort of turned out to be a non-problem.

The fifth problem is that crime is dropping in women at the same rate as in men – women never really committed that many crimes, but now they’re committing fewer. Women do have some testosterone, so it’s possible that declining testosterone could affect female violence as well, but it wouldn’t be the first thing I expected. Also, I’m not sure if there are any secular trends in female testosterone levels, though I’d be fascinated to see data.

So overall while I like the approach of this hypothesis, I don’t think it gets the time window right. It would be a nice way to explain a gradual fifty-year decrease in violent crime starting in the 50s and continuing to the present day. Instead, we have a big spike in the 50s and a big drop in the 90s, which were not particularly abnormal in terms of testosterone decline.

This doesn’t really make sense to me. If testosterone is declining, it should cause a decrease in crime. One might argue that testosterone levels have been steadily operating behind the scenes causing very long term declines while other things account for the more visible short-term trends, but that seems like a cop-out.

I’d like to see studies comparing testosterone levels in violent criminals (both male and female) to those in the general population.

Also, we have cemeteries full of millions of dead people from every era of history, all carefully marked with what age they were when they died. Somebody needs to dig some of them up and measure their digit ratios – I assume you can still measure the digit ratio of bones, the overall length is still there. Then we can have a good answer for whether testosterone levels in men (and women) have been declining over time, when it started, and whether it’s been picking up recently. If it has been, the chance that it hasn’t had an important effect on our society worth exploring is pretty much nil.

I know, just once I want to get through an entire blog post without a call for disinterring the dead, but this is important.

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How Likely Are Multifactorial Trends?

Vox recently wrote about 16 Theories For Why Crime Plummeted In The US.

Their story is based on a report by the Brennan Center For Justice, which I haven’t read, so I’m hesitant to critique it too much. The little I got off of Vox I don’t like. For example, if I understand correctly they’re arguing that the lead-crime connection is overblown because although lead was banned in the 1970s (thus affecting people who reached peak crime-committing age in the 1990s), the decline in crime continued even into the 2000s. But lead stays in the environment a long time, there’s still a lot of work to be done eliminating various sources of lead, and so blood lead levels continue to decline. That makes their argument ring a little hollow.

But I want to talk about a more meta-level point.

The analysis ends up concluding that there is no “smoking gun” and crime probably declined because of a bunch of reasons coming together. For example, they say that “up to 12 percent of the drop in property crime during the 1990s was due to the rise in incarceration, but it was probably more like 6 percent”, and “up to ten percent of the drop in crime in the 1990s was caused by hiring more police.” The general picture I get is that there were about ten different factors, each explaining ten percent of the decline.

Imagine two different perspectives on this.

First, a learned professor says “Oh yes, the public always wants to hear about how one big exciting thing caused the decline in crime, but that kind of thinking is unsophisticated. Something as complicated as crime is governed by many factors, and you certainly wouldn’t expect one big knockout change to lower it to this degree. Like everything else, it’s probably a combination of different things that came together, each accounting for a small percent of the variance.”

Second, someone counterargues: “If ten different factors caused the decline in crime, that would require that ten different things suddenly changed direction, all at the same time in 1994. That’s a pretty big coincidence. In fact, let’s reductio ad absurdum this. Imagine it was ten million different factors, each accounting for one ten-millionth of the decline. But that seems stupid. For example, since there are only about ten million criminals in the US, we could structure this as one factor per criminal. Imagine that, in 1994, each of America’s ten million criminals independently and coincidentally had a major life change that made crime seem less attractive. That’s ridiculous. But in that case, any other explanation based on ten million factors should seem ridiculous. And if we give a heavy credibility penalty to a story with ten million factors, we should give some credibility penalty to a story with ten factors.”

The second person seems to me to have a strong argument, which makes me think Vox and the Brennan Center’s model where ten different trends each explain about ten percent of the decline is unlikely.

I feel like somebody has already thought about this and there’s an entire literature I’m missing, but Google is failing me (badly – this was my first search result). Can somebody point me to it? Are there ways to calculate how much less likely a ten-factor explanation is than a one-factor explanation?

