My family and I will be travelling until Labor Day; you should not expect any new posts on FmH until I am back home. Enjoy the last week of summer!

This is something I’ve been curious about and don’t really know where to ask. I like to update my music collection with the little thumbnails of the album art that iTunes displays in the lower left corner. I notice that the songs to which I have added art are updated on my iPod the next time I synchronize. Could there possibly be a hidden mode on the iPod that would display (lo-res) images of the album art, given that the data is there, or do I have to wait for the next-generation machine? Any iPod aficionados out there who might know?

“When Mr. Bush accepted the party’s nomination in Philadelphia in 2000, he stepped up to a typical battleship-style stage, with multiple video screens and a sweep of stairs leading up to a lectern. But the Bush campaign team has had four years to think about their next convention, and from the beginning it signaled a desire to do something different.” (New York Times via abby)

“Want to learn how to create and sustain psychosis on a national scale? Look carefully at the public statements made by the Department of Homeland Security.” — Bruce Schneier (Minneapolis Star-Tribune op-ed)

Taking a closer look at the War Medals of George W. Bush [thanks, carol]

Are these signs of erratic desperation or part of a calculated campaign strategy, as things go from bad to worse for Bush? At this point, it is difficult ot say for which candidate, Kerry or Bush, the Swift Boat Veterans furor has done more damage, as the illegal coordination and overlap with the Bush campaign becomes more and more evident. Most likely, this announcement on Bush’s part was part of a deal Bush and McCain made to ensure McCain continues to campaign for Bush. McCain has also called for Kerry to pull the ads, to which I referred last week, in which McCain is shown taking a speechless Bush to task for smearing McCain’s war record during the 2000 primary campaign.

But (on the erratic side?) Bush also let slip an admission that he had miscalculated post-invasion conditions in Iraq (and then quickly clammed up and stonewalled additional questions attempting to get him to amplify on his admission; it would have been nice to be a fly on the wall in the interview and see the beady-eyed panic-stricken look on his face at that point). Yet this is juxtaposed with the following:

Fascinating, useful summary of of readers’ accounts of their professions’ clever little occupational secrets (The Morning News) [via boing boing]

And speaking of the tricks of the trade, Republican conduct during this campaign reminds us that, even within a profession, there are gradations. Here’s a dissection of the Bush family skullduggery tradition. (CBS News). And UC Berkeley’s George Lakoff, linguist extraordinaire whose consulting work is so much in demand by progressive groups in this election season that he had to shelve his research plans for his recent sabbatical, explains why the Republicans are so much better at dominating the terms of debate (and obscuring the fact that they are in control) than the Democrats. Watch for his commentary on the Republican Convention, and his forthcoming book, Don’t Think of an Elephant: Know Your Values and Frame the Debate. Lakoff advises, among other things, that progressive opponents of the current dysadministration avoid the term “War on Terror”. [My reasoning is similar in making sure that all my references to it are ironic and sarcastic in tone. Readers of FmH will recognize that, whenever I have used the term, I turn it into a product brand name “WoT®”.] For another take on the issue of word choice in political spin, see this New York Times piece. If you are writing about current political struggles, sharpen your discourse; it matters! If you are reading my discourse, refine it for me by offering criticisms and corrections whenever I become undisciplined. Let us wake up; this is one of the more important fronts on which the battle for hearts and minds is being fought.

Thanks to walker for suggesting this reflection by the curmudgeonly Dr. Dalrymple on ‘a moral confusion typical of our age’. A recent Lancet editorial considered the controversy over whether alcoholic liver failure ought to disqualify one for a liver transplant, given the predominant opinion that the condition is self-inflicted. The Lancet authors cite evidence that alcoholism is not the patient’s fault, since “clear genetic and environmental influences exist.” Yet Dalrymple points out that the data the Lancet reviews shows that, after liver transplantation, former alcoholics have vastly increased rates of abstinence compared to those who have undergone ‘conventional treatment’ for their alcohol abuse. His conclusion is that alcoholics with sufficient motivation can control their drinking, that despite influences one has the freedom to resist; Dalrymple considers these equivalent to confirmation of the ‘self-inflicted’ terminology.

If the evidence is clear that motivation can affect abstinence, Dalrymple wonders why the medical profession has gone to such lengths to ‘acquit those suffering from alcoholic cirrhosis of the self-infliction charge.’ He finds the answer in the ‘crude sentimentality of our modern moral sensibility’, in which only victims are worthy of sympathy. Since there are so many alcoholics, it would be cruel to be so unsympathetic, so we perforce pretend that they are all victims of circumstances beyond their control. Dalrymple would rather we take a more spiritual (he does not use the term, but what he really means is more Christian) viewpoint in which one forgives and does not withhold sympathy from someone even who has harmed themself.

Without saying so, Dalrymple has taken on one of the core issues I see in modern medicine — what threshold must a maladaptive lifestyle choice cross to be worthy of being called a disease? However, his moral triumphalism relies on setting up and then overthrowing a straw man. Very few physicians take the black and white view he accuses them of having — that alcoholism must be a matter of either free will or determinism. The more nuanced understanding, that genetic and environmental influences create a likelihood and a vulnerability that makes abstinence more difficult than it would be for the next person, but not impossible, is actually the most common. Dalrymple is back in the ’50’s or ’60’s, when debates about nature vs. nurture raged, at least in psychiatry. These have long since been resolved in the minds of all but the most naive thinkers in the field. And Dalrymple forgets that the helpful emotion for a physician is not sympathy — either for the ‘fallen man’ (and, Dr. Dalrymple, what about alcoholic women?) or the ‘victim’ — but empathy for the complexities of the struggle. True, where free will plays a part, we are in a different realm of medicine than that which treats, for example, juvenile onset diabetes or rheumatoid arthritis, which no one in their right mind would accuse the patient of having caused. (Notice, I did not use the more paradigmatic examples of cancer and heart disease, about which legitimate controversies over lifestyle contributions and ‘self-infliction’ exist.) But embracing the more difficult empathic stance places the physician right with the patient in the midst of the struggle over their motivation and ‘willpower’, rather than at Dalrymple’s morally superior distance. While he may be willing to be sympathetic, to bestow forgiveness, to facilitate salvation, on sufferers, his attitude just as easily leaves itself open to heaping moral opprobrium on them. Although it sounds sophisticated, it is really not very different from that which I hear from the families of my psychiatric patients who in their lack of understanding inject an element of moral failing into their loved ones’ mental illnesses all the time — that the sufferer is ‘just not trying hard enough’, needs ‘nothing more than a swift kick in the pants to get going’, is deliberately prolonging their invalidism, is ‘indulging themself’, ‘everybody gets a little down once in awhile but most of us don’t let it get to us like you do’. It is true that, as a physician educating and counseling such a family, I want to say something like, “(S)he can’t help it, it’s a disease, (s)he needs your sympathy,” but we don’t say it because we believe that only guiltless victims of impersonal forces deserve sympathy; it is in large measure public stigmatization the physician is attempting to counter here. Dr. Dalrymple, I fear, misunderstands, despite the fact that moralists always want to paint themselves as more understanding and sympathetic, and their opponents’ ability for sympathy impaired by their faulty understanding.

Of course, I am talking from the perspective of a psychiatrist, one of whose core skills is examining and clarifying countertransference feelings, one’s own hidden assumptions about and attitudes toward our patients, so these are not the powerful behind-the-scene players they otherwise would be. Most physicians and other healthcare workers outside the mental health end of the field have probably never heard of countertransference, not to mention explored their own.Still, I think, most physicians have a more complicated view of their patients’ moral agency than Dalrymple assumes. What, I wonder, would Dalrymple make of the views of humanity of such physician-writers as Sherwin Nuland, Jerome Groopman, Oliver Sacks or indeed William Carlos Williams?

The unsophistication of Dalrymple’s viewpoint becomes clearer if one examines the most successful technique for helping alcoholics become and remain abstinent, the AA model. What is AA’s position on the role of ‘willpower’ in sobriety? On the surface of it, it seems that AA is dead set against it. The first, dogmatic, step in the AA program is acknowledging that one is helpless against alcoholism and cannot help oneself. Of course, AA doesn’t work for everyone, because of the difficulties some have with its remedy for such powerlessness — to ask for help from the group, and from a ‘Higher Power’. But, for those whose interpersonal capacities and spiritual inclinations allow, those steps are the foundations of success. And it seems to me that they are an embrace of paradox the significance of which is lost on Dalrymple. By acknowledging powerlessness, the alcoholic bolsters their willpower and motivation to exert control for recovery. By invalidating the effectiveness of willpower, one gains power. The embrace of such paradox is clear in the AA credo per the ‘serenity prayer’, in which one yearns for both “the serenity to accept the things I cannot change (and the) courage to change the things I can” (as well as “the wisdom to know the difference”). Perhaps the theory of alcoholism and recovery that elucidates it best is psychiatrist Gregory Bateson’s ‘cybernetic’ model (in Steps to an Ecology of Mind), describing the ways in which willpower and powerlessness are not dichotomous, in conflict in one mind, but that they are rather coexistent and interdependent, at different levels of abstraction of the self.

I will not be ‘blogging for dollars’, in case you wondered…

Guess he feels ‘Mission Accomplished’ (Yahoo! News)

This historical quote was not written by an observer of the 2004 Republican campaign, but it may as well have been:

“All this was inspired by the principle – which is quite true in itself – that in the big lie there is always a certain force of credibility; because the broad masses of a nation are always more easily corrupted in the deeper strata of their emotional nature than consciously or voluntarily; and thus in the primitive simplicity of their minds they more readily fall victims to the big lie than the small lie, since they themselves often tell small lies in little matters but would be ashamed to resort to large-scale falsehoods. It would never come into their heads to fabricate colossal untruths, and they would not believe that others could have the impudence to distort the truth so infamously. Even though the facts which prove this to be so may be brought clearly to their minds, they will still doubt and waver and will continue to think that there may be some other explanation. For the grossly impudent lie always leaves traces behind it, even after it has been nailed down, a fact which is known to all expert liars in this world and to all who conspire together in the art of lying. These people know only too well how to use falsehood for the basest purposes.” [via kos via unfutz]

Click on the link above to see the author identified, or post your guess here as a comment (no cheating).

“Reruns on demand: We can get there legally or illegally.” (MIT Technology Review)

Bush contradicts his own “Roadmap to Peace” by reversing himself on the West Bank settlements, in an attempt to help embattled Israeli prime minister Sharon get his Gaza withdrawal plan past the recalcitrant right wing of his own party. Palestinians have feared all along that the Gaza plan is a cover for reinforcing the Israeli presence on the West Bank.

This April, 2003 report of a blue ribbon federal panel of mental health professionals has recently attracted attention because it is interpreted as proposing an alarming plan to screen the mental health of every American, beginning in the schools. The Bush administration is using the ‘New Freedom’ rubric to refer to a hodge podge of initiatives directed toward people with disabilities; this report maps out the mental health component of the effort. The fact that, as a politically savvy mental health professional, I had never heard of this commission, this report or this initiative may be an indication of how little impact it will have on real mental health practice, but I reviewed the report at the urging of several FmH readers and other webloggers who wanted a professional’s perspective.

Some critics view the screening mandate as a giveaway to the pharmaceutical industry, and place it in the context of the Republicans’ efforts, to paraphrase Bill Moyers, to “privatize public services in order to enrich the corporate interests that fund campaigns and provide golden parachutes to pliable politicians. If unchecked, the result of these machinations will be the dismantling of every last brick of the social contract…. I think this is a deliberate, intentional destruction of the United States of America.” Further alarm is raised by the report’s embrace of “evidence-based” practices and treatment by standardized algorithms exemplified by the Texas Medical Algorithm Project (TMAP). This has been a monumental attempt to reduce medicine to a cookbook approach — if conditions A, B, and C exist, you try treatment X, (which is usually a medication) then if it doesn’t work you go to Y, etc. Treatment guidelines in the algorithms are “evidence-based”, the hot buzzword in clinical medicine (including psychiatry), which is meant to refer to practices proven by research data rather than based on intuition. (I probably don’t need to remind you that most research into treatment outcomes of medications is funded by the pharmaceutical companies that have a vested interest in the findings.) Critics of the TMAP claim that it is driven by a “political/pharmaceutical alliance” for the sole purpose of making newer, expensive, profitable drugs the mainstays of treatment for various disorders. Furthermore, critics claim, Texas officials have reportedly received financial perks from the pharmaceutical industry to influence their adoption of the algorithms. (Let me caution that a critique based on the assumption that drug companies’ contributions are meant to ensure that their drug gets recommended are naive and easily refuted. The pharmaceutical industry usually wields its influence more subtly; by dispensing its largesse to create a warm and fuzzy feeling in the researchers, clinicians and regulators who are worth influencing, rather than as direct bribes.)

Let’s start with the TMAP angle. My reservations about the funding of pharmacological research apart, I have always found algorithm-based medical practice fundamentally flawed. The whole process of identifying what class of patients a given individual falls into, and then treating that individual in a rote manner, seems to ignore crucial aspects of each patient’s uniqueness and the health professional’s need for sensitivity, skill, yes, artistry in applying medical knowledge to the case at hand. This is especially true in the psychiatric field. Thus, the foremost danger of algorithm-based treatment is not that it is a giveaway to Big Pharma. The newer, more expensive medications are used not because they are mandated by algorithms but, simply, because they represent signficant medical advances in efficacy and tolerability. Those of us who scoff at algorithms do not use less of the expensive new medications. The obscenity is not that a government interested in industry giveaways is trying to mandate more expensive drugs as better; it is that it is doing nothing to make better drugs less expensive. Even without algorithms, the pharmaceutical industry already has a captive audience of sick consumers in desperate need on whom it can foist its price-fixing. One of the greatest flaws in the commission report, to my reading, is that the penetration of the drug manufacturers into medical practice is not addressed at all despite an awful lot of highfalutin’ language about making mental health care ‘consumer-driven’ and ‘recovery-based.” In this case, with all due respects to Bill Moyers, it does not appear so much to be a potential windfall for the industry but rather protecting it from a firestorm of criticism that is the Bush administration’s major favor to its friends. It is worth noting, however, the pharmaceutical industry was not overtly represented on the panel, whose members are a large and varied cross-section of the mental health professions, from community mental health practitioners to academics and administrators.

Apart from the algorithmic and “evidence-based” agenda and the screening proposals, the other goals the commission articulates for improving mental health care include reducing stigmatization and enhancing the rights of the mentally ill, achieving parity with physical health care, promoting a national strategy for suicide prevention, promoting comprehensive individual care plans, improving access to mental health services in underserved areas and making mental health care culturally sensitive, improving child psychiatric services and school-based mental health care, improved recognition of the co-occurrence of substance use and mental disorders, shaping research priorities to address clinically useful questions, “develop(ing) the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care”, and improving the integration of modern electronic technologies in the delivery of mental health care. In medical school, we are taught to generate a comprehensive ‘problem list’ for each patient we follow. If the patient were the American mental health care system, I am struck by how closely this list gibes with my own problem list. The question is whether there is an action-based agenda to back up the goals, and whether we will put our money where our mouth is.

I have seen too many treatment plans for patients based on comprehensive problem lists in which the plan for problem A is little more than “treat problem A.” In a similar vein, the commission’s verbiage on achieving these goals for the improvement of ailing American mental health care is diffuse and vague. The list includes: educating the public about mental illness to reduce stigmatization; enhancing affordability, access and choice; emphasizing the interconnection of physical and mental health and the coordination of the care of both; a recovery-based model; better alignment of federal mental health policy across agencies, to coordinate health care with the other human needs of mentally ill consumers; community-baase alternatives to institutions; making supported housing and supported employment opportunities more available; improving mental health care in the penal system; meeting specific rural and minority mental health needs; addressing the shortage of personnel in the mental health fields. Yawn. For a specific example of the mind-numbing vagueness that passes for a plan, here are the report’s suggestions for improving acute mental health care (my main interest as an inpatient psychiatrist treating patients with major mental illness during acute crises): “synthesizing the …knowledge base, reviewing the many outstanding model programs…, developing new knowledge as necessary, assessing existing capacities and shortages, and proposing workable solutions.” I know we are supposed to like generics in mental health care, but I thought they were talking about generic drugs, not verbiage!

I usually find “recovery-based” language worrisome, since much mental health care should not be oriented toward an unrealistic goal of curing the patient’s psychiatric illness but helping them stabilize acute symptoms and adapt to what is often a lifelong chronic condition. The commission report counterbalances this with enough attention to mental illness as a lifelong disability and the expectation that consumers will have to negotiate the systems of providing their human needs as mentally ill clients. There is little, however, about the sort of community-based psychosocial rehab, vocational training and social club models that are incredibly useful and humane; nor about the powerful assertive community treatment model to keep our sickest clients in the communities and out of the hospitals. I collaborate enthusiastically with ACT teams around some of the most desperately ill patients I see recurrently in my hospital practice, but they should be providing services to at least three times as many patients as they are able to do.

So, at last, turning to the controversial screening proposals, early identification of and intervention with both at-risk and precociously symptomatic patients, yes, through school- and population-based screening programs, is another area with proven potential to slow or halt the progression to chronicity, and it is another area which is woefully neglected in current mental health practice. The rationale for a school-based focus is at least partially because it is a nonstigmatizing setting a fragile child is already accustomed to, in comparison to hospitals and doctors’ offices. If cases are identified earlier in life and treatment needs, including psychopharmaceutical approaches, are addressed sooner, suffering can be alleviated. Furthermore, the proportion of a child’s social and cognitive demands that occur in the school setting is, of course, enormous, so school-based treatment is community treatment. Screening is no handout to the pharmaceutical industrly unless — and this is a big unless — nothing is done to rectify the current problems with pediatric overdiagnosis, overtreatment and inadequate followup.

By my reasoning, an effective early intervention program would actually alleviate some of these problems. Here’s how it goes. Readers of FmH know that I think the expansion of medication use has been driven not only by the rapacious pharmaceutical industry but by market pressures within psychiatry itself. As MDs have priced themselves out of the market and have been replaced progressively by cheaper non-MD professionals in the delivery of mental health services, the psychiatric profession has been forced to expand the range of conditions it defines as medication-responsive, since psychiatrists are (almost) the only ones who can prescribe. This has ushered in the era of “cosmetic psychopharmacology”, which is fist-in-glove with the dumbing down of psychiatric training to the point that newly-qualified psychiatrists neither see the value of nor have the inclination or skills to do psychotherapy, i.e. communicate effectively, get to know their patients, create a relationship with a patient whose suffering often makes them difficult to reach, and to use that relationship as a healing instrument. If a coherent process exists to match the expansion of the mental health workforce with the expansion of identified treatment needs, my hope is that the market pressure to prescribe needlessly for more trivial conditions will atrophy. It is not likely someone not in the business of delivering mental health services understands how critical the shortage of providers to address pediatric mental health needs is. Children wait days in ERs for a bed in a psychiatric hospital after demonstrating the urgent need; they wait weeks or months to access outpatient services. If screening reprioritizes the focus of care to the truly, urgently sick, and is accompanied by an expansion in manpower, I am all for it. On the other hand, I’m not a health care economist, just a doctor. (When he comes to town, a world-renowned health care economist from Stanford who is a family friend picks my brain on the view from the trenches; I’m going to have to turn the tables the next time I see him — whichshould be next week — and pump him for his reactions to the commission report from a health policy perspective.)

On the other hand, if a national screening agenda is not matched by a dramatic increase in mental health personnel at both the primary care and the referral levels, I am afraid such a program would be carried out through some totally inadequate standardized testing program akin to the standardized educational testing that has become the sole, braindead, standard for ‘leaving no child behind’ educationally. While a robust, individualized and sensitive screening process with adequate personnel and funding could provide early detection and treatment if it focused on at-risk children, those with behavioral problems, and those referred by concerned classroom teachers, the literature shows that standardized, survey-based measures of mental health of entire populations have proven of dubious value when used for epidemiological research purposes, are of no value in targeting clinical interventions, and are too unwieldy to carry out. Again, as in the educational sphere, I can see federal funds for mental health care being tied to state compliance in administering the screening protocols. And, again, as with No Child Left Behind, an unscrupulous Bush or Bush-like administration could comandeer mental health data for other purposes such as military conscription classification. (How would you like to be told that you cannot have a psychiatric deferment from the coming draft, despite the insistence of a sympathetic psychiatrist such as myself that you are mentally unfit to serve, because your childhood psychometric scores ‘proved’ you were across-the-board well-adjusted?)

In short, the report is a puff piece that is not likely to turn into implementable policy. To the extent that it is, I think the concerns about “Bush wanting to be your shrink” are kneejerk alarmism. Although there are a range of issues about which to be concerned in the report, they are not the ones upon which the critics have so far focused. And while, in one alarmist’s turn of phrase, “your first great freedom, the power to control your own thoughts, … (and) your secondary freedom of being able to control the approval for your own medical treatments” are indeed important frontiers of modern freedom, the New Freedom Commission on Mental Health does not represent the immediate threat to them it is made out to be. The greatest problems of the ‘reform’ of the mental health care system proposed by this commission, as I see it, are that it does not address the sellout of psychiatric care to the pharmaceutical industry and the increasing tendencies to conduct treatment in a rote, braindead manner. Even if you had the improved access to mental health services you deserve under this system, you would still end up being treated by someone with little training in or tendency toward creative independent thinking; inadequate familiarity with the range of available (both new and time-honored) treatment options and the possibilities of an individualized and original approach to your problems; and little immunity to having prescribing practices bought and sold by corporate influences. In other words, the problem with the new initiative is not that it will create massive intolerable changes in your care and infringe on your civil rights, as the naive critics propose; rather, it is that it will not change anything. Besides, Ashcroft will not be in charge of the mental health screening, and Bush and his intiiative will be out of office in January in any case, right?

Let the flamewars begin…

This April, 2003 report of a blue ribbon federal panel of mental health professionals has recently attracted attention because it is interpreted as proposing an alarming plan to screen the mental health of every American, beginning in the schools. The Bush administration is using the ‘New Freedom’ rubric to refer to a hodge podge of initiatives directed toward people with disabilities; this report maps out the mental health component of the effort. The fact that, as a politically savvy mental health professional, I had never heard of this commission, this report or this initiative may be an indication of how little impact it will have on real mental health practice, but I reviewed the report at the urging of several FmH readers and other webloggers who wanted a professional’s perspective.

Some critics view the screening mandate as a giveaway to the pharmaceutical industry, and place it in the context of the Republicans’ efforts, to paraphrase Bill Moyers, to “privatize public services in order to enrich the corporate interests that fund campaigns and provide golden parachutes to pliable politicians. If unchecked, the result of these machinations will be the dismantling of every last brick of the social contract…. I think this is a deliberate, intentional destruction of the United States of America.” Further alarm is raised by the report’s embrace of “evidence-based” practices and treatment by standardized algorithms exemplified by the Texas Medical Algorithm Project (TMAP). This has been a monumental attempt to reduce medicine to a cookbook approach — if conditions A, B, and C exist, you try treatment X, (which is usually a medication) then if it doesn’t work you go to Y, etc. Treatment guidelines in the algorithms are “evidence-based”, the hot buzzword in clinical medicine (including psychiatry), which is meant to refer to practices proven by research data rather than based on intuition. (I probably don’t need to remind you that most research into treatment outcomes of medications is funded by the pharmaceutical companies that have a vested interest in the findings.) Critics of the TMAP claim that it is driven by a “political/pharmaceutical alliance” for the sole purpose of making newer, expensive, profitable drugs the mainstays of treatment for various disorders. Furthermore, critics claim, Texas officials have reportedly received financial perks from the pharmaceutical industry to influence their adoption of the algorithms. (Let me caution that a critique based on the assumption that drug companies’ contributions are meant to ensure that their drug gets recommended are naive and easily refuted. The pharmaceutical industry usually wields its influence more subtly; by dispensing its largesse to create a warm and fuzzy feeling in the researchers, clinicians and regulators who are worth influencing, rather than as direct bribes.)

Let’s start with the TMAP angle. My reservations about the funding of pharmacological research apart, I have always found algorithm-based medical practice fundamentally flawed. The whole process of identifying what class of patients a given individual falls into, and then treating that individual in a rote manner, seems to ignore crucial aspects of each patient’s uniqueness and the health professional’s need for sensitivity, skill, yes, artistry in applying medical knowledge to the case at hand. This is especially true in the psychiatric field. Thus, the foremost danger of algorithm-based treatment is not that it is a giveaway to Big Pharma. The newer, more expensive medications are used not because they are mandated by algorithms but, simply, because they represent signficant medical advances in efficacy and tolerability. Those of us who scoff at algorithms do not use less of the expensive new medications. The obscenity is not that a government interested in industry giveaways is trying to mandate more expensive drugs as better; it is that it is doing nothing to make better drugs less expensive. Even without algorithms, the pharmaceutical industry already has a captive audience of sick consumers in desperate need on whom it can foist its price-fixing. One of the greatest flaws in the commission report, to my reading, is that the penetration of the drug manufacturers into medical practice is not addressed at all despite an awful lot of highfalutin’ language about making mental health care ‘consumer-driven’ and ‘recovery-based.” In this case, with all due respects to Bill Moyers, it does not appear so much to be a potential windfall for the industry but rather protecting it from a firestorm of criticism that is the Bush administration’s major favor to its friends. It is worth noting, however, the pharmaceutical industry was not overtly represented on the panel, whose members are a large and varied cross-section of the mental health professions, from community mental health practitioners to academics and administrators.

Apart from the algorithmic and “evidence-based” agenda and the screening proposals, the other goals the commission articulates for improving mental health care include reducing stigmatization and enhancing the rights of the mentally ill, achieving parity with physical health care, promoting a national strategy for suicide prevention, promoting comprehensive individual care plans, improving access to mental health services in underserved areas and making mental health care culturally sensitive, improving child psychiatric services and school-based mental health care, improved recognition of the co-occurrence of substance use and mental disorders, shaping research priorities to address clinically useful questions, “develop(ing) the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care”, and improving the integration of modern electronic technologies in the delivery of mental health care. In medical school, we are taught to generate a comprehensive ‘problem list’ for each patient we follow. If the patient were the American mental health care system, I am struck by how closely this list gibes with my own problem list. The question is whether there is an action-based agenda to back up the goals, and whether we will put our money where our mouth is.

I have seen too many treatment plans for patients based on comprehensive problem lists in which the plan for problem A is little more than “treat problem A.” In a similar vein, the commission’s verbiage on achieving these goals for the improvement of ailing American mental health care is diffuse and vague. The list includes: educating the public about mental illness to reduce stigmatization; enhancing affordability, access and choice; emphasizing the interconnection of physical and mental health and the coordination of the care of both; a recovery-based model; better alignment of federal mental health policy across agencies, to coordinate health care with the other human needs of mentally ill consumers; community-baase alternatives to institutions; making supported housing and supported employment opportunities more available; improving mental health care in the penal system; meeting specific rural and minority mental health needs; addressing the shortage of personnel in the mental health fields. Yawn. For a specific example of the mind-numbing vagueness that passes for a plan, here are the report’s suggestions for improving acute mental health care (my main interest as an inpatient psychiatrist treating patients with major mental illness during acute crises): “synthesizing the …knowledge base, reviewing the many outstanding model programs…, developing new knowledge as necessary, assessing existing capacities and shortages, and proposing workable solutions.” I know we are supposed to like generics in mental health care, but I thought they were talking about generic drugs, not verbiage!

I usually find “recovery-based” language worrisome, since much mental health care should not be oriented toward an unrealistic goal of curing the patient’s psychiatric illness but helping them stabilize acute symptoms and adapt to what is often a lifelong chronic condition. The commission report counterbalances this with enough attention to mental illness as a lifelong disability and the expectation that consumers will have to negotiate the systems of providing their human needs as mentally ill clients. There is little, however, about the sort of community-based psychosocial rehab, vocational training and social club models that are incredibly useful and humane; nor about the powerful assertive community treatment model to keep our sickest clients in the communities and out of the hospitals. I collaborate enthusiastically with ACT teams around some of the most desperately ill patients I see recurrently in my hospital practice, but they should be providing services to at least three times as many patients as they are able to do.

So, at last, turning to the controversial screening proposals, early identification of and intervention with both at-risk and precociously symptomatic patients, yes, through school- and population-based screening programs, is another area with proven potential to slow or halt the progression to chronicity, and it is another area which is woefully neglected in current mental health practice. The rationale for a school-based focus is at least partially because it is a nonstigmatizing setting a fragile child is already accustomed to, in comparison to hospitals and doctors’ offices. If cases are identified earlier in life and treatment needs, including psychopharmaceutical approaches, are addressed sooner, suffering can be alleviated. Furthermore, the proportion of a child’s social and cognitive demands that occur in the school setting is, of course, enormous, so school-based treatment is community treatment. Screening is no handout to the pharmaceutical industrly unless — and this is a big unless — nothing is done to rectify the current problems with pediatric overdiagnosis, overtreatment and inadequate followup.

By my reasoning, an effective early intervention program would actually alleviate some of these problems. Here’s how it goes. Readers of FmH know that I think the expansion of medication use has been driven not only by the rapacious pharmaceutical industry but by market pressures within psychiatry itself. As MDs have priced themselves out of the market and have been replaced progressively by cheaper non-MD professionals in the delivery of mental health services, the psychiatric profession has been forced to expand the range of conditions it defines as medication-responsive, since psychiatrists are (almost) the only ones who can prescribe. This has ushered in the era of “cosmetic psychopharmacology”, which is fist-in-glove with the dumbing down of psychiatric training to the point that newly-qualified psychiatrists neither see the value of nor have the inclination or skills to do psychotherapy, i.e. communicate effectively, get to know their patients, create a relationship with a patient whose suffering often makes them difficult to reach, and to use that relationship as a healing instrument. If a coherent process exists to match the expansion of the mental health workforce with the expansion of identified treatment needs, my hope is that the market pressure to prescribe needlessly for more trivial conditions will atrophy. It is not likely someone not in the business of delivering mental health services understands how critical the shortage of providers to address pediatric mental health needs is. Children wait days in ERs for a bed in a psychiatric hospital after demonstrating the urgent need; they wait weeks or months to access outpatient services. If screening reprioritizes the focus of care to the truly, urgently sick, and is accompanied by an expansion in manpower, I am all for it. On the other hand, I’m not a health care economist, just a doctor. (When he comes to town, a world-renowned health care economist from Stanford who is a family friend picks my brain on the view from the trenches; I’m going to have to turn the tables the next time I see him — whichshould be next week — and pump him for his reactions to the commission report from a health policy perspective.)

On the other hand, if a national screening agenda is not matched by a dramatic increase in mental health personnel at both the primary care and the referral levels, I am afraid such a program would be carried out through some totally inadequate standardized testing program akin to the standardized educational testing that has become the sole, braindead, standard for ‘leaving no child behind’ educationally. While a robust, individualized and sensitive screening process with adequate personnel and funding could provide early detection and treatment if it focused on at-risk children, those with behavioral problems, and those referred by concerned classroom teachers, the literature shows that standardized, survey-based measures of mental health of entire populations have proven of dubious value when used for epidemiological research purposes, are of no value in targeting clinical interventions, and are too unwieldy to carry out. Again, as in the educational sphere, I can see federal funds for mental health care being tied to state compliance in administering the screening protocols. And, again, as with No Child Left Behind, an unscrupulous Bush or Bush-like administration could comandeer mental health data for other purposes such as military conscription classification. (How would you like to be told that you cannot have a psychiatric deferment from the coming draft, despite the insistence of a sympathetic psychiatrist such as myself that you are mentally unfit to serve, because your childhood psychometric scores ‘proved’ you were across-the-board well-adjusted?)

In short, the report is a puff piece that is not likely to turn into implementable policy. To the extent that it is, I think the concerns about “Bush wanting to be your shrink” are kneejerk alarmism. Although there are a range of issues about which to be concerned in the report, they are not the ones upon which the critics have so far focused. And while, in one alarmist’s turn of phrase, “your first great freedom, the power to control your own thoughts, … (and) your secondary freedom of being able to control the approval for your own medical treatments” are indeed important frontiers of modern freedom, the New Freedom Commission on Mental Health does not represent the immediate threat to them it is made out to be. The greatest problems of the ‘reform’ of the mental health care system proposed by this commission, as I see it, are that it does not address the sellout of psychiatric care to the pharmaceutical industry and the increasing tendencies to conduct treatment in a rote, braindead manner. Even if you had the improved access to mental health services you deserve under this system, you would still end up being treated by someone with little training in or tendency toward creative independent thinking; inadequate familiarity with the range of available (both new and time-honored) treatment options and the possibilities of an individualized and original approach to your problems; and little immunity to having prescribing practices bought and sold by corporate influences. In other words, the problem with the new initiative is not that it will create massive intolerable changes in your care and infringe on your civil rights, as the naive critics propose; rather, it is that it will not change anything. Besides, Ashcroft will not be in charge of the mental health screening, and Bush and his intiiative will be out of office in January in any case, right?

Let the flamewars begin…

Rafe Colburn comments on the slime machine:

Colburn is despondent today, thinking that the Swift Boat Veterans will torpedo Kerry’s chances to win the presidency all on their own.

But Josh Marshall thinks Kerry is getting fighting mad, discussing a new Kerry campaign ad which uses 2000 footage of John McCain castigating candidate Bush’s attempt to besmirch his war record, finishing with a shot of Bush’s speechless trapped face that cannot fail to convince us what a shameless coward he was, and is. It strikes me that this is as much Kerry’s response to McCain’s re-embrace of the President, about which I wrote below, as to Bush’s smear attack.

And Ed Fitzgerald holds a hand out for people trying to find a way to kick the self-deceived-Republican-vote habit:

Fitzgerald is building on this wonderful plain speakin’ from Matt Yglesias:

Reduced to its essence, Yglesias is trying to hammer home a single concept, on which I repeatedly harp here — that, as he puts it, “intelligence matters more than character.” FmH readers will know that I have been pretty despondent about the voters’ receptivity to this notion.

But, hey, Bush and his slimy ilk just sink further and further into their sleazy morass, as made clear by this pair of columns from Bob Herbert and Paul Krugman on their latest Florida dirty trick. Maybe even the voters who still believe they need to vote for righteousness regardless of brains will have their eyes opened if this sort of thing continues.

PS: Do voters who like South Park have a sense of humor?

“A top government scientist who concluded last year that most antidepressants are too dangerous for children because of a suicide risk wrote in a memo this week that a new study confirms his findings.” (New York TimesThe ) The senior FDA epidemiologist drew his conclusion from a study of 22 studies, but his findings were reportedly suppressed by his bosses at the FDA. A newer study using different data analyzed by a different methodology parallels his conclusions. Should antidepressant prescribing to children be banned? Certainly, the credible evidence that they are more likely to commit suicide when administered antidepressants is worrisome. Children have less ability than adults to understand and contain the bodily agitation, the feeling “like you’re crawling out of your skin” (in the words of numerous patients), that some antidepressants can cause, so they are far more likely to get into trouble with these medications. And I feel that, like most psychotropics, they are far overprescribed by the pharmacological evangelists most of my profession have become, uncritically. However, I would be concerned if the rare truly, desperately, lethally depressed child were deprived of the possibility of a properly used powerful therapeutic agent. In other branches of medicine, doctors use very dangerous medications when the potential benefit outweighs the risk, and they are capable of using them carefully. Police the profession, not its armamentarium! And get the damn pharmaceutical industry and its single-minded devotion to its profit, which mediates for prescribing to more and more patients more and more uncritically, out of the central role it has in healthcare!

Actually, the FDA does not have the power to ban thei drugs’ use. As the equivalent agency in the UK has done, they can recommend restrictions in a medication’s use, but any licensed physician is able to prescribe a legal drug for any indication, including so-called ‘off-label’ uses, they deem necessary. Making antidepressant use off-label for children would have several consequences. First, one would hope doctors would become far more cautious, since an adverse outcome arising from an off-label use presents far more liability to the physician. Second, risk management in off-label prescribing requires far more stringent informed consent to the patient (or the patient’s parents or guardians). A thorough explanation of regulatory concerns about these drugs’ use would make many a parent too skittish to consent. Finally, prescription coverage by third-party payors for off-label uses may be denied or may require prior approval, effectively placing the drugs out of financial reach of many patients.

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An effective Democratic response to this would be to paint McCain’s newfound compliance as the selfserving attempt that it is to reestablish his party loyalty iin order to position himself for a 2008 presidential run.

One of my readers alluded to this study in a comment on another post on medical ethics, but it certainly deserves to be put out front. The medical profession has always considered such breaches as failures of individual ethical responsibility, and taken individual disciplinary action. This is consistent with the official whitewash of the Abu Ghraib scandal, where I predict (and have predicted) that official ‘soulsearching’ will ignore systemic permissiveness and facilitation of abuse in the military command structure and Pentagon/administration culture, blaming only the ‘morally depraved’ perpetrators. The evidence of medical and psychiatric participation in the abuses calls for an examination of broader issues of the corruption of inherent medical standards when used to support an immoral war machine.

Juan Cole wonders. His thinking is that Muslim Americans are an important voting bloc in the Midwest, including several important swing states. Adding to Muslim (and Christian Arab?) voters’ dismay at the defilement of the holy city are the domestic trampling on civil rights of Arab Americans, the poor economy and the ripple effect of rising oil prices because of the continuing Iraqi unrest. Much of the Arab American support Bush got on 2000, Cole says, was based on fears that a Gore-Lieberman administration would be heavily pro-Israel.

“He can find another way to advertise himself.” (Sports Illustrated) Another team member (whose cousin and several friends were killed by US military action in Fallujah) said that, if he were not playing soccer, he would “for sure” be fighting with the resistance to the US occupation.

This LA Times report says the embarrassed CIA Iraq Survey Group charged with finding WMD in Iraq will release a final report next month that shifts gears into speculating on what Iraq’s arsenal might have looked like by 2008 if the US had not invaded. The report is being assailed as a departure from the mandate of the group, as designed to obscure the fact that WMD were never found, as confusing the distinction between evidence and fanciful speculation, and as clearly politically motivated. It seems to me that David Kay (former director of the survey group)’s main problem was in resigning too soon. Of course, the dysadministration would try to repair the damage by putting in place a successor without his integrity who would be willing to have the group’s agenda hijacked in this manner. With the deceptions about WMD at the core of the growing outrage about the war and the change in dysadministration justification of the invasion from asserting Iraq had WMD to asserting it had intentions of and capability for weapons production, shouldn’t opponents have had their sights on what the Iraq Survey Group was doing for, oh, the past year or so? It was only last month that Congressional leaders were taken aback to learn of this plan in briefings from a representative of the weapons survey team who acknowledged (before moving on to another assignment and refusing to comment further) that its mandate indeed was “the search for and elimination of weapons of mass destruction.” While an outraged Representative’s request for assurances from John McLaughlin, interim director of the CIA, that the group’s report confine itself to what the search efforts in Iraq had actually yielded has gone unanswered, a CIA spokesperson dismissed charges that the shift in the group’s focus is politically motivated as [perhaps the most common phrase on the lips of government officials these days? &m-dash; FmH] “nonsense.”

Ostracizing the people who were right on Iraq.:

Cannabis extract shrinks brain tumours (New Scientist)

Pollen-blocking cream cuts hayfever (New Scientist)

Novelist Tibor Fischer reflects on what he learned in reading 126 novels as a Booker Prize judge:

Review of The End of Faith: Religion, Terror, and the Future of Reason by Sam Harris:

What can the history of psychosurgery tell us about medicine today? An interview with Elliot Valenstein, author of Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, 1986).

“STAY FREE!: What brought on the backlash? How did that come about?

VALENSTEIN: Well, there were some scientists who argued that, since we now know a lot more about the brain, psychosurgery should be revisited. This was at a time when there was a lot of public concern about violence in the streets. Two doctors, Frank Ervin and Vernon Mark, had published a book called Violence and the Brain, which argued that brain abnormalities can cause violence. Word got out that the Department of Justice, which maintains federal prisons and special prisons for violent inmates, had some exchanges with the authors. There was a lot of suspicion that the Department of Justice was going to perform massive psychosurgical procedