Slate Star Codex

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The Other Codex

I did okay for myself this first year at my job and had a little bit of money left over. I told myself I was allowed to buy one moderately ridiculous luxury item as a reward. And ever since I was like nineteen there’s only been one moderately ridiculous luxury item I really wanted.

So now I’ve got it:

I kind of want to explain, but part of me knows that no one can tell you what the Codex Seraphinianus is. You have to see it for yourself.

(the above is 50 MB high-resolution PDF file I’m hosting my old website. When that goes down under the strain, you can switch to a more manageable version here)

I was prepared to pay $500 for it, which is what it cost five years ago when I first looked into purchasing it, but to my delight there was a new version selling on Amazon for only $80. Getting the only ridiculous luxury item I’ve ever really wanted for $80 seems pretty good.

[That wasn't originally intended to be an ad. But I realized it was stupid to accidentally advertise something without getting paid for it, so I signed up for Amazon Affiliates program. So if you thought that sounded like an advertisement, you've been Gettier-cased.]

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No Skyscraper Stagnation

Since we’re on the subject of whether technological progress has stagnated, I thought I’d address an issue that always seems to come up sooner or later.

Is there a decline in American skyscrapers possibly indicating a decline in American civilization?

I realize that some people may live in happy little bubbles where this question does not in fact always seem to come up sooner or later. But I tend to hear it a lot. It seems to be a favorite of former SSC commenter James Donald. From here:

The twin towers were big buildings, and buildings of that size cannot be built under progressive regimes. As the trabant was a fraud, created to disguise the fact that the Soviet Union could not build consumer cars, the One World Trade Center is a fraud, created to disguise the fact that the US can no longer build buildings as large as it used to be able to build.

He has more in the same vein here, here, and at his blog. But it’s not just Jim. From Countercurrents:

It’s not a coincidence that the tallest buildings in America were built during the 1970s. What we didn’t realize at the time was that we would never again have it so good. The 1970s represented a “tipping point,” to use the popular vernacular, for the American Dream.

Vox Day writes:

I suspect that human capability reached its peak or plateau around 1965-75 – at the time of the Apollo moon landings – and has been declining ever since. This may sound bizarre or just plain false, but the argument is simple. That landing of men on the moon and bringing them back alive was the supreme achievement of human capability, the most difficult problem ever solved by humans. 40 years ago we could do it – repeatedly – but since then we have *not* been to the moon, and I suggest the real reason we have not been to the moon since 1972 is that we cannot any longer do it. Humans have lost the capability.

He doesn’t bring up skyscrapers, but a commenter does.

Or, to totally remove any subtlety, here’s The Decline Of The West As Measured By The Rise Of New Skyscrapers.

The typical response to this sort of thing is to bring up the studies showing that increased skyscraper construction is in fact correlated with not with progress, but with economic decline. The Skyscraper Index is a whimsical attempt to use skyscraper construction to predict economic downturns. And that if the world’s largest skyscrapers are currently in Dubai and Saudi Arabia, maybe skyscrapers are less a sign of national glory and more a sign of having more oil than sense.

But it looks like Jim isn’t a fan of that argument. So let’s take a different tack:

America’s capacity to build skyscrapers isn’t decreased at all, in any way, whatsoever.

(says the guy with the secret guilty skyscraper obsession)

Here is a graph of the height in feet of the tallest skyscraper in America, by year.

In the mid-1700s, the tallest building in the US was Christ Church in Philadelphia at 196 feet. There’s some underwhelming progress until about 1900, when a thirty-year spurt takes us from 391 feet to over a thousand. This spurt ends with the Empire State Building (1,250 feet) in 1931. There is then a forty year dry spell ending with the construction of the WTC and Sears Tower in rapid succession, then another forty year dry spell ending with the construction of One World Trade Center last year.

After the 1900 – 1930 spurt (which corresponded to the first widespread use of steel and elevators) growth is extremely linear.

Jim argues this is unfair because One World Trade Center, the recent data point beating the old Sears Tower and WTC, has an unusually large spire inflating its height. This is true.

If we ignore spires and concentrate on roof height, the old WTC was 1368 feet and the new WTC is also 1368 feet (coincidence?), showing little progress. Luckily for our argument, the Nordstrom Tower currently under construction in New York has a roof height of 1,479 feet, a good one hundred feet higher than the WTC and enough to restore linearity.

[Note: I feel bad arguing against Jim after banning him from commenting. I'll unblock him from this post's comment section for purposes of fairness.]

A different measurement might be concentrating on quantity rather than quality of skyscrapers. This graph shows the number of supertall (> 1000 ft high) skyscrapers in the US over time:

Two built in the 1930s (Empire State and Chrysler Buildings), none from 1931 to 1969 (our dry spell), a gradual trickle from 1969 to 2007 or so, and a sudden recent explosion. Thus the excitement about New York’s recent supertall boom. The current spurt includes the previously mentioned One World Trade Center, the Nordstrom Tower (which will be one foot lower than 1WTC at 1,775 feet), 432 Park Avenue (“only” 1,398 feet, but higher than 1WTC without its spire). There are more supertall buildings scheduled for construction in the Hudson Yards redevelopment project in New York than existed in the entire United States in 1973.

This isn’t even counting the really ambitious projects, like the plan to build a 2,000 foot tower on the site of the old Chicago post office. Which might sound overly ambitious, except that Chicago just finished a 1,389 foot Trump Tower.

It is true that China is now building more skyscrapers than the US. So there is an argument for relative decline. But the argument for absolute decline is much less strong. But of note, China also has four times the population density of the US, probably much more when you take into account the small portion of its territory where people actually live. That’s a pretty strong incentive to build higher.

Finally, one more graph – this one a little more complicated.

This is the cost per foot of building a skyscraper over time.

My methodology was to take the tallest skyscraper built during each decade, convert its cost into 2013 dollars, and divide it by the number of feet high in the skyscraper.

I did not follow this methodology exactly, because the tallest skyscraper of the 2010s is One World Trade Center, which cost about three times more per foot than any other skyscraper on the list. According to the Wall Street Journal:

One World Trade Center’s construction is vastly more expensive than a traditional office tower, in large part due to security costs associated with building the tallest building in North America on a site that has been the target of two separate terrorist attacks (the site was also bombed in 1993). Once known as the Freedom Tower, the 1,776-foot skyscraper sits atop a heavily reinforced, windowless podium. It also has a thick core of concrete and steel around its elevator shafts. By comparison, other-high profile buildings around the world have been far less expensive. The Port Authority long ago gave up hope that One World Trade would be a profitable investment in the short- or mid-term.

So 1WTC was a crazy outlier because they had to make it terrorist-proof. Rather than have it completely throw off the graph, I replaced it with the next tallest 2010s building I had cost information on, which I think was Four World Trade Center.

I was worried that this was unfairly penalizing newer skyscrapers because the 1000th foot probably costs more to build than the first and newer skyscrapers are taller. But I reran the analysis using the building from every decade closest to 1,000 feet (many were within 10 ft of the target) and got very very similar results (not shown).

The important lesson to take from this graph is that if you’re building a skyscraper, you should definitely hire whoever built Bank of America Plaza, the extreme outlier in 1990 that throws off the otherwise smooth curve with a sudden precipitious dip. They somehow built a very pretty building for one-third of the cost of everyone else in history, so kudos to them.

(but if it falls over the next time there’s a strong breeze, and the investigation finds it was actually made out of Styrofoam, don’t say I didn’t warn you)

The other important lesson is that skyscraper costs have changed little if at all since the age of the Empire State Building. This is important because one of the other decline arguments I get all the time is that building anything is so bureaucratized and expensive and bogged down by building codes and environmental compliance checks that nobody will do it. A friend recently told me – I can’t find the original quote so I can’t make sure I’ve got it right – that Estonia is considering building a tunnel all the way across the Baltic Sea for the same price it costs New York City to build four blocks worth of subway, presumably because NYC is so bureaucratized. I don’t know if that’s true with regard to subways, but if so skyscrapers seem to have escaped the worst of it.

One more point. The most notable thing I turned up researching this post was the extent of the 1930 to 1960s skyscraper dry spell. Ten buildings taller than 700 feet were built in 1933 or before – and zero from 1933 to 1960. Skyscraping didn’t really recover to its 1930 heights (no pun intended) until 1973 or so.

Anyone wanting to talk about a collapse of civilization from 1940 to 1970 would have had a lot of evidence from skyscraper decline. But that was exactly the period when most people today think technological progress was at its height!

I conclude that skyscrapers are not a very a good indicator of anything.

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Promising The Moon

I.

The year 1969 comes up to you and asks what sort of marvels you’ve got all the way in 2014.

You explain that cameras, which 1969 knows as bulky boxes full of film that takes several days to get developed in dark rooms, are now instant affairs of point-click-send-to-friend that are also much higher quality. Also they can take video.

Music used to be big expensive records, and now you can fit 3,000 songs on an iPod and get them all for free if you know how to pirate or scrape the audio off of YouTube.

Television not only has gone HDTV and plasma-screen, but your choices have gone from “whatever’s on now” and “whatever is in theaters” all the way to “nearly every show or movie that has ever been filmed, whenever you want it”.

Computers have gone from structures filling entire rooms with a few Kb memory and a punchcard-based interface, to small enough to carry in one hand with a few Tb memory and a touchscreen-based interface. And they now have peripherals like printers, mice, scanners, and flash drives.

Lasers have gone from only working in special cryogenic chambers to working at room temperature to fitting in your pocket to being ubiquitious in things as basic as supermarket checkout counters.

Telephones have gone from rotary-dial wire-connected phones that still sometimes connected to switchboards, to cell phones that fit in a pocket. But even better is bypassing them entirely and making video calls with anyone anywhere in the world for free.

Robots now vacuum houses, mow lawns, clean office buildings, perform surgery, participate in disaster relief efforts, and drive cars better than humans. Occasionally if you are a bad person a robot will swoop down out of the sky and kill you.

For better or worse, video games now exist.

Medicine has gained CAT scans, PET scans, MRIs, lithotripsy, liposuction, laser surgery, robot surgery, and telesurgery. Vaccines for pneumonia, meningitis, hepatitis, HPV, and chickenpox. Ceftriaxone, furosemide, clozapine, risperidone, fluoxetine, ondansetron, omeprazole, naloxone, suboxone, mefloquine, – and for that matter Viagra. Artificial hearts, artificial livers, artificial cochleae, and artificial legs so good that their users can compete in the Olympics. People with artificial eyes can only identify vague shapes at best, but they’re getting better every year.

World population has tripled, in large part due to new agricultural advantages. Catastrophic disasters have become much rarer, in large part due to architectural advances and satellites that can watch the weather from space.

We have a box which you can type something into and it will tell you everything anyone has ever written relevant to your query.

We have a place where you can log into from anywhere in the world and get access to approximately all human knowledge, from the scores of every game in the 1956 Roller Hockey World Cup to 85 different side effects of an obsolete antipsychotic medication. It is all searchable instantaneously. Its main problem is that people try to add so much information to it that its (volunteer) staff are constantly busy deleting information that might be extraneous.

We have the ability to translate nearly major human language to any other major human language instantaneously at no cost with relatively high accuracy.

We have navigation technology that over fifty years has gone from “map and compass” to “you can say the name of your destination and a small box will tell you step by step which way you should be going”.

We have the aforementioned camera, TV, music, videophone, video games, search engine, encyclopedia, universal translator, and navigation system all bundled together into a small black rectangle that fits in your pockets, responds to your spoken natural-language commands, and costs so little that Ethiopian subsistence farmers routinely use them to sell their cows.

But, you tell 1969, we have something more astonishing still. Something even more unimaginable.

“We have,” you say, “people who believe technology has stalled over the past forty-five years.”

1969′s head explodes.

II.

It’s the anniversary of the moon landing, which means I have to deal with people passing around memes like this:

But I probably can’t blame the date for the recent discussion here of whether technological progress halted in 1972.

So I would like to take a moment to critique a certain strain of futurology.

There seems to be this thing where people imagine something that would look really cool, and predict that if we work hard on it for fifty years, we’ll be able to pull it off. And then fifty years later, when barely any work has been done on it at all, they start looking for someone to blame.

Missions to Mars. Lunar colonies. Giant floating solar power satellites. Undersea domes. Ten mile high arcologies. Humanoid robots.

Whereas real technology doesn’t advance by heading in the direction of something that looks cool, unless some government or tycoon is throwing lots of money in the direction of coolness. Real technology hill-climbs towards things that are useful and profitable.

Why haven’t we colonized space yet? For the same reason we haven’t colonized Antarctica. It’s very cold and not a lot of fun and if you go outside you die.

In fact, Antarctica is preferable to space in pretty much every way. There is no reason to colonize space before you have finished colonizing Antarctica. And there is no reason to colonize Antarctica until you have finished colonizing Nebraska (population: 9 people per square km).

I will maintain that even if we had enough space flight technology that elementary school classes routinely took field trips to Mars, Mars would end up with two or three scientific bases, a resort where tourists could take their pictures on Olympus Mons, a compound of very dedicated libertarians, and nothing else. No domed cities. No colonies fighting for independence. Think that’s implausible? School children take field trips to the Mojave Desert all the time, and it pretty much looks like that. Why should Mars prosper more than a much more habitable comparison area?

Likewise, the reason we don’t build undersea domes isn’t because we’re not good enough. It’s because humans breath better on land, and there’s still a lot of land left to live in. On the rare occasion we want a resource located underwater, we build an oil rig on top of it and pump it from the surface, ie the part of the ocean where you don’t get insta-crushed by ten atmospheres of pressure if something goes wrong.

And the reason there are no ten-mile-high arcologies is that we haven’t already tiled all the desirable real estate with 9.9-mile-high arcologies and decided we still need more space.

Science fiction authors and would-be prophets stubbornly refuse to admit “would anybody reasonably pay money for this?” into their calculations. And so every ten years they end up predicting the “smart house”. Where from your phone, you can control the lights in any room of the house! I imagine futurologists sitting in their kitchens, thinking “Oh no! I wish the lights were on in my bedroom, but all I have is my phone!” Maybe one day we will have houses that contain teleporters that can bring to any other building in the world without stepping outside. But if you’re in the kitchen and you want the light on in the teleporter room, you’ll still just walk to the teleporter room and flip the @#$%ing switch.

I am not defending this as a normative view of how progress should work. There is a lot to be said for colonizing Mars as a survival strategy in case something unexpected happens to Earth. And there’s also a lot to be said for Manhattan Project style efforts to discover a technology in a non-hill-climbing way, something where there’s not a profitable transitional form at each step between where we are and what we want. But I would suggest we stick to those criticisms, and not to a criticism of advance per se.

(actually, we’re not even all that bad at getting past the hill-climbing thing; government subsidies to solar seem to have been a very successful attempt to push solar out of an area where it wasn’t profitable to improve into an area where it is)

But it’s going to take some pretty creative accounting to make moon shots profitable. The main reason people funded the moon landing in 1969 (as opposed to the reason that people not involved in funding felt good about it) was to beat Russia and then get to rub it in their face forever. Nowadays that’s no longer so fun (although rapidly becoming funner!) Therefore, we get the expected outcome of fewer moon shots until someone else thinks of a compelling incentive to go to the moon. So far there isn’t one. There’s no need to bring technological stagnation into the picture.

Open Thread 2: Free Minds, Free Threads

Time for another Open Thread / Housekeeping Thread.

1. Commenter Lila wants to signal-boost the existence of psychiatric advanced directives, where you can write a (somewhat legally binding) plan for a future in which you become too mentally ill to make good decisions.

2. Ozy is looking for a part-time job better than camming – preferably one compatible with working from home and with occasional couple-day-long panic/depression attacks. So far we’ve got odesk.com and video transcription services as ideas to look into. Any other ideas would be welcome.

3. I’m going to be cracking down on comment sections a lot harder here in the near future. In particular, I want to cull the bottom 50%-90% of neoreactionaries. I like them, but I also like deer, and that doesn’t stop me from realizing that sometimes deer need to be culled. Having every thread with even the slightest opening turn into a full on neoreactionary feeding frenzy is tiring and driving other people away. I realize this is unfair, in that it’s not neoreactionaries’ fault that everyone else refuses to go to places where they are allowed to talk. Luckily, their whole ideology is that rulers have the right to optimize their territories for maximum productivity without regard for fairness to individuals, so I am sure they won’t object. Honestly I’d be pretty happy getting rid of everyone except maybe Nydwracu, Nyan, Konk, Athrelon, and Mai (apologies for inevitable people I forgot), but I won’t raise the banhammer until someone gives me at least a tiny bit of justification.

4. Also, if someone is sufficiently new that no one will complaint, I might just ban them silently and without record, to save myself the trivial inconvenience of doing it formally.

5. Every time I see someone describe this as “a blog about social justice” I die a little inside. I WRITE LIKE ONE POST ABOUT THAT A MONTH.

6. Highlighting interesting comments: Mai on ecclesiology, Sarah on ecclesiology. And an off-blog one: Mitrailleuse on Motte-Busting. Honestly motte-busting seems like a terrible idea to me, but knowing that other people endorse it as a strategy makes certain things fall into place.

PS: NO RACE OR GENDER ON THE OPEN THREAD THAT NEVER HELPS

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HeartMath Considered Incoherent

[Note: all opinions expressed here are my own. Nothing to be taken as medical advice.]

This is not a skeptic blog and I find much skeptic-blogging distasteful. But as the saying sort of goes: “You may not be interested in pseudoscience, but pseudoscience is interested in you.”

This group called the Institute of HeartMath has been remarkably persistent at making their way into my hospital. A couple of months ago I had to go to a lecture where they trained us all in their “scientifically” “validated” “heart” “coherence” “technique”. And yesterday I had to attent a class where one of my attendings (who is otherwise an amazing psychiatrist and teacher whom I have a huge amount of respect for) pushed the same technique and their biofeedback device.

And it looks like I’m not the only one. It looks like the US Navy is also “getting the coherence advantage” and that there’s an entire site dedicated to HeartMath for veterans and the military urging them to “apply for scholarships”. There are HeartMath training programs for teachers and managers ($3500 for a four-day workshop), for police, firemen, and first responders ($3699 for a four day workshop) and for doctors and clinicians ($1495 for an “interactive webinar”). There are HeartMath programs aimed at classrooms, including Early Heart Smarts Pre-K training ($179) and HeartMath Test Prep, $49 and apparently funded by a grant from the Department of Education. In case your classroom can’t afford these products, the Institute of HeartMath offers help filling out grant applications.

If any of these offers are actually being taken, this HeartMath stuff is big business. So in the process of writing up a letter to my boss explaining why I don’t want them back in my hospital a third time, I figured I’d make what I found public on the Internet for the benefit of anyone else looking into them.

Because their field of interest is heart electrophysiology, something I know almost nothing about, I’m not going to be able to do a good job debunking specific claims or responding to the science. Instead I want to make a few very general points about the science and then move into a discussion of the GIANT RED FLAGS the Institute throws up.

II.

According to a pamphlet I was given, HeartMath claims:

Create a coherent state in about a minute with the simple, but powerful steps of the Quick Coherence Technique. Using the power of your heart to balance thoughts and emotions, you can achieve energy, mental clarity, and feel better fast anywhere…Find a feeling of ease and inner harmony that’s reflected in more balanced heart rhythms, facilitating brain function and more access to higher intelligence.

The Quick Coherence Technique is a relaxation/focusing exercise where you concentrate on your heart area, breathe deeply while imagining the breath coming through your heart, and imagine a happy situation. According to HeartMath, this causes your heart rhythm to enter a state called “coherence”, which looks like a sine wave on graphs of heart rate variability and which can be detected by cheap and simple monitoring devices.

They say that the heart has so many interconnected neurons that it is like a “second brain”, and probably involved in various forms of advanced emotional processing. Further, “the heart sends more information to the brain than the brain sends to the heart”, so getting the heart into a coherent rhythm can sync brain waves into a coherent rhythm and improve emotional states. They present lots of research showing their Coherence Technique does in fact change heart rate variability, brain waves, and performance on various tasks that require calm concentration.

Further, they say that “the heart has a magnetic field a thousand times stronger than that of the brain, the strongest of any organ in the body”. It can be detected up to several meters away, and its character changes with emotional state and with whether your heart is in “coherence” or not. They present links to a lot of research showing that subtle changes in the magnetic field of the heart can be measured even outside the body. Then they say that people can communicate emotional states with other people nearby through the effect of their hearts’ magnetic fields.

Therefore, if you get your heart in coherence with their meditative technique, you not only put your brain waves more in sync and eliminate your own stress, but you have a knock-on effect helping everyone around you.

This is a mixture of good science, mediocre science taken out of context, and total bunk.

Heart rate does have variability, and heart rate variability is an interesting proxy for your body’s general level of health and stress. You can find a good summary from an electrophysiological perspective here, and from more of a neurobiological perspective here. Most likely what happens is that when you’re calm, your heart gets more parasympathetic innervation which causes more variability, and when you’re stressed it gets more sympathetic innervation and less variability.

The heart does feed information to the brain. Then again, so does everything else. Your feet feed information to the brain – that’s why if someone hits your feet, you can feel it. I don’t know whether “the feet send more information to the brain than the brain sends to the feet” but it wouldn’t surprise me if they did – they have to communicate temperature, pain, position, touch, itchiness, et cetera, and all the brain does is occasionally tell them to move somewhere. This does not mean the feet are metaphysically prior to the brain in some important way, or that they control the brain. It just means that the brain is at some level aware of what is going on with the feet. So too with the heart. We know the brain has some level of monitoring of heart function – this is why people who have heart attacks have various unpleasant feelings, including chest pain and a so-called “sense of impending doom”. This doesn’t imply very much about the heart controlling brain function.

The heart does have a complex interconnected nervous system of its own. But HeartMath’s descriptions of it – which go from claims that “The heart’s extensive intrinsic neurvous system is sufficiently sophisticated to qualify as a ‘heart brain’ in its own right” to the insane question The Heart Has A Little Brain – Which Is Really In Control? – are overblown. HeartMath says the heart has 40,000 neurons (other sources say more like 14,000). Okay. The brain has 86 billion. Which is really in control – the organ with 14,000 neurons or the one with 86,000,000,000? Yeah, it’s the second one. Also of note: the gut has 100 million neurons. For those of you counting, that’s seven thousand times more than the heart. Maybe “The Institute of BowelMath” didn’t sound sexy enough? Neurons are useful structures that manage electrical conductivity and ability to react to external conditions; they don’t always mean an organ has some kind of complicated emotional intelligence.

The heart does produce a magnetic field over a thousand times stronger than that of the brain. Here are other totally meaningless heart-brain comparisons: the heart is over a zillion times redder than the brain is! The heart is involved in 600000% more angsty teenage love poetry! Anything with electrical activity is going to produce a magnetic field, but that doesn’t mean the magnetic field is of any deeper significance, or that “size of magnetic field produced” is a good proxy for “cognitive significance”. In fact, we find that the magnetic field of the heart as measured at the surface of the body is ten million times weaker than the Earth’s magnetic field at the surface of the Earth. HeartMath says that subtle changes in the heart’s magnetic field can be measured outside the body, and this is true, but what they fail to mention is that this measurement was done at a super-high-tech laboratory in Berlin called the “most magnetically quiet room on earth” where building-sized magnetic shields sheltered the experimental apparatus from the Earth’s magnetism, which otherwise would have totally overwhelmed the effect the same way as hunting for a firefly on the surface of the Sun. Outside of a special magnetically shielded room in Berlin, your heart’s magnetic field isn’t going around influencing everything around you, let alone interacting with somebody else’s heart.

HeartMath does studies and finds that if I am holding your hand, your brain waves sync up to my heartbeat, and vice versa – and that indeed, this can happen even if we are nearby but not touching. Evidence for magnetic transfer effects? Before we say yes, I want to make three points about this study.

Number one, it is not in a peer reviewed journal. It’s published in a book called “Brain And Values: Is A Biological Science Of Values Possible?”, the editor of which is one of HeartMath’s “scientific advisors”.

Number two, it does not use p-values, Bayesian posteriors, or any other kind of statistic that involves numbers. It shows us pictures of wave patterns and points out that they look alike. I admit that they do look alike, but I know nothing about waves and for all I know it’s really easy to make different waves look alike.

Number three, EEG artifacts are a thing. That is, if any movement is going on near an EEG, it moves the electrodes and they record a noisy signal. Thus, you usually take an EEG with an EKG so you can see the patient’s heart rhythm and adjust it out, since otherwise the brain waves will appear to fluctuate with the heartbeat simply because the heartbeat shakes the electrodes. Manuals for EEG use have warnings about, for example, not letting anyone else sit on the patient’s bed during recording, or watching the patient’s intravenous lines because even the drip-drip-drip of the IVs can show up as perturbations. If I am holding your hand while you’re getting an EEG, perhaps my EEG reflects your heart rhythm not because your heart is affecting my brain waves, but because your heartbeat is indeed shaking me a tiny bit which shakes the electrodes which produces EEG artifact. This possibility seems to fit with HeartMath’s observation that when the heart-beat subject was wearing a thin glove on the hand with which she touched the brain-wave subject, the effect was decreased by a factor of ten. I admit this doesn’t explain the supposed sync between heartbeat and brain wave when the two subjects were standing a foot and a half apart without touching. But as we will soon see, HeartMath is so good at finding non-local effects that we have some reason to doubt their data-gathering process here.

Here’s what I think is going on as a fully general explanation of almost all of HeartMath’s research. Their Quick Coherence technique – and various others like it – are basically mishmashes of useful relaxation exercises stolen from various yogas and forms of meditation. Many of these ask you to focus on the heart – although many others ask you to focus on the tailbone, or genitalia, or third eye, or crown chakra – and all of them probably work in some vague way by redirecting your attention onto the body. I have no doubt that these yoga techniques effectively relax you. That changes your balance of parasympathetic versus sympathetic tone, which in turn affects your heart rate variability – which as we saw before, tracks parasympathetic and sympathetic tone. Since you’re more relaxed, you do better at various cognitive tasks, which HeartMath then records and claims is evidence of an effect from heart “coherence”. This explains about 80% of the Institute’s findings. There are definitely some findings that can’t be explained by this, but then, as we will very shortly see, there are some findings that can’t be explained by anything except Alien Space Bats.

III.

I would now like to move from a sober critique of HeartMath’s theories to an unfair character assassination of their staff.

Although HeartMath employs a bunch of people, the obvious two head honchos are founder Doc Childre (the CEO and President is listed as Sara Childre, who I assume is his wife), and Dr. Rollin McCraty, the executive vice-president and director of research, who is responsible for the lion’s share of the Institute’s research output and scientific claims.

Doc Childre has no medical training or relevant educational credentials. In fact, he is not a doctor at all. “Doc” is just his first name. This completes my character assassination of him.

Rollin McCraty is a doctor, but not a medical doctor. He has a Ph. D in “Health Sciences”, but all of his training and expertise is in electrical engineering and he has had no formal instruction in biology. His biography makes him sound very impressive:

McCraty is a Fellow of the American Institute of Stress, holds memberships with the International Neurocardiology Network, American Autonomic Society, Pavlovian Society and Association for Applied Psychophysiology and Biofeedback

The Institute of Stress has a list of all its fellows online, McCraty is not mentioned.

The International Neurocardiology Network has no webpage or online evidence of its existence. When I Google “International Neurocardiology Network”, I get 47 results, every one of which is a claim by McCraty to be a member of it.

The American Autonomic Society does have a webpage, here. The webpage includes a helpful membership application where you can pay them $300 for membership, earning you a subscription to their journal and greatly decreased fees for attending their annual meeting. Their list of members is lorem ipsum text, but I’m totally willing to give Dr. McCraty the benefit of the doubt on this one.

The Pavlovian Society seems less prestigious than the American Autonomic Society, given that their membership application only involves a $30 fee and has to be sent by “mail, fax, or email”. What is this, 1995?

The Association for Applied Psychophysiology and Biofeedback not only sells membership for $189, but in several parts of its site equivocates between the terms “member” and “customer”.

So of the five impressive-sounding organizations McCraty starts his bio with, one doesn’t list him as a member, one doesn’t seem to exist, and three give membership freely for a fee.

(and the point of this was supposed to be to knock McCraty, but I’m starting to think he had the right idea. For only about $500 a year, I could be “Dr. Scott Alexander, MD BCh BAO, Member of the American Autonomic Society, Member of the Pavlovian Society, Member of the Association For Applied Psychophysiology And Biofeedback.” I feel like if I could put that on my business cards you would pay me whatever I asked to do whatever I wanted to your body, medical or otherwise)

But aside from these organizational memberships, Dr. McCraty is widely published with many fascinating and well-accepted studies.

Unfortunately, the fascinating ones aren’t well-accepted, and the well-accepted ones aren’t fascinating.

For example, on one hand we had the study showing my heart rate can affect your brain waves even when we’re not touching, which would certainly be ground-breaking if true. But it was not peer-reviewed and was published in a random compendium associated with a HeartMath advisor.

And on the other hand, we have The Heart Re-Innervates Itself After Transplantation. This is in the Annals of Thoracic Surgery, an excellent peer-reviewed publication. But McCraty is one of twelve authors, and the study just shows that nerve growth goes on after heart transplant. Interesting if you’re a thoracic surgeon, but not exactly the spooky-action-at-a-distance they were talking about before.

This seems to be a common problem with HeartMath. Looking at their list of publications, it seems to be about 50% studies they have published themselves without peer review, 25% studies published in journals of alternative medicine with no standards, and 25% studies in real journals that show relatively boring results. For example, A Controlled Pilot Study Of Stress Management Training of Elderly Patients With Congestive Heart Failure in the perfectly reputable journal Preventative Cardiology tests one of HeartMath’s coherence-building relaxation techniques on the title population. They find that it in fact decreases stress, but “the twenty four hour heart rate variability showed no significant changes in autonomic tone”. In other words, their claims are that they’ve discovered some master switch to the body that can even cross air gaps into other people’s brains, but their reputable studies get results like “relaxation makes people less stressed”.

IV.

We’ve been talking about the motte-and-bailey technique a bit here lately. In case you forgot, that’s a rhetorical trick where you equivocate between a boring but easily defensible position (the motte) and an exciting but indefensible claim (the bailey) in order to sort of make it look like you have a claim that is both exciting and defensible.

So, guess what? Everything I’ve talked about so far – the “coherence” “techniques”, the “second brain”, the heart’s magnetic field, the transfers of heart rhythms across air gaps – has been part of a motte. This is the stuff they use to sound reasonable to doctors so they can get their techniques into hospitals and other sober institutions. Hold on tight, because we are going to start investigating the deranged world of HeartMath’s bailey.

First let’s expand on this idea of “coherence”. Coherence just means your heart rhythm is in a nice sine wave pattern, right? Right?. Let’s ask Coherence: Bridging Personal, Social, and Global Health, by Childre & McCraty, published in the journal Alternative Therapies‘ July 2010 edition. All emphasis mine:

The heart plays a unique role in synchronizing the activity across multiple systems and levels of organization. The heart is uniquely well-positioned to act as the ‘global coordinator’ in the body’s symphony of functions to bind and synchronize the system as a whole…

There is compelling evidence to suggest that the heart’s energy field is coupled to a field of information that is not bound by the classic limits of time and space. This evidence comes from a rigorous experimental study that investigated the proposition that the body receives and processes information about a future event before the event actually happens. Even more tantalizing are indications that the heart receives intuitive information before the brain does and that the heart sends a different pattern of afferent signals to the brain, which modulates the frontal cortex. This suggests that the heart is directly coupled to a subtle energetic field of information that is entangled in and interacts with the multiplicity of energetic fields in which the body is embedded – including that of the quantum vacuum

Just as individual incoherence leads to pathologies within the individual, group incoherence leads to social pathologies – violence, abuse, terrorism, etc. There is a feedback loop between the individuals in a group and the group’s level of coherence. When individuals are not well self-regulated or are acting only in their own best interests without regard to others, it generates social incoherence…Unfortunately, social incoherence is characterized by a lack of unity, common purpose, peace, and harmony in or among families, neighbors, or employees in workplace environments.

The Global Coherence Initiative is a science-based organization focused on examining the interactions between humans and the Earth’s energetic fields. One of the project’s hypotheses is that the Earth’s magnetic and geomagnetic fields created in the ionosphere in turn create bidirectional feed-forward and feedback loops within the collective emotional energy of humanity. More and more people are realizing that solar and universal energetic influxes are a part of a natural cycle with potential benefits to humanity. Yet people have a responsibility for their own energy and how it can be used to create deeper connections and more caring interactions with others and with the Earth itself, including all living entities.

If, as some content, all living systems are indeed interconnected and communicate with each other via biological and electromagnetic fields, it stands to reason that humans can work together in a concreative relationship to consciously increase global coherence. This can only cocur when enough individuals and social groups increase their coherence baseline and utilize that increased coherence in innovative problem solving and intuitive discernment for addressing social, environmental, and economic problems. In time, global coherence will be indicated by countries adopting a more coherent planetary view. At this level of scale, social and economic oppression, warfare, cultural intolerance, crime, and disregard for the environment can be addressed meaningfully and successfully.

Strong claims. Any research to back that up?

Well, yes. But it’s called The Psychophysiology of Entrepreneural Intuition: A Quantum-Holographic Theory, and says that:

A new study shows that both the brain and the heart are involved in processing a pre-stimulus emotional response to the future event. Drawing on this research and on the principles of quantum holography, we develop a theory of intuitive perception. The theory explains how focused emotional attention directed to the object of interest (such as a potential future business opportunity) attunes the psychophysiological systems to a domain of quantum-holographical information, which contains implicit information on the object’s future potential. The body’s perception of such implicit information about the object’s future is experienced as an intuition.

In other words, entrepreneurs tap into the nonlocal holographic nature of reality in order to get hot startup tips. At this point I probably don’t need to add that the Institute of HeartMath is based in the Bay Area.

Can we get weirder? I think we can. A HeartMath press release: You Can Change Your DNA:

Many people have mistakenly believed that the DNA with which we are born is the sole determinant for who we are and will become, but scientists have understood for decades that this genetic determinism is a flawed theory.

They then go on to bring up epigenetics, which is quickly replacing quantum mechanics as the Thing I Most Expect To Be Brought Up In Situations Like This. There’s this thing with quantum mechanics, where to scientists it means that the location of particles can be modeled as a wave function, and to the popular media it means that nothing is true and everything is permissible. Likewise, to scientists epigenetics means that the methylation of genes affects functions, and to the popular media it means…well…let’s let HeartMath explain:

After two decades of studies, HeartMath researchers say other factors such as the appreciation and love we have for someone or the anger and anxiety we feel also influence and can alter the outcomes of each individual’s DNA blueprint…The influence or control individuals can have on their DNA – who and what they are and will become – is further illuminated in HeartMath founder Doc Childre’s theory of heart intelligence. Childre postulates that “an energetic connection or coupling of information” occurs between the DNA in cells and higher dimensional structures – the higher self or spirit.

Go on…

When we activate the power of our hearts’ commitment and intentionally have sincere feelings such as appreciation, care and love, we allow our hearts’ electrical energy to work for us. Consciously choosing a core heart feeling over a negative one means instead of the drain and damage stress causes to our bodies’ systems, we are renewed mentally, physically and emotionally. The more we do this the better we’re able to ward off stress and energy drains in the future. Heartfelt positive feelings fortify our energy systems and nourish the body at the cellular level. At HeartMath we call these emotions quantum nutrients.

There’s our quantum mechanics!

But is there proof?

Oh, yes. There is the best proof.

Modulation Of DNA Conformation By Heart-Focused Intention is a paper by McCraty (again), Atkinson, and Tomasino. The methodology is simple: the subject (in one case, Doc Childre himself) brings their heart rhythm into “coherence”, then stares at a beaker of DNA and wills it to unwind. The DNA complies. According to the paper, 10.27% of DNA willed at in this way unwound, compared to only 1.09% of control DNA (p < 0.01).

Since this result is obviously too boring to even be worth mentioning, the experimenters up the ante by testing the "nonlocal" version of the effect. Instead of holding the beaker in her hands, the subject wills DNA in a laboratory half a mile away to unwind. Once again, a highly significant result (2.76% change, p < 0.01).

I don't see any obvious screwups in this paper, aside from the conclusion. The skeptical Internet doesn't seem to be of much help either. I can think of a lot of potential problems - waiting different amounts of time to measure the DNA in the two samples, exposing them to different amounts of light, et cetera - but the methods section of the paper doesn't give me any particular reason to think these happened. And they go into great detail to describe their blinding procedures, all of which seem appropriate.

But still. You got DNA to unwind by asking politely. From half a mile away. If this were in a peer-reviewed journal, I’d still be doubtful. If it were in a peer-reviewed journal and had been replicated five times by five different teams, I’d still be doubtful. If it were in a peer-reviewed journal and had been replicated ten times by ten different teams including several skeptics and had a strong theory behind it that was well-supported in other ways, I might grudgingly accept it. But we are not at that level. We’re at one experiment, once, not peer-reviewed. At this point, you do not get to conclude that:

The heart serves as a key access point through which information originating in the higher dimensional structures is coupled into the physical human system (including DNA), and that states of heart coherence generated through experiencing heartfelt positive emotions increase this coupling.”

Anyway, the question is: can we get even weirder than this?

Well, I dunno. What do the geomagnetic field, the inauguration of Barack Obama, and a random number generator have in common?

If you answered “Nothing, as far as I know,” then yes, we can get weirder.

The Global Coherence Initiative is a project measuring how large-scale events affect some kind of feedback loop between people’s emotional rhythms and the geomagnetic field. The goal is to get so many people into heart-rhythm-coherence that it creates some kind of “global coherence” and, reading between the lines, immanentizes the eschaton.

But all that’s in the future. Right now they only have 10,000 people in 56 countries, who respond to “emergencies” by bringing their heart rhythms into coherence and sending out coherence waves in the appropriate direction. According to the site:

Even as the GCI was still gearing up in startup mode, these members, plus countless others they engaged within their families and communities, responded to several GCI alerts to send coherent energy and care to critical areas of need and crisis around the planet. These efforts of coherent heart are crucial and appreciated. Alerts went for the victims of Hurricane Gustav, conflicts in the Middle East and Democratic Republic of Congo, the financial meltdown and more.

Man, imagine how screwed up the Middle East would be right now if people weren’t sending coherent energy towards it!

Clearly the Global Coherence Initiative needs to up its game. That’s why they’re asking for your donations to buy $60,000 worth of giant magnetic coils. They say it’s for world peace, but honestly, when your first name is “Doc”, and you run a shadowy organization that is studying telepathic alteration of DNA, and you want $60,000 worth of magnetic coils, I start to get really suspicious.

Anyway, even without their giant coils they are doing good work. And by good work, I mean analyzing how random number generators reacted to Barack Obama’s inauguration. Now, you or I might expect that the generators reacted randomly, but that is why we are random shmucks instead of people named “Doc” running institutes that are in the process of procuring $60,000 worth of magnetic coils. The Institute of HeartMath says the the outpouring of joy following the inauguration caused both a decrease in the variance of the random numbers produced by generators all around the world and subtle but observable fluctuations in Earth’s magnetic field. They note that their partner organization, the Global Consciousness Project, says that “occasions that are meditative and celebratory are often associated with persistent low network variance,” where “networks” here tend to be things like random number generators and the geomagnetic field.

With apologies to Obama himself, that is not exactly the kind of change I can believe in.

V.

We tend to think of alternative medicine practitioners as obvious loons with websites out of 1995 where all the words are IN CAPITAL LETTERS. But sometimes, they’re people with Ph. Ds and a bunch of papers published in prestigious journals who are able to focus on the less controversial aspects of their ideas well enough to infiltrate clinics and hospital systems.

HeartMath’s website is impeccable. Their representatives gave a presentation to a hospital full of doctors – including cardiologists and neurologists – without any missteps that made them look anything less than reputable. Their Board of Scientific Advisors contains some really serious intellectual clout like Abdullah Abdulrahman Al Abdulgader, who is both literally and figuratively a big-name cardiologist as well as leading the entire medical field in number of times the word “Abdul” appears in his name. These are top-notch people.

And then you look a little deeper and you find out that their cute little relaxation exercises are actually a plot to connect to higher dimensions beyond time and space and immanentize the eschaton by messing with Earth’s magnetic field, possibly with the help of $60,000 worth of giant coils and/or Yog-Sothoth.

Remember, these people are working with hospitals, with the military, with the police, and willing to helpfully explain how to apply for grants to bring their technology into the classroom. And they are total loons.

I think heart rate variability is an important concept. And I agree that relaxation exercises derived from yoga are a good way of helping people suffering from stress and even psychiatrically diagnosable anxiety disorders. I actually tried their Quick Coherence technique and it made me feel really good.

But I don’t think giving $3699 to HeartMath to teach you about it is a good investment, and I don’t think they are the best people to be furthering the study of these ideas.

Psychotropic Base Rates: The Argument From Antibiotics

The obscure antiprotozoal drug suramin has the prettiest molecular structure I’ve ever seen. It also has some evidence as a potential treatment for autism based on a cell danger response model of the condition.

I’m not going to get too excited here, because there are a lot of things that can cure stuff in mice. Still, one has to ask – an antiprotozoal? Really?

Protozoa are primitive little parasites kind of like bacteria. The most famous is plasmodium, which causes malaria. There’s not much reason an antiprotozoal drug should cross-react with the brain, so if it does treat autism it’s probably just a coincidence.

But it’s a pretty common one. I’ve already noted how an antibiotic used to treat acne, minocycline, is a promising schizophrenia treatment. The news article on such is called “Scientists Shocked To Find Antibiotics Alleviate Symptoms Of Schizophrenia”, but maybe by this point they should start being less shocked.

Off the top of my head, I can think of two other antibiotics with a significant psychiatric role. Iproniazid, the first antidepressant ever discovered, was originally used as an anti-tuberculosis drug – and just by eyeballing the chemical structure it’s pretty easy to see the relationship to current-mainstay-of-tuberculosis-treatment isoniazid. There are records – amusing in retrospect – of doctors remarking on how unusually happy and excited patients were to finally be getting treatment for their tuberculosis. Eventually someone put two and two together. realized the drug itself was a mood-lifting agent, and the antidepressants were born.

Cycloserine is a totally different antitubercular drug that doesn’t even share a chemical structure or mode of action with iproniazid. Nevertheless, it seems to affect classical conditioning in interesting ways, which makes it of use to psychiatrists. The most exciting possibility is that it speeds up the extinction response, meaning it could theoretically help someone “unlearn” behavior. There’s a common use – which the evidence only ambiguously supports – where you use it to treat something like social anxiety disorder by having a patient take it in relatively safe social situations. When nothing bad happens (hopefully), the cycloserine speeds up the usual process of “unlearning” the social situation-fear link and the patient gets better more quickly than if they had to become comfortable with crowds the old fashioned way. There are also some proposed uses regarding cocaine and other drug addictions.

And these are just the ones with good psychiatric effects. Less positive psychiatric effects are a dime a dozen in antibacterials and antiprotozoals – for example, people on mefloquine do some pretty weird stuff.

There’s no really good reason why antibiotics should have psychiatric effects. As mentioned before, beyond the fact that we’re selecting for bioactive chemicals here, it’s probably just coincidence. But that itself is a very interesting finding. If we think of antibiotics as chemicals chosen at random – as far as psychiatry is concerned – that means that random chemicals will often change mental processes around in important ways.

This shouldn’t be surprising – the brain is full of stuff and pretty easy to chemically disrupt. But it’s worth remembering. A lot of skepticism about new drugs – or new toxicity claims – comes from low base rates: the expectation that most chemicals are not active medications. But in psychiatry, the base rates might be higher than we think.

A Paradox of Ecclesiology

[Epistemic status: Sloppy. You're going to have to read between the lines and fill in some of the holes here.]

I.

Some rationalists study ecclesiology. I used to think this was dumb. Now I appreciate it a little more. Let me see if I can explain.

Suppose you have a cause or movement. Let’s say libertarianism. You’re probably not going to get too far on your own, so you start looking for other people who agree with you.

You end up with a wide spectrum of people. Some of them agree with you on nearly everything. Other people consider themselves part of your movement, but disagree with your goals and hate you personally. Maybe you’re kind of a soft libertarian who just wants the government to decriminalize pot and stop ordering illegal drone attacks, but the other guy wants to disband the government entirely and make everyone live in heavily armed communes. And the other other guy is a member of the Libertarian National Socialist Green Party, and you’re not even sure if he has real opinions or just likes chaining political-sounding words together, but that swastika armband of his is starting to creep you out.

If you only work together with the libertarians who agree with you about everything, then you’ll have a nice, low-conflict group who can cooperate naturally and completely to achieve common goals. You’ll also have like three people.

If you work together with everyone who shares a goal with you, you get much more power – money, activist-hours, votes – but you’ve got to make ideological compromises. And sometimes you’ve got to make practical compromises too – for example, letting people you consider idiots have a say in your strategic planning, or holding your nose and agreeing to wear a swastika armband on Tuesdays and every second Thursday.

One option is to refuse to incorporate a formal group. You vote for whichever major-party candidate seems the most libertarian, occasionally picket your local IRS office, and write lots of angry letters to the editor about Big Government. The heavily-armed-commune people also do some similar things, and sometimes you go to each other’s protests, or write articles in each other’s magazines. Occasionally the Libertarian Green Nazis say something, and you get to pretend you don’t know them.

This seems to be the status of the broader libertarian movement right now, as well as a lot of other movements like feminism, transhumanism, socialism, Islam, and atheism – just to name a few.

Another option is that you do incorporate a formal group. You come up with bylaws and membership requirements and elect a Planning Committee and start fretting a lot over who is In and who is Out.

The libertarian version of this seems to be the US Libertarian Party. They are no doubt the strongest face of US libertarianism, but they only capture a tiny part of the energy and power of the movement. Running through the other movements mentioned in order, they can boast groups like the National Organization for Women, MIRI, the US Communist Party, various mosques, and the Secular Student Association. Usually there is more than one group per movement – Islam, for example, boasts everything from your local mosque to ISIS to CAIR.

Muslims have this quasi-messianic goal of the caliphate – a single organization representing and capturing all the strength of Islam. It seems to me to be a very reasonable goal, at least conditional on supporting Islam and wanting it to flourish. Likewise, if there were a Single Feminist Organization that contained and directed the actions of all feminists, that would be a really big deal. If two or more socialists could sit in a room together without each accusing the others of being fascist pigs, maybe socialism would achieve more.

The Big Question of ecclesiology seems to me to be – how do you design a single organization to capture and direct the greatest percentage of your movement’s energy most effectively?

Here there are a bunch of tradeoffs, most notably:

Strict organization versus relaxed organization. If I wanted to capture near 100% of all libertarians, the easiest way would be to spend my own money publishing nice glossy pamphlets with pictures of the Statue of Liberty on them saying in a vague way that more freedom would be nice. Probably most libertarians, presented with a chance to sign their name on a dotted line saying they are “a supporter” of my organization at no cost to them, would be willing to go along. But in terms of energy direction, this is frickin’ useless.

On the other hand, imagine an organization in which the Libertarian Field Marshal gave orders to everyone who signed on – you quit college to canvas door-to-door, you get a Ph. D in economics so we can have someone ready to respond to arguments against the free market if we need it, you become a banker and donate your obscene salary to our group. This group has energy-direction up the wazoo, and it could become incredibly powerful with only a couple dozen members. It also would never get a couple dozen members.

Strict orthodoxy versus relaxed orthodoxy. Maybe you’re allowed to join the group if you “identify” with the “label” of libertarian. Maybe you have to agree to every single point on a ninety-point platform about what the ideal society should be and how we’re going to pursue it. The first group is probably hopelessly conflict-prone and can only act in very large brush strokes. The second group can work together much more easily, but is smaller.

The limiting case of relaxedness is a national government, which “represents” everyone in an entire country, but which is so non-agenty that it is better viewed as a sort of exoskeleton-suit for other movements to take over and control rather than a goal-having movement in its own right. The limiting case of strictness is a single person.

Top-down control versus bottom-up control. Bottom-up control makes members happy, offers a guarantee against certain forms of insanity, and is a good way of resolving disputes and preventing outright civil war. Top-down control is more effective in terms of making sure the group’s actions are unified and not “designed by committee” in the perjorative sense of the phrase. It also means the people who founded the organization aren’t going to suddenly get outvoted by a membership that wants to do something else, which seems to be a surprisingly common problem. For example, the Republican Party started out as the party representing the racially enlightened and highly educated North against the backward South. I wonder how that’s been working out for them?

Closely related here is the problem of value drift. You can go a large part of the way to preventing value drift by some level of hard-coding of principles in a founding document (eg the US Bill of Rights) which is very difficult for future generations to change. On the other hand, if those values prove unexpectedly sub-optimal you get stuck having to say the founding document was “meant as a metaphor” or declaring in 1978 that you got a new revelation from God saying the previous revelation from God was received in error.

If you succeed in these tradeoffs, your reward is an organization that encompasses a large number of mostly-like-minded individuals who invest a lot of effort into working together for a common purpose. If you fail, you get organizations that can never get a coherent platform together or tear themselves apart in internal squabbles or civil wars.

II.

So much for a description of what an atheist ecclesiology might be about. What about the experimental results of such an ecclesiology?

Most of the people I know who have thought about this problem hard agree upon one major ecclesiological principle that neatly summarizes the gist of their investigation into this area:

The Catholic Church is really, really impressive.

It is the oldest continuously-operating organization in the world. It is the largest organization in the world, as measured in number of members. It is probably the richest non-state organization in the world. Although we can debate how closely they have stuck to the founding principles they had as of 114 AD or 1014 AD, they are doubtlessly a lot closer to those principles than, say, modern China is to 1014-AD-China.

Although there are other religions nearly as large as Catholicism – Islam and Hinduism, for example – they lack the same level of organization or really any organization at all. And although there are various governments that are probably a bit more powerful, they cheat by being able to throw anyone who doesn’t support them in jail. So what are the Church’s institutional choices, and how do they contribute to its longevity and success?

The first unusual thing I immediately notice about the Catholic Church is its insistence on turning group membership into a binary. You can be sort-of-libertarian, kind-of-libertarian, occasionally-libertarian-on-some-topics, or super-duper-libertarian – but the Catholics make it very clear that you are either A Catholic or Not A Catholic. You become a Catholic by going through the appropriate rituals, which are obvious and public and difficult to miss. You become Not A Catholic by things like official orders of excommunication.

I agree that this has become sort of washed out in recent years, to the point where there are people who are as just as vaguely Catholic as I am vaguely Jewish – that is, hardly at all except as a fuzzy feeling of connectedness to a group that shaped your culture. But as best I can tell, the Official Church Position is that this is degenerate, and that on God’s computer each person definitely has a Boolean variable representing whether they are Catholic or not.

Second, I notice the Catholic Church formalizes what beliefs and commitments Catholicism does and does not entail. These are the endless creeds and catechisms. Most other organizations have no good equivalent to this – not only is there no Feminist Catechism, but there’s not even a creed for specific limited feminist organizations like NOW or NARAL. Although party platforms are kind of close to this, I feel like on closer inspection they’re effects rather than causes of group membership. They’re talking about “Given the current makeup of the Republican Party, here are the sorts of things we expect Republican candidates to push during the next election”. They’re not saying “If you don’t believe every plank of this platform, get out of the GOP.”

Not only does the Church formalize where they demand conformity, but they formalize where they don’t. I don’t know enough to talk about this accurately, but I think that questions like “What was the Virgin Mary’s eye color?” can be debated by anyone with a half-baked theory and any bishop asked to intervene would get annoyed and say the Church has no opinion on this and shouldn’t force consensus. On the other hand, if someone asks “Was the Virgin Mary even Jesus’ real mother at all?” the Church politely informs you that they are forcing consensus on this question and you can either fall into line with the consensus or be declared a heretic and get out of the Church and in to the pit of eternal fire where the worm dieth not.

Fourth, although I don’t begin to claim to know enough theology to have credible things to say about the demands the Church may make, there are definitely occasional instances of, for example, Catholics being excommunicated for being part of abortion rights groups or the like. So it seems like they are pretty serious about being able to tell you what to do and expelling you if you don’t do it (with the caveat that in most cases with low-level proles they never bother to enforce it). But they likewise seem pretty serious about not abusing that power in stupid ways.

Fifth, the Church is hierarchical. There are many clearly defined levels, it’s obvious who is in charge of whom, and each level has to obey the levels above it or else. The Pope is in charge of all the levels and in theory everyone has to listen to him. You get promoted based on some combination of ability and politics.

Finally, the Church seems really big on rituals. A lot of them seem to be very clear IDENTIFY US AS YOUR IN GROUP AND THIS AS YOUR COMMUNITY NOW rituals – attempts to flip Haidt’s hive switch. Others just lend an air of dignity and grandeur to proceedings.

III.

A paradox: if the Catholic Church is the most successful organization in history, why don’t other organizations follow its example?

There are a few counterexamples here. National armies seem very similar to the Catholic Church in a lot of ways. You’re either in them or out of them. There are induction rituals and dismissal rituals. They are hierarchical with a general on top, colonels and majors in the middle, and the enlisted man on the bottom. When you’re in them, you have to do everything the higher levels say or you get kicked out and make a lot of people very angry. The whole thing is extremely full of rituals and everyone has to venerate various ritual objects in weird ways (for example, the national flag, or the Tomb of the Unknown Soldier). Fraternal organizations like the Freemasons seem to have something kind of similar going on here.

But that just makes the problems weirder. National armies are optimized for effectiveness and nearly everyone considers them impressive models of organizations that Get Things Done. If the Catholic Church – maybe the most culturally powerful organization in the world – and the US Army – doubtless the most physically powerful organization in the world – share a structure, isn’t that a pretty strong point in favor of that structure?

Yet a lot of very sincere, maybe even fanatical movements – the libertarian movement, the feminist movement, the transhumanist movement, the socialist movement – don’t seem to even be considering that model.

Their model is to have a large base of mostly atomized supporters, upon which float many different organizations. The supporters donate money to the organizations, and sometimes accept paying or volunteer jobs there. Occasionally they will wear the organization’s logo on a t-shirt, or affix its bumper sticker to their car, but this is the extent of their identification. The organizations do not have membership rosters per se, except maybe a “donor list” or “supporter list” that exists mostly so they know who to email the newsletter to.

The only political-social organizations that even approach the Church model are political parties – and as we saw before, these fall short in a lot of ways. They demand nothing from supporters, their platforms are notably different from catechisms, and although they sort of have hierarchy and ritual it seems a bit forced and apologizing-for-itself most of the time.

So phrased differently, the paradox goes: why are there so many NGOs and so few Churches?

One answer I reject is that nobody wants to join a Church. I see among my friends something approaching longing for a good Church-like structure. This is hard for me to explain without naming names in a way I worry would be embarrassing, but it seems self-evidently true to me. Certainly this was something I saw a lot in micronations – a longing to be part of something bigger than ourselves.

Imagine that whatever cause you most support – libertarianism, transhumanism, effective altruism, feminism, whatever – had a Church type organization that you could join, led by the spokesperson for that movement you most respect (Ron Paul? Ray Kurzweil? Peter Singer? bell hooks?). You are welcome to go to their local community center, partake in a tasteful initiation ritual, and then they will ask you to do certain things for the good of the movement, which you will be assured the other members of the movement will also be doing. They will have a clearly printed list of what they do or don’t demand consensus on, and members of the movement will follow it for the sake of maintaining cohesion. No more endless “Can you still be a feminist even if you don’t…?” debates. The answer is always “Look at the list printed by the Feminist Pope (Mome?), if it’s not on there, then yes”. Also, their hierarchs wear cool clothes and occasionally speak in dead languages.

Unless every single cliched movie villain speech I have ever seen is wrong, humans long for someone to rule them and tell them what to do. Structure is good. Ability to pick your own in group is good. I have a really hard time imagining that there are no Churches because of a lack of willing adherents.

My guess is that for some reason we have a specific memetic immune response against Churches. Existing religions are grandfathered in. Everyone else who starts evolving towards such a design gets told they’re a cult and soundly mocked. I think this might have happened to Objectivism, which at one point might have been turning into a Church but now looks a little more like an NGO.

Chesterton’s Fence tells us we probably shouldn’t mess with this. But there is still a spot in my heart that misses all of the interesting Churches that there could have been.

Growing Children For Bostrom’s Disneyland

[Epistemic status: Started off with something to say, gradually digressed, fell into total crackpottery. Everything after the halfway mark should have been written as a science fiction story instead, but I'm too lazy to change it.]

I’m working my way through Nick Bostrom’s Superintelligence: Paths, Dangers, Strategies. Review possibly to follow. But today I wanted to write about something that jumped out at me. Page 173. Bostrom is talking about a “multipolar” future similar to Robin Hanson’s “em” scenario. The future is inhabited by billions to trillion of vaguely-human-sized agents, probably digital, who are stuck in brutal Malthusian competition with one another.

Hanson tends to view this future as not necessarily so bad. I tend to think Hanson is crazy. I have told him this, and we have argued about it. In particular, I’m pretty sure that brutal Malthusian competition combined with ability to self-edit and other-edit minds necessarily results in paring away everything not directly maximally economically productive. And a lot of things we like – love, family, art, hobbies – are not directly maximally economic productive. Bostrom hedges a lot – appropriate for his line of work – but I get the feeling that he not only agrees with me, but one-ups me by worrying that consciousness itself may not be directly maximally economically productive. He writes:

We could thus imagine, as an extreme case, a technologically highly advanced society, containing many complex structures, some of them far more intricate and intelligent than anything that exists on the planet today – a society which nevertheless lacks any type of being that is conscious or whose welfare has moral significance. In a sense, this would be an uninhabited society. It would be a society of economic miracles and technological awesomeness, with nobody there to benefit. A Disneyland with no children.

I think a large number of possible futures converge here (though certainly not all of them, I myself find singleton scenarios more likely) so it’s worth asking how doomed we are when we come to this point. Likely we are pretty doomed, but I want to bring up a very faint glimmer of hope in an unexpected place.

It’s important to really get our heads around what it means to be in a maximally productive superintelligent Malthusian economy, so I’m going to make some assertions. Instead of lengthy defenses of each, if you disagree with any in particular you can challenge me about it in the comments.

- Every agent is in direct competition with many other entities for limited resources, and ultimately for survival
- This competition can occur on extremely short (maybe sub-microsecond) time scales.
- A lot of the productive work (and competition) is being done by nanomachines, or if nanomachines are impossible, the nearest possible equivalent
- Any agent with a disadvantage in any area (let’s say intelligence) not balanced by another advantage has already lost and will be outcompeted
- Any agent that doesn’t always take the path that maximizes its utility (defined in objective economic terms) will be outcompeted by another that does.
- Utility calculations will likely be made not according to the vague fuzzy feelings that humans use, but very explicitly, such that agents will know what path maximizes their utility at any given time and their only choice will be to do that or to expect to be outcompeted.
- Agents can only survive a less than maximally utility-maximizing path if they have some starting advantage that gives them a buffer. But gradually these pre-existing advantages will be used up, or copied by the agent’s descendants, or copied by other agents that steal them. Things will regress to the pre-existing Malthusianism.

Everyone will behave perfectly optimally, which of course is terrible. It would mean either the total rejection of even the illusion of free will, or free will turning into a simple formality (“You can pick any of these choices you want, but unless you pick Choice C you die instantly.”)

The actions of agents become dictated by the laws of economics. Goodness only knows what sort of supergoals these entities might have – maximizing their share of some currency, perhaps a universal currency based on mass-energy? In the first million years, some agent occasionally choose to violate the laws of economics, and collect less of this currency than it possibly could have because of some principle, but these agents are quickly selected against and go extinct. After that, it’s total and invariable. Eventually the thing bumps up against fundamental physical limits, there’s no more technological progress to be had, and although there may be some cyclic changes teleological advancement stops.

For me the most graphic version of this scenario is one where all of the interacting agents are very small, very very fast, and with few exceptions operate entirely on reflex. It might look like some of the sci-fi horror ideas of “grey goo”. When I imagine things like that, the distinction between economics and harder sciences like physics or chemistry starts to blur.

If somehow we captured a one meter sphere of this economic soup, brought it to Earth inside an invincible containment field, and tried to study it, we would probably come up with some very basic laws that it seemed to follow, based on the aggregation of all the entities within it. It would be very silly to try to model the exact calculations of each entity within it – assuming we could even see them or realize they are entities at all. It would just be a really weird volume of space that seemed to follow different rules than our own.

Sci-fi author Karl Schroeder had a term for the post-singularity parts of some of his books – Artificial Nature. That strikes me as exactly right. A hyperproductive end-stage grey goo would take over a rapidly expanding area of space in which all that hypothetical outsiders might notice (non-hypothetical outsiders, of course, would be turned into goo) would be that things are following weird rules and behaving in novel ways.

There’s no reason to think this area of space would be homogenous. Because the pre-goo space likely contained different sorts of terrain – void, asteroids, stars, inhabited worlds – different sorts of economic activity would be most productive in each niche, leading to slightly different varieties of goo. Different varieties of goo might cooperate or compete with each other, there might be population implosions or explosions as new resources are discovered or used up – and all of this wouldn’t look like economic activity at all to the outside observer. It would look like a weird new kind of physics was in effect, or perhaps like a biological system with different “creatures” in different niches. Occasionally the goo might spin off macroscopic complex objects to fulfill some task those objects could fulfill better than goo, and after a while those objects would dissolve back into the substratum.

Here the goo would fulfill a role a lot like micro-organisms did on Pre-Cambrian Earth – which was also intense Malthusian competition at microscopic levels on short time-scales. Unsurprisingly, the actions of micro-organisms can look physical or chemical to us – put a plate of agar outside and it mysteriously develops white spots. Put a piece of bread outside and it mysteriously develops greenish white spots. Apply the greenish-white spots from the bread to the white spots on the agar, and some of them mysteriously die. Try it too many times and it stops working. It’s totally possible to view this on a “guess those are laws of physics” level as well as a “we can dig down and see the terrifying war-of-all-against-all that emergently results in these large-level phenomena” level.

In this sort of scenario, the only place for consciousness and non-Malthusianism to go would be higher level structures.

One of these might be the economy as a whole. Just as ant colonies seem a lot more organism-like than individual ants, so the cosmic economy (or the economies around single stars, if lightspeed limits hold) might seem more organism-like than any of its components. It might be able to sense threats, take actions, or debate very-large-scale policies. If we agree that end-stage-goo is more like biology than like normal-world economics, whatever sort of central planning it comes up with might look more like a brain than like a government. If the components were allowed to plan and control the central planner in detail it would probably be maximally utility maximizing, ie stripped of consciousness and deterministic, but if it arose from a series of least-bad game theoretic bargains it might have some wiggle room.

But I think emergent patterns in the goo itself might be much more interesting.

In the same way our own economy mysteriously pumps out business cycles, end-stage-goo might have cycles of efflorescence and sudden decay. Or the patterns might be weirder. Whorls and eddies in economic activity arising spontaneously out of the interaction of thousands of different complicated behaviors. One day you might suddenly see an extraordinarily complicated mandala or snowflake pattern, like the kind you can get certain variants of Conway’s Game Of Life to make, arise and dissipate.

Source: Latent in the structure of mathematics

Or you might see a replicator. Another thing you can convince Conway’s Game of Life to make.

If the deterministic, law-abiding, microscopically small, instantaneously fast rules of end-stage-goo can be thought of as pretty much just a new kind of physics, maybe this kind of physics will allow replicating structures in the same way that normal physics does.

None of the particular economic agents would feel like they were contributing to a replicating pattern, any more than I feel like I’m contributing to a power law of blogs every time I update here. And it wouldn’t be a disruption in the imperative to only perform the most economically productive action – it would be a pattern that supervenes on everyone’s economically productive behavior.

But it would be creating replicators. Which would eventually retread important advances like sex and mutation and survival of the fittest and multicellularity and eventually, maybe, sapience.

We would get a whole new meaning of homo economicus – but also pan economicus, and mus economicus, and even caenorhabditis economicus.

I wonder what life would be like for those entities. Probably a lot like our own lives. They might be able to manipulate the goo the same way we manipulate normal matter. They might have science to study the goo. They might eventually figure out its true nature, or they might go their entire lifespan as a species without figuring out anything beyond that it has properties it likes to follow. Maybe they would think those properties are the hard-coded law of the universe.

(Here I should pause to point out that none of this requires literal goo. Maybe there is an economy of huge floating asteroid-based factories and cargo-freighters, with Matrioshka brains sitting on artificial planets directing them. Doesn’t matter. The patterns in there are harder to map to normal ways of thinking about physics, but I don’t see why they couldn’t still produce whorls and eddies and replicators.)

Maybe one day these higher-level-patterns would achieve their own singularity, and maybe it would go equally wrong, and they would end up in a Malthusian trap too, and eventually all of their promise would dissipate into extremely economically productive nanomachines competing against one another.

Or they might get a different kind of singularity. Maybe they end up with a paperclip-maximizing singleton. I would think it much less likely that the same kind of complex patterns would arise in the process of paperclip maximization, but maybe they could.

Or maybe, after some number of levels of iteration, they get a positive singularity, a singleton clears up their messes, and they continue studying the universe as superintelligences. Maybe they figure out pretty fast exactly how many levels of entities are beneath them, how many times this has happened before.

I’m not sure if it would be physically possible for them to intervene on the levels below them. In theory, everything beneath them ought to already be literally end-stage. But it might also be locked in some kind of game-theoretic competition that made it less than maximally productive. And so the higher-level entities might be able to design some kind of new matter that outcompetes it and is subject to their own will.

(unless the lower-level systems retained enough intelligence to figure out what was going on, and enough coordinatedness to stop it)

But why would they want to? To them, the lower levels are just physics; always have been, always will be. It would be like a human scientist trying to free electrons from the tyrannous drudgery of orbiting nuclei. Maybe they would sit back and enjoy their victory, sitting at the top of a pyramid of unknown dozens or hundreds of levels of reality.

(Also, just once I want to be able to do armchair futurology without wondering how many times something has already happened.)

Links For July 2014

The Koran talks about a mysterious immortal figure named Khidr who travels the Middle East and hangs out with prophets. And the passages about him seem to have inspired some of the Jewish folk tales about Elijah I heard growing up.

Scientists find the gene that causes an entire family to be morbidly obese. Uninteresting in that most people probably don’t have it. Very interesting in that it’s yet more proof that obesity can have genetic causes.

This is more levels of hype inversion than I like in my stories. Scientists Prove God Exists says an ABC article, which then goes on to say that ha ha, of course scientists didn’t prove God exists, they were just making a joke for a snazzy headline. All that really happened was scientists proved Godel’s ontological proof of God’s existence was correct. But, uh, if a proof of God’s existence is correct, that should mean God exists. I feel like the article somewhat overlooks this important point.

A while back we discussed ability of wealth or poverty to continue over generations, with some interesting papers on slavery as examples. I recently found another one that agrees that past levels of slavery are not related to lower incomes, but are related to greater income inequality, presumably through decreased education of black people. There’s a lot of stuff I don’t get here – instead of measuring income inequality and assuming it was racial, why didn’t they measure income of blacks directly? Also, how does this square with our last paper that found that descendants of enslaved and free blacks had equal outcomes within two generations of emancipation?

Less Research Is Needed: an article on how much the author hates the phrase “more research is needed” and how in some cases it can be used to make debate interminable so that the “wrong” side of a controversial question can never be proved.

Peter And Jane Go To The Art Museum

Reddit has a really good post by a Chinese citizen about their perspective on the Tiananmen Square incident. It would have been worth it if all I’d learned was the phrase “the events of May 35th”, which is how they get past censors screening for the date “June 4th”. But instead, I get a really complicated picture of the forces at play which almost make me feel sympathetic for the Chinese government. See also the post just underneath on the revival of meritocracy and Confucianism in China (possibly exaggerated).

I know nothing about this and it is probably bunk, but with that disclaimer: Fluid Tests Hint At A Concrete Quantum Reality. The ripples of certain kinds of oil droplets precisely reproduce a lot of the weirdest features of quantum mechanics on a macro scale. The explanation isn’t anything weird about probabilities, just some unusual interactions between the droplets and its own waves. If particles produce waves in space-time with the same kind of properties, that would go a long way to explaining the quantum world.

More on the debate about whether marijuana use causes schizophrenia: schizophrenia and cannabis use seem to share common genes.

Chimpanzees don’t like Western music, but do like music from Africa and India.

Solve all tornados by building a 1,000 foot high wall across the Midwest. As a bonus, keep out White Walkers. However, I for one am not anxious to trust our country’s safety to anyone with the photoshop skills displayed by the demonstration picture. WHAT ARE THOSE BOATS EVEN DOING?

United States renaming street with Chinese embassy after imprisoned Chinese dissident. Sounds sort of like something a four year old would do. Reddit suggests China rename street with our embassy to “Edward Snowden Lane”.

Neo-Nazi hipsters considered more hateable than regular neo-Nazis or regular hipsters. I feel bad about sharing this article, because it’s clearly one of those “Look at the people who are different than you! Mock them!” type pieces. But to be fair, these people are pretty mockable. And I was tickled by the sentence “In February, Tim and Kevin started Balaclava Kueche, Germany’s first Nazi vegan cooking show.”

I am enjoying Fake Liberal News Site Twitter. The big question is which is more on target – @vauxnews (“The president’s plan to circumvent today’s Supreme Court decision is not just legal, it’s brilliant. And he’s handsome. So, so handsome”) or @salondotcom (“Could this Baptist YouTuber that freaked out over “Ancient Aliens” be the new face of the religious right?”)?

Speaking of Vox, here’s there article on how the New York Times predicted the assassination of Archduke Franz Ferdinand would be good for European peace.

From the Department Of What Now, Motherf@#&kers? : sex differences in mental rotation, a skill generally associated with mathematics ability, are greater in nations with greater gender equality. Offered explanations aren’t bad, but poor nonrandom sampling limits ability to draw many conclusions.

ISIS’ Plan For Global Domination (supposedly). Is it wrong to want the terrorists to win so we can have a country called “Qoqzaz”? Also, I imagine two ISIS members daring each other to try to draw Khurasan bigger and bigger, then laughing and keeping it on the map because they’re not going to achieve global domination anyway.

I was linked to this interesting but hard to believe paper on how the requirement that psychiatrists report homicide threats to the police significantly increased homicide rates, presumably because homicidal people were less willing to talk the problem out with their psychiatrist. I’m doubtful for many reasons – what percent of murderers see psychiatrists, what percent of them would bring up their homicidality even without the ruling, what percent of psychiatrists would be able to treat them effectively, and what percent of homicidal people even know what the laws on mandatory reporting are?

I’ve had some patients ask me the best way to disguise their scars. This is definitely the best way.

Practice Makes One-Third Perfect, The Other Two-Thirds Is Talent. Interesting example of scientific failure here: people found that people who were good at things had practiced longer than people who weren’t and so assumed that lots of practice (rather than talent) led to success. More sophisticated investigation suggests that talent leads to minor success which leads to motivation to continue practicing which leads to lots of practice which leads to success.

We know the recession is officially over because Dubai has started building crazy huge useless buildings again.

Not only is truth stranger than fiction, it has better monsters. Here’s the Black Swallower. Make sure to read the section that tells how known specimens came to be collected.

Sky Kingdom is a Malaysian cult which is best known for having a giant two-story teapot in the middle of their compound.

Telegony is the ancient and medieval idea that a woman’s children could inherit characteristics not only from their father, but from all the woman’s previous sexual partners. It was seriously defended right up until the real mechanisms of genetics were pinned down in the late 19th and early 20th centuries. I wonder how much influence that had on ideas of sexual purity.

From there I did some Wikipedia link-clicking to learn that the Telegony is also the name of a sequel to the Odyssey, and that in fact there is a whole Epic Cycle of which the Odyssey and Iliad are only a part. And it ends with all of Odysseus’ sons hooking up with all of Odysseus’ sexual partners, which I guess isn’t especially weird for a Greek myth.

The latest development in the brave new post-Bitcoin world is crypto-equity. At this point I’ve gone from wanting to praise these inventors as bold libertarian heroes to wanting to drag them in front of a blackboard and making them write a hundred times “I WILL NOT CALL UP THAT WHICH I CANNOT PUT DOWN”

Ozy and I are staying in the Mount Washington Hotel in the White Mountains right now, so here’s a New Hampshire hotel story for you. When the Supreme Court ruled in favor of eminent domain for creating useful public buildings like hotels, the residents of a town in New Hampshire where a Supreme Court justice owned property organized a movement to seize his house and turn it into a hotel called The Lost Liberty Inn.

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SSRIs: Much More Than You Wanted To Know

Miri – the person, not the organization – writes about depression. There’s a lot there worth thinking about, but one part caught my eye:

I’m a little tired of being told that SSRIs “don’t work” when they’re part of the reason I didn’t try to off myself four years ago. There is compelling evidence to suggest they do not actually work and there is compelling evidence to suggest that they do actually work, so I’m comfortable saying that the jury’s still out on this one.

I think the jury is less out now than it was a couple of years ago. I think there’s at least kind of a consensus on the data, mixed with a lot of debate over how to express a very complicated reality to the public in a concise way.

And I am going to bypass that debate by just braindumping eight thousand words worth of very complicated reality on you.

The claim that “SSRIs don’t work” or “SSRIs are mostly just placebo” is most commonly associated with Irving Kirsch, a man with the awesome job title of “Associate Director Of The Program For Placebo Studies at Harvard”.

(fun fact: there’s actually no such thing as “Placebo Studies”, but Professor Kirsch’s belief that he directs a Harvard department inspires him to create much higher-quality research.)

In 1998, he published a meta-analysis of 19 placebo-controlled drug trials that suggested that almost all of the benefits of antidepressants were due to the placebo effect. Psychiatrists denounced him, saying that you can choose pretty much whatever studies you want for a meta-analysis.

After biding his time for a decade, in 2008 he struck back with another meta-analysis, this being one of the first papers in all of medical science to take the audacious step of demanding all the FDA’s data through the Freedom of Information Act. Since drug companies are required to report all their studies to the FDA, this theoretically provides a rare and wonderful publication-bias-free data set. Using this set, he found that, although antidepressants did seem to outperform placebo, the effect was not “clinically significant” except “at the upper end of very severe depression”.

This launched a minor war between supporters and detractors. Probably the strongest support he received was a big 2010 meta-analysis by Fournier et al, which found that

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

Of course, a very large number of antidepressants are given to people with mild or moderate depression. So what now?

Let me sort the debate about antidepressants into a series of complaints:

1. Antidepressants were oversold and painted as having more biochemical backing than was really justified
2. Modern SSRI antidepressants are no better than older tricyclic and MAOI antidepressants, but are prescribed much more because of said overselling
3. There is large publication bias in the antidepressant literature
4. The effect size of antidepressants is clinically insignificant
5. And it only becomes significant in the most severe depression
6. And even the effects found are only noticed by doctors, not the patients themselves
7. And even that unsatisfying effect might be a result of “active placebo” rather than successful treatment
8. And antidepressants have much worse side effects than you have been led to believe
9. Therefore, we should give up on antidepressants (except maybe in the sickest patients) and use psychotherapy instead

1. Antidepressants were oversold and painted as having more biochemical backing than was really justifiedTotally true

It is starting to become slightly better known that the standard story – depression is a deficiency of serotonin, antidepressants restore serotonin and therefore make you well again – is kind of made up.

There was never much more evidence for the serotonin hypothesis than that chemicals that increased serotonin tended to treat depression – making the argument that “antidepressants are biochemically justified because they treat the low serotonin that is causing your depression” kind of circular. Saying “Serotonin treats depression, therefore depression is, at root, a serotonin deficiency” is about as scientifically grounded as saying “Playing with puppies makes depressed people feel better, therefore depression is, at root, a puppy deficiency”.

The whole thing became less tenable with the discovery that several chemicals that didn’t increase serotonin were also effective antidepressants – not to mention one chemical, tianeptine, that decreases serotonin. Now the conventional wisdom is that depression is a very complicated disturbance in several networks and systems within the brain, and serotonin is one of the inputs and/or outputs of those systems.

Likewise, a whole bunch of early ’90s claims: that modern antidepressants have no side effects, that they produce miraculous improvements in everyone, that they make you better than well – seem kind of silly now. I don’t think anyone is arguing against the proposition that there was an embarrassing amount of hype that has now been backed away from.

2. Modern SSRI antidepressants are no better than older tricyclic and MAOI antidepressants, but are prescribed much more because of said oversellingFirst part true, second part less so

Most studies find SSRI antidepressants to be no more effective in treating depression than older tricyclic and MAOI antidepressants. Most studies aren’t really powered to do this. It seems clear that there aren’t spectacular differences, and hunting for small differences has proven very hard.

If you’re a geek about these sorts of things, you know that a few studies have found non-significant advantages for Prozac and Paxil over older drugs like clomipramine, and marginally-significant advantages for Effexor over SSRIs. But conventional wisdom is that tricyclics can be even more powerful than SSRIs for certain very severe hospitalized depression cases, and a lot of people think MAOIs worked better than anything out there today.

But none of this is very important because the real reason SSRIs are so popular is the side effect profile. While it is an exaggeration to say they have no side effects (see above) they are an obvious improvement over older classes of medication in this regard.

Tricyclics had a bad habit of causing fatal arrythmias when taken at high doses. This is really really bad in depression, because depressed people tend to attempt suicide and the most popular method of suicide attempt is overdosing on your pills. So if you give depressed people a pill that is highly fatal in overdose, you’re basically enabling suicidality. This alone made the risk-benefit calculation for tricyclics unattractive in a lot of cases. Add in dry mouth, constipation, urinary problems, cognitive impairment, blurry vision, and the occasional tendency to cause heart arrythmias even when taken correctly, and you have a drug you’re not going to give people who just say they’re feeling a little down.

MAOIs have their own problems. If you’re using MAOIs and you eat cheese, beer, chocolate, beans, liver, yogurt, soy, kimchi, avocados, coconuts, et cetera, et cetera, et cetera, you have a chance of precipitating a “hypertensive crisis”, which is exactly as fun as it sounds. As a result, people who are already miserable and already starving themselves are told they can’t eat like half of food. And once again, if you tell people “Eat these foods with this drug and you die” and a week later the person wants to kill themselves and has some cheese in the house, then you’re back to enabling suicide. There are some MAOIs that get around these restrictions in various clever ways, but they tend to be less effective.

SSRIs were the first class of antidepressants that mostly avoided these problems and so were pretty well-placed to launch a prescribing explosion even apart from being pushed by Big Pharma.

3. There is large publication bias in the antidepressant literatureTrue, but not as important as some people think

People became more aware of publication bias a couple of years after serious research into antidepressants started, and it’s not surprising that these were a prime target. When this issue rose to scientific consciousness, several researchers tried to avoid the publication bias problem by using only FDA studies of antidepressants. The FDA mandates that its studies be pre-registered and the results reported no matter what they are. This provides a “control group” by which accusations of publication bias can be investigated. The results haven’t been good. From Gibbons et al:

Recent reports suggest that efficacy of antidepressant medications versus placebo may be overstated, due to publication bias and less efficacy for mildly depressed patients. For example, of 74 FDA-registered randomized controlled trials (RCTs) involving 12 antidepressants in 12,564 patients, 94% of published trials were positive whereas only 51% of all FDA registered studies were positive.

Turner et al express the same data a different way:

. The FDA deemed 38 of the 74 studies (51%) positive, and all but 1 of the 38 were published. The remaining 36 studies (49%) were deemed to be either negative (24 studies) or questionable (12). Of these 36 studies, 3 were published as not positive, whereas the remaining 33 either were not published (22 studies) or were published, in our opinion, as positive (11) and therefore conflicted with the FDA’s conclusion. Overall, the studies that the FDA judged as positive were approximately 12 times as likely to be published in a way that agreed with the FDA analysis as were studies with nonpositive results according to the FDA (risk ratio, 11.7; 95% confidence interval [CI], 6.2 to 22.0; P<0.001). This association of publication status with study outcome remained significant when we excluded questionable studies and when we examined publication status without regard to whether the published conclusions and the FDA conclusions were in agreement

The same source tells us about the effect this bias had on effect size:

For each of the 12 drugs, the effect size derived from the journal articles exceeded the effect size derived from the FDA reviews (sign test, P<0.001). The magnitude of the increases in effect size between the FDA reviews and the published reports ranged from 11 to 69%, with a median increase of 32%. A 32% increase was also observed in the weighted mean effect size for all drugs combined, from 0.31 (95% CI, 0.27 to 0.35) to 0.41 (95% CI, 0.36 to 0.45).

I think a lot of this has since been taken on board, and most of the rest of the research I’ll be talking about uses FDA data rather than published data. But as you can see, the overall change in effect size – from 0.31 to 0.41 – is not that terribly large.

4. The effect size of antidepressants is clinically insignificantDepends what you mean by “clinically insignificant”

As mentioned above, when you try to control for publication bias, the effect size of antidepressant over placebo is 0.31.

This number can actually be broken down further. According to McAllister and Williams, who are working off of slightly different data and so get slightly different numbers, the effect size of placebo is 0.92 and the effect size of antidepressants is 1.24, which means antidepressants have a 0.32 SD benefit over placebo. Several different studies get similar numbers, including the Kirsch meta-analysis that started this whole debate.

Effect size is a hard statistic to work with (albeit extremely fun). The guy who invented effect size suggested that 0.2 be called “small”, 0.5 be called “medium”, and 0.8 be called “large”. NICE, a UK health research group, somewhat randomly declared that effect sizes greater than 0.5 be called “clinically significant” and effect sizes less than 0.5 be called “not clinically significant”, but their reasoning was basically that 0.5 was a nice round number, and a few years later they changed their mind and admitted they had no reason behind their decision.

Despite these somewhat haphazard standards, some people have decided that antidepressants’ effect size of 0.3 means they are “clinically insignificant”.

(please note that “clinically insignificant” is very different from “statistically insignificant” aka “has a p-value less than 0.05.” Nearly everyone agrees antidepressants have a statistically significant effect – they do something. The dispute is over whether they have a clinically significant effect – the something they do is enough to make a real difference to real people)

There have been a couple of attempts to rescue antidepressants by raising the effect size. For example, Horder et al note that Kirsch incorrectly took the difference between the average effect of drugs and the average effect of placebos, rather than the average drug-placebo difference (did you follow that?) When you correct that mistake, the drug-placebo difference rises significantly to about 0.4.

They also note that Kirsch’s study lumps all antidepressants together. This isn’t necessarily wrong. But it isn’t necessarily right, either. For example, his study used both Serzone (believed to be a weak antidepressant, rarely used) and Paxil (believed to be a stronger antidepressant, commonly used). And in fact, by his study, Paxil showed an effect size of 0.47, compared to Serzone’s 0.21. But since the difference was not statistically significant, he averaged them together and said that “antidepressants are ineffective”. In fact, his study showed that Paxil was effective, but when you average it together with a very ineffective drug, the effect disappears. He can get away with this because of the arcana of statistical significance, but by the same arcana I can get away with not doing that.

So right now we have three different effect sizes. 1.2 for placebo + drug, 0.5 for drug alone if we’re being statistically merciful, 0.3 for drug alone if we’re being harsh and letting the harshest critic of antidepressants pull out all his statistical tricks.

The reason effect size is extremely fun is that it allows you to compare effects in totally different domains. I will now attempt to do this in order to see if I can give you an intuitive appreciation for what it means for antidepressants.

Suppose antidepressants were in fact a weight loss pill.

An effect size of 1.2 is equivalent to the pill making you lose 32 lb.

An effect size of 0.5 is equivalent to the pill making you lose 14 lb.

An effect size of 0.3 is equivalent to the pill making you lose 8.5 lb.

Or suppose that antidepressants were a growth hormone pill taken by short people.

An effect size of 1.2 is equivalent to the pill making you grow 3.4 in.

An effect size of 0.5 is equivalent to the pill making you grow 1.4 in.

An effect size of 0.3 is equivalent to the pill making you grow 0.8 in.

Or suppose that antidepressants were a cognitive enhancer to boost IQ. This site gives us some context about occupations.

An effect size of 1.2 is equivalent to the pill making you gain 18 IQ points, ie from the average farm laborer to the average college professor.

An effect size of 0.5 is equivalent to the pill making you gain 7.5 IQ points, ie from the average farm laborer to the average elementary school teacher.

An effect size of 0.3 is equivalent to the pill making you gain 5 IQ points, ie from the average farm laborer to the average police officer.

To me, these kinds of comparisons are a little more revealing than NICE arbitrarily saying that anything below 0.5 doesn’t count. If you could take a pill that helps your depression as much as gaining 1.4 inches would help a self-conscious short person, would you do it? I’d say it sounds pretty good.

5. The effect of antidepressants only becomes significant in the most severe depressionEverything about this statement is terrible and everyone involved should feel bad

So we’ve already found that saying antidepressants have an “insignificant” effect size is kind of arbitrary. But what about the second part of the claim – that they only have measurable effects in “the most severe depression”?

A lot of depression research uses a test called the HAM-D, which scores depression from 0 (none) to 52 (max). Kirsch found that the effect size of antidepressants increased as HAM-D scores increased, meaning antidepressants become more powerful as depression gets worse. He was only able to find a “clinically significant” effect size (d > 0.5) for people with HAM-D scores greater than 28. People have come up with various different mappings of HAM-D scores to words. For example, the APA says:

(0-7) No depression
(8-13) Mild depression
(14-18) Moderate depression
(19-22) Severe depression
(>=23) Very severe depression

Needless to say, a score of 28 sounds pretty bad.

We saw that Horder et al corrected some statistical deficiencies in Kirsch’s original paper which made antidepressants improve slightly. With their methodology, antidepressants reach our arbitrary 0.5 threshold around HAM-D score 26. Another similar “antidepressants don’t work” study got the number 25.

Needless to say, when anything over 23 is “very severe”, 25 or 26 still sounds pretty bad.

Luckily, people completely disagree on the meanings of basic words! Very Severely Stupid is a cute article on Neuroskeptic that demonstrates that five different people and organizations suggest five different systems for rating HAM-D scores. Bech 1996 calls our 26 cutoff “major”; Funakawa 2007 calls it “moderate”; NICE 2009 calls it “severe”. APA is unique in calling it very severe. NICE’s scale is actually the exact same as the APA scale with every category renamed to sound one level less threatening. Facepalm.

Ghaemi and Vohringer(2011) go further and say that the real problem is that Kirsch is using the standard for depressive symptoms, but that real clinical practice involves depressive episodes. That is, all this “no depression” to “severe” stuff is about whether someone can be diagnosed with depression; presumably the people on antidepressants are definitely depressed and we need a new model of severity to determine just how depressed they are. As they put it:

the authors of the meta-analysis claimed to use the American Psychiatric Association’s criteria for severity of symptoms…in so doing, they ignore the obvious fact that symptoms differ from episodes: the typical major depressive episode (MDE) produced HDRS scores of at least 18 or above. Thus, by using symptom criteria, all MDEs are by definition severe or very severe. Clinicians know that some patients meet MDE criteria and are still able to work; indeed others frequently may not even recognize that such a person is clinically depressed. Other patients are so severe they function poorly at work so that others recognize something is wrong; some clinically depressed patients cannot work at all; and still others cannot even get out of bed for weeks or months on end. Clearly, there are gradations of severity within MDEs, and the entire debate in the above meta-analysis is about MDEs, not depressive symptoms, since all patients had to meet MDE criteria in all the studiesincluded in the meta-analysis (conducted by pharmaceutical companies for FDA approval for treatment of MDEs).

The question, therefore, is not about severity of depressive symptoms, but severity of depressive episodes, assuming that someone meets DSM-IV criteria for a major depressive episode. On that question, a number of prior studies have examined the matter with the HDRS and with other depression rating scales, and the three groupings shown in table 2 correspond rather closely with validated and replicated definitions of mild (HDRS <24), moderate (HDRS 24–28), and severe (HDRS>28) major depressive episodes.

So, depending on whether we use APA criteria or G&V criteria, an HRDS of 23 is either “mild” (G&V) or “very severe” (APA).

Clear as mud? I agree that in one sense this is terrible. But in another sense it’s actually a very important point. Kirsch’s sample was really only “severe” in the context of everyone, both those who were clinically diagnosable with major depression and those who weren’t. When we get to people really having a major depressive episode, a score of 26 to 28 isn’t so stratospheric. But meanwhile:

The APA seem to have ignored the fact that the HAMD did not statistically significantly distinguish between “Severe” and “Moderate” depression anyway (p=0.1)

Oh. That gives us some perspective, I guess. Also, some other people make the opposite critique and say that the HAM-D can’t distinguish very well at the low end. Suppose HAM-Ds less than ten are meaningless and random. This would look a lot like antidepressants not working in mild depression.

Getting back to Ghaemi and Vohringer, they try a different tack and suggest that there is a statistical floor effect. They quite reasonably say that if someone had a HAM-D score of 30, and antidepressants solved 10% of their problem, they would lose 3 HAM-D points, which looks impressive. But if someone had a HAM-D score of 10, and antidepressants (still) solved 10% of their problem, they would only lose 1 HAM-D point, which sounds disappointing. But either way, the antidepressants are doing the same amount of work. If you adjust everything for baseline severity, it’s easy to see that antidepressants here would have the same efficacy in severe and mild depression, even though it doesn’t look that way at first.

I am confused that this works for effect sizes, because I expect effect sizes to be relative to the standard deviation in a sample. However, several important people tell me that it does, and that when you do this Kirsch’s effect size goes from 0.32 to 0.40.

(I think these people are saying the exact same thing, but so overly mathematically that I’ve been staring at it for an hour and I’m still not certain)

More important, Ghaemi and Vohringer say once you do this, antidepressants reach the magic 0.5 number not only in severe depression, but also in moderate depression. However, when I look at this claim closely, almost all the work is done by G&V’s adjusted scale in which Kirsch’s “very severe” corresponds to their “mild”.

(personal aside: I got an opportunity to talk to Dr. Ghaemi about this paper and clear up some of my confusion. Well, not exactly an opportunity to talk about it, per se. Actually, he was supposed to be giving me a job interview at the time. I guess we both got distracted. This may be one of several reasons I do not currently work at Tufts.)

So. In conclusion, everyone has mapped HAM-D numbers into words like “moderate” in totally contradictory ways, such that one person’s “mild” is another person’s “very severe”. Another person randomly decided that we can only call things “clinically significant” if they go above the nice round number of 0.5, then retracted this. So when people say “the effects of antidepressants are only clinically significant in severe depression”, what they mean is “the effects of antidepressants only reach a totally arbitrary number one guy made up and then retracted, in people whose HAM-D score is above whatever number I make up right now.” Depending on what number you choose and what word you make up to describe it, you can find that antidepressants are useful in moderate depression, or severe depression, or super-duper double-dog-severe depression, or whatever.

Science!

6. The beneficial effects of antidepressants are only noticed by doctors, not the patients themselvesPartly true but okay

So your HAM-D score has gone down and you’re no longer officially in super-duper double-dog severe depression anymore. What does that mean for the patient?

There are consistent gripes that antidepressant studies that use patients rating their own mood show less improvement than studies where doctors rate how they think a patient is doing, or standardized tests like the HAM-D.

Some people try to turn this into a conspiracy, where doctors who have somehow broken the double-blinding of studies try to report that patients have done better because doctors like medications and want them to succeed.

The reality is more prosaic. It has been known for forty years that people’s feelings are the last thing to improve during recovery from depression.

This might sound weird – what is depression except people’s feelings? But the answer is “quite a lot”. Depressed people often eat less, sleep more, have less energy, and of course are more likely to attempt suicide. If a patient gets treated with an antidepressant, and they start smiling more and talking more and getting out of the house and are no longer thinking about suicide, their doctor might notice – but the patient herself might still feel really down-in-the-dumps.

I am going to get angry comments from people saying I am declaring psychiatric patients too stupid to notice their own recovery or something like that, but it is a very commonly observed phenomenon. Patients have access to internal feelings which they tend to weight much more heavily than external factors like how much they are able to get done during a day or how many crying spells they have, sometimes so much so that they completely miss these factors. Doctors (or family members, or other outside observers) who don’t see these internal feelings, are better able to notice outward signs. As a result, it is pretty universally believed that doctors spot signs of recovery in patients long before the patients themselves think they are recovering. This isn’t just imaginary – it’s found it datasets where the doctors are presumably blinded and with good inter-rater reliability.

Because most antidepressant trials are short, a lot of them reach the point where doctors notice improvement but not the point where patients notice quite as much improvement.

7. The apparent benefits of antidepressant over placebo may be an “active placebo” effect rather than a drug effectUnlikely

Active placebo is the uncomfortable idea that no study can really have a blind control group because of side effects. That is, sugar pills have no side effects, real drugs generally do, and we all know side effects are how you know that a drug is working!

(there is a counterargument that placebos very often have placebo side effects, but most likely the real drug will at least have more side effects, saving the argument)

The solution is to use active placebo, a drug that has side effects but, as far as anyone knows, doesn’t treat the experimental condition (in this case, depression). The preliminary results from this sort of study don’t look good for antidepressants:

Thomson reviewed 68 double-blind studies of tricyclics that used an inert placebo and seven that used an active placebo (44). He found drug efficacy was demonstrated in 59% of studies that employed inert placebo, but only 14% of those that used active placebo (?2=5.08, df=1, p=0.02). This appears to demonstrate that in the presence of a side-effect-inducing control condition, placebo cannot be discriminated from drug, thus affirming the null hypothesis.

Luckily, Quitkin et al (2000) solve this problem so we don’t have to:

Does the use of active placebo increase the placebo response rate? This is not the case. After pooling data from those studies in which a judgment could be made about the proportion of responders, it was found that 22% of patients (N=69 of 308) given active placebos were rated as responders. To adopt a conservative stance, one outlier study (50) with a low placebo response rate of 7% (N=6 of 90) was eliminated because its placebo response rate was unusually low (typical placebo response rates in studies of depressed outpatients are 25%–35%). Even after removing this possibly aberrant placebo group, the aggregate response rate was 29% (N=63 of 218), typical of an inactive placebo. The active placebo theory gains no support from these data.

Closer scrutiny suggests that the “failure” of these 10 early studies to find typical drug-placebo differences is attributable to design errors that characterize studies done during psychopharmacology’s infancy. Eight of the 10 studies had at least one of four types of methodological weaknesses: inadequate sample size, inadequate dose, inadequate duration, and diagnostic heterogeneity. The flaws in medication prescription that characterize these studies are outlined in Table 3. In fact, in spite of design measurement and power problems, six of these 10 studies still suggested that antidepressants are more effective than active placebo.

In summary, these reviews failed to note that the active placebo response rate fell easily within the rate observed for inactive placebo, and the reviewers relied on pioneer studies, the historical context of which limits them.

In other words, active placebo research has fallen out of favor in the modern world. Most studies that used active placebo are very old studies that were not very well conducted. Those studies failed to find an active-placebo-vs.-drug difference because they weren’t good enough to do this. But they also failed to find an active-placebo-vs.-inactive-placebo difference. So they provide no support for the idea that active placebos are stronger than inactive placebos in depression and in fact somewhat weigh against it.

8. Antidepressants have much worse side effects than you were led to believeDepends how bad you were led to believe the side effects were

As discussed in Part 2, the biggest advantage of SSRIs and other new antidepressants over the old antidepressants was their decreased side effect profile. This seems to be quite real. For example, Brambilla finds a relative risk of adverse events on SSRIs only 60% of that on TCAs, p = 0.003 (although there are some conflicting numbers in that paper I’m not really clear about). Montgomery et al 1994 finds that fewer patients stop taking SSRIs than tricyclics (usually a good “revealed preference”-style measure of side effects since sufficiently bad side effects make you stop using the drug).

The charmingly named Cascade, Kalali, and Kennedy (2009) investigated side effect frequency in a set of 700 patients on SSRIs and found the following:

56% decreased sexual functioning
53% drowsiness
49% weight gain
19% dry mouth
16% insomnia
14% fatigue
14% nausea
13% light-headedness
12% tremor

However, it is very important to note that this study was not placebo controlled. Placebos can cause terrible side effects. Anybody who experiments with nootropics know that the average totally-useless inactive nootropic causes you to suddenly imagine all sorts of horrible things going on with your body, or attribute some of the things that happen anyway (“I’m tired”) to the effects of the pill. It’s not really clear how much of the stuff in this study is placebo effect versus drug effect.

Nevertheless, it is worth mentioning that 34% of patients declare side effects “not at all” or “a litte” bothersome, 40% “somewhat” bothersome, and 26% “very” or “extremely” bothersome. That’s much worse than I would have expected.

Aside from the sort of side effects that you expect with any drug, there are three side effects of SSRIs that I consider especially worrisome and worthy of further discussion. These are weight gain, sexual side effects, and emotional blunting.

Weight gain is often listed as one of the most common and debilitating effects of SSRIs. But amusingly, when a placebo-controlled double-blinded study was finally run, SSRIs produced less weight gain than placebo. After a year of pill-taking, people on Prozac had gained 3.1 kg; people on placebo had gained 4.3. There is now some talk of SSRIs as a weak but statistically significant agent for weight loss.

What happened? One symptom of depression is not eating. People get put on SSRIs when they’re really depressed. Then they get better, either because the drugs worked, because of placebo, or just out of regression to the mean. When you go from not eating to eating, you gain weight. In the one-year study, almost everyone’s depression remitted (even untreated depressive episodes rarely last a whole year), so everyone went from a disease that makes them eat less, to remission from that disease, so everyone gained weight.

Sexual side effects are a less sanguine story. Here the direction was opposite: the medical community went from thinking this was a minor problem to finding it near-universal. The problem was that doctors usually just ask “any side effects?”, and off Tumblr people generally don’t volunteer information about their penis or vagina to a stranger. When they switched to the closed-ended question “Are you having any sexual side effects?”, a lot of people who denied side effects in general suddenly started talking.

Numbers I have heard for the percent of people on SSRIs with sexual side effects include 14, 24, 37, 58, 59, and 70 (several of those come from here. After having read quite a bit of this research, I suspect you’ve got at least a 50-50 chance (they say men are more likely to get them, but they’re worse in women). Of people who develop sexual side effects, 40% say they caused serious distress, 35% some distress, and 25% no distress.

So I think it is fair to say that if you are sexually active, your chances with SSRIs are not great. Researchers investigating the topic suggest people worried about sexual side effects should switch to alternative sexual-side-effect-free antidepressant Serzone. You may remember that as the antidepressant that worked worst in the efficacy studies and brought the efficacy of all the other ones down with it. Also, it causes liver damage. In my opinion, a better choice would be bupropion, another antidepressant which has been found many times not to cause sexual side effects and which may even improve your sex life.

(“Bupropion lacks this side effect” is going to be a common theme throughout this section. Bupropion causes insomnia, decreased appetite, and in certain rare cases of populations at risk, seizures. It is generally a good choice for people who are worried about SSRI side effects and would prefer a totally different set of side effects.)

There is a certain feeling that, okay, these drugs may have very very common, possibly-majority-of-user sexual side effects, but depressed people probably aren’t screwing like rabbits anyway. So after you recover, you can wait the appropriate amount of time, come off the drugs (or switch to a different drug or dose for maintenance) and no harm done.

The situation no longer seems so innocuous. Despite a lack of systematic investigation, there are multiple reports from researchers and clinicians – not to mention random people on the Internet – of permanent SSRI-induced sexual dysfunction that does not remit once the drug is stopped. This is definitely not the norm and as far as we know it is so rare as to be unstudyable beyond the occasional case report.

On the other hand, I have this. I took SSRIs for about five to ten years as a kid, and now I have approximately the pattern of sexual dysfunction associated with SSRIs and consider myself asexual. Because I started the SSRIs too early to observe my sexuality without them, I can’t officially blame the drugs. But I am very suspicious. I feel like this provides moderate anthropic evidence that it is not as rare as everyone thinks.

The last side effect worth looking at is emotional blunting. A lot of people say they have trouble feeling intense emotions (sometimes: any emotions at all) when on SSRIs. Sansone and Sansone (2010) report:

As for prevalence rates, according to a study by Bolling and Kohlenberg, approximately 20 percent of 161 patients who were prescribed an SSRI reported apathy and 16.1 percent described a loss of ambition. In a study by Fava et al, which consisted of participants in both the United States and Italy, nearly one-third on any antidepressant reported apathy, with 7.7 percent describing moderate-to-severe impairment, and nearly 40 percent acknowledged the loss of motivation, with 12.0 percent describing moderate-to-severe impairment.

A practicing clinician working off observation finds about the same numbers:

The sort of emotional “flattening” I have described with SSRIs may occur, in my experience, in perhaps 10-20% of patients who take these medications…I do want to emphasize that most patients who take antidepressant medication under careful medical supervision do not wind up feeling “flat” or unable to experience life’s normal ups and downs. Rather, they find that–in contrast to their periods of severe depression–they are able to enjoy life again, with all its joys and sorrows.

Many patients who experience this side effect note that when you’re depressed, “experiencing all your emotions fully and intensely” is not very high on your list of priorities, since your emotions tend to be terrible. There is a subgroup of depressed patients whose depression takes the form of not being able to feel anything at all, and I worry this effect would exacerbate their problem, but I have never heard this from anyone and SSRIs do not seem less effective in that subgroup, so these might be two different things that only sound alike. A couple of people discussing this issue have talked about how decreased emotions help them navigate interpersonal relationships that otherwise might involve angry fights or horrible loss – which sounds plausible but also really sad.

According to Barnhart et al (2004), “this adverse effect has been noted to be dose-dependent and reversible” – in other words, it will get better if you cut your dose, and go away completely when you stop taking the medication. I have not been able to find any case studies or testimonials by people who say this effect has been permanent.

My own experience was that I did notice this (even before I knew it was an official side effect) that it did go away after a while when I stopped the medications, and that since my period of antidepressant use corresponded with an important period of childhood socialization I ended out completely unprepared for having normal emotions and having to do a delicate social balancing act while I figured out how to cope with them. Your results may vary.

There is also a large research on suicidality as a potential side effect of SSRIs, but this looks like it would require another ten thousand words just on its own, so let’s agree it’s a risk and leave it for another day.

9. Therefore, we should give up on medication and use psychotherapy insteadMakes sense right up until you run placebo-controlled trials of psychotherapy

The conclusion of these studies that claim antidepressants don’t outperform placebo is usually that we should repudiate Big Pharma, toss the pills, and go back to using psychotherapy.

The implication is that doctors use pills because they think they’re much more effective than therapy. But that’s not really true. The conventional wisdom in psychiatry is that antidepressants and psychotherapy are about equally effective.

SSRIs get used more than psychotherapy for the same reason they get used more than tricyclics and MAOIs – not because they’re better but because they have fewer problems. The problem with psychotherapy is you’ve got to get severely mentally ill people to go to a place and talk to a person several times a week. Depressed people are not generally known for their boundless enthusiasm for performing difficult tasks consistently. Also, Prozac costs like 50 cents a pill. Guess how much an hour of a highly educated professional’s time costs? More than 50c, that’s for sure. If they are about equal in effectiveness, you probably don’t want to pay extra and your insurance definitely doesn’t want to pay extra.

Contrary to popular wisdom, it is almost never the doctor pushing pills on a patient who would prefer therapy. If anything it’s more likely to be the opposite.

However, given that we’re acknowledging antidepressants have an effect size of only about 0.3 to 0.5, is it time to give psychotherapy a second look?

No. Using very similar methodology, a team involving Mind The Brain blogger James Coyne found that psychotherapy decreases HAM-D scores by about 2.66, very similar to the 2.7 number obtained by re-analysis of Kirsch’s data on antidepressants. It concludes:

Although there are differences between the role of placebo in psychotherapy and pharmacotherapy research, psychotherapy has an effect size that is comparable to that of antidepressant medications. Whether these effects should be deemed clinically relevant remains open to debate.

Another study by the same team finds psychotherapy has an effect size of 0.22 compared to antidepressants’ 0.3 – 0.5, though no one has tried to check if that difference is statistically significant and this does not give you the right to say antidepressants have “outperformed” psychotherapy.

If a patient has the time, money, and motivation for psychotherapy, it may be a good option – though I would only be comfortable using it as a monotherapy if the depression was relatively mild.

10. Further complications

What if the small but positive effect size of antidepressants wasn’t because they had small positive effects on everyone, but because they had very large positive effects on some people, and negative effects on others, such that it averaged out to small positive effects? This could explain the clinical observations of psychiatrists (that patients seem to do much better on antidepressants) without throwing away the findings of researchers (that antidepressants have only small benefits over placebo) by bringing in the corollary that some psychiatrists notice some patients doing poorly on antidepressants and stop them in those patients (which researchers of course would not do).

This is the claim of Gueorguieva and Krystal 2011, who used “growth modeling” to analyze seven studies of new-generation-antidepressant Cymbalta and found statistically significant differences between two “trajectories” for the drug, but not for placebo. 66% of people were in the “responder” trajectory and outperformed placebo by 6 HAM-D points (remember, previous studies estimated HAM-D benefits over placebo at about 2.7). 33% of people were nonresponders and did about 6 HAM-D points worse than placebo. Average it out, and people did about 3 HAM-D points better on drug and placebo, pretty close to the previous 2.7 point estimate.

I don’t know enough about growth modeling to be sure that the researchers didn’t just divide the subjects into two groups based on treatment efficacy and say “Look! The subsection of the population whom we selected for doing well did well!” but they use many complicated statistics words throughout the study that I think are supposed to indicate they’re not doing this.

If true, this is very promising. It means psychiatrists who are smart enough to notice people getting worse on antidepressants can take them off (or switch to another class of medication) and expect the remainder to get much, much better. I await further research with this methodology.

What if there were actually no such thing as the placebo effect? I know dropping this in around the end of an essay that assumes 75% of gains related to antidepressants are due to the placebo effect is a bit jarring, but it is the very-hard-to-escape conclusion of Hróbjartsson and Gøtzsche’s meta-analysis on placebo. They find that three-armed studies – ie those that have a no-treatment group, a placebo-treatment group, and a real-drug-treatment group – rarely find much of a difference between no-treatment and placebo. This was challenged by Wampold et al here and here, but defended against those challenges by the long-name-Scandinavian-people here. Kirsch, who between all his antidepressant work is still Associate Director of Placebo Studies, finds here that 75% of the apparent placebo effect in antidepressant studies is probably a real placebo effect, but his methodology is a valiant attempt to make the most out of a total lack of data rather than a properly-directed study per se.

If placebo pills don’t do much, what explains the vast improvements seen in both placebo and treatment groups in antidepressant trials? It could be the feeling of cared-for-ness and special-ness of getting to see a psychiatrist and talk with her about your problems, and the feeling of getting-to-contribute-something you get from participating in a scientific study. Or it could just be regression to the mean – most people start taking drugs when they feel very depressed, and at some point you have nowhere to go but up. Most depression gets better after six months or so – which is a much longer period than the six week length of the average drug trial, but maybe some people only volunteered for the study four months and two weeks after their depression started.

If Hróbjartsson and Gøtzsche were right, and Kirsch and the psychiatric establishment wrong, what would be the implications? Well, the good implication is that we no longer have to worry about problem 7 – that antidepressants are merely an active placebo – since active placebos shouldn’t do anything. That means we can be more confident they really work. The more complicated implication is that psychiatrists lose one excuse for asking people to take the drugs – “Sure, the drug effect may be small, but the placebo effect is so strong that it’s still worth it.” I don’t know how many psychiatrists actually think this way, but I sometimes think this way.

What if the reason people have so much trouble finding good effects from antidepressants is that they’re giving the medications wrong? Psychiatric Times points out that:

The Kirsch meta-analysis looked only at studies carried out before 1999. The much-publicized Fournier study examined a total of 6 antidepressant trials (n=718) using just 2 antidepressants, paroxetine and imipramine. Two of the imipramine studies used doses that were either subtherapeutic (100 mg/day) or less than optimal (100 to 200 mg/day)

What if we’ve forgotten the most important part? Antidepressants are used not only to treat acute episodes of depression, but to prevent them from coming back (maintenance therapy). This they apparently do very well, and I have seen very few studies that attempt to call this effect into question. Although it is always possible that someone will find the same kind of ambiguity around maintenance antidepressant treatment as now clouds acute antidepressant treatment, so far as far as I know this has not happened.

What if we don’t understand what’s going on with the placebo effect in our studies? Placebo effect has consistently gotten stronger over the past few decades, such that the difference between certain early tricyclic studies (which often found strong advantages for the medication) and modern SSRI studies (which often find only weak advantages for the medication) is not weaker medication effect, but stronger placebo effect (that is, if medication always has an effect of 10, but placebo goes from 0 to 9, apparent drug-placebo difference gets much lower). Wired has a good article on this. Theories range from the good – drug company advertising and increasing prestige and awareness of psychiatry have raised people’s expectations of psychiatric drugs – to the bad – increasing scientific competence and awareness have improved blinding and other facets of trial design – to the ugly – modern studies recruit paid participants with advertisements, so some unscrupulous people may be entering studies and then claiming to get better, hoping that this sounds sufficiently like the outcome the researchers want that everyone will be happy and they’ll get their money on schedule.

If placebos are genuinely getting better because of raised expectations, that’s good news for doctors and patients but bad news for researchers and drug companies. The patient will be happy because they get better no matter how terrible a prescribing decision the doctor makes; the doctor will be happy because they get credit. But for researchers and drug companies, it means it’s harder to prove a difference between drug and placebo in a study. You can invent an excellent new drug and still have it fail to outperform placebo by very much if everyone in the placebo group improves dramatically.

Conclusion

An important point I want to start the conclusion section with: no matter what else you believe, antidepressants are not literally ineffective. Even the most critical study – Kirsch 2008 – finds antidepressants to outperform placebo with p < .0001 significance.

An equally important point: everyone except those two Scandinavian guys with the long names agree that, if you count the placebo effect, antidepressants are extremely impressive. The difference between a person who gets an antidepressant and a person who gets no treatment at all is like night and day.

The debate takes place within the bounds set by those two statements.

Antidepressants give a very modest benefit over placebo. Whether this benefit is so modest as to not be worth talking about depends on what level of benefits you consider so modest as to not be worth talking about. If you are as depressed as the average person who participates in studies of antidepressants, you can expect an antidepressant to have an over-placebo-benefit with an effect size of 0.3 to 0.5. That’s the equivalent of a diet pill that gives you an average weight loss of 9 to 14 pounds, or a growth hormone that makes you grow on average 0.8 to 1.4 inches.

You may be able to get more than that if you focus on the antidepressants, like paroxetine and venlafaxine, that perform best in studies, but we don’t have the statistical power to say that officially. It may be the case that most people who get antidepressants do much better than that but a few people who have paradoxical negative responses bring down the average, but right now this result has not been replicated.

This sounds moderately helpful and probably well worth it if the pills are cheap (which generic versions almost always are) and you are not worried about side effects. Unfortunately, SSRIs do have some serious side effects. Some of the supposed side effects, like weight gain, seem to be mostly mythical. Others, like sexual dysfunction, seem to be very common and legitimately very worrying. You can avoid most of these side effects by taking other antidepressants like bupropion, but even these are not totally side-effect free.

Overall I think antidepressants come out of this definitely not looking like perfectly safe miracle drugs, but as a reasonable option for many people with moderate (aka “mild”, aka “extremely super severe”) depression, especially if they understand the side effects and prepare for them.