Beware a new/old pharmaceutical trend of which this is an egregious example! “Eli Lilly and Co. on Monday said it has won regulatory approval to sell its new drug Symbyax to treat the depressive phase of bipolar disorder.

The U.S. Food and Drug Administration approved the drug, which is a combination of the active ingredients in two other drugs _ the anti-depressant Prozac and the anti-psychotic Zyprexa, which is used for treating manic stages of bipolar disorder.” —Dallas-Ft Worth Star-Telegram

I have difficulty with referring to this as a ‘drug’, or referring to ‘the anti-depressant Prozac and the anti-psychotic Zyprexa’ as ‘drugs’. These are products; the ‘drugs’ or ‘medications’ are the ‘active ingredients’. I refuse to prescribe products, writing all my prescriptions by the generic names, i.e. the ‘active ingredients’, instead, and challenging all the nurses who take off my orders in the hospital to learn the generic names. (It is sort of like refusing to wear teeshirts that make me a walking billboard for a product name…) It may seem a foolish conceit or a merely semantic difference but it is a polemical point upon which I insist. In a case such as this, it clarifies the thinking and helps one see readily that there is no ‘new drug for bipolar disorder’ here, really just a new product which combines several existing drugs.

A generation ago in psychopharmacology, we got rid of such ‘fixed-dose combinations’, which have several problems. The obvious one is that I can already prescribe the two pertinent medications independently and in combination for the patient, and have much greater control over the two dosages independently. The only downside of the latter approach is that the patient will have to swallow twice the number of pills, or thereabouts, as in the new product. But I have rarely seen a patient in whom the advantages of that outweigh the disadvantages of the fixed-dose combination, although the drug company will try to sell the product to doctors by appealing to its convenience to their patients. If you grant me that there is no medical advantage to the fixed-dose combination, then it becomes clear that it is for drug company profit alone. For one thing, if they succeed in pushing this product, they retain the right to sell the ‘new drug’ at a high price even as generic versions of its constituent medications become available. Generic fluoxetine for far less than Prozac brand is already here, and in several years olanzapine will be off-patent and available for far less than Zyprexa brand as well. Furthermore, if I am a devotee of this product, whenever my patient on Lilly’s antipsychotic Zyprexa requires an antidepressant, I would be sure to be giving Lilly’s antidepressant, Prozac, rather than a competing and possibly superior one. Finally, the drug company hopes that some doctors will, carelessly, give in to the temptation to give the two-component medication to patients for whom one of the two alone would suffice, i.e. patients will receive an antipsychotic medication and an antidepressant together even if they are nonpsychotically depressed, or nondepressively psychotic. This will double the drug company’s profit on such patients in one fell swoop.

There is already a problem of ‘polypharmacy’ in modern psychopharmacology; I see patients, especially the chronically mentally ill whom I specialize in treating, arrive at the hospital with appallingly long lists of medications they are prescribed. Drugs are added readily for new twists or turns in their disease presentation, but rarely are others reduced or eliminated. Little thought is given to what might or might not be working. It is no wonder these patients cannot or will not comply with their medication regimens, given the bewildering complexity of their daily dosing schedules and the unmanageable side effects their medication combinations may be causing. Imagine how much more problematic this will become when, at every swipe of the pen, their doctors can add two new medications to their list!

If you are interested in the psychopharmacological treatment of bipolar disorder, there are several further problems with this product in particular, over and above my generic objections to ‘fixed-dose combinations’. The fluoxetine (antidepressant) component to this product may be largely unnecessary to begin with. Many psychiatrists feel that one of the advantages of the newer, so-called ‘atypical’, antipsychotic medications such as olanzapine (Zyprexa) is concomitant mood-stabilizing and antidepressant activity as well as the antipsychotic efficacy. If you read the article, you will see claims that this product may begin to work more rapidly than less novel approaches. Although I have heard this claim accompanying the introduction of every new psychopharmaceutical during my twenty-year career (and it never turns out to be borne out in practice; the drug companies’ marketing departments just know how to play on the heartstrings of those of us who have to wait for the onset of action of the medications we give to people while they are in agonizing distress), if it has any merit in this case it may be because most patients for whom it has been prescribed will heretofore have been on Zyprexa or another atypical antipsychotic and, as I stated above, therefore may have gotten a headstart on antidepressatn effects as well.

Furthermore, a bipolar or manic depressive patient can only benefit from an antidepressant during their (time-limited) depressive episodes. It is actually dangerous to keep them on an antidepressant when they are nondepressed, because the antidepressant can drive them to the other extreme, a manic ‘high’ (with eiher euphoria and self-destructive boundless energy and drive, or dramatic hyperirritability and ultimately psychosis). A physician who follows path-of-least-resistance prescribing may also be one who does not get around to changing the patient back from Symbyax to plain vanilla Zyprexa rapidly enough when they come out of their depressive phase. Bye bye mood stability…

So: if you or your loved one are prescribed a new medication (oops! product), be sure to ask the prescriber (a) if it is a ‘fixed-dose combination’; (b) if it is, whether both the medications are really necessary, or if one might suffice; and (c) why the two cannot be prescribed as separate pills rather than together.

By the way, I have previously noted the loony appeal of all the ‘q’s, ‘x’s, ‘y’s, and ‘z’s in the names of the newest psychopharmaceuticals. There is scarcely one without, especially among the most-recently developed antidepressant products: Prozac, Desyrel, Zoloft, Paxil, Luvox, Serzone, Celexa, Lexapro, Effexor and Zyban; now Symbyax. In the last fifteen years or so, only Remeron fails to meet the bill. Three of the six most-recently introduced antipsychotic products are: Clozaril, Zyprexa, and Seroquel. The product-naming consultants the industry uses show this brain-dead lack of creativity in their long-hackneyed approach, but they still, as far as I have heard, make enormous consulting fees for each of these crazy names. This xenophilic trend tends to strengthen the esoteric and occult flavor of the physician’s role and the inaccessibility of her knowledge to the layperson, I imagine.

