The Schelling Point for being on the Discord server (see sidebar) is Wednesdays at 10 PM EST

Highlights From My Notes From Another Psychiatry Conference

I took a break from my busy schedule of learning all the reasons you shouldn’t eat bats to attend another local Psychiatry Conference.

This conference consisted of a series of talks about all the most important issues of the day, like ‘The Menace Of Psychologists Being Allowed To Prescribe Medication’, ‘How To Be An Advocate For Important Issues Affecting Your Patients Such As The Possibility That Psychologists Might Be Allowed To Prescribe Them Medication’, and ‘Protecting Members Of Disadvantaged Communities From Psychologists Prescribing Them Medication’.

As somebody who’s noticed that the average waiting list for a desperately ill person to see a psychiatrist is approaching the twelve month mark in some places, I was pretty okay with psychologists prescribing medication. The scare stories about how psychologists might prescribe medications unsafely didn’t have much effect on me, since I continue to believe that putting antidepressants in a vending machine would be a more safety-conscious system than what we have now (a vending machine would at least limit antidepressants to people who have $1.25 in change; the average primary care doctor is nowhere near that selective). Annnnnyway, this made me kind of uncomfortable at the conference and I Struck A Courageous Blow Against The Cartelization Of Medicine by sneaking out without putting my name on their mailing list.

But before I did, I managed to take some notes about what’s going on in the wider psychiatric world, including:

– The newest breakthrough in ensuring schizophrenic people take their medication (a hard problem!) is bundling the pills with an ingestable computer chip that transmits data from the patient’s stomach. It’s a bold plan, somewhat complicated by the fact that one of the most common symptoms of schizophrenia is the paranoid fear that somebody has implanted a chip in your body to monitor you. Can you imagine being a schizophrenic guy who has to explain to your new doctor that your old doctor put computer chips in your pills to monitor you? Yikes. If they go through with this, I hope they publish the results in the form of a sequel to The Three Christs of Ypsilanti.

– The same team is working on a smartphone app to detect schizophrenic relapses. The system uses GPS to monitor location, accelerometer to detect movements, and microphone to check tone of voice and speaking pattern, then throws it into a machine learning system that tries to differentiate psychotic from normal behavior (for example, psychotic people might speak faster, or rock back and forth a lot). Again, interesting idea. But again, one of the most common paranoid schizophrenic delusions is that their electronic devices are monitoring everything they do. If you make every one of a psychotic person’s delusions come true, such that they no longer have any beliefs that do not correspond to reality, does that technically mean you’ve cured them? I don’t know, but I’m glad we have people investigating this important issue.

– I’ll come out and say it: cluster randomization is really sketchy. Today I got to hear about a multi-center trial which randomized by location – half of their hospitals were the control group, the other half were the experimental group. Problem is, the patients in each hospital were given group-appropriate consent forms – either “We will be treating you as usual, but monitoring you more closely for a study” or “We will be giving you extra experimental treatment”. Not only does that break blinding, but it implies a different population of patients in each group – the ones willing to consent to monitoring versus the ones willing to consent to treatment? Might sicker people be more willing to sign the treatment consent, since they don’t want to deal with monitoring but treatment offers the chance for personal gain? Might paranoid people be more willing to sign the control consent, since they’re not being used as guinea pigs? I don’t know. But I checked those pre-intervention inter-group comparisons they have to show, and there were big differences between the two groups (for example, I think one – I can’t remember which – had like twice as many black people). Either randomize peopple properly or at least keep people blind to condition.

– On the other hand, I’m quickly losing my prejudice that RCTs always beat naturalistic studies. I’ll write more about this later, but today’s showcase was long-acting injectable versus oral antipsychotics. Conventional wisdom is that long-acting antipsychotics, in the right patient population, decrease relapse because they remove the option of not taking the medication. The best randomized controlled trials don’t find that. The best naturalistic epidemiological studies do. The expert who spoke today theorized – and I agree – that the naturalistic studies are right. He argued that one feature of RCTs is very close monitoring, which means the patients in them comply with their medication at an unnaturally high rate – thus removing the long-acting drugs’ one advantage. The studies conducted in the real world of patients not taking their medications regularly are more relevant.

– They say psychotic people don’t take their meds because they hate the side effects, or because they’re too crazy to know better, or because they just can’t be bothered. But one of the doctors today raised a novel hypothesis: are antipsychotics anti-addictive? After all, some of the most addictive drugs are those that raise dopamine levels – cocaine, meth, and MDMA are all either dopamine releasing agents or dopamine reuptake inhibitors. Antipsychotics have pretty much the opposite effect as those, lowering dopamine in the brain. Suspicious. But I have a feeling this isn’t true. Dopamine is more complicated than that. Levodopa-carbidopa, which is one step short of pure dopamine and is given to dopamine-deficient Parksinson’s patients, is as far as I know not addictive at all. It’s also very clearly antagonistic to antipsychotics. Probably antipsychotics are the opposite of non-addictive levodopa, not the opposite of cocaine or anything. I don’t know how to phrase it more rigorously than that. Still, I like the way that person thinks.

– Ever since Indiana’s legislature debated a bill that implied pi = 4, Midwestern states have had a reputation for trying to legislate science. Maybe this had something to do with the claim by one psychiatry lobbyist that Kansas’ legislature is trying to ban the DSM. I can’t find anything on it online and it sounds like an urban legend to me. Tangentially related silly clickbait: Arizona lawmakers say horses aren’t animals.

– Unintentional puns are some of my favorite puns. I still remember fondly when the head of a psychiatric hospital where I used to work said that if Obamacare passed there would be too many patients and the place would “turn into a madhouse”. I collected another good one today when an activist was talking about gun rights for psychiatric patients: “Taking guns from psychiatric patients isn’t going to be a panacea for violence – would anyone like to take a stab at why?”

– Clozapine really is the best antipsychotic, hands down, and the evidence isn’t even subtle. It’s also the most dangerous, and the rules say that you should only prescribe it to a patient after you’ve tried and failed with two other antipsychotics. One of the speakers was a researcher who’s trying to get a grant to prove that it’s actually more effective to try clozapine after only one failed antipsychotic, but the NIMH rejected his proposal because “even if you proved that, no one would listen”. They’re probably right. A lot of psychiatrists hate clozapine because it’s messy, scary, and requires a lot of paperwork and monitoring. The speaker presented survey after survey of psychiatrists making lame excuses like “My patients wouldn’t want it”, and then survey after survey of those psychiatrists’ patients saying they do so want it but nobody asked them. Clozapine is messy and scary and requires lots of paperwork, but if you’re a good doctor you’ll give your patient the drug that will help them anyway.

– The APA representative says that 95% of candidates supported by the APA’s PAC get elected. I think it was supposed to be a boast, like “look how effective we are”, but that’s a bit much. Either the APA single-handedly controls all American politics, or else they’re very careful to always back the winning side. Properly understood, that number should probably be taken as a measure of exactly how cynical they are.

– Not that they didn’t admit their cynicism straight out. Our Political Activism Consultant explained that state legislators are all sorta new and confused and inexperienced all the time because of term limits. And if you put on a nice suit and a tie and tell them “Hey, I’m a doctor from your district, here’s how you need to do health care policy…” you have a pretty good chance of getting them to nod along and assume you know what you’re doing. I didn’t realize how easy this was, and I hope I never use this power for evil.

– This is basically how the Eternal War Against Psychologists Being Allowed To Prescribe Medications is being fought, but the psychologists have caught on and now they have nice suits and ties too. Also, it turns out senators have a hard time differentiating the APA (American Psychiatric Association, fighting tooth and claw against psychologist prescribers) from the APA (American Psychological Association, fighting tooth and claw for psychologist prescribers) and they end up freaking out and trying to figure out why the same people are lobbying for both sides and whether this is some kind of weird shrink mind game thing.

– Drug companies were giving out stress brains! Like stress balls, only they’re shaped like brains and have little sulci and gyri on them! If in ten years I’m one of those people who never prescribes clozapine, it’ll because I’m prescribing the drug by the company that gave me a stress brain instead.

This entry was posted in Uncategorized and tagged . Bookmark the permalink.

171 Responses to Highlights From My Notes From Another Psychiatry Conference

  1. The vindication of schizophrenia patients reminds me of the whole story about Ernest Hemmingway in the last years of his life deteriorating into intense paranoia and eventually insanity. His closest friends and family say that he talked constantly about the FBI following him, tapping his phone calls, and intercepting his mail. He was committed to an institution and given 11 electric shock treatments before eventually killing himself.

    Which is really sad, given that later FOIA reports reveal that during that period, it happened that the FBI actually *was* following him, tapping his phone calls, and intercepting his mail. And none of his closest friends or family believed him.

    http://www.nytimes.com/2011/07/02/opinion/02hotchner.html?_r=0

    • Avantika says:

      Whoa, that’s awful. I had no idea. Thanks for linking to that.

    • DanPeverley says:

      He was also a KGB informant, so that does explain why they were spying on him.

      • Once, just once I would like it if the people complaining about being persecuted by the FBI didn’t turn out to actually be Russian spies.

        • Jiro says:

          Martin Luther king Jr. sort of counts. Although when I loook at the Wikipedia article, it mentions that the investigations were “largely superficial until 1962, when the FBI learned that one of King’s most trusted advisers was New York City lawyer Stanley Levison”, who had been an actual party member. So assuming King was innocent, this still wasn’t a case of surveilling him for no reason whatsoever except his race.

          • Chiva says:

            King wanted a (non-violent) Socialist revolution in the US. So, nope. Besides various forms of racism, the reason that so many Civil Rights leaders were tracked was due to the fact that many of them actually were/are various types of Socialists and Communists. The policy, at the time, for the FBI and CIA was active suppression of communist and socialist groups.

            (This is not a personal endorsement of appalling government behavior. )

      • HeelBearCub says:

        Which probably explains the paranoia more than the actual monitoring?

        In other words, he had a secret to hide, and he had a justifiable fear of the consequences of exposure. Therefore he was hyper-alert to signs that this was occurring and detecting these signs was stressful.

        If a random person’s communications started being monitored by the FBI, even if the person detects some anomalies, it isn’t likely to be stressful, as their perceved exposure to negative consequences is negligible.

        • Douglas Knight says:

          Except that the timing is all off. He did have a secret to hide for the first decade of surveillance, but he didn’t complain about it until a decade after he stopped having contacts.

          • Chiva says:

            Douglas,
            Poppa was a bit of a diva. That’s pretty plain but are you saying “he complained after they stopped monitoring him”? It was my understanding that they continued to monitor him thorough out his life. Are my facts wrong?

          • Chiva writes:

            “It was my understanding that they continued to monitor him thorough out his life. Are my facts wrong?”