[EDIT: Yes, there’s the trivial case where all ten factors are correlated, for example they all have to do with an improving economy. I’m talking about the non-boring version of the question.]

[EDIT2: I might have subconsciously absorbed this thought process from Stefan Schubert]

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Drug Testing Welfare Users Is A Sham, But Not For The Reasons You Think

Some people say the War on Drugs is ‘unwinnable’. But there’s actually a foolproof solution that cures drug addiction approximately 100% of the time. That solution is – put people on welfare in Tennessee.

Or at least that is what I am led to believe by articles like Mic’s A Shocking Thing Happened When Tennesee Decided To Drug Test Its Welfare Recipients, which describes said shocking thing as:

1 out of 812 applicants tested positive for drugs. One. Single. Person. Tennessee conservatives suspicious that welfare recipients are a bunch of drug-addicted slackers were proven dead wrong. Big surprise!

After instituting dehumanizing drug-testing requirements to welfare recipients on July 1, 10 people total were flagged for possible drug use and asked to submit to testing. Five others tested negative, and four were rejected after refusing. As Think Progress notes, that means that just 0.12% of all people applying for cash assistance in Tennessee have tested positive for drugs, compared to the 8% who have reported using drugs in the past month among the state’s general population. If you assume the four people who refused were on drugs, it’s still a paltry 0.61%.

In other words, the plan intended to verify right-wing beliefs that welfare recipients are a bunch of drug-addicted slackers looking for a handout has demonstrated exactly the opposite.

The article has 11,000 notes on Tumblr right now, I’ve seen it all over my Facebook feed as well, and the same story has been taken up, with the same editorial line, by a host of other news sources. Jezebel: State Drug Program Busts A Whopping 37 Welfare Applicants. Wall Street Journal: Few Welfare Applicants Caught In Drug Screening Net So Far. New Republic: Red States’ New Tax On The Poor. Daily Kos: Tennessee Just Wasted A Lot Of Money Drug Testing Welfare Recipients. ReverbPress: Another GOP Fail: 0.2% Of Tennessee Welfare Recipients Found To Use Illegal Drugs. Mommyish: Results Of State Drug Testing Prove Gross Assumptions About Welfare Applicants Are Wrong. Washington Post: Scott Walker’s Yellow Politics.

These stories all make the point that we have many stereotypes about the poor, and one such stereotype is that the use lots of drugs, but in fact these sorts of welfare programs find them to use fewer drugs than the general population, and therefore we should stop being so prejudiced.

And if they were found to use only two-thirds, or half as many drugs as the general population, this might indeed be the lesson.

But look at the numbers in the quoted Mic article. Welfare users use only about one percent as many drugs as the general population. Really?

No. Not really at all. According to legitimate research in this area, poor people use as many drugs as anyone else and probably more. The National Household Survey on Drug Abuse found that illegal drug use was slightly higher in families on government assistance (9.6%) than families not on government assistance (6.8%). The National Coalition For The Homeless notes that about 26% of them use drugs, which is about 2.5x as high as the general population. I crunched some data I have from the hospital I work at, and it shows that poor people (defined as people who get health insurance through an aid program) have moderately higher rates of drug use related problems than the general population. So these articles are reporting a drug use rate in the Tennessee population about one percent of that ever reported in any comparable poor population anywhere else.

Kate from Gruntled and Hinged brings up another curious inconsistency. The false positive rate for drug tests is – well, it depends on the test procedure, but it’s usually at least 1%. So if every single welfare user in Tennessee was 100% clean, we would still expect between 1% to 5% positive drug tests. Instead, they got 0.12% positive drug tests. This isn’t just suspiciously good, it’s impossibly good.

So what’s going on here?

Before I explain, here’s a collage of the stock photos displayed above some of those news stories I linked to.

I now have a picture on my website called urine_collage.png

If you’re familiar with the state of the American media, you won’t be surprised to learn that urine was not involved in the ovewhelming majority of this program’s drug tests.