Ascroft’s hounds of hell are demonstrating that they are unable to tell the difference between a racketeering conspiracy and legitimate medical practice, in the cases of several high-profile prosecutions of pain specialists for their volume of narcotics prescribing. The established medical use of opiates is, some doctors say, becoming criminalized, while Ashcroft crows about “our commitment to bring to justice all those who traffic in this very dangerous drug” (OxyContin). Obviously, Ashcroft has never suffered from one of the debilitating chronic pain conditions for which OxyContin and similar medication advances have been the only solution, and has no compunctions about throwing babies out with bathwater.

While there are certainly mendacious physicians who run “prescription mills” for quick profit, writing painkiller ‘scripts for all comers regardless of medical need, it seems these prosecutions are capturing mainly those unfortunate doctors whose only crime may have been choosing to specialize in a field of medicine, pain management, that makes them conspicuous to our ever-vigilant law enforcement bulldogs. Their names will appear on the radar screens simply due to the volume of ‘scripts they issue and the almost inevitable likelihood that, somewhere along the line, someone will divert some of their OxyContin to the extremely lucrative street trade. There are no certainties in managing pain, and doctors are at different points along the continuum of attention to (or paranoia about?) issues of diversion and addiction. While I am not a pain specialist and shy away from prescribing narcotics de novo, I certainly often maintain a narcotics-dependent patient on their preexisting prescriptions when they come into the hospital with psychiatric problems (which, as you realize, I’m sure, may be difficult to disentangle from substance-abuse difficulties). I do interpret my mandate to first do no harm to include not facilitating narcotics abuse and addiction, but I remind myself that I am not omniscient and, despite my skills, will be deceived from time to time as to the legitimacy of the pain complaints of a patient. I console myself with the reminder that these patients are primarily fooling themselves. I don’t take it personally, but then again I do not have Ashcroft’s thugs breathing down my neck either.

[It bears pointing out, in my continuing tirade about the irresponsibility of the pharmaceutical industry, that OxyContin could have been formulated in a manner that would prevent the pils from being processed for street users to shoot up, as is the case with other sustained-release narcotics preparations which are not diverted in a similar manner.]

There is a new British edition of The Devil’s Dictionary by Ambrose Bierce, one of my favorite books, from Bloomsbury. Illustrated by Ralph Steadman, no less. Reading Bierce, I know I have more than met my match in cynicism and misanthropy. A belated Christmas present?

A reader posted this to Dave Farber’s IP mailing list:

I wanted to send out some sort of holiday greeting to my friends, but it is

so difficult in today’s world to know exactly what to say without offending

someone. So I met with my attorney today, and on his advice (and after $299

in attorneys fees) I wish to say the following:

Please accept with no obligation, implied or implicit, my best wishes for an

environmentally conscious, socially responsible, low stress, nonaddictive

gender neutral, celebration of the winter solstice holiday, practiced within

the most enjoyable traditions of the religious persuasion of your choice, or

secular practices of your choice, with respect for the religious/secular

persuasions and/or traditions of others, or their choice not to practice

religious or secular traditions at all.

I also wish you a fiscally successful, personally fulfilling, and medically

uncomplicated recognition of the onset of the generally accepted calendar

year 2004, but not without due respect for the calendars of choice of other

cultures whose contributions to society have helped make America great (not

to imply that America is necessarily greater than any other country or is

the only “AMERICA” in the western hemisphere), and without regard to the

race, creed, color, age, physical ability, religious faith, or sexual

preference of the wishes.

By accepting this greeting, you are accepting these terms: This greeting is

subject to clarification or withdrawal. It is freely transferable with no

alteration to the original greeting. It implies no promise by the wisher to

actually implement any of the wishes for her/himself or others, and is void

where prohibited by law, and is revocable at the sole discretion of the

wisher. This wish is warranted to perform as expected within the usual

application of good tidings for a period of one year, or until the issuance

of a subsequent holiday greeting, whichever comes first, and warranty is

limited to replacement of this wish or issuance of a new wish at the sole

discretion of the wisher…

–

Disclaimer:

No trees were harmed in the sending of this message, however, a significant

number of electrons were inconvenienced.

Here is how the Guardian sums up 2003 (this is a review of its year-end summary book):

“Of course Iraq is central, sickeningly portrayed by Suzanne Goldenberg’s ‘Picture of Killing’ and Audrey Gillan’s ‘Death by Friendly Fire’ – though there’s too little about the aftermath or about Hutton’s inquiry into how we were duped.

But other themes flood in – Hamas’s ‘total war’ (omitting that it is because the Middle East peace map has been distorted by Sharon into a road to nowhere), and Sarah Boseley’s heart-rending picture of a soon-to-die mother in Malawi, illustrating the fate of 29 million people with Aids in sub-Saharan Africa.

Martin Kettle assesses the neocon hard-right assault on US affirmative action and pro-diversity laws. Raekha Prasad denounces the UN ‘protection areas’ for refugees that enable Britain to deport more asylum-seekers. Polly Toynbee dissects the growing trade of female trafficking, a modern variant of the slave transportation of past centuries, with 2 million women trafficked each year – a less remarked-on aspect of globalisation. Martin Jacques chronicles the jeering and booing at the Williams sisters and their father in middle-class, lily-white tennis. Racism is never far beneath the surface, and the accentuation of inequality in 2003 has served only to make it more pronounced.

The American imperium, with its unalloyed unilateralism, entered this year in full spate, and leaves it in deep disarray. But its workings are a great deal subtler and more pervasive than merely enforcing regime change. Ian Traynor recounts the brute diplomacy to secure war crimes immunity deals for Americans and the exercise of the aid card to bring vulnerable countries into compliance with US demands for exemption from the international criminal court. And George Monbiot admirably captures the new messianic order: America is not so much a project as a religion. It’s not just that Americans are God’s chosen people; America now perceives itself as on a divine mission for the liberation of mankind.”

The reviewer, a former MP, notes some omissions, however:

t would have been nice, but not essential, to have had an angle on the rise and rise of the corporate state, the first clear signs of the coming oil crunch, the collapse of party democracy, the plague of obesity, the neglect of global warming as the greatest threat to the planet, and the rebellion against spin … But you can’t have everything.

“…but not essential…”??

