Annotated Links #2

In the NY Times, Daphne Merkin writes about her life with recurrent and "treatment-resistant" depression. A Journey Through Darkness is eloquent and honest, but it offers no convincing explanations as to the origin of her bouts of melancholy. Sometimes she is depressed and then eventually the state passes. In Merkin's account, and in my personal experience, being depressed is a brute fact. It is experienced, not understood. To call it a "journey" or anything else which implies some kind of narrative is misleading. And when a depression passes, it goes with a whimper not a bang:

It was about 4:30, the time of day that, by mid-August, brings with it a whiff of summer’s end. I looked up into the startlingly blue sky; one of the dogs was sitting at my side, her warm body against my leg, drying me off after the swim I had recently taken. I could begin to see the curve of fall up ahead. There would be new books to read, new films to see and new restaurants to try. I envisioned myself writing again, and it didn’t seem like a totally preposterous idea. I had things I wanted to say. Everything felt fragile and freshly come upon, but for now, at least, my depression had stepped back, giving me room to move forward. I had forgotten what it was like to be without it, and for a moment I floundered, wondering how I would recognize myself. I knew for certain it would return, sneaking up on me when I wasn’t looking, but meanwhile there were bound to be glimpses of light if only I stayed around and held fast to the long perspective. It was a chance that seemed worth taking.

The Royal Swedish Academy of Sciences issues a welcome statement condemning "lie-detector" peddlers Nemesysco for their attempt to gag two Swedish scientists. (See also Ministry of Truth for an extensive take-down of Nemesysco and all who use their products). Although, given that this happened several months ago, they certainly took their time about it...

Incidents of this kind are a threat to research freedom and, by extension, to the free dissemination of information in society. Threats to sue must not be used to restrict scientific discussion.

Finally, I know I said I don't believe in music reviews, but Neko Case is brilliant.

Annotated Links #2

In the NY Times, Daphne Merkin writes about her life with recurrent and "treatment-resistant" depression. A Journey Through Darkness is eloquent and honest, but it offers no convincing explanations as to the origin of her bouts of melancholy. Sometimes she is depressed and then eventually the state passes. In Merkin's account, and in my personal experience, being depressed is a brute fact. It is experienced, not understood. To call it a "journey" or anything else which implies some kind of narrative is misleading. And when a depression passes, it goes with a whimper not a bang:

It was about 4:30, the time of day that, by mid-August, brings with it a whiff of summer’s end. I looked up into the startlingly blue sky; one of the dogs was sitting at my side, her warm body against my leg, drying me off after the swim I had recently taken. I could begin to see the curve of fall up ahead. There would be new books to read, new films to see and new restaurants to try. I envisioned myself writing again, and it didn’t seem like a totally preposterous idea. I had things I wanted to say. Everything felt fragile and freshly come upon, but for now, at least, my depression had stepped back, giving me room to move forward. I had forgotten what it was like to be without it, and for a moment I floundered, wondering how I would recognize myself. I knew for certain it would return, sneaking up on me when I wasn’t looking, but meanwhile there were bound to be glimpses of light if only I stayed around and held fast to the long perspective. It was a chance that seemed worth taking.

The Royal Swedish Academy of Sciences issues a welcome statement condemning "lie-detector" peddlers Nemesysco for their attempt to gag two Swedish scientists. (See also Ministry of Truth for an extensive take-down of Nemesysco and all who use their products). Although, given that this happened several months ago, they certainly took their time about it...

Incidents of this kind are a threat to research freedom and, by extension, to the free dissemination of information in society. Threats to sue must not be used to restrict scientific discussion.

Finally, I know I said I don't believe in music reviews, but Neko Case is brilliant.

Lithium and Antidepressants in Tap Water

Lithium, as everyone knows, is a song by Nirvana. (It's also a different, and worse, song by Evanescence). It's also a chemical element. And it's a drug, used in psychiatry to treat bipolar disorder and, sometimes, severe depression.

One thing which lithium seems to do rather well - or at least better than other drugs - is make people less likely to commit suicide. At least, that's what most authorities say, so let's assume it's true.

Now a Japanese team report that the amount of lithium in tap water are negatively correlated with suicide rates - Lithium levels in drinking water and risk of suicide. (Someone has helpfully put this up on Scribd for people without academic access).

They analyzed the water supplies in the 18 subdivisions of Oita prefecture in southern Japan, and compared the lithium levels in the water with the average suicide rate (normalized for age and gender). Here's what happened -
Now, on paper that's a pretty solid correlation. But how believable is it? The maximum lithium level in the water was found to be 59 micrograms per liter. By contrast, if someone were taking lithium for bipolar disorder, they would on average be taking about 1 gram of lithium carbonate (Li2CO3) per day, which works out at about 100 mg of lithium (and 900 mg of inert carbonate).

Assuming that people drink about two liters of tap water per day (almost certainly they drink less), that's about 120 micrograms per day. That's 0.12 mg. So about a thousand-fold less than you'd take if you were bipolar.