            As best I can tell, the FBI never “monitored” him. At least, the webbed FOIA FBI file on him does not mention either phone taps or mail intercepts or any other information that they wouldn’t have gotten in conventional ways, such as attending public events where he was present, interviewing people who had had past contacts with him, responding to a query from him (possibly via Mayo) and the like.

            Do you have a source for anything more than that, other than the NYT article that claims to be based on the FOIA material?

          • Chiva says:

            @David Friedman

            I do not!

            I have this from a book I read ages ago, someone who lived in the Florida Keys, and a “biography” style short doc on him. None of these are excellent sources. They didn’t dive deep here *and* they are encounters I had years ago (college). Not reliable at all. But, due to my vague interest in ‘people the government have watched for insane reasons” it just stuck in my head. This is why I asked about Poppa in ze first place.

            The MLK stuff, from my post above, on the other hand, I have tons of easy to access resources for.

          • Mary says:

            Guilty conscience.

    • “given that later FOIA reports reveal that during that period, it happened that the FBI actually *was* following him, tapping his phone calls, and intercepting his mail.”

      Can you offer any support for that? There is a FOIA file of FBI information on Hemmingway webbed at:

      http://vault.fbi.gov/ernest-miller-hemingway/ernest-hemingway-part-01-of-01/view

      It’s interesting reading, but almost all of it deals with his activities in Cuba during WWII when he was friends with people in the U.S. consulate and volunteered to collect intelligence information for them from his contacts among Spanish Republican refugees living in Cuba. The FBI concluded that the information he was providing was worthless. Reading the notes, it sounds as though Hemingway was self dramatizing himself as a private operator of a spy network and probably didn’t know what he was doing. That also fits the story I found about his role as a “KGB spy” during about the same period.

      “However, he failed to “give us any political information” and was never “verified in practical work”, so contacts with Argo had ceased by the end of the decade.”

      There are some notes suggesting that the FBI viewed him as a Communist sympathizer on the basis of his activities during the Spanish Civil War. The only thing I could find related to what you wrote was one memo about his being a patient at Mayo Clinic. The relevant part reads:

      “(something whited out) Mayo Clinic, advised to eliminate publicity and contacts by newsmen, the Clinic had suggested that Mr. Hemingway register under the alias GEORGE SEVIER. (something whited out) stated that Mr. HEMINGWAY is now worried about his registering under an assumed name, and is concerned about an FBI investigation. (something whited out) stated that inasmuch as this worry was interfering with the treatment of Mr. HEMINGWAY, he desired authorization to tell HEMINGWAY that the FBI was not concerned with his registering under an assumed name. (something whited out) was advised that there was no objection.”

      It sounds from that as though Hemingway asked the FBI whether they were concerned with his registering under an assumed name, which is evidence that Hemingway believed they were watching him, not that they were. I can find no support in the webbed documents for the “tapping his phone calls, and intercepting his mail” part of the story.

      The NYT story claims that:

      “Decades later, in response to a Freedom of Information petition, the F.B.I. released its Hemingway file. It revealed that beginning in the 1940s J. Edgar Hoover had placed Ernest under surveillance because he was suspicious of Ernest’s activities in Cuba. Over the following years, agents filed reports on him and tapped his phones. The surveillance continued all through his confinement at St. Mary’s Hospital. It is likely that the phone outside his room was tapped after all.”

      But unless there is another FBI Hemingway file released under FOIA, it isn’t true.

      Further, if you look at the details of the NYT story, written by a friend of Hemingway long after his death, it sounds more like paranoia than actual evidence that the FBI was watching him. For instance:

      “We rode for miles in silence. As we turned into Ketchum, Ernest said quietly: “Duke, pull over. Cut your lights.” He peered across the street at a bank. Two men were working inside. “What is it?” I asked.

      “Auditors. The F.B.I.’s got them going over my account.”

      “But how do you know?”

      “Why would two auditors be working in the middle of the night? Of course it’s my account.”

      All his friends were worried: he had changed; he was depressed; he wouldn’t hunt; he looked bad.

      Ernest, Mary and I went to dinner the night before I left. Halfway through the meal Ernest said we had to leave immediately. Mary asked what was wrong.

      “Those two F.B.I. agents at the bar, that’s what’s wrong.”

      Do you have any support for what you wrote other than the NYT article? Do you know of any support for its claims other than the FBI file released under FOIA and webbed?

    • Anonymous says:

      This reminds me of how, after reading the CIA tried to find Osama bin Laden by testing DNA obtained via fake vaccination campaigns, I was able to understand why people might be scared of vaccines

  2. Avantika says:

    I have seen those stress brains! My instant reaction was exactly the same (They have sulci and gyri! They have things in approximately the right places!) I totally understand why they’re tempting.

    • Harald K says:

      On an exhibit on the brain in the local Science museum, they had a claw machine, of the kind they have in tivolis, but picking up foamy rubber brains instead of teddy bears. Not sure if it was the same type of stress brain, but they did have some medical corporation’s logo on them.

      You could try as many times as you wanted, and you also had free access to the difficulty setting part of the machine. They weren’t conducting addiction research on us, although I think the allusion was deliberate.

  3. Douglas Knight says:

    Maybe close monitoring is a feature of actually existing RCT on this topic, but it isn’t a necessary feature. If you’re designing a study specifically to study compliance, in particular, if you are studying a drug designed to improve compliance, then you want loose monitoring. And you should should judge the trial, in part, by how low is the compliance in the control arm, whether it matches other measure of compliance. (Maybe close monitoring is a necessary feature of phase 3 trials, though.)

    • Scott Alexander says:

      I think part of it is the patients know they’re being watched.

      • Douglas Knight says:

        If merely telling patients that they are in a study causes compliance, problem solved! Yes, it is hard to make studies of compliance realistic, but randomization is too powerful to give up on.

        I wonder if psychiatry tends to use the healthiest patients in the trials, while other fields of medicine use the sickest patients? Well, I suppose that there are a lot of experiments on institutionalized patients, but that’s not relevant to compliance. And outside of psychiatry, compliance is probably not very correlated with severity.

  4. Economists should be able to prescribe drugs because we understand risk, trade offs, and messy data.

    • Avantika says:

      And statisticians should be able to prescribe everything.

    • Scott Alexander says:

      “Uh, doc, your patient’s blood pressure just crashed and now they’re dead.”

      “Keynesian theory predicted that!”

      “No, Keynesian theory predicted their blood pressure would go way up!”

      “Well, if you had just prescribed a higher dose of Keynes…”

      “Shut up, Dr. Krugman.”

      • kernly says:

        D’you have any examples in mind of Keynesianism gone wrong?

        • Dale says:

          My guess is Scott is referring to this

          http://www.washingtonpost.com/wp-srv/special/business/unemployment-predictions/

          – essentially, some keynesian economists predicted how high unemployment would get, and then how much lower it would be with fiscal stimulus. The fiscal stimulus was passed, but it turned out that reality (with stimulus) was worse than they had predicted for no stimulus. Krugman blamed this on there being *not enough* stimulus.

          There are of course other cases. For example, keynesian predictions that the US/West would sink into a huge depression after government spending was cut back post WWII. Similarly, many keynesians warned that 2013 would be a bad year due to austerity – but actually it was better than 2012.

          • Dale says:

            (I attempted to include citations for the other examples but wordpress wouldn’t allow the comment through with more than one link. Still, if you’re interested you might enjoy the puzzle of deciphering this highly-encoded url. )

            macromarketmusings dot blogspot dot com/2014/01/paul-krugman-plugs-market-monetarism dot html

        • Scott Alexander says:

          I don’t actually have a strong opinion on Keynesianism, this is just how all conversations between economists sound to me.

          • Tracy W says:

            Macro and micro economics are very different things. Macroeconomics is mostly kept going by the fact that people hate recessions (I include myself) so there’s immense pressure to come up with *something*. And quite a bit of funding. Never mind the massive problems of being simultaneously unable to give a good (or any) theoretical answer to the aggregation problem of going from individuals to “the economy” and the empirical problem of being unable to do controlled experiments.

          • Herpaderp says:

            Paul Krugman observed that the stimulus would be too small *before* it was passed, not afterwards (Well, afterwards too but…).

            The Obama administration selected the size of the stimulus A. based on underestimations of the shock and B. with the understanding that Congress would pass additional stimulus if it was needed. So two mistakes there. And while I’m aware that “politics is the mindkiller,” I’m just going to state that I don’t blame both blocs equally here.

            I’m also going to be updating on the fact that you get information from Marginal Revolution.

          • 27chaos says:

            What do you mean by “aggregation problem”? Is macroeconomics inconsistent with known aspects of microeconomics, or something? Why is this a problem?

          • HeelBearCub says:

            Scott,

            As you are someone who tilts libertarian at times, this is a huge hole in your understanding. Honestly, if you don’t feel conversant in general economic theory, you should spend some time exploring these issues. For instance, understanding what effects switching from commodity currency to fiat currency has on an economy, how inflation works, what effects government debt and deficits have on an economy are quite important to understand.

    • Harald K says:

      In fact, we should just turn society over to the economists. Lots of economists seems to think it’s a good idea, and who am I to disagree?

      (I think you’re joking. But it’s a bit sad that I’m not sure).

  5. Not that they didn’t admit their cynicism straight out. Our Political Activism Consultant explained that state legislators are all sorta new and confused and inexperienced all the time because of term limits. And if you put on a nice suit and a tie and tell them “Hey, I’m a doctor from your district, here’s how you need to do health care policy…” you have a pretty good chance of getting them to nod along and assume you know what you’re doing. I didn’t realize how easy this was, and I hope I never use this power for evil.

    Fortunately or unfortunately, it doesn’t work that way.

    Michigan’s draconian term limits mean that individual state reps and senators don’t know anything, usually don’t care much about anything, and defer on every contested issue to party leaders. Contrary to the folklore that everybody believes, term limited legislators generally have no way to act independently.

    For each member, the clock is constantly ticking down to when they will be out of a job. Their ability to find a new job at that point depends critically on how happy they make their party leaders.

    You can explain a problem to a state legislator, get them to nod along, hell, even get seemingly enthusiastic agreement, but it has little impact when bills come up for a vote.

    • Scott Alexander says:

      The psychiatric lobbyist I heard from said that her organization had actually gotten representatives to propose entirely new bills for them, or to drop bills they had previously been thinking of proposing. I think maybe for complicated controversial issues the party leader thing is how it works, but I think some of these psych issues might be too small to make it on their radar, or the bottleneck might be getting them into committee in the first place.

      • Deiseach says:

        Being someone who sees the other side of how representation works, let me tell you: in my old job and now in my new one, we constantly get local councillors, and TDs, who are the elected representatives to the national parliament, and even Ministers who are in the cabinet of the government of the day, making representations to us on behalf of people looking for all kinds of grants and housing and places and this, that and the other.

        And it don’t mean a thing if it conflicts with the regulations.

        What we would like to tell them (but can’t because we’ve just been issued a protocol on ‘How to Interact with Council Members’) is “Don’t ask us to reverse decisions. Go to your fellow party member(s), the TD(s), and ask them to lean on the Minister (who is also a member of your party this time round) and get him to talk to the Taoiseach who’s leader of the government about changing the rules”.

        Frankly, it’s all kabuki. They just want to be able to go back to the person who made the request, who is a constituent/likely voter, and tell them “Yeah, I put a word in for you”. There has been a case at work, just this week, where the department section head told a councillor that no, [thing] could not be done. Councillor went back to client and told them there was every chance they’d get what they were asking for 🙂

        Result? We’re the ones who look like The Bad Guys when the client gets the refusal letter, while Councillor X is the guy (or gal) who tried but was foiled by evil bureaucrats and their evil red tape.

        So your lobbyist is not going to come out and tell your organisation “I know you’ve elected us to a special committee where we get an extra payment for wearing nice suits or dresses and going to talk to legislators, but in reality, random chance would mean you’d be as likely to get what you wanted”. Of course they are going to say “Remember Bill Z about Topic W? Our input got that passed/dropped!” They won’t talk about Bills A, B and Q that were passed (when you wanted them dropped) or dropped (when you wanted them passed) in spite of their lobbying.

      • chaosmage says:

        Just like advertisers overemphasize the effectiveness of ads (they sell ads, not their client’s product), I would expect lobbyists to overemphasize the effectiveness of lobbying (they sell lobby work, not results).

    • John Schilling says:

      For something on the scale of psychologists maybe prescribing drugs, as I understand it, talking to the representative or senator in question is mostly just a formality for the lobbyist. You do it once, to demonstrate sincerity and respect, but the real action is with the staff.

      The legislator is not actually going to research the issue in depth and carefully deliberate over the optimal policy, nor is he going to seek out the highest bidder to sell his vote – whether honest or corrupt, his time is better spent on bigger issues. And the party leadership has better things to do than track how each representative votes on each minor issue. So it mostly comes down to assigning a staffer to write a white paper laying out the case for / case against on the proposal[*], check that both sides’ lobbyists are offering reasonable campaign contributions, and devote maybe a couple of hours to the subject in total.

      The staffers are young and underpaid, and if they are any sort of specialist, it’s on something as broad as “health policy”. They are on the hook for ten white papers this week, on subjects they knows little or nothing about. And they are only working the staff job for a few years to build their resume and his network for something better.

      Enter the lobbyist, with a dinner invite to someplace nice and expensive. And a position paper from his organization he’d like to brief the staffer on. Lays out the case for / case against psychologists prescribing drugs, or whatever. It would of course be unethical for the kid to put his or her name on top and hand it in as his own work, nobody’s suggesting that of course, but, well, it could come in useful somehow. And did I ever tell you about my time in the trenches, working for congressman so-and-so back in the day? That was before I became a lobbyist, with an expense account that allows me to fly around the country first class wining and dining the rich and powerful and the occasional congressional staffer. Hey, best of luck in your future career, whatever it is, and here’s my card if you want to talk about, you know, stuff.

      Term limits can matter for the major issues, because long-serving legislators will have a core of professional staff they trust with the big stuff. On the smaller matters, the staffers are basically temps so it doesn’t matter how long the boss serves.

      [*] “Case for” meaning “the following powerful groups with be thankful”, and “Case against” meaning “the following powerful groups will be angry”, with actual social benefit being a secondary consideration.

  6. suntzuanime says:

    I tend to assume my electronic devices are monitoring everything I do, as part of the NSA’s bulk collection programs. I don’t think I’m crazy, but I guess I wouldn’t, would I?

    Now I’m wondering if the NSA would have infiltrated the organizations that produce the diagnostic manuals to gaslight the surveilled population on a massive scale.

    • ilzolende says:

      I’ve tested the audio recording functionality of my iPod: It records passably through a backpack/purse with a case on (though I obviously want better sound quality and therefore open up the case and remove it from my bag when purposefully recording). However, if anyone can get a good enough Internet connection to stream audio in real time to it when the device is incapable of talking to cell towers and outside of regions with open wi-fi networks, I will be some combination of surprised and annoyed, because I want to use that connection. Also, battery life is far higher when I make no attempt to use a wi-fi connection, another sign that the device is not being used for monitoring purposes.

      I’ve been tempted to just record myself every day (I have the storage space), but my state has two-party consent laws, so I would have to either break said laws or tell every single person I talk to that I am recording them, perhaps by carrying a sign. Also, keeping those records is probably a bad idea, because there probably are way fewer legal problems with making me turn over the contents of my own hard drive than using records that aren’t supposed to exist, AFAIK. (Not that I think I do illegal things, but all sorts of random stuff, such as buying turtles from New York, seems to be illegal, so I have probably committed some sort of crime by now, and can reasonably expect that other people would commit similar crimes in my presence. Also, if I record my whole day except for 5 minutes, that’s kind of suspicious, isn’t it?)

      Also, if the general population thinks it, it generally doesn’t count as delusional. See the case of [pet peeve really false belief].

      • Saint_Fiasco says:

        >However, if anyone can get a good enough Internet connection to stream audio in real time to it when the device is incapable of talking to cell towers and outside of regions with open wi-fi networks, I will be some combination of surprised and annoyed, because I want to use that connection. Also, battery life is far higher when I make no attempt to use a wi-fi connection, another sign that the device is not being used for monitoring purposes.

        Your device might record you, store the recordings on internal memory and then when you are on wi-fi transmit the accumulated data. That way, you wouldn’t notice anything odd with your battery life or signal quality.

      • Harald K says:

        There’s one consolation: There’s little the NSA can’t do, but there’s still a lot they can’t do without risking detection. If your phone turns on, starts recording, and uses the internet connection, that is extremely detectable.

        And thankfully, there are people out there, like Wikileaks and friends, who are very good at monitoring such suspicious behavior, and telling us about it.

        Spy agencies’ capabilities are, as always, limited by what they risk by using the capabilities they have. Neither of us are probably important enough to warrant targeted surveillance (though I was on my guard for a while after Snowden replied to my question about civil disobedience). In the event that we are spied upon, we have more potential to cause damage by catching them in the act, than they have to win by spying on us.

        Mass surveillance, though, is another matter.

  7. This is basically how the Eternal War Against Psychologists Being Allowed To Prescribe Medications is being fought, but the psychologists have caught on and now they have nice suits and ties too. Also, it turns out senators have a hard time differentiating the APA (American Psychiatric Association, fighting tooth and claw against psychologist prescribers) from the APA (American Psychological Association, fighting tooth and claw for psychologist prescribers) and they end up freaking out and trying to figure out why the same people are lobbying for both sides and whether this is some kind of weird shrink mind game thing.

    That is hilarious!

    I’ll have to ask my wife about the prescribing privileges thing when she is awake, but I thought this war was over, and the psychiatrists had won.

    I had the impression that only a small minority of psychologists were even interested in getting prescribing powers, but admittedly, I’ve heard nothing about this issue in years, so I’m probably just out of touch.

    • Scott Alexander says:

      Three states currently allow psychologists to prescribe. A lot of others (including Michigan) are in various stages of considering it, with it getting intermittently quashed by the psychiatric lobby and then resurrecting itself after an appropriate wait.

      The lobbyist I heard from said that it was only a “vocal minority” of psychologists who want prescribing privileges, but I didn’t know whether to trust her. She said that vocal minority had taken over most of the big psychologist lobbyist associations.

      • Deiseach says:

        My impression of this was that the psychiatrists were “We’re proper doctors, we’ve been to medical school and everything, all you lot do is sit around and make “Mmm-hmm” noises and talk about feelings, no way you get to do Proper Doctor Things like prescribe drugs because you don’t know Science! And besides, if you can prescribe, people won’t know the difference between a psychiatrist and a psychologist at all and I didn’t spend years learning about brain anatomy when I could have been out partying for that kind of loss of status!”

      • William O. B'Livion says:

        Never mind, brain is on cold.

      • Garrett says:

        Would it make sense to make a “Psychologist Practitioner” much like nurse practitioners exist now? It would probably require more education, but would allow people who’ve mastered the patient contact/therapy parts to prescribe a subset of medications where appropriate?

        • HeelBearCub says:

          If you want to go that route, wouldn’t you just become an NP? I realize there isn’t any easy path from psychologist to NP, but cant’ NPs go the psych route?

      • Rash92 says:

        When I ask what the difference between psychologists and psychiatrist s are, the answer is usually “psychiatrist s can prescribe stuff and are actual doctors, psychologists can’t”

        If psychologists might be able to prescribe stuff, what’s the actual difference?

  8. jjbees says:

    If psychologists are allowed to prescribe medication, then what is the point of going to medical school?

    At that point you’re just a jumped up psychologist, but with more debt.

    We need to figure out why there is a 12 month waiting period to see a psychiatrist. Is it because no one wants to become a psychiatrist? Give prescribing powers to psychologists and no one will choose the field. Psychiatry as a field needs to do something to make medical students want to become psychiatrists, not just give up to mid-levels zombies that want to eat our brains and steal our patients.

    • Scott Alexander says:

      Right now nurse practitioners are allowed to prescribe medication. What’s the point of going to medical school?

      I think the best system – which we mostly already have – is something more like a tiered hierarchy of providers. Cheaper providers with less training can handle the easier cases, then refer to more expensive experts for the harder cases. Right now it sort of works like this – the primary care doctor will handle simple cases of depression, but if it’s complicated and treatment refractory they’ll refer to a psychiatrist, and if it’s super super complicated and treatment refractory the psychiatrist may refer to an expert psychiatrist at a top tertiary care institution who’s done a fellowship in that condition. Each level requires more training but has more responsibilities.

      I am pretty sure that, in 24 hours, I could teach a randomly-selected IQ 120 person armed with Anki to prescribe SSRIs better and more safely than the average primary care doctor (primary care doctors prescribe the majority of antidepressants now), and I am perfectly willing to prove this in some kind of clinical study if anyone wants to take me up on the bet. We know that nurse practitioners, who have much less training than doctors, equal or exceed their performance on the subareas they’re allowed to prescribe in. If I’m right and that finding transfers, then the giant cost problem and the even bigger access problem we have for psychiatric care is total deadweight loss.

      There are people beating at the door to become psychiatrists – medical schools (and psychiatric residencies) turn away most of their applicants. The reason there are waiting periods is complicated. The most optimistic view is that residencies (post-grad training programs for doctors) are both very expensive and mostly government funded, and the government doesn’t budget enough money to fund lots of them. The most pessimistic view is that the AMA and APA deliberately restrict the supply of doctors in order to keep wages high, and the problems with the training programs are totally deliberate to those ends. I think anything that successfully routes around that problem without compromising safety would be a really positive development for patients.

      • Deiseach says:

        In Ireland, they appear to be tackling the problem of GPs prescribing (over-prescribing?) antidepressants with the Counselling in Primary Care initiative.

        That’s what I was referred to when I went to my GP about being depressed. Instead of getting a prescription, I got a referral. 8-10 week waiting period and then see a counsellor for an assessment, and if deemed suitable, get 8 weeks of counselling.

        In the meantime, what do you do? Well, if you’re suicidal/self-harming, you’ll go to secondary care (which is psychiatric assessment/in-patient hospital). If you’re coping, hang on for another 8-10 weeks, sure why would you need medication, aren’t you doing fine as you are?

        I have no idea if or how it works, since I cancelled the preliminary appointment, since if I’m supposed to be able to hang on without drugs, what good is a nice chat once a week about “And how do you feel?” going to do for me?

        And I apologise, Nornagest, if I sound like I’m taking “gratuitous cheap shots” but I do feel like I got fobbed off and that I have nowhere to turn.

      • Lancelot Gobbo says:

        If you’re going to shit on family doctors, let me throw some back. The biggest issue I see is that psychiatrists are stuck in the model of (eventually) seeing and taking on a patient and then providing follow-up care, often in the long term. There would be time for more assessments (and the wait for them would be shorter) if there was less follow-up. You should consider the shared-care model, in which you give direction to the family doctor after an assessment, and he or she can ask advice when needed. This makes efficient use of the time of both parties and provides the patient with faster care, complete with specialist supervision as needed, and provides most of it in the familiar and less stigmatising setting of their family doc’s office. I support this model as after 30 years of being the 24/7 primary care physician in my little rural community as I can see it working better than the old one for many specialties. My wife is a sub-sub-specialised psychiatrist (yes, she travels a long way to work in four hospitals in this province and one in another). She feels strongly her time is wasted every time someone wants to see her for a refill, and that she is best used for what she is good at: initial assessment and input when needed after that.
        If you want to get a better understanding of the work of family doctors, get one. Most physicians don’t have a family doctor, and obviously ought to have. You might be surprised to see things from the other side of the table.

        • HeelBearCub says:

          At least in the U.S. isn’t this, if not wholly at least substantially, due to the fee for service model?

          Repeat business is the life blood of almost every single retail organization, and it’s built into the income expectation of every fee-for-service driven psychiatrist. Take away their repeat business and they will have to work harder/longer or lose income.

          See the fight in OB-GYN over whether Pap smears are necessary every year or every three years for an easy example.

        • Deiseach says:

          Oh, I’m not blaming my GP. The cynical part of my personality is saying this is due to the Department of Health in my country wanting to reduce the drugs bills, so telling GPs “Don’t prescribe drugs, refer for counselling instead (unless they’re self-harming/suicidal)”.

          You see, I don’t ask for drugs. Until my health legitimately broke down in my late 40s, I never went near a doctor. I’ve avoided asking for medication for psychological/psychiatric problems for, quite literally and I mean this literally, decades (despite a family history and heritage of everyone on my paternal side being on the Autism Spectrum and associated disorders, and ending up on long-term medication for mental problems) because I’ve seen said family members dependent on medication and I did not want to go that way.

          If I believed that the Department was honest about wanting to improve community mental health, then I think they’d put resources into not having to wait ten weeks just to be assessed to see “yep, you really are depressed”. I don’t believe that; I believe it is, as I’ve said, a money-saving exercise (because Health is a money sink, and they’re constantly running over budget, and our austerity government needs to cut, cut, cut where it can).

          So I’m not shitting on my GP, I believe she’s doing the best she can, and she’s been instructed not to write out new prescriptions for new patients.

          But what do I do, in the meantime? If I try throwing myself off the bridge into the harbour, sure, I’ll be bumped up to ‘requires second-level intervention’. As it is, I have finally burned through and worn out every last scrap of coping I can manage, and I’m getting in return the proverb “Live horse and get grass”.

          I wouldn’t ask for drugs unless I really thought there was nothing else I could do. My sister is on anti-depressants with about five years but I didn’t cave in and go to the doctor at that time. Well, now I did – and I’m told, by my country’s health service, “the best we can do for you is tell you to keep on keeping on until we can manage to get a counsellor free to see you”.

          And this is the new, improved service, allegedly. Look – antidepressants typically start working after about six weeks. While I’m waiting the ten weeks to be seen by someone, wouldn’t it help me to go on a short-term prescription which would kick in during the waiting period and keep me able to get up in the morning and go to work and not end up wanting to slash my wrists?

          When I got my Type II diabetes diagnosis two years ago, there was no bullshit about “Here’s our new revised programme where instead of a prescription we tell you to hold off for two and a half months until you can be assessed for a ‘healthy thinking’ course”. No, my GP immediately put me on metformin and a statin because she said sure, you can try diet and exercise, but it’s better to start treatment as fast as possible to help stave off complications.

          Why is mental illness not considered somehow as ‘real’ or necessitating treatment as physical illness? My brain is involved in one, my pancreas in the other, and going by this, my pancreas is deemed the more vital organ.

          But hey, what do I know, I’m only “shitting on family doctors”! I would also like to point out that if I sound unreasonable, there’s a reason for that: right now, my mental balance is affected and I can’t think right. That’s what being “mentally unwell” means. Depression is not “Ooh, feeling a bit down because I had a row with my partner”, it’s being stuck in a hole with nothing that seems fixable or worthwhile and asking for help and being told ‘just keep doing what you’re doing’ and if I’m sounding like I’m being mean to hard-working family doctors, I’m sorry, but it’s taking me all I can manage to hold myself together and I can’t worry about your bruised feelings.

          Yes, I’m being a bitch. It’s the only way I can survive this particular patch until I manage somehow (and I don’t know the fuck how I’m going to do that) to claw my way out of this mineshaft all on my own. Again. And pretend to be functional and pass for normal. Again. Like I’ve been doing for years and years before finally admitting I can’t do it anymore and asking for help.

          And getting nothing that I can use RIGHT NOW not to drown. Give me a reason why I should keep breathing, because I genuinely don’t – of my own accord – see any point in not being dead.

          And nobody (to my diseased mental state) is helping me do anything about that, and I am sorry if that is “shitting on family doctors” but I. CAN’T. DO. ANY. BETTER. RIGHT. NOW.

          • 123 says:

            That situation sucks. In case you haven’t thought of the following yet: can you skip the stuff with the state and just pay for an appointment with a private psychiatrist? I did just that when I wanted to try a certain drug a few months ago, but I’m a different country so it could be irrelevant for you.

          • Ptoliporthos says:

            Sorry about your situation. I’m not sure how our host feels about amateur medical advice and self-medication, but I’ll throw it out there that you could take over-the-counter antihistamines — they’re all antidepressants and basically safe.

          • Anonymous says:

            Ehhh, you don’t want to be taking anticholinergics long-term.

          • That’s really nasty. Best wishes, and please do keep on keeping on…

          • Anonymous says:

            Deiseach, you should contact Aware. They might be able to tell you what to say to your doctor to explain to them that you need antidepressants urgently, (without accidentally getting yourself committed!) Probably don’t tell them you think your GP got it wrong, but that the situation has deteriorated or something. They must have some kind of “what to say to your GP” script that you can crib from.

            I’ve called their helpline a couple of times, when paralyzing depression kicked in and I really urgently needed to get stuff done. It’s not a terrible experience. I found talking to their volunteers for five minutes was enough to kickstart my brain and body out of that immobilized depressed zone, whereas weirdly enough, calling friends did not have the same effect. (I guess because I wasn’t worried that I was being weird and needy to helpine volunteers?) So that’s a resource that exists that you can use to get through the day, if you ever need it.

            Don’t dismiss the therapy either. I gather you already have, but it is more than just a nice cup of tea and a chat. Aware also do free courses of CBT, and have sessions starting in the next couple of weeks. You can do the courses either online with the support of a volunteer to guide you through the programme, or in groups in cities around the country. I know you think it won’t work for you but it is worth a shot.

            Also, can you go back to a different doctor? I know it’s expensive to keep making doctor visits but this sounds important.

            Another possible option is St John’s Wort. It’s just as effective as most prescription antidepressants, or that was the state of the evidence when I was reading up about it a few years ago. It’s not legal in Ireland due to how our government interprets certain EU regulations, but you can get it in any health food shop in the North or you can order it online (or get a Nordy friend to post you some.) Read up on drug interactions if you go this route, especially if you later get an antidepressant prescription.

        • Garrett says:

          I suspect that part of this boils down to the “standard of care” or “ethics” of the profession. After all, if you’re considered the only group of people capable of determining that somebody needs a particular medication, they must be the only people who are able to determine they still need the medication.
          The reverse of that is that many general practitioners may not feel reasonable prescribing/refilling medications that they aren’t certain about how to determine the effecacy and monitoring of.
          Don’t get me wrong – I love the tiered model. In order for that to work, I think you need to address the culture on both ends to make this appropriate and desireable.

      • Daniel Armak says:

        If so, why can’t we just implement the prescription algorithm in software, with doctors (or whoever) guiding people through answering a questionnaire for input data, and adding their own observations through another questionnaire?

        I am not a medicine-related professional of any kind and maybe this has already happened somewhere I don’t know about.

      • Toggle says:

        It sounds like the optometry/opthamology model might be an appropriate thing to shoot for. As far as I know, that’s a fairly stable and high-functioning system.

    • vV_Vv says:

      I’m neither a psychiatrist nor a psychologists, but in my understanding it makes sense that drugs with common and severe side effects like the clozapine Scott was talking about, are prescribed only by people with a good understanding of medical science, while safer drugs may be prescribed by people with a less specific training.

  9. Will_BC says:

    It boggles my mind that they want to give schizophrenic patients pills with computers chips and have their phones monitor them. That seems incredibly stupid or unkind, yet I’m holding out hope that it could have some benefit like desensitizing patients, though I remain skeptical.

    • Scott Alexander says:

      I mean, they would be telling these patients and getting their consent.

      • Deiseach says:

        “People think I’m crazy when I say the government want to implant me with chips and monitor me through my phone!”

        “Well, don’t worry. We’ll treat your irrational fears by – implanting you with chips and monitoring you through your phone”.

        I don’t quite see how that is supposed to make you feel better about what The Powers That Be are doing?

        • randy m says:

          Right, because you could no longer claim, without some difficult to parse nuance, either that such is impossible or that they aren’t likely to merit such attention.