The killer illness for a new world order, a 2001 Slate piece by David Plotz, written in response to the European BSE scare and now resurrected in the face of the current spectre of American panic:

“Mad cow fits the classic profile of a disease likely to cause hysteria. Ebola, AIDS, and polio—three of the most flamboyant illnesses of the century—overshadowed deadlier but less flashy plagues, such as malaria, for several reasons. First, the hysteria-inducing illnesses usually affect young people and strike in particularly gruesome ways. Ebola causes massive bleeding from every orifice. AIDS is responsible for grotesque cancers and infections. Polio paralyzed young children.

Second, at the moment of the panic—before much is learned about the disease’s origin—everyone seems vulnerable, and it’s not clear that prevention is possible. Maybe an Ebola victim flew in from the Congo and breathed on you! Maybe your dentist is HIV-positive! And finally, the disease organism is new and weird and seems to have sprung from a dark, mysterious place. AIDS is a creepy mutating monkey virus. Ebola remains a riddle: The Hot Zone traces it to the bats in a spooky East African cave.

Mad cow is similarly vicious, unstoppable, and mysterious. It murders by driving its young victims insane, then melting their brains. It theoretically puts anyone who ever ate English beef at risk. It was spawned in the miasma of rendering plants and slaughterhouses, our own hell’s kitchens. And the disease organism is a mystery.”

Presenting Deliberation Day: A radical proposal to help voters make better decisions, write Bruce Ackerman, Sterling Professor of Law and Political Science at Yale University, and James Fishkin, Janet M. Peck Chair in International Communication and Director of the Center for Deliberative Democracy at Stanford University.

“In our soon-to-be-released book, we offer a new way of thinking about democratic reform, proposing a new national holiday—Deliberation Day. It would replace Presidents’ Day, which does no service to the memories of Washington and Lincoln, and would be held two weeks before major national elections.

Registered voters would be called together in neighborhood meeting places, in small groups of 15 and larger groups of 500, to discuss the central issues raised by the campaign. Each deliberator would be paid $150 for the day’s work of citizenship. To allow the business of the world to carry on and as many as possible to participate, the holiday would be a two-day affair.”

They note that, while sustained public conversations about issues, particularly around political campaign seasons, do take place, the overall level of public ignorance is appalling. Here is an entertaining anecdote:

George Bishop and his colleagues at the University of Cincinnati dramatized this point in their study of attitudes toward the “Public Affairs Act of 1975.” Asked for their opinion of the act, large percentages of the public either supported or opposed it, even though no such act was ever passed. In 1995, The Washington Post celebrated the “twentieth unanniversary” of the nonexistent act by asking respondents about its “repeal.” Half the respondents were told that President Clinton wanted to repeal the act; the other half were informed that the “Republican Congress” favored its repeal. The respondents apparently used these cues to guide their answers, without recognizing the fictional character of the entire endeavor.

They suggest that it actually makes sense for the voters to remain ignorant; the acquisition and analysis of adequate information about public affairs is time-consuming and competes with other priorities, and if there is no payoff because your vote really doesn’t matter, why bother? This argument is based on the idea that, usually, one does not see a “direct cost for an ignorant decision” in the political sphere, in contrast to the personal penalties suffered if one does not make an informed decision when buying a car or a house, for example.

While I think that the idea of a Deliberation Day holiday is an absurd way to remedy the situation, I appreciate the analysis. It points to the simple fact that impressing the public with the direct costs to themselves of supporting the present dysadministration, for example, is the most efficient way to regime change in 2004. Of course, nothing in the authors’ examination of the value of deliberation in the political process appears to me to be relevant on a national scale, especially since their central premise that an informed electorate might have genuine, enfranchised power is a political fiction on that scale. I haven’t read their book, but it sounds like it will be a useful study on modern disenfranchisement even though not proposing a useful solution. This is not surprising, since no one really has any useful solutions to the powerlessness of the masses.

“False collectives — what Americans call ‘weasel words’ — poison the language we use to talk about public affairs by cobbling together spurious majorities”, writes Roger Kerr in Policy, the quarterly review from New Zealand’s The Centre for Independent Studies. I have never heard of the phrase ‘weasel word’, which Kerr attributes to anti-collectivist social philosopher Friedrich Hayek (The Fatal Conceit: The Errors of Socialism), who wrote:

. . . it has in fact become the most harmful instance of what, after Shakespeare’s ‘I can suck melancholy out of a song, as a weasel sucks eggs’ (As You Like It, II, 5), some Americans call a ‘weasel word’. As a weasel is alleged to be able to empty an egg without leaving a visible sign, so can these words deprive of content any term to which they are prefixed while seemingly leaving them untouched. A weasel word is used to draw the teeth from a concept one is obliged to employ, but from which one wishes to eliminate all implications that challenge one’s ideological premises.

While I was drawn to this article because I share its apparent bias against the tyranny of the majority and am interested in an analysis of how our language contributes to that tyranny, this is really a stalking horse for a tirade against big government. His biases are clearly Republican. For example, I was struck by this passage:

A good example comes from the United States in the mid-1990s. In 1994, a new Republican-dominated Congress thought it had a clear mandate to move towards a balanced budget. It duly put up proposals to reduce the growth rate of some welfare entitlement programmes. But no sooner had the proposals been passed than President Clinton vetoed them, invoking the support of a new majority opposing them. Which did US citizens want? A balanced budget or guaranteed entitlement levels? They wanted both. The ‘will of the people’ may be systematically ambiguous on the decisions that governments make on a daily basis.

He does not note that the dilemma he poses was only a dilemma within Republican ideology, and that Clinton’s administration did in fact balance the budget without gutting entitlements as drastically as Republicans called for (although Clinton was by no stretch of the imagination a friend of the welfare state, and his welfare ‘reform’ platform was designed to appeal to the Right).

In warning against the ‘we’ word, as Kerr concludes, because “despite its apparently communitarian connotations, it so often portends a weakening rather than a strengthening of social cohesion”, he is a bellwether of the increasingly fractious state of modern political discourse in the neo-con-dominated late-20th century US. One of the ongoing tactics of neo-con agit-prop is to accuse their opponents of disenfranchising them and threatening social cohesion. Essentially, the concept of a ‘spurious majority’ only makes sense if you do not accept the notion of an implicit ‘social contract’. However, Kerr, who is the executive director of the New Zealand Business Roundtable, may in fact be accurate if we take his argument to imply that the notion of the social contract is outmoded in a world in which corporations have more rights than individuals and governments exist mostly to protect their interests.

Related (maybe): A review of Death Sentence — the Decay of Public Speech by historian Don Watson: “A terrible thing is happening to the language, he believes, and at the end of the day, in a globalised world, it is not a positive communications outcome. In other words, there is a pox upon our public speech. ” —The Age

“The FBI is warning police nationwide to be alert for people carrying almanacs, cautioning that the popular reference books covering everything from abbreviations to weather trends could be used for terrorist planning.

In a bulletin sent Christmas Eve to about 18,000 police organizations, the FBI said terrorists may use almanacs ‘to assist with target selection and pre-operational planning.’

It urged officers to watch during searches, traffic stops and other investigations for anyone carrying almanacs, especially if the books are annotated in suspicious ways.” —New York Times [via IP]

“The great digital music giveaway is about to begin. In the new year, some of the world’s biggest brands will promote their products and services by doling out millions of free downloads through alliances with digital music services.” —CNN

The results confirm an intuitive bond people feel with their shady outlines. “Our brains instinctively view our shadows as an extension of our bodies, a new research has shown.

Subjects in the study reacted to stimuli near the shadow of one hand as if the stimuli were affecting the hand itself, found Francesco Pavani, at Royal Holloway University of London, UK, and Umberto Castiello, at the Università degli Studi di Trento, Italy.” —New Scientist

“A trial starting on Wednesday will allow thousands of Japanese mobile phone owners to use their phones as a swipe card to pay for purchases, as travel passes, and as concert and movie tickets.” —New Scientist

“The first images from NASA’s new infrared space telescope reveal the drama and beauty of the infrared Universe.” —New Scientist

“The man leading the US hunt for biological, chemical and nuclear weapons in Iraq is to resign, according to reports. The loss of David Kay is being interpreted by many analysts as signalling the end of the major effort to discover any hidden weapons.

A number of observers now believe it is unlikely that any weapons of mass destruction (WMD) existed. However, officials from the US administration maintain that if Kay does leave, it would have no impact on the ongoing work of the Iraq Study Group he heads.

According to The Washington Post, Kay has told administration officials that he plans to leave before the completion of the ISG’s final report, expected in autumn 2004. He may even leave before the next interim report in February.

Kay has cited personal reasons for resigning, the paper says. But in recent weeks he has softened his line on the probability of finding banned WMD. He is said to be frustrated that some of the ISG’s 1400 staff were reallocated to counter-insurgency duties in Iraq in October.” —New Scientist

“Why are humans nearly hairless? And why do some wish to become more so?” —The Economist

“Today, physicists suppose that a particle can travel many different paths simultaneously, or travel backwards in time, or randomly pop into and out of existence from nothingness. They enjoy treating the entire universe as a ‘fluctuation of the vacuum,’ or as an insignificant member of an infinite ensemble of universes, or even as a hologram. The fabric of this strange universe is a non-entity called ‘spacetime,’ which expands, curves, attends yoga classes, and may have twenty-six dimensions.

In short, the recent literature on physics makes one nostalgic for anything as reasonable as a witch trial.

For the past decade many physicists have been wandering the streets with signs that read: ‘The End of Physics Is Near.’ They claim to be developing a final ‘theory of everything,’ which will leave future physicists with nothing to do but play computer games. We can dismiss their megalomania, yet still be tempted to agree with their message. The end that seems near, however, is not a climactic rise to omniscience but an embarrassing descent into pseudo-science.”

Although I don’t understand all that much of modern physics, I suspect that the author, David Harriman, despite his M.S. in Physics, is out of his depth in branding it pseudoscience. If his yearning for the naive simplicity of Newtonian science is not enough evidence, there is the fact that he is the editor of Journals of Ayn Rand and a senior writer for the Ayn Rand Institute in Irvine, Calif.

The dire consequences of species loss and the Bush dysadministration’s culpability in its acceleration. —Mother Jones

“Silver cars are much less likely to be involved in a serious crash than cars of other colours, suggests a new study of over 1000 cars.

People driving in silver cars were 50 per cent less likely to suffer serious injury in a crash compared with drivers of white cars, the research in New Zealand found.

White, yellow, grey, red and blue cars carried about the same risk of injury. But those taking to the roads in black, brown or green cars were twice as likely to suffer a crash with serious injury.” —New Scientist

Book Review: “Attention, parents: Now that you’ve seen your kids’ first report cards of the year, it’s time for a little homework of your own. No doubt you’re doing the best you can to ensure your little ones’ eventual membership in Mensa — promoting stimulating dinner conversation, reading a chapter together each night, maybe even playing Mozart during bath time. But wait — there’s more. You’ll find your next assignment in the pages of Colleen Moore’s Silent Scourge: Children, Pollution, and Why Scientists Disagree.

You probably already know that lead is not an appropriate component of any cerebral calisthenics program. But nor is it the only pollutant that can stunt intellectual development. In Silent Scourge, Moore, a developmental psychologist, reviews the case against lead and five additional types of pollutants — mercury, PCBs, pesticides, noise, and radioactive and chemical wastes.” —Grist As a psychiatrist, I have always paid attention to the subtle cerebral insults that create less-than-obvious impairments in intellectual and emotional functioning and behavior. I keep an environmental toxicology textbook on my desk at the hospital and like to think I see alot of influences on my patients to which psychiatrists without such an orientation might be less sensitive. I have often wondered why it is not plausible to think that the overall environmental assault our unaccustomed organisms suffer is not taking its toll, and especially on the critical stages of CNS development in childhood. This book is definitely on my reading list, as a parent as well as a mental health proessional.

“Once a curmudgeonly champion of ‘usable’ design, cognitive scientist Donald A. Norman argues that future machines will need emotions to be truly dependable” —Scientific American

“The coffee-houses that sprang up across Europe, starting around 1650, functioned as information exchanges for writers, politicians, businessmen and scientists. Like today’s websites, weblogs and discussion boards, coffee-houses were lively and often unreliable sources of information that typically specialised in a particular topic or political viewpoint.” —The Economist. Has anyone else noticed an explosion of attention to late-17th and early-18th century European intellectual life recently? I have, but I am not sure whether it is just because I have been engrossed in Neal Stephenson’s Quicksilver in recent weeks, in which, for example, Leibniz and Newton play major roles and the rise of the coffee house phenomenon receives more than passing attention.

A compilation of links to the-year-in-arts reviews —Arts Journal

All the progressive punditry in one simple compilation: “Every pundit, blogger, correspondent, presidential candidate, reporter, scam artist, and all of their mothers, have something to say about Saddam. Here’s our roundup of what they’re spouting: from capture to trial to conspiracy theories, it’s all here (well, a lot of it anyway).” —Utne Reader

“The sooner the United States starts behaving like one country among many, rather than a global bully, the better the prospects for peace on earth become. The irony is that the post-9/11 bellicosity of the Bush Administration has been so extreme that in the long run it may lead more directly to a world with a common aversion to wars and empires.

If we’re willing, much of the rest of the world is ready. It’s in our hands.” —Geov Parrish, AlterNet

“Jailed former Yugoslav President Slobodan Milosevic and another accused war criminal could become members of Serbia’s parliament after their extreme nationalist allies swept weekend elections, according to results released Monday.” —SF Chronicle

“2003 gave us a lot to gripe about — overblown action pictures, witless sequels, pointless remakes, misbegotten literary adaptations, mopey little art films shot in headache-inducing digital video — but these failures reveal less about the state of cinema than about the fate of most creative endeavors, which is to land in the fat, mediocre middle of the artistic bell curve.

To look at the three top 10 film lists displayed in this section — and at the dozens more that sprout from nearly every printed publication and Web site in the land — is to be struck by the sheer variety and vitality of the movies, which, according to some historians, marked their centenary as a narrative art form this year. The number of good motion pictures released this year is less impressive — and harder to agree on — than their diversity.” —New York Times

…in Battle Over Next DVD Format —New York Times

Not only did I miss several weeks’ worth of important developments, but in particular the clarity of thinking that the Christmas spirit brings. As Rafe Colburn observes:

“I’ve often said that the fundamental difference between most hardcore conservatives and the rest of us is a lack of appreciation for the old bromide, ‘There but for the grace of God go I.’ The inability to put yourself in the shoes of people worse off than yourself, or just different than you, period, is the enabler for what passes for modern conservatism.”

Rafe also has a cogent argument about why it doesn’t wash to claim that Libya’s renunciation of WMD is a consequence of the US invasion of Iraq, even though dysadministration propaganda crows about how it is our victory.

Another thing that may not be our victory to crow about is the apprehension of Saddam Hussein, who may actually have been taken into custody by the Kurdish opposition, hogtied and left for the US to claim.

Thank heavens the Plame affair hasn’t been entirely been swept under the rug as I had feared. Washington Post

“In his interview with the Monitor, Howard Dean repeated his contention that Saddam Hussein’s recent capture had made America no safer.

‘My opponents spent the week criticizing me for that, which I think was to their detriment’ since the federal government had just increased the terror alert level to orange, indicating an elevated risk of an attack.

But he said two other recent events had benefited national security: the capture of a ship loaded with drugs in the Persian Gulf – ‘which is almost certainly how al-Qaida is partly financing their operations,’ Dean said – and Libya’s decision to declare its illegal weapons programs and get rid of them.” Concord (NH) Monitor

Dean doesn’t mention the unabated continuation of assassinations of US occupiers by insurgents, which has prompted an increased bounty on the heads of the remaining at-large Baathist most wanted.

A Missouri transportation unit headed for Iraq sought extra protection for non-combat vehicles. Local businesses donated the costs for a local steel fabricator to sheath their trucks and Humvees.

The 72 vehicles operated by the 428th are not designed for battle. They have thin metal floorboards and, in some cases, a canvas covering for doors. Iraqi guerrilla groups have been targeting all types of military vehicles with homemade bombs and small-caliber weapons.

E-mails from soldiers already deployed in Iraq urged the Missouri reservists to get extra armor if possible, said 1st Sgt. Tim Beydler, a member of the 428th.

Unfortunately, although official US Army add-on armor is still under development and not yet ready, the Pentagon will not allow this jury-rigging, since it has not been approved through official channels. [Oh, and because one of Cheney's cronies has to be awarded the price-gouging contract to do the retrofits instead?] Washington Post

“While security checks have reached a certain consistency, it may not remain so for too long. Before you head for the airport, you may want to check a frequently updated list of everything that is and is not allowed on a flight. This information comes from the Transportation Security Administration, part of the Department of Homeland Security.

It’s presented in chart form, telling you what you’re allowed to carry on or check, and it may not always be what you think.” PCWorld

I admit to a guilty pleasure — I love those year-end ‘best this’ and ‘worst that’ lists. They are the modern equivalent of the memory palace artifice. I do alot of my CD shopping (although not my bookbuying, since I tend to keep up better with the latter throughout the year) after the music lists come out. Any links to quality year-end lists you send me will be gratefully appreciated and likely posted here. To start with, here’s what one Guardian observer wants to deep-six for the new year. Unless you are a devotee of English tabloid culture, you might miss some of the references, but you also might agree with many of them, as I do.

Addendum: and the suggestions start rolling in. Thanks to Sam for pointing to the compilation of year-in-review lists at Fimoculous.

And, thanks to walker, some top-10-words-of-the-year lists (top phrases, the top names, the best and worst product names, top Enron inspired words, top YouthSpeak words, and others….) which reveal how the mutable English language can be influenced even on the timescale of one year’s developments.

“The United States doesn’t even pretend to respect the Geneva Conventions these days. Obviously, shooting unarmed demonstrators in the back as they flee is a war crime. But then neocons don’t do international law.

As Bush has repeatedly made clear, he believes international treaties are for wimps, appeasers, and the irrelevant. International law is for pantywaists such as the French, not intractable and self-righteous Americans engaged in a forever war against ‘terr’ism,’ otherwise known as the Islamic religion.” `–Kurt Nimmo, Counterpunch

Not only did I miss several weeks’ worth of important developments, but in particular the clarity of thinking that the Christmas spirit brings. As Rafe Colburn observes:

“I’ve often said that the fundamental difference between most hardcore conservatives and the rest of us is a lack of appreciation for the old bromide, ‘There but for the grace of God go I.’ The inability to put yourself in the shoes of people worse off than yourself, or just different than you, period, is the enabler for what passes for modern conservatism.”

Rafe also has a cogent argument about why it doesn’t wash to claim that Libya’s renunciation of WMD is a consequence of the US invasion of Iraq, even though dysadministration propaganda crows about how it is our victory.

Another thing that may not be our victory to crow about is the apprehension of Saddam Hussein, who may actually have been taken into custody by the Kurdish opposition, hogtied and left for the US to claim.

Just back from two weeks’ media cold turkey and, as in past years, you will have to endure an element of my getting back into the swing of things, catching up with developments I missed, and making observations that will probably already seem to you readers to be the obvious. To start with — the big fat bullseye painted on Howard Dean’s back, now he has solidified his frontrunner position, has emerged in earnest while I was gone, with barbed arrows headed in his direction as suggested in this prescient post from Atrios .

Just back from two weeks’ media cold turkey and, as in past years, you will have to endure an element of my getting back into the swing of things, catching up with developments I missed, and making observations that will probably already seem to you readers to be the obvious. To start with — the big fat bullseye painted on Howard Dean’s back, now he has solidified his frontrunner position, has emerged in earnest while I was gone, with barbed arrows headed in his direction as suggested in this prescient post from Atrios .

My family and I will be away, and I will not be posting here, until after Christmas Day. My warmest wishes to you and those dear to you, that the joy of the season be yours now and for all the year to come.

I salute you.

There is nothing I can give you which you have not,

but there is much that while I cannot give,

you can take.

No heaven can come to us unless our hearts find rest in it today.

Take heaven.

No peace lies in the future which is not hidden in this present instant.

Take peace.

The gloom of the world is but a shadow. Behind it, yet within our reach, is joy.

Take joy.

And so at this Christmastime,

I greet you, with the prayer

that for you,

now and forever,

the day breaks

and the shadows

flee away.

— Fra Giovanni, 1513 AD

“Downloading copyrighted music from peer-to-peer networks is legal in Canada, although uploading files is not, Canadian copyright regulators said in a ruling released Friday.” —CNET News.com

“It bears the utterly uninformative title of Veith et al vs Jubelirer (docket number 02-1580). But the case, which the US Supreme Court heard yesterday, deals with the explosive political issue of gerrymandering – and its ruling next year could literally reshape America’s democracy.” Gerrymandering is so widespread and has become so effective that only four incumbent congresspeople were defeated in the last round of elections, and the number of districts in which the House race is a foregone conclusion is astounding. ‘ “Voters no longer choose members of the House, the people who draw the lines do,” says Samuel Issacharoff, professor at Columbia Law School.’ The precision with which databases full of demographic data can predict voting patterns by neighborhood, street or household is largely to blame. The threat to incumbents is often no longer the general election but the primary, which does not have the same intolerance of extremism. Hence, the political process is far more polarized with the ubiquity of gerrymandering. In the past, the Supreme Court has only heard challenges to the practice based on racial grounds, otherwise considering it a fact of life. Yet the Court decided to hear this case, for reasons as unclear as which way they will lean in ruling on it. —Independent.UK

Anti-war, or pro-peace, children’s books [via wood s lot; thanks!]

Author and psychologist Bruce Levine, interviewed on Salon, pummels psychiatry, psychotropic drugs and the role both may have played in the case of Andrea Yates. “The theory that depression and other disorders are caused by ‘chemical imbalances’ in the body that can be remedied by psychotropic medication is, according to Levine, ‘just that: a theory.’ Not only does he believe that psychotropic medication is, at best, ineffective; he also claims that the rush to solve social problems by medicating individuals is blinding us to the ways in which people are rebelling against an ‘institutional society’ that doesn’t meet human needs.”

“One of the greatest marketing feats of the past 20 years is use of pharmaceutical companies’ dollars to convince the mass media that psychiatrists who prescribe these companies’ drugs are basing their treatment on anything resembling science.”

But Levine, a non-medically-trained psychologist, not an MD, is guilty of basic mistakes in his understanding of the psychiatric theory he criticizes. For example:

All these new antidepressants — Prozac, Paxil, Zoloft — are SSRIs [selective serotonin reuptake inhibitors]; they all increase the level of the neurotransmitter serotonin in the brain. The theory is that this increase fixes depression.

But they’ve changed their theory every five or 10 years of which neurotransmitter fixes depression. So if you look back 20 or 30 years, they were talking about norepinephrine and that’s why they were giving out things like Tofranil and Elevil [sic; I don't know if it is his misspelling or Salon's].

Not so. If you look back twenty or thirty years, they were talking about a biogenic amine theory of depression, the amines in question being both norepinephrine and serotonin. “Things like Tofranil and Elavil”, which are tricyclic antidepressants, are thought to affect both of these chemicals. They are still talking about both chemicals. The SSRIs are “selective” for serotonin, but they were developed and relied upon not because the prevailing theory changed so that it was only serotonergic dysfunction that was thought to be involved in depression. Far from it; our knowledge of the interactions of serotonin and norepinephrine have become far more sophisticated. In certain regions of the brain, serotonergic neurons may be “upstream” of and modulate the activity of norepinephrine. Furthermore, medications that modulate serotonin selectively tend to be more tolerable and safer (and, yes, more marketable). Norepinephrine was never forgotten. Newer drugs like venlafaxine (Effexor) and mirtazepine (Remeron) are, in fact, not selective, but thought to be combined serotonin/norepinephrine reuptake inhibitors, or SNRIs, with broader and arguably more effective action against depression. Even when psychiatrists were trying to treat everything with serotonin-specific drugs, it was clear that resistant cases often needed the addition of augmenting medications that would work on the norepinephrine side of the equation. So the theory never changed. This is so profound a misunderstanding, or rhetorical misrepresentation, of psychiatric theory that Levine’s observations lose all authority for me.

Levine is also a pitiful reductionist. He criticizes treatments that alter serotonin because serotonin is not necessarily the cause of the syndrome. This betrays a massive misunderstanding that medications rarely do just one thing (there are even basic debates within psychiatry about whether some effects certain medications have are unwanted side effects or part of their therapeutic benefit!) and a massive misunderstanding about the unimaginably complex interactions between the actions of the various neurotransmitters and the various anatomical regions of the brain. To treat through serotonin does not mean one is affecting only serotonin. Far from it. My guess is that Levine played hookey during the day or two that his psychological training addressed neurotransmitter theory, or that he was so angry about that take on things that he could not effectively learn the material. Here’s a quiz question for you, Dr. Levine — through what neurochemicals might your anger affect your ability to attend to and learn salient facts?

The more profound sin of his broadside, which is shared with most of the other so-called radical critiques of modern psychopharmacology, is to assume that the fact that the theory — the biogenic amine theory or whatever — is inadequate, that we really do not understand how the brain works, is grounds to conclude that we should not use the medications. Psychiatrists will be the first to agree that we do not have anything like a complete theory of the actions of the medications we use. It is a deep misunderstanding of basic pharmacology to think we need to know precisely, to the molecular level, how a medication works before we can assert that it is effective. By that standard, there would be almost no therapeutics anywhere in medicine at all. We would not use aspirin, we would not use narcotics, we would not use insulin or any cardiac drugs. Think how absurd it would be, in other fields, to warn consumers not to buy technologies whose basic theory is not completely understood. Praxis and theory are dialectically related, not linearly…

The process of drug discovery, about which I would venture a guess Dr. Levine knows little, illustrates this. Often, it is serendipitous observation that first suggests a certain substance (in nature or in the laboratory) will control a certain symptom, to be later confirmed by clinical trials. The theory of how a drug works chemically often guides me in drug choice and understanding of side effects and results of combining it with other medications, but it is never lost to me that we discovered rather than invented the drug and its effectiveness (although we may be at the dawn of the often-promised era of ‘rational drug design’). Readers know that I often remind you that the CNS is a ‘black box’ whose inner workings are still largely opaque to us. It is in fact usually our investigation of the mechanism of action of a medication known to be effective that illuminates how the brain (at least in pathology) works, rather than an understanding of the brain that illuminates how the drug works. The process of drug development builds on the original serendipity to invent basically similar, if more refined, versions of the same compound by analogy.

This is a more serious critique of psychiatry; that the lens through which we understand the chemistry of a mental state has been determined by coincidence or accident, and that different ways of understanding (and different, potentially efficacious medications that work by novel mechanisms) are so much harder to discover. Substances with many modes of chemical action in the brain (or, for that matter, elsewhere in the body) might be effective against depression, for example, but we haven’t happened upon them yet, except for those that work on the familiar neurotransmitters serotonin and norepinephrine. Furthermore, it may only be by accident that we think they work on those neurotransmitters. That activity may be an epiphenomenon distant from the therapeutic effect (although probably correlated with it).

In fact, evidence is emerging that there may be totally different mechanisms of the known antidepressant drugs that contribute to their therapeutic effectiveness, such as modulation of nerve growth factors and neuroprotective benefits. Again, these discoveries about the actions of the molecules feed back to influence our understanding of the workings of the brain and the ‘lesion’ in depression; a new model is emerging involving damage to neurons probably mediated by stress hormones which neatly explains some aspects of depression (including its chronicity, its relationship to loss and stress, and some physical findings in depressed patients) and complementing the amine mechanisms.

The truth about investigating the workings of the brain is something like the parable of the blind men and the elephant. Just because the appreciation by each blind man in the parable of the true and complete essence of an elephant was incomplete and inaccurate does not mean that they should not interact with the beast. But I wouldn’t expect Levine to understand this…

It was a mixed blessing, but my stomach was strong enough to go on with the interview with Levine, because I was curious about what he had to say about Yates. Although I suspect he and I would differ greatly in the details, we probably actually agree that irresponsible psychiatric treatment should bear much of the culpability for the deaths of those five unfortunate children, I reasoned. Suddenly, I come upon this:

When people are taken off Haldol, they routinely become really agitated, they feel completely out of control. Sometimes people can’t even keep food down; if they haven’t eaten for a while, they often experience dry heaving.

This is absolutely inaccurate, thoroughly irresponsible grandstanding. Not only not “routinely”, but never, have I seen a reaction like this, and I have prescribed alot of haloperidol during my career. Honestly, I don’t know where he gets this stuff, although it makes good press and may sell books. And they want to give nonmedically-trained psychologists like him the right to prescribe?

But while he goes drastically wrong in his criticism of drug-based treatment, Levine makes a crucial point with which I agree. Focusing on brain disease has certainly put the blinders on the field of psychiatry. As a whole, it is as deeply reductionistic as I’ve just finished accusing Levine of being from the other side. While psychiatric disorders appear to be proliferating, it is not merely the pharmaceutical industry’s profit-hungry marketing pressures that are to blame, even though it is true that if the only tool you have is a hammer, you will tend to see nails everywhere. He says:

Psychiatry is part of the problem in that it is exploiting this situation, but it is also diverting people from taking a true look at what is happening in the culture to cause all of these problems. Our society is perhaps the most economically successful culture in the history of the world, materially. But in our one-dimensional quest for productivity, consumption and efficiency, we have forgotten about a whole bunch of things that people need to stay human — like community, autonomy, diversity. All of those things have shrunk.

Taken together, this may help to explain why so many kids are being diagnosed with attention deficit disorder and all these other various childhood disorders. The largest increases we have seen in new illnesses are the ones that affect children.

…We have created that. And that is what we, as a culture, don’t want to admit: We’ve created fewer and fewer places for different kinds of personalities to feel good about themselves and to make a living.

Stay with that thought, Dr. Levine; psychiatry needs to hear it (and be pummelled).

“Modern antidepressant drugs which have made billions for the pharmaceutical industry will be banned from use in children today because of evidence, suppressed for years, that they can cause young patients to become suicidal.

The Medicines and Healthcare Products Regulatory Agency (MHRA) told doctors last night not to prescribe all but one of the antidepressants known as selective serotonin reuptake inhibitors (SSRIs).

The exception is Prozac, which is licensed for use in depressed children in the US. But the MHRA will warn that, at best, it helps only one child in 10.” —Guardian.UK

I have written extensively about the thoughtful psychiatrist’s balancing act in the face of the rapacity of Big Pharma on the one hand and the somewhat histrionic overreaction on the other of those with sometimes good and sometimes bent intentions to protect psychopharmacological patients, sometimes from the care they need. This decision was prompted by public outcry and throws the baby out with the bathwater. Based on my own practice standards, I have said all along that the best antidote to adverse outcomes of drug treatment is prudent responsible doctoring, not regulation, but, I don’t know, I suppose I should not speak for the profession as a whole. It may serve society’s interests better to prevent harmful bad practice than rely on good. It is indicative of the sorry state of modern medical practice to be at the mercy of both market forces and hysteria and not steer through the currents with any authority or respect.

Two of the SSRI class of drugs have already been banned – or, technically, contra-indicated in children – by the agency.

The first, in June, was Seroxat, which goes by the generic name paroxetine (Paxil); the second, in September, was Efexor (venlafaxine) (Effexor); joining them now will be Lustral (sertraline) (Zoloft), Cipramil (citalopram) (Celexa), Cipralex (escitalopram) (Lexapro) and Faverin (fluvoxamine) (Luvox).

[I have added in italics the corresponding trade names of these drugs in the US. — FmH]

If this British pronouncement works anything like analogous decrees in the US, it is worth pointing out that it does not have the force so much of law as of recommendation (“technically, contraindicated”, rather than “banned”), and will serve to give prescribers but more importantly patients or parents, pause. It is just another eddy being introduced into the marketplace. When alarm in the US last year resulted in a recommendation that one SSRI, Zoloft (sertraline) not be prescribed for children, I am not sure it changed prescribing practices much. I would be interested in the data.

It may influence GPs more than psychiatrists. As you know, I feel that the proper source of consumer concern over adverse effects of psychiatric medications is the fact that they are mismanaged by poorly prepared general practitioners who have been the major targets of Pharma’s marketing efforts over the twenty years since the SSRIs were introduced. That shift in targeting strategy has been, I am convinced, the biggest cause of the change in the landscape of modern psychiatry during my practice, and I have fought bitterly against it. The single most helpful thing to do to insure maximal benefit from psychopharmacological treatment is to take your loved one, or yourself, to a reputable psychiatric specialist rather than allow your medication to be prescribed by your general practitioner.

Now, turning to the other claim, that antidepressants may not be very effective in children, that should rightly prompt profound consumer skepticism when a doctor reaches for a prescription pad, especially to treat a child. There is an epidemic of both overdiagnosis and overprescription for conditions in which medication may not be effective. However, I am dubious about the 1:10 claim. I am not a child psychiatrist but I know that my colleagues in that end of the field have far greater success rates than 10%, when diagnosis is properly performed and prescribing is targeted and prudent. A truly depressed child is at considerable risk of morbidity and mortality, and prudent antidepressant use has an invaluable role in ameliorating her/his suffering and preventing a dire outcome. It just has to be managed by someone properly trained, adequately experienced, well-intentioned, and not in the pockets of the drug companies.

Cobb says:

“Al Gore, that fundamentally quirky guy, has given the finger to Joe Lieberman. Good.

Let the Democrats be populist and leave Lieberman in the dirt. He needs to switch parties and quit kidding himself anyway. Liberals need to be radically populist and if Dean is the best they can do, fine. Even Hillary Clinton, whom I do not love to hate, is sounding hawkish, hardheaded and sensible these days. What’s up with that?

Message to Democrats. There is no triangulation left to do. It has been done. Get your cudgels, torches and pitchforks and bring your radical stuff to the streets. That’s what you do best, so get to it. What’s wrong with you people anyway? Where are your hemp handbags and Act Up antics? Where are your plastic inflatable rats and black balaclavas? Where are your effigies and misspelled picket signs? Where are your balls?

You’re not going to let a wimp like GWBush beat you again are you? Here’s a little secret. The first party to nominate a candidate with a beard will have my vote for life.”

(book, that is): “It’s Iraq. The Sunnis, Shias and Kurds are at each other’s throats, only cooperating long enough to attack the foreign army that is occupying their country. The army is tasked with nation-building, and is running into serious difficulty. The man in charge is… no, not America’s Paul Bremer, but General Sir Aylmer Haldane. The year is 1920.

Published in 1922, Haldane’s book, Insurrection in Mesopotamia 1920, long ago vanished into the dusty fastnesses of antiquarian booksellers. But not any more. We hear that Sir Aylmer is required reading in Washington these days. Evidently, the Pentagon and state department are snapping up all available copies – the price on the web has hit $250 and is rising. Why?” —Guardian.UK

Renowned, outspoken contrarian psychiatrist E. Fuller Torey says the report of President Bush’s Commission on Mental Health was a near-total waste and its nineteen recommendations “a hodgepodge of boilerplate and evasion.” —City Journal

James K. Galbraith: “In 1963, JFK ordered a complete withdrawal from Vietnam.” —Boston Review That is, exit without victory. Galbraith supports the much-maligned Vietnam analogy, with which punctilious historians quibble but which I have argued here is too important to be left to the academics.

Steve Silberman’s fascinating piece starts out being about an 11-year old jazz genius but ends up a far-reachng exploration of the spectrum of autism, the savant phenomenon, and the nature of creativity. —Wired

A blast felt ’round the world: “Since 1893, when ‘The Scream’ was rendered, various art historians have speculated about the nature of that event, and when it occurred. Now Dr. Donald Olson, an astronomer at Texas State University, and colleagues say these experts have overlooked an earth-shaking fact.

In the February 2004 issue of Sky & Telescope, the Texas group asserts that ‘The Scream’ was the direct consequence of a cataclysm half a world away from Norway: the volcanic explosion on the Indonesian island of Krakatoa.” —New York Times

Seattle cab drivers are now free to dress up as their favourite public figures. “This is not just good news for taxi drivers but good news for journalists. If the taxi driver is dressed up as ‘a generally well known public figure’ then it could save the reporter all the bother of finding the public figure to interview. If the habit spreads from Seattle, then journalists will be able to fly from city to city interviewing ‘readily identifiable and generally well known public figures’ without ever having to track down the real thing.” —Guardian.UK