Could such a tiny amount of lithium do anything? Well, maybe. It's not impossible that it would have some small effect on suicide rates, but it seems very unlikely that it would account for the difference between a rate of 120 and a rate of 80 which is what the graph seems to imply. The effect is just too large to be credible, if you ask me.

Although that said, another paper just out found that tiny amounts of antidepressants (the amounts that you find in rivers because so many people take them and some of them are stay in urine) could affect the behaviour of baby fish. And presumably also baby humans. Unfortunately I can't access this study, so I don't know whether that's nonsense or not, but it's food for thought.

Ohgami, H., Terao, T., Shiotsuki, I., Ishii, N., & Iwata, N. (2009). Lithium levels in drinking water and risk of suicide The British Journal of Psychiatry, 194 (5), 464-465 DOI: 10.1192/bjp.bp.108.055798

Lithium and Antidepressants in Tap Water

Lithium, as everyone knows, is a song by Nirvana. (It's also a different, and worse, song by Evanescence). It's also a chemical element. And it's a drug, used in psychiatry to treat bipolar disorder and, sometimes, severe depression.

One thing which lithium seems to do rather well - or at least better than other drugs - is make people less likely to commit suicide. At least, that's what most authorities say, so let's assume it's true.

Now a Japanese team report that the amount of lithium in tap water are negatively correlated with suicide rates - Lithium levels in drinking water and risk of suicide. (Someone has helpfully put this up on Scribd for people without academic access).

They analyzed the water supplies in the 18 subdivisions of Oita prefecture in southern Japan, and compared the lithium levels in the water with the average suicide rate (normalized for age and gender). Here's what happened -
Now, on paper that's a pretty solid correlation. But how believable is it? The maximum lithium level in the water was found to be 59 micrograms per liter. By contrast, if someone were taking lithium for bipolar disorder, they would on average be taking about 1 gram of lithium carbonate (Li2CO3) per day, which works out at about 100 mg of lithium (and 900 mg of inert carbonate).

Assuming that people drink about two liters of tap water per day (almost certainly they drink less), that's about 120 micrograms per day. That's 0.12 mg. So about a thousand-fold less than you'd take if you were bipolar.

Could such a tiny amount of lithium do anything? Well, maybe. It's not impossible that it would have some small effect on suicide rates, but it seems very unlikely that it would account for the difference between a rate of 120 and a rate of 80 which is what the graph seems to imply. The effect is just too large to be credible, if you ask me.

Although that said, another paper just out found that tiny amounts of antidepressants (the amounts that you find in rivers because so many people take them and some of them are stay in urine) could affect the behaviour of baby fish. And presumably also baby humans. Unfortunately I can't access this study, so I don't know whether that's nonsense or not, but it's food for thought.

Ohgami, H., Terao, T., Shiotsuki, I., Ishii, N., & Iwata, N. (2009). Lithium levels in drinking water and risk of suicide The British Journal of Psychiatry, 194 (5), 464-465 DOI: 10.1192/bjp.bp.108.055798

Neuroskeptic Voted Person of The Year

...well, not quite. At least not yet. But I have been linked to by Time Magazine.

The Time article discusses a paper that I also blogged about recently, Can Phase III Trial Results of Antidepressant Medications Be Generalized to Clinical Practice? A STAR*D Report

In a nutshell, this paper found that out of a large sample of depressed people who are fairly representative of the general population of patients presenting with depression in America, only 22% would have been accepted into a typical antidepressant trial. They were on average richer, better educated, more likely to have a job, and less likely to be black or Hispanic. In other words, typical antidepressant trials only recruit a narrow cross-section of society, tending to exclude the poor and disadvantaged and those with multiple mental health problems.

The study also found that this 22% tended to report a better response to an antidepressant, citalopram, than the rest. But as I said at the time...

Does this mean that rich white people really get more benefit from citalopram? Or do they just tend to report more benefit? Or do they experience larger placebo effects? It's impossible to say.

One of the problems with the this trial was that there was no placebo group. So the fact that the select 22% reported better response doesn't mean that they actually experienced a more powerful drug effect. It's entirely possible (and I would say, likely) that they could be just the kind of people who like to play along, comply with expectations and report greater benefits, for example. Whereas in fact they might have done equally well without any drugs, whereas the people who reported a smaller benefit might have done even worse with no treatment. We just don't know.

So when Time says that

a major new study suggests that both critics and proponents might be right about SSRIs: the drugs can work, but they appear to work best for only a subset of depressed patients — those with a limited range of psychological problems. People whose depression is compounded with, say, substance abuse or a personality disorder may not get much help from SSRIs —

That's one possibility, but not the only one.

Neuroskeptic Voted Person of The Year

...well, not quite. At least not yet. But I have been linked to by Time Magazine.