        • bartlebyshop says:

          Stuff like this makes a great case for death. “I’m here to help,” said the panopticon, “and your protests only encourage me.”

    • Incidentally, this also happens in Infinite Jest.

      A patient thinks that a group of people are going to strap him down and inject him with strange chemicals, so his doctors stick him full of radioactive chemicals so they can see the patterns they make as they go through his skull.

      • SFG says:

        That actually exists, it’s called a nuclear medicine scan. I don’t think they use them for psychiatry though.

  10. The APA representative says that 95% of candidates supported by the APA’s PAC get elected. I think it was supposed to be a boast, like “look how effective we are”, but that’s a bit much. Either the APA single-handedly controls all American politics, or else they’re very careful to always back the winning side. Properly understood, that number should probably be taken as a measure of exactly how cynical they are.

    I keep trying to tell people that the independent power of money in electoral politics is enormously overrated. This is one of the reasons why: everybody likes to give money to the winner. The winner usually ends up with enormously more money than is really needed.

    If you have a race between two equally plausible candidates, where both of them are already spending enough money to be competitive, additional money on one side makes very little difference to the outcome.

    If a candidate running for office doesn’t have enough money to be competitive, usually the most important problem is not the money. If a candidate has a good shot at winning (say) a legislative seat, there will be money to do it with.

    Obviously this system privileges mainstream polling and punditry and their analysis of who is likely to win and who has no chance, but those kinds of predictions are very good in the short run.

    And the short run is all that matters to the people in your PAC who choose where to send checks during election season.

    • Deiseach says:

      Probably the APA gives donations to both sides. It happens in Ireland, I’m fairly sure it happens in the U.K. and I’d be very surprised if it didn’t happen in the U.S.

      From this newspaper report from 2012:

      The donations include €212,000 from Harcourt Developments and its subsidiary Airscape between 2001 and 2010 shared between Fianna Fail, Fine Gael, Labour and the PDs.

      …Hospitality chain O’Callaghan Hotels donated €54,000 to various parties through its company Persian Properties and other donations from its director Noel O’Callaghan, of which just €8,000 was disclosed.

      …Mosney PLC, the company which runs the refugee reception centre at the site of the former Co[unty] Meath holiday resort, donated just under €20,000 to various parties over three years, with a quarter of this being disclosed by the political parties.

      Run with the hare, hunt with the hounds?

      • DES3264 says:

        While this is extremely common lobbyist behavior, it would seem to contradict the lobbyist’s boast: In that case, only 50% of the APA’s supported candidates would win.

        • HeelBearCub says:

          Not if you calculate “percent of winning candidates supported by the APA in races where the APA supported one or more candidate” and reported that stat using a suitably vague description.

          And this is made even easier when you consider that the vast majority of US Congressional races (if that is what we are measuring) are de-facto no-contest races where incumbents are easily re-elected and donating to the other major party candidate would be relatively pointless.

          • DES3264 says:

            Here we see the important difference between “95% of candidates supported by the APA’s PAC get elected” and “[95%] percent of winning candidates [are] supported by the APA” — a good lesson in Bayesian principles. Of course, we don’t know either how carefully the lobbyist phrased their boast, or how carefully Scott remembered it.

      • The difference between the US and parliamentary democracies is that individual candidates are pretty much on their own here. Each candidate’s campaign committee does its own separate fund raising effort.

        The APA probably does give to “both sides” in the sense that they give to expected winners in both parties. They presumably avoid giving any money to candidates in either party who are not likely to win.

        (Note that due to gerrymandering and regional variations in party strength, almost every district is safely Republican or safely Democratic. Few members of the Michigan Legislature face meaningful opposition from the other party. Other states are similar.)

        So, yes, I expect that their statistic is literally true, that 95% of their contributions end up in the hands of winning campaigns.

  11. Markus Ramikin says:

    What does DSM stand for?

  12. Steve Sailer says:

    “If you make every one of a psychotic person’s delusions come true, such that they no longer have any beliefs that do not correspond to reality, does that technically mean you’ve cured them?”

    !!!

  13. Ilya Shpitser says:

    The chip monitoring thing is a much much funnier version of the Gettier problem!

  14. creative username #1138 says:

    Before I finished reading this post I googled APA and was confused what the American Psychological Association was doing bragging about their lobbying at a psychiatry conference. Trying to convince psychiatrists of the futility of their own lobby attempts?

    The psychologists have won the war for the APA acronym.

    • Anon says:

      I agree that the psychologists won the war for the acronym; I think a contributing reason is that they published a style/format that for some reason became extremely influential and well-known so APA style infiltrated the minds of a very large portion of people going to colleges, associating the APA = american psychological association idea. I mean, I had to use that formatting stuff a bunch in university, and I never had to interact with the american psychiatrist association so that second meaning for the acronym was unknown until I read this post.

    • LTL says:

      Meanwhile nobody even notices that the American Philosophical Association is a thing, too (says the philosophy major :P).

      • Protagoras says:

        I thought of that too. Three letters is just not enough for generating confusion-resistant abbreviations, especially when so many of them use A for American as one of the letters, and A for association or agency as another of the letters.

      • RCF says:

        Or the Analrapist Panamerican Association.

  15. Sarah says:

    So, I had absorbed the Conventional Wisdom that typical antipsychotics are scary and cause tardive dyskinesia, and atypical antipsychotics are mild and friendly and don’t cause tardive dyskinesia. (I even seem to remember depressed undergraduates gossiping as to whether they should take Risperdal.)

    Then I saw a number of big meta-studies that said “no, all antipsychotics cause tardive dyskinesia and other dopamine-related side effects; the atypical ones only seem better when you take into account the fact that people tend to be given really high doses of typical antipsychotics.”

    So a.) do you think this is true, Scott? and b.) if it’s true, why give people atypical antipsychotics (which have the old side effects plus a bunch of new ones like weight gain, without a huge efficacy increase)?

    • Scott Alexander says:

      This is a very complicated issue and many studies conflict. I get the impression that atypicals are a little better, but not as much as promised. Probably the biggest confounding factor is that Haldol, by far the most common typical used in real life, is unusually bad for EPS and TD, so psychiatrists’ observation that their typical patients develop much more EPS and TD might be true without being fully applicable.

      This review is pretty good.

  16. The confounding effect of close monitoring in RCTs is probably even larger in economics RCTs.

    While better than the alternative of “let’s just do whatever sounds nice”, too often they infer from “sending a bunch MIT PhDs to manage program X with a lot of intensive oversight has a positive effect” to “Program X will have a positive effect when rolled out at scale with local staff without the oversight”.

  17. Are there any studies on the influence of cognitive biases on people receiving / getting prescriptions?

    So there’s some bias or other that people over-weight really good personal outcomes in their calculations, and are willing to risk bad things happening to them, maybe disproportionately, if they have a chance of a perfect outcome. So I’d expect the patients to want the medication that might just cure them perfectly, even if there are risks. I know that’s how I’ve acted in other medical circumstances.

    And on the other hand, people dislike bad things to happen as a direct result of their actions, which could influence doctors into prescribing stuff which, although it might not be as likely to cure, is certainly less likely to have very bad effects.

    …and this whole comment might just be me making up ideas to fit what I just heard above and have heard before, and all these fears might be dominated by the fear of malpractice suits and such not. But still, it would be interesting to try to do some kind of study on this.

  18. Speedwell says:

    Scott, someday they might understand enough about brains and chemicals and drugs to figure out why the conventional antidepressants (SSRIs; I try to refuse anything that will make me even more obese, and Wellbutrin did nothing at all) I’ve been prescribed hit me like an atomic bomb. They make me nonfunctional, even psychotic, within days of the first dose, and I feel horrible too (my old psychiatrist told me, “that can’t possibly happen”, ugh). I also get steroid psychosis from the smallest doses. I’m not asking for any kind of diagnosis, just telling you why I now avoid drugs for my depression and anxiety. But I am always thrilled to read your posts because I can tell you genuinely care and want to help, and I’m so grateful for that.

  19. Tim Brownawell says:

    Clozapine is messy and scary and requires lots of paperwork, but if you’re a good doctor you’ll give your patient the drug that will help them anyway.

    Do you have enough spare time to actually do all that paperwork without having to turn away (more?) patients, or take shortcuts in other areas of their care?

  20. Anonymous Coward says:

    Re antipsychotics and addiction: I used to have a little bit of a methylphenidate problem. Okay, more than a little bit of a problem. Anyway, unsurprisingly, taking large quantities of stimulants and never sleeping led to some paranoia and stuff, so I got prescribed an antipsychotic. Which made me sleep 14 hours a day and, more importantly, made the Ritalin not work at all. So I quit after about four days of that. Anyway, since then I’ve wondered if antipsychotics might be effective for stimulant addiction in the same way disulfram works for alcoholism.

  21. vV_Vv says:

    If you make every one of a psychotic person’s delusions come true, such that they no longer have any beliefs that do not correspond to reality, does that technically mean you’ve cured them?

    LoL! Sounds like the kind of things a stereotypical AI would do. 🙂

  22. Troy says:

    The APA representative says that 95% of candidates supported by the APA’s PAC get elected. I think it was supposed to be a boast, like “look how effective we are”, but that’s a bit much. Either the APA single-handedly controls all American politics, or else they’re very careful to always back the winning side. Properly understood, that number should probably be taken as a measure of exactly how cynical they are.

    My understanding is that the dominant view among economists/political scientists who study this is that money tends to follow the winner rather than the other way around. Jason Brennan discusses this in his Ethics of Voting.

    I’m quickly losing my prejudice that RCTs always beat naturalistic studies.

    Scott: You may be interested in some recent research on drawing causal inferences from historical data: basically the idea is that noise in the data has asymmetric effects in the effect vs. the cause, and that this is reflected in the data. Here’s a blog post on the subject:

    https://medium.com/the-physics-arxiv-blog/cause-and-effect-the-revolutionary-new-statistical-test-that-can-tease-them-apart-ed84a988e

    If you’re interested in the more technical details, check out Hoyer et al.’s paper, “Nonlinear causal discovery with additive noise models.”

    • Douglas Knight says:

      The paper is here, but I think this is really missing the point.

    • RCF says:

      Combining those two ideas, is there statistical analysis studying whether more money causes better electoral success, and would a passive study be more effective than randomly assigning some candidates to a control group, and giving others large amounts of campaign funds?

  23. simon says:

    What kind of training would psychologists need to have? Can they monitor CBZ, Li, Clozaril and be alert to side effects? I doubt it. i don’t understand why your ok with that.

    SSRIs are a different matter. Sell them over the counter for all I care. But

    • Scott Alexander says:

      1. Primary care doctors right now have prescribing ability, and almost none of them prescribe lithium or clozapine. A few will refill prescriptions of those if someone else has prescribed them and the patient is doing well. But if they don’t feel comfortable with it, they refer the patient to the psychiatrist. I don’t see why psychologists with prescription privileges would suddenly start doing things that primary care doctors with prescription privileges don’t.

      2. I think the states where this is already a thing require something like a year of in-class-training and then a long internship under a doctor or an existing prescribing-psychologist.

      3. Ask a person who just graduated from medical school about lithium. Ask them, I dunno, the appropriate doses, the appropriate monitoring schedule, the appropriate blood levels, any question more difficult than just “is it a thing that cures bipolar disorder”? I bet you almost no medical students will know this information. Most of those people either become primary care doctors who continue not to know it, surgeons or something who continue not to know it, or they become psychiatrists and learn it in residency. So since they’re not actually learning about the intricacies of lithium and Clozaril in medical school, why do you think someone who hadn’t gone through medical school, but had a residency-equivalent apprenticeship, wouldn’t be able to do it?

      4. Lithium’s a tough medication, but it’s not quantum-physics-tough. There are a couple of worrying side effects, a few necessary monitoring procedures, some drugs and conditions that it might interact with, and you’ve got to remember how to set doses. My copy of Stahl’s got lost in the flood, but I think it had like five to ten pages on lithium. How long does it take to learn five to ten pages of information about something? I feel like the answer shouldn’t be “four years of medical school + $200,000 + another four years of residency + another $500,000 mostly paid by the taxpayer”. In fact, I think the average psychiatric nurse has absorbed a lot of this by osmosis already. So let them read the textbook, give them an expert to ask if they have any questions, then put them in an apprenticeship type position where they can solidify their knowledge.

      5. You know those 80-20 rules? I think medicine is more like a 95-5 rule. 5% of the information the average doctor learns does 95% of the work. If you’ve got somebody with renal failure and an obscure vasculitis and the MRI machine happens to be broken that day, then you’ve got to dig into the remaining 95% of your training. But it still seems to me like there’s a role for people to whom we teach the important 5%, then turn them loose on the easy cases to deal with cost and access issues. And if one in a thousand times that causes an extra problem because something rare got missed, that’s probably fewer problems than the problems we get from most psychiatric patients going untreated, or Medicare imploding because the money’s run out, or whatever.

      • simon says:

        Good points, thanks for the reply. Just a couple thoughts.

        “I feel like the answer shouldn’t be “four years of medical school + $200,000 + another four years of residency + another $500,000 mostly paid by the taxpayer”.

        This is definitely correct, but it can be said for most specialties. Ortho probably needs less knowledge of the collecting duct than psychiatrists do, yet they have the same education.

        There is definitely a problem with primary care doctors rxing these drugs as an afterthought, but the response isn’t to spread the rot further IMO. It’s to train more psychiatrists who are skilled in the art of discriminating psychopathology based on the patients presentation and with good, Stahl level knowledge of psychopharm. That’s the best answer for patients, I think. But you may be right that the access problem is so dire that giving rx privledges for a limited range of medications might be the most humanitarian option in the short run. I’m just a medical student intersted in the field though, so maybe I don’t know what I’m talking about (seriously)

        But I can say as a medical student that we definetly had to know a lot about Li and Clozapine for the shelf.

  24. Deiseach says:

    I want to apologise to Scott in particular and to all the rest of you in general.

    Some of you have pointed out that I’m always angry or cutting or taking cheap shots when I comment on here, and I think that’s fair comment and fair criticism.

    The thing is, I know I come on here and yell, but that’s me screaming in pain. Not physical pain, but psychic pain. And I have nowhere else to do it, because in the real world, I feel I’m yelling into the void.

    On here, you understand. Even when I’m arguing with certain of you, your experiences, interests, lives, and general head-space are closer than anyone in my immediate, physical, real-world surroundings. There’s a commonality here that I don’t get anywhere else. I had that underlined in a recent conversation with a co-worker who was trying to be friendly and make small talk about common interests. Nothing there. Do I watch [popular TV show]? No. Did I watch [popular TV show that has just ended, that entire nation was watching and talking about]? No, and I had no interest in doing so. And I couldn’t tell her what I really liked to read, listen to, talk about, think about, because that all that is too weird. I’ve had that all my life. But at least, on here, you know (a lot of) the books I’ve read, or other things. We can talk/argue/discuss matters and there’s “Yes, I know about that, and it’s not something that I would look at you as if you were a two-headed Martian if we spoke about it face-to-face in real life”.

    You know the worst thing my sister ever said to me, and she didn’t mean it as a bad thing? “Oh, [your nephew] is just like you!”

    My heart sank. I don’t want him to be just like me. I don’t want anyone to be just like me, because it’s horrible.

    Thankfully, that doesn’t seem to be true. The paternal genetic heritage is diluted enough in his case that, although he has some similar interests, he can certainly at least pass for normal (hell, maybe he even is normal). He has friends. He goes places and does things. He has a girlfriend. Next year when he finishes secondary school he’ll very probably go on to college. He has, and can have, “a life”.

    He’s not like me except in the most tangential of ways, and you have no idea how very, very glad I am for that.

    So, I want to apologise, and I want to thank you all for your patience and how you’ve helped me (yes, even when we’ve been exchanging snotty remarks).

    As a side-note, does anybody know if cheese is addictive? Because for the past couple of weeks, I have been having serious cheese cravings and gobbling down the stuff, everything from cheddar to Emmenthal to Brie (and I never eat Brie usually) to (today) Wensleydale with blueberries.

    • Speedwell says:

      You’re OK with me, Deiseach. 🙂

      Cheese? Hmm. Tyrosine, maybe? If you have a thyroid, or adrenal, or dopamine issue, it could be related. If your craving is for the really mature aged cheeses, that is. Otherwise, maybe something is off with your salt balance, or… wait, is that Wensleydale with blueberries? I’ll solve your problem by removing the temptation 😀

    • Leo says:

      Point taken.

      You’re describing a problem young nerds always have, but adult nerds rarely do. You might try meetups of something you’re interested in in your area, or the #lesswrong (extremely friendly to bitchiness) and #slatestarcodex IRC channels.

      I also have massive cheese cravings. They decrease but remain severe when I eat more salt. I suspect a lack of fatty acids, and have been eating walnuts, which seems to help and goes well with cheese. You might also try fish such as mackerel. It could also be a lack of protein, or that you’re just not eating enough (relative to the weight your body is trying to get you to).

    • I enjoy your comments on this blog. Cheese does not agree with me, and I really should abstain, but sometimes it calls me.

    • Just a note to say that I didn’t find anything objectionable in your long response to me re Strongbow, Dermot, etc. al., not even your nationalistic prejudice against William Marshall’s grandfather in law, who was probably no worse than the people he was fighting. I thought part of your argument was wrong, and said so—but that’s part of the point of exchanges in a comment thread. And it was nice to have a response from someone who actually knew something about the history I had mentioned.

    • Scott Alexander says:

      Yeah, I don’t have any problem with you either and appreciate your perspective.

      What you’re describing is pretty much how I felt when I found LW. There is definitely “a type”. You are especially interesting because you are very much the type in some ways and very much not the type in others and so have a unique perspective.

      (on the other hand, there is a small community of female rationalist social workers you might be interested in getting to know better; if you want I can give you introductions)

      I think the usual solution to this problem is to move to the Bay Area, but I understand that’s probably not an option for you.

      I don’t think you’re horrible or that being like you should be horrible. Did you ever get your depression issues looked at? If you’re *still* stuck in the bureaucracy, it might be time to start trying things you can get for free over the Internet.

      • Deiseach says:

        Thank you, Scott, and thank you to everyone else. I hate that I sounded like I was whining for attention, as though I were asking “Everyone please feel sorry for poor little me!”. I know there’s things I can and should be doing, rather than expecting a magic cure to happen out of nowhere. It’s simply a matter of pulling myself together enough to go and do those things.

        Re: cheese and fatty acids and possible adrenal/thyroid – yes, I’ve also had a craving for mackerel in the past week and had some (yummy!). I know I’ve been eating poorly recently for a variety of reasons, so it could be protein craving plus fatty acid need plus salt balance out of kilter.

        Also, Wensleydale with blueberries is delicious 🙂

        I was wondering about the adrenal/thyroid thing as well, but if I’m to believe my last in-depth blood test, nothing is wrong there. Hmmm. Well, I’m not going to call my doctor a liar!

        • speedwell says:

          Yes, I know. They don’t usually diagnose thyroid issues until you are practically dead, and subclinical but problematic levels are routinely handwaved. The correct level for thyroid is what helps YOU YOU YOU function at a normal level. I’ve heard that the only good test to see whether you need thyroid medication is to try thyroid medication and see whether you respond. I’ve also heard, anecdotally from thyroid patients, that you may even need thyroid medication that affects more than just the one or two hormones most usually at fault. “Adrenal fatigue” is 99 percent nonsense, but the fact that you have type 2 diabetes (as do I, but mildly) means that something is likely up with your cortisol, either as cause or as effect, because cortisol and adrenaline have a lot to do with insulin and blood sugar. I’m not diagnosing; just saying that if your GP is intelligent like mine, take a list of thyroid and adrenal symptoms in with you and discuss it with them, and if warranted ask for a thyroid medication trial (preferably the natural kind with all the hormones in it, if it is available here).

        • Elissa says:

          I think it would probably be a good thing if societal norms shifted toward accepting that people sometimes need attention and sympathy, and asking for what you need is a good way to get it. Hugs if-and-only-if wanted.

        • Nita says:

          Hey, I’m late to the Deiseach Appreciation Party, but I’ve brought a gift — a rather inconvenient conclusion from my own experience.

          Here it is: positive in-person interaction with the right people is inexplicably uplifting, even if you seem to be getting enough socialization online. Even if you don’t feel any longing for it. Even if thinking about it makes you anxious.

          Also, depression is bad, and cheese is delicious — confirmed.

    • Deiseach, you’re great and these comment threads would be much worse without you. I hope you’re getting your depression looked after, because this comment fairly reeks of it, and I hate to see you suffer.

      I don’t know about the cheese, though. What you’re describing sounds like “every day” to me.

    • Anonymous says:

      On the food cravings issue: I can’t stop craving peanuts, and even when I’m full I have room for peanuts. This has been the case for a few months now. I don’t remember exactly when it started. What could it be? Low salt?

    • Deiseach, I very much enjoy your comments and have never found them off-putting, even when we disagree.

      As to cheese, I myself gave up eating dairy products more than a year ago, with no regrets.

      Staying away from dairy helped me lose a lot of weight I needed to lose. Moreover, my father died from aggressive prostate cancer, so I am at risk, and dairy in the diet apparently increases that risk.

      My wife did persuade me to take a small bite of some fancy cheese a couple weeks ago. It was wonderful — but it didn’t cause any cheese cravings.

    • Honestly, ‘snotty’ is not an adjective I’d use to describe you. ‘Opinionated’, perhaps – but part of what’s awesome about Scott’s blog comment space is that people are not trapped in an echochamber of ideas.

      So, really? I’d like to thank you (and most of everyone else) for helping me – even when I don’t comment (which is most of the time), I usually learn a lot from reading the comments here. I wouldn’t do that if everyone here always agreed with each other.

      🙂

    • Rauwyn says:

      I’m not an especially frequent commenter, but your comments really add a lot to the discussion here, and I always look forward to reading what you have to say. I’m sorry you’re hurting.

    • Tom Womack says:

      Deiseach, you’re one of the people I read this blog for. There’s no need to apologise.

    • chamomile geode says:

      speedwell and leo have good cheese-craving theories, so i’m just gonna offer a possibility: could the cheese-cravings be a probiotic thing? i don’t know how true the depression-is-too-little-serotonin actually is, but i do know that the gut microbiome is supposed to be involved in serotonin production–it’s possible your body is going, “hmmmm, my microbiome’s not doing so well, fermented things like cheese usually have probiotics in them so i’m gonna crave cheese,” not knowing that nowadays cheese is usually pasteurized. you could try probiotic foods or supplements and see if that helps?

    • Anonymous says:

      @Deiseach, like many of the others, I enjoy your curmudgeonly comments 🙂

      As for cheese, one explanation holds that cheeses naturally contain morphine-line compounds. (Other sources say this is bunk.) I’ve known people, myself included, who use cheese to fight off sad moods. (My current diet limits dairy, but I have a block of cheddar in the fridge that I’m saving to pair with Ritz crackers, which is how I “get high.”)

      Also, I’m trying to not develop type II diabetes and have been taking inositol after reading about positive effects on insulin sensitivity in women with PCOS. I recommend reading up on it (assuming armchair endocrinology is your thing).

    • Peter says:

      We’ve had our share of arguments, but like everyone else is saying, it’s good to have you around.

  25. jj says:

    What do you think about adding an addictive drug to anti-psychotics? Has this concept ever been tried, with any drugs?

    • BillWallace says:

      No idea, as I’m not in medicine in any capacity, but that sounds like a very interesting idea to me.

    • HeelBearCub says:

      Doesn’t this sort of fall into the same objection as electronic monitoring? (i.e. “They are putting drugs in my _____ “. where the blank here is drugs.)

  26. William O. B'Livion says:

    The scare stories about how psychologists might prescribe medications unsafely didn’t have much effect on me, since I continue to believe that putting antidepressants in a vending machine would be a more safety-conscious system than what we have now (a vending machine would at least limit antidepressants to people who have $1.25 in change; the average primary care doctor is nowhere near that selective).

    Aerial spraying of prozac?

    Again, interesting idea. But again, one of the most common paranoid schizophrenic delusions is that their electronic devices are monitoring everything they do.

    So the app just counts the amount of time it’s been locked in the dark and silent.

    And these days if you *don’t* think your smart phone is spying on you you’ve got problems with reality. The only question is who it’s spying *for*.

  27. William Eden says:

    My guess is that dopamine antagonists aren’t anti-addictive, they simply lack / block addictive properties. Instead, my candidate for a true anti-addictive substance would be a kappa opioid agonist, such as salvia or ibogaine.

    • Anonymous says:

      NMDA antagonism is anti-addictive, but many NMDA antagonists are dopaminergic, which means overall they tend to be reinforcing.

  28. Dude Man says:

    I collected another good one today when an activist was talking about gun rights for psychiatric patients: “Taking guns from psychiatric patients isn’t going to be a panacea for violence – would anyone like to take a stab at why?”

    I’m guessing that this wasn’t unintentional.

  29. anonymous says:

    You know, i rather suspect that psychologists would be better than psychiatrists at prescribing to patients without any significant non-brain issues like blood pressure or liver disease or whatever, since the former have PhDs in psychology and actually run psychometric tests, as opposed to MDs who mostly have degrees in generalized medicine with a little brain stuff sprinkled on top at the end.

    I’m neither a clinical psychologist or psychiatrist, but I’m in neuro and so know members of both groups socially and have also visited both as a patient. I like my psychiatrist as a person, but he’s mostly just a pill vendor who nods and smiles and gives me the prescription, whereas my psychologist gave me a psychometric battery before attempting diagnosis. Which of those two people prescribed would make zero difference, but only one of those people added anything substantial to the process.

    Granted, an MD comes in handy when a patient comes in from overdose or has complications and allergies and what not, but that’s often not the case and it’s not hard to refer to a doctor when necessary.

    • simon says:

      Psychiatrists need to start getting this type of training. They can dx medical causes of mood/psychotic disorders but most of them havnt been taught neuropsychological testing. THat said most psychologists I know don’t know this either. They do know CBT and many other therapies. Yours sounds good.

      • anonymous says:

        >most of them havnt been taught neuropsychological testing

        Seriously? That surprises me. Wouldn’t that make psychologists redundant with the (less educated and therefore more affordable) therapists and councilors?

        Also, ugh. What is the point of making objective diagnostic tools if clinicians don’t bother using them? We have effective tools, we know performance enhancement almost always has a ∩ curve, yet dosage titration + psychometrics isn’t even part of the protocol. Even my apparently-more-competent-than-average clinician didn’t suggest it, I had do to it on my own with the n back (which is a substandard tool compared to the clinical ones, but their psychometric testing software was too expensive to justify purchase).

        I’m not even into clinical stuff and this almost makes me want to open a clinic when i grow up to model how things aught to be done…

  30. emily says:

    I think you are on to something with antipsychotic drugs being anti-addictive. Addictive drugs make you feel good, have more energy, and be more productive. Therefor you have college students faking ADHD to get Adderall, not faking schizophrenia to get Risperdal. Someday maybe they will come up with a schizophrenia drug that is good enough that people will actually fake the diagnosis to get the drug. But the current drugs aren’t fun, they don’t give you energy, and they don’t make you more productive- and they do make you gain a whole lot of weight. You’d have to be crazy to take them…

    And the NIMH doesn’t care what patients want. I wrote them saying that I am a 40-something female who takes Zyprexa and I’d like to see research that addresses whether hormone replacement therapy increases or decreases the chance of getting tardive dyskinesia- and I think that this would be pretty relevant for all females who take antipsychotics. I got a response saying that they have no influence over research content- that would is not their role- and that I should contact individual researchers to try to get them to study this (and I guess hope that they can get an NIMH grant). I was kind of disillusioned- I thought that they would at least care- or pretend to care- about the priorities of actual people with mental illness.

    • Protagoras says:

      People’s individual reactions to drugs are so different. I guess that’s why they’re supposed to get medical supervision, but that doesn’t always seem to be sufficient. I’m always a little puzzled by people talking about the addictive properties of adderall and the like. I’ve taken such drugs for ADHD, and they help me cope. When I’ve take more than I’m supposed to, because I needed to stay up for an all nighter or something, I felt kind of wired and a little sick, and I felt no inclination to take extra any time it wasn’t important to stay awake. And the reason I had extras lying around to abuse that way is because I didn’t always take the full prescribed dose; I would feel like it wasn’t necessary for me to take anything some days, because I wasn’t doing anything important that day, and if I didn’t need the focus, the drugs had no appeal for me. They never made me feel like I wanted to take them to feel good. And it’s not because I have any general resistance to addictions; I’ve had problems with alcohol, and share the problems others have mentioned resisting the allure of cheese. But oral stimulants just don’t produce cravings for me the way some other things do.

      I understand that amphetamines are much more addictive if they are taken in other ways, if they are, say, injected rather than ingested, and I’ve never taken them in anything other than pill form. But it does seem that some people do find them addictive even in pill form, which seems totally alien to my experience.

    • SFG says:

      I’d imagine writing the NIMH to say you need a study on your specific psychiatric issues is about as effective as writing the federal Department of Transportation to say there’s a dangerous beam crack on a heavily traveled bridge outside your house–they’re a giant organization and everything goes through a huge bureaucratic process with a heavy political component.

      I do wonder if it might be better to start blogging about this, maybe reach out to feminists (you can pitch this as oppression of women, even if most likely there are other reasons). Does anyone here who’s longer term or knows more about social media have any idea if this is a viable strategy?

    • anonymous says:

      I’m loosely affiliated with academia, and it’s true that the NIMH really can’t address your concerns (other than, like you said, fund a grant written by someone researching this – but that comes down to the specifics of how good that person’s research plan is. Whether or not someone gets funded has less to do with what they are studying and more to do with how good their plan to study it is).

      In short, they gave you an honest answer, which I personally think is better than saying some nice-sounding stuff pretending to address it. (Keep in mind whoever is manning the emails at the NIMH is just an ordinary person trained to interact with researchers making various inquiries, not the public.)

      If you were to write out a *methodologically sound* epidemiological report showing that your issue is, in fact, a major problem (which includes theoretical basis for suspecting an interaction between the treatments) and submitted it to journals, you might successfully direct more research to the area – but keep in mind that this is HARD and for all you know after you do the research you might discover it’s not as clinically relevant as you thought.

      FWIW, estrogen increases the concentration of neurotransmitters such as serotonin, dopamine, and norepinephrine and tardive dyskinesia is a typical antipsychotic (mostly dopamine receptor blocking) side effect, so in hand-wavey-theory-land there’s probably more of a case for DECREASED risk. Unless you’ve read something that leads you to believe an interaction exists, I’d personally not eschew HRT for this reason if it were me.

  31. emily says:

    My guess is that a similar number of patients stop taking statins. Maybe we should put chips in cardiac patients or give them long-acting injectables so that they can’t decide that they don’t like the side effects or don’t like taking the drug, etc., and this will reduce the chance of them having a future heart attack and reduce future costs.

  32. RiversHaveWings says:

    So whatever happened to DHA-clozapine? Did the stuff work but fail to reach the market for some other reason? Or was it just flawed in some other way? Nevertheless forming an amide with an omega-3 fatty acid like that is a clever trick and I’d like to know whatever came of it.

    • Scott Alexander says:

      I always wondered that too! Nobody’s said anything about it for years now. I think the company that was building it got bought out by someone else.

      • RiversHaveWings says:

        Any generalizable trick that improves drug selectivity for specific systems is a huge win. Use your imagination…

    • Elissa says:

      It appears Protarga, the small biotech company responsible for DHA-clozapine, filed for Chapter 11 in 2003 and the company that bought their portfolio isn’t betting on it for whatever reason.

      • speedwell says:

        Maybe the commentariat could buy it out and engage in a private fund-me cooperative to produce it and other neglected (but scientifically verified and promising) psychiatric medications? I’d personally be willing to spend time, money, and labor on such an enterprise.

        • Scott Alexander says:

          Sarah, Vassar, either of you know anyone you could convince to look into this?

          The antipsychotic market is one of the biggest in all of medicine, and if this works as promised it would absolutely dominate it.

  33. Anonymous says:

    >Boss: Okay, what’s the most common cause of Parkinson’s disease in drug users?
    >Me: Drugs laced with MPTP.

    I’ve never read of MPTP contamination of anything but MPPP or Demerol and I’ve never even seen any mentions of MPPP use outside of the Wikipedia article, so I’m inclined to call bs on this.

  34. I wonder if the chipped pills and monitoring systems could be used as a sort of exposure therapy?

  35. Albatross says:

    Chipped pills sound great. I’m guessing they would reduce unwanted pregnancy and reduce overdose in the elderly. Nothing worse than when someone tells you they can’t remember if they took their meds… it would great if you could just check their chip.

    As far as whether changes in reality cure delusions is fascinating. I mean, sometimes people really are trying to kill you (recent example: ISIS has a hit list of veterans it is trying to kill). And it is normal to freak out about that. Someone should study the idea.

    • speedwell says:

      Chipped Metformin could work with an enhanced version of my blood sugar monitor to help me track how dosages and timings affect my individual blood sugar control. My major worry about chips in pills would be that anyone with a reader could walk by and see what I was taking, which would violate my medical privacy in the creepiest possible way.

  36. NonsignificantName says:

    The bill actually defined pi as 3.2, which is at least accurate to one signoficant figure

    • Scott Alexander says:

      I was reading the Wikipedia page. It looks like the wacky squaring-the-circle project defined it both ways if you look at different steps.

      • HeelBearCub says:

        It sounds that the “definitions” were all by simplifying some other proposed “fact” in the bill.

        Don’t get me wrong, the whole squaring the circle bill seems like it was fairly wacky, but I dislike it when things are presented in a salacious way, as if the title of the bill was “The Indiana Pi Valuation Decree” and the final sentence of the bill was “therefore let it be resolved that Pi is 4 except when it is 3.2”

  37. dipitty do says:

    As far as I can tell, my schizophrenic friend received an actual visit from the Secret Service shortly before beginning full delusions of being in psychic communication with various gov’t agents.

    I have to suspect that the real visit did not help matters.

  38. RCF says:

    “Properly understood, that number should probably be taken as a measure of exactly how cynical they are.”

    But according to EDT, candidates should still try to get the endorsement of the APA!

  39. RCF says:

    What’s you objection to cluster randomization? The issue you brought up is blinding, which is orthogonal to cluster randomization.

    • Scott Alexander says:

      The blinding problem was a result of the randomization problem. One hospital was the control group (and so only consented its patients for control group stuff) and another was the experimental group (and so consented its patients for experimental group stuff).

      I agree that a non-clustered study could have made this mistake (or a clustered one avoided it) but it seemed to be the clustering that made them think they could get away with it.

      Actually, maybe I should take that back. They were testing intensive intervention…like sending people to employment counseling, etc – and I can see why they would have trouble blinding that. I would argue they should still sort of blind it – ie tell both groups they were getting “treatment as usual” for schizophrenia and not tell one group “this is an exciting new intervention” – but I guess I can see why they expected that not to work, and from there you go to “well, this site doesn’t even have the fancy employment counselor, and they’ll notice that” to “why bother blinding?”

  40. Julie K says:

    Why is it so expensive to train residents? I would have naively thought that a hospital was getting a good deal, since they don’t pay their residents very much.

    • Hari Seldon says:

      I would guess that some of the expense is related to the fact that it is subsidized by the federal government. Several years ago, the federal funding for dental residencies was completely cut for many programs. The fear was that either the residencies would cease to exist or they would become so expensive that the applicant pools dried up. Neither of those happened. Many residents no longer get a stipend for living expenses, but it hasn’t decreased the competition for residency spots one iota.

      There are countless examples of costs being bid up due to government subsidy at some point in the chain: housing, college costs, natural gas vehicles. The list goes on. I’m sure there are lots of other factors, but government subsidy is likely big slice of the pie chart.

    • Scott Alexander says:

      Good question, and I don’t know the answer or even if this is true vs. an urban legend. I would guess that malpractice insurance is a big deal (residents are very new and more likely to make dangerous mistakes); and that you have to hire as teaching faculty the sort of very smart expert doctors whom you want training the next generation, and these people don’t come cheap.

      There’s also a lot of rules on how you have to expose residents to one-of-everything. For example, the law says psych residents must do a month of electroconvulsive therapy (even though almost no psychiatrists will be practice this in their career). My hospital doesn’t have an electroconvulsive therapy unit, so they have to pay another hospital to let us hang around their ECT unit and get trained in it by their doctors. Multiply this by a dozen or so similar requirements and that’s not cheap.

  41. gwern says:

    The expert who spoke today theorized – and I agree – that the naturalistic studies are right. He argued that one feature of RCTs is very close monitoring, which means the patients in them comply with their medication at an unnaturally high rate – thus removing the long-acting drugs’ one advantage. The studies conducted in the real world of patients not taking their medications regularly are more relevant.

    Then he should be able to show that the RCTs’ effect sizes are increased inversely to their attrition/compliance rates, and likewise in the correlational studies. Biases and issues related to intent-to-treat and partial compliance are not unknown.

  42. Ialdabaoth says:

    – The newest breakthrough in ensuring schizophrenic people take their medication (a hard problem!) is bundling the pills with an ingestable computer chip that transmits data from the patient’s stomach. It’s a bold plan, somewhat complicated by the fact that one of the most common symptoms of schizophrenia is the paranoid fear that somebody has implanted a chip in your body to monitor you. Can you imagine being a schizophrenic guy who has to explain to your new doctor that your old doctor put computer chips in your pills to monitor you? Yikes. If they go through with this, I hope they publish the results in the form of a sequel to The Three Christs of Ypsilanti.

    – The same team is working on a smartphone app to detect schizophrenic relapses. The system uses GPS to monitor location, accelerometer to detect movements, and microphone to check tone of voice and speaking pattern, then throws it into a machine learning system that tries to differentiate psychotic from normal behavior (for example, psychotic people might speak faster, or rock back and forth a lot). Again, interesting idea. But again, one of the most common paranoid schizophrenic delusions is that their electronic devices are monitoring everything they do. If you make every one of a psychotic person’s delusions come true, such that they no longer have any beliefs that do not correspond to reality, does that technically mean you’ve cured them? I don’t know, but I’m glad we have people investigating this important issue.

    I truly wish that I lived in such a world that any>/i> of this surprised me at fucking all.

  43. Matt C says:

    Is “addictive” more sharply defined than “people really want to do it and keep doing it even when it’s not good for them”? Is it measured any other way than seeing how often people keep doing the whatever?

    I thought that was all there was to it. So I would guess lots of drugs (and would-be habits) could reasonably be called anti-addictive. Does that have another meaning in a clinical context?

  44. Alex Godofsky says:

    If you make every one of a psychotic person’s delusions come true, such that they no longer have any beliefs that do not correspond to reality, does that technically mean you’ve cured them?

    Isn’t this really the Gettier problem?

    edit: Ilya Shpitser mentioned it first

  45. loki says:

    I feel like the bit here about why schizophrenic patients don’t take their meds (and like, nearly all discourse about why schizophrenic people don’t take their meds) ignores the important group of people who want to take their meds but for various reasons don’t.

    For instance, a lot of us crazy people are not too crazy to know better about taking our meds, but are too crazy to take them even though we want to. That is to say: you want to take your meds but executive dysfunction caused by your illness or your meds prevents you from remembering to do so, or from remembering to/mustering the spoons to refill your prescription.

    I think there’s a tendency to always view undesirable (from the perspective of the viewer) behaviour from crazy people as a choice; they’re just perversely defying you, and that’s what leads to the kind of ideas discussed in this post.

    Helping crazy people remember stuff and making it easier for us to get our meds every month isn’t going to require cool sci-fi sounding technology, but it’s also less likely to feed psychosis and seems to me like it might actually work.

    ETA: I also think it’s like the idea that crazy people must always have Crazy Problems, like thinking their meds are radioactive spiders from space, instead of Normal Problems like a bad memory.

  46. loki says:

    When I was institutionalised as a psychiatric patient, there were a lot of things the staff did that seemed, at the time, calculated to make me more paranoid and crazy. And obviously the trouble with that mindset is that it’s recursive – the more you worry that they seem to be trying to make you more paranoid the more you think you sound crazy and paranoid, the more you worry about being crazy and paranoid.

    In actuality, their behaviour was probably more a consequence of assuming I was more crazy than I was (or at least, that the cause of a statement or behaviour couldn’t be something other than my craziness).

    Specifically, they:

    Denied the existence of silverfish (bugs) in a hospital room when I pointed them out, and only when a nurse huffily agreed to come with me to confirm that I was just seeing things did she admit that they were real.

    When I was permitted to go on a walk with my mum who was visiting, obviously didn’t believe me about some of the dry grass in the car park smoking as if about to catch fire from the sun/heat. I presume someone later caught this as the car park didn’t burn down, but the point is my non-crazy mum saw it too and refusing to believe me and telling me I was seeing things just made me feel more crazy and as if they were trying to make me crazy.

    When I heard am alarm go off, insisted that I hadn’t heard anything instead of explaining when asked what it was for.

    So, I’m kind of not surprised by these ideas.

    I mean, psychiatric hospital itself is an environment where people are watching you and recording your behaviour all the time while refusing to explain to you why or show you what they’re writing – it’s like it’s tailor-made to make you more paranoid.

    Edit: Proposed experiment – treat neurotypical people the way psychiatric inpatients are treated and see how long it takes for them to develop paranoia.

      • loki says:

        I’ve read about that – it is an interesting study, but while there are interesting reports as to how the non-crazy people felt in that situation, that wasn’t what they were studying.

        I’m not at all surprised that the real patients could spot them. For all that psychs love to talk about us ‘lacking insight’ I’ve found far more useful insight, advice and basically informal therapy* from other crazies than any psychiatric professional has been able to give me.

        I don’t mean to malign Scott’s profession here – or at least, not him by association, as he sounds like exactly the guy I would want dealing with my head – but there are serious problems here.

        * in the sense that the distinction between ‘some crazies drink non-alcoholic beer, bitch about their shrinks and generally talk openly about stuff’ and ‘group therapy’ is not one that I find particularly meaningful.

  47. Pingback: Being a cyborg proves more boring than anticipated. | Aceso Under Glass

  48. Pingback: The latest “breakthrough” in helping schizophrenics take their medicine « Quotulatiousness