So how did they test people for drugs?

They gave them a written test, where the test question was basically “do you use illegal drugs or not?” You can see the exact procedure on the sidebar here.

And lo and behold, the overwhelming majority of people answered that they didn’t.

A more accurate stock photo they could have used

Now the numbers make sense. It’s not that only 0.2% of welfare recipients use drugs. All this tells us, if anything, is that 0.2% of welfare recipients are on so many drugs they can’t figure out how to check “NO” on a form.

Why would the government do something like this? As best I can tell, the plan was originally to give everyone urine checks, but in Florida the courts decided that urine-checking people without prior suspicion was unconstitutional. The Republicans were pretty attached to their “drug test welfare recipients” plan and didn’t want to look like they were wimps who backed down just because of one little court case, so they decided to give people the written test in the hopes of having prior suspicion for the people who said yes. Sure, it made no sense, but they could still tell their constituents they were drug testing those welfare recipients, and in principle they’d won an important victory. Or something.

Which raises another interesting question – how did Florida’s urine-based program do before the courts struck it down?

According to the media, abysmally. MSNBC: Drug Testing Welfare Recipients Looks Even Worse, “[Florida Governor] Scott’s policy was an embarrassing flop. Only about 2 percent of applicants tested positive, and Florida actually lost money”. TBO: Welfare Drug Testing Yields 2% Positive Results, “Newton said that’s proof the drug-testing program is based on a stereotype, not hard facts.” ATTN: Why Drug Testing Poor People Is A Waste Of Time And Money, “Florida tested welfare recipients for four months before its drug test mandate was thrown out by the courts. Only 2.6 percent of welfare recipients tested positive. The rest of the Florida’s population use drugs at a rate of 8 percent. So, again, welfare recipients used drugs less than everyone else.”

Now we’re merely at one-quarter of the drug use rate people with good methodologies find. Improvement!

So I looked up exactly how this works. Apparently welfare recipients were asked to pay for their own drug tests, and would be reimbursed if the results came back negative. 7000 welfare users did this, but 1600 declined to do so – numbers that were not mentioned in most of the pieces above.

Opponents of the program say that maybe those 1600 people could not find drug testing centers near them, or couldn’t afford to pay for the tests even with the promise of reimbursement later, or something like that. I am sure that some of them did indeed decline for reasons like those.

But also, people on welfare don’t have very much money [citation needed]. If I were a welfare recipient, and they were going to drug test me and not reimburse me if I came out positive, and I was on drugs, I would decline the hell out of that test.

Suppose that the poor in Florida use drugs at the same rate as the poor in various studies and surveys – about 10%. We have 8600 welfare recipients, so we would expect 860 drug users. Of the 7000 who agreed to testing, we know that 2.5% are drug users – that’s 175 people. That in turn would suggest that of the 1600 who refused testing, about 685 were drug users – 40% or so. That would imply that about 80% of drug users versus about 12% of nonusers refused testing.

These numbers seem pretty reasonable to me. Most welfare users want to keep their benefits, so the majority will agree to testing, but a few will inevitably fall through the cracks because they can’t reach a testing center or because they have moral objections to the tests. On the other hand, clued-in drug users will realize that for them, testing means a major inconvenience and monetary charge without any likely corresponding gain. So we would expect drug users to decline testing at a higher rate than nonusers. In order to use the Florida data to say that welfare recipients in general use drugs at a rate of 2%, we would need to assume that drug users were no more likely to refuse drug testing than nonusers, even though the testing rewarded non-use with money but punished use with a loss of money.

(note that there are some different numbers in different places for Florida. I assume that these represent different years, stages of testing, parts of Florida, etc, but I’m not sure. The only one that is seriously different from what I’m saying above is the one that says “only 1% of people declined testing”. After some search, I’m pretty sure that’s referring to that only 1% of people made appointments for testing, then cancelled later. But I am less confident in the Florida numbers than in the analysis of Tennessee)

So the Florida numbers are consistent with welfare recipients using drugs less, more, or the same amount as the general population.