The Time article discusses a paper that I also blogged about recently, Can Phase III Trial Results of Antidepressant Medications Be Generalized to Clinical Practice? A STAR*D Report

In a nutshell, this paper found that out of a large sample of depressed people who are fairly representative of the general population of patients presenting with depression in America, only 22% would have been accepted into a typical antidepressant trial. They were on average richer, better educated, more likely to have a job, and less likely to be black or Hispanic. In other words, typical antidepressant trials only recruit a narrow cross-section of society, tending to exclude the poor and disadvantaged and those with multiple mental health problems.

The study also found that this 22% tended to report a better response to an antidepressant, citalopram, than the rest. But as I said at the time...

Does this mean that rich white people really get more benefit from citalopram? Or do they just tend to report more benefit? Or do they experience larger placebo effects? It's impossible to say.

One of the problems with the this trial was that there was no placebo group. So the fact that the select 22% reported better response doesn't mean that they actually experienced a more powerful drug effect. It's entirely possible (and I would say, likely) that they could be just the kind of people who like to play along, comply with expectations and report greater benefits, for example. Whereas in fact they might have done equally well without any drugs, whereas the people who reported a smaller benefit might have done even worse with no treatment. We just don't know.

So when Time says that

a major new study suggests that both critics and proponents might be right about SSRIs: the drugs can work, but they appear to work best for only a subset of depressed patients — those with a limited range of psychological problems. People whose depression is compounded with, say, substance abuse or a personality disorder may not get much help from SSRIs —

That's one possibility, but not the only one.

Help! There's an Epidemic of Anxiety! (Part II)

In my last-post-but-one I slammed the claim that the British are suffering from an epidemic of anxiety disorders. I declared it a myth pushed by the Mental Health Foundation and echoed uncritically by British newspapers (although The Economist has since run a kind-of skeptical piece on it.) But I also promised that there are important lessons to be learned here. So, here we go:

The Mental Health Foundation produced a report, In The Face of Fear, which contains various interesting thoughts about the role of fear in public debates. Here's just one:

Individually we experience both rational and irrational fears that drive our behaviour and fear also drives communities and social policies... Excessive fear poses an enormous burden on our society directly through anxiety related illness, which can be physical as well as mental, and indirectly through inappropriate behaviours such as excessive supervision of children or failure to invest. It also paralyses long term rational planning to deal with key future threats such as global warming by diverting attention to more immediate but less important fears.

This is true. Everyone should be scared of global warming. Most people aren't. They're scared of... well, it varies. Cervical cancer was scary a few weeks ago, before that it was the crisis in child protection services, right now it's the Mexican swine flu crisis - not to mention the economic crisis, the knife crime "crisis" - and that's just England.

I'm not saying that we shouldn't care about these things. I'm worried about Mexican swine flu, and so should you be. Especially you, Simon "The Armchair Virologist" Jenkins. But in the face of crisis after crisis after crisis, it becomes hard to take the really crucial crises, such as global warming, seriously. There's a temptation to see every apparant crisis as just another piece of overblown nonsense in need of "debunking" as Ben Goldacre has just discovered. One could call this "crisis fatigue", but that's not exactly right. We're too fond of crises. There are just too many of them.

This is why the MHF felt the need to be so "creative" with the data. As I explained in Part I of this post, the best available figures show that the prevalence of anxiety disorders in Britain has remained boringly level since at least 2000. The MHF simply ignored those numbers in order to make it look as though we're currently facing an epidemic of anxiety. A crisis.

I wish they hadn't. But I don't really blame them for what they did. They did it because they knew that if they didn't, no-one would care about anything they had to say. In an ideal world they would have said: Although British anxiety and depression levels are probably not rising, and although they're not as high as in some countries, they're still higher than in other countries, so we can and should try harder to reduce them. That's the truth. But the truth doesn't involve a crisis, so it wouldn't have made the headlines, or if it did, no-one would have cared. Thus it is that a report warning (inter alia) about the dangers of scaremongering ended up becoming a prime example of scaremongering.

This is the point where, conventionally, one blames "the media" for only publishing "sensationalist" stories in order to "sell papers". Well, that's all true. But the media don't behave that way just for fun. A sensational story is a good story. People want sensationalist stories. Nothing wrong with that, as such. And there's nothing wrong with caring more about a crisis than about a mere problem. A crisis, by definition, is something that deserves urgent attention.

But the result of this is that today, in order to get attention, a problem has to be a crisis - something which is bad and getting worse, fast. Just being a problem in need of a solution isn't enough. There are too many problems - no-one can possibly care about them all. Whereas if something is a crisis, it might just get a little attention. Hence why the MHF had to do what they did. They needed a crisis, so they created one.

If I were a humanities graduate, I would now start explaining how it's all the fault of our postmodern, "post-historical" condition in which there are no grand narratives or central moral authorities to tell us what to care about, leaving every political or moral cause (and organization) to fend for itself in a Darwinian (or market) struggle for attention (and money) in which the only way to survive is to adopt the language of panic, crisis, and emergency thereby devauling that very discourse in a cultural tragedy-of-the-commons. But I'm a science graduate, so I wouldn't dream of doing that.

[BPSDB]