So I have a question for you guys.

How come Brian Williams is being dragged over the coals for lying in the media, but everyone who publishes these kinds of articles gets off scot-free?

If I understand correctly, Williams said that his helicopter got shot at when he was in Iraq, but in reality he was just in a helicopter in Iraq at the same time as some other helicopter nearby was getting shot at. This is obviously stretching the truth, but it seems to me it could have been worse. No important policy decisions are going to hinge upon exactly which helicopter Brian Williams was in. And he didn’t get it infinitely wrong – for example, there was, in some sense, a war in Iraq.

On the other hand, discussions of how many poor people use drugs is pretty important for all sorts of policy questions, and these people completely dropped the ball. So why does nobody get reprimanded for this kind of thing?

You might argue that Brian Williams’ actions were obviously malicious and deceitful, but that screwing up drug numbers is an excusable mistake. I say it’s exactly the opposite. Brian Williams did exactly what I unfortunately do all the time – unthinkingly tell a story the much cooler way it should have happened, the way it happened in my head – rather than the way it actually did happen (my colleagues elsewhere in the psychiatry blogosphere go further and call this “normal brain function”).

On the other hand, I have more trouble imagining a situation in which I would accept the claim “only 0.1% of poor people use drugs, which is barely one percent of the rate in the general population” without wanting to do a little more research to see if it is true. If your reporters are capable of making this mistake honestly, get better reporters.

But I’m not sure it’s honest. A lot of these sources admit they took their story from a Think Progress piece on the issue. Think Progress does mention that the tests are a sham, although only in one sentence that is easy to miss. Either the secondary reporters didn’t read Think Progress thoroughly, or they consciously decided not to mention it.

But even if it was an honest mistake, I still have trouble excusing their arrogance. I mean look at that Jezebel article. The writer says this proves that people who think welfare recipients use drugs “consider ‘facts’ troublesome” and that their “entire social philosophy boils down to ‘Ew, poor people.'”

You’re saying that’s not as bad as a helicopter-related embellishment?

Yes, okay, drug testing welfare applicants is in fact probably a bad idea. It’s a bad idea because the courts have banned doing it in a way more effective than asking them politely if they use drugs or not, but it was a bad idea even before that. It’s a bad idea because drug tests have frequent false positives, but it’s a bad idea even without that. It’s a bad idea because quitting drugs is really hard and denying people benefits isn’t going to help.

But if, in the service of proving this to be a bad idea, you decide it’s acceptable to fudge the numbers to make your point, horrible things happen. First, you contribute to a culture of telling lies and lose the opportunity to protest when the other side does it. Second, you make it harder to trust you on anything else.

But most important, tell one lie and the truth is forever after your enemy. I recently argued that we need to reform suboxone prescribing laws, because it’s the best anti-addiction medicine we’ve got and right now poor people can’t access it. . Why should anyone listen to me now? They can just answer “Actually, that would be a waste of money. As per an article I read in Jezebel, pretty much no poor person has ever been addicted to drugs.” Then the laws don’t get reformed and people die.

Money, Money, Everywhere, But Not A Cent To Spend

The DSM is written mostly by academics, which is why it gets so excited about distinctions like schizoid personality versus schizotypal personality. If it were written by clinicians, it might better reflect the sort of cases that make it into a hospital.

There would, for example, be an entire chapter on the scourge of ‘My Boyfriend Broke Up With Me’ spectrum disorders. More attention would get paid to the plague of chronic ‘I Got Angry At My Dad And Told Him I Was Going To Kill Myself To Freak Him Out And He Overreacted And Called The Cops And Now Here I Am In Hospital But Honestly I Didn’t Mean It’. Society would finally wake up to the epidemic of ‘I Wanted To Take My Medicine But My Hand Slipped And I Somehow Took The Entire Bottle All At Once Even Though I Would Never Do Something Like Intentionally Overdose’. And the sufferers of ‘This Patient Probably Has Some Kind Of Complicated Neurological Problem But Neurology Is Tired Of Trying To Figure It Out So They Have Declared It To Be Psychiatric’ might at last get some relief.

But the biggest change to the medical lexicon would be the introduction of ‘Poverty NOS’.

I recently got a patient, let’s call him Paul…

(all of my patient stories are vague composites of a bunch of people with details changed to protect privacy)

…who was in hospital after trying to hang himself. He said he was so deep in debt he was never going to get out. He’d been involved in a messy court case, had to hire a lawyer to defend himself, lawyer ended up running to the tune of several thousand dollars. He was a clerk at a clothing store, barely made minimum wage, maxed out his credit cards, then maxed out other credit cards paying off the first credit cards.

He didn’t seem to have major depressive disorder, but when someone comes in admitting to a serious suicide attempt, procedure says he gets committed. He wasn’t thrilled about this, saying if he missed work then he might lose his job and this was just going to make him further behind on his payments, but I checked with my attending and as usual the answer was “admit”.

Something especially bothered me about this case, and after thinking about it I’ve figured out what it is.

It’s not just that the psychiatric hospitalization won’t help and might hurt. That’s pretty common. The ‘My Boyfriend Broke Up With Me’s, the ‘I Got Angry At My Dad’s, unless they have some underlying disorder all of these people get limited value from the psychiatric system and tend to just sit in hospital for a couple of days, go to some group therapy, get asked a hundred times if they’re depressed, then go home. And then they’re still broken up with their boyfriend or still have a terrible relationship with their dad and the same thing’s going to happen again.

In this case, it was that – well, the guy is a minimum wage worker from inner city Detroit. He didn’t tell me exactly how much money this debt was, but from a couple of numbers he mentioned I got the impression it was in the ballpark of $5000. That might not seem like an attempt-suicide level of money to some people, but to this guy with his job the chance of ever paying it off seemed low enough that it wasn’t worth waiting and seeing.

So what bothered me is that psychiatric hospitalization costs about $1,000 a day. Average length of stay for a guy like him might be three to five days. So we were spending $5,000 on his psychiatric hospitalization, which was USELESS, so that we could send him out and he could attempt suicide again because of his $5,000 debt which he has no way of paying off. And probably end up in the hospital a second time, for that matter.

I assume that since he was poor, Medicaid paid his hospital bill. I’m not complaining that the cost of the hospital bill was added to his debt, I’m pretty sure it wasn’t, although in some other cases it would be. I’m complaining that here’s this guy, so desperate for money that he wants to kill himself over it, and he has to sit helplessly as we throw thousands of dollars at getting a parade of expensive doctors and nurses and social workers to talk to him, conclude that yup, his problem is definitely that he’s poor, and then throw him back out. I feel like this fails to be, as the buzzwords say, “patient-centered care”.

Problem is, you don’t have to be an economics PhD to realize that “give $5,000 to anyone who attempts suicide and says they need it” might create some bad incentives.

I have no good solution to this. Offering people who are so poor they want to kill themselves very expensive psychiatric care seems maybe a little better than doing nothing. But it also seems insulting, patronizing, paternalistic, wasteful, and occasionally heartbreaking.

And this is why I can never decide whether to identify as a libertarian or a liberal. On the one hand, top-down institutionalized bureaucracies seem so ridiculously inefficient at solving problems that it’s an outrage and a disaster. On the other hand, there are a lot of problems that really need solving, they don’t seem to have solved themselves yet, and governments are the only entity with enough coordination power to attempt the task.

Solution there, it seems to me, is to create unimpoverishable populaces. I think if we were to implement a Basic Income Guarantee we might save more money in psychiatric care than we think – since we compete with the prison system to be the warehouse for people who can’t make it out in the world and nobody knows what to do with. It might produce some of the same kind of savings as giving the homeless people houses. If I got fired because we’d solved all the problems relating to poverty, and the population of seriously mentally ill people was too small to support the current number of psychiatrists, that would be a pretty neat way to go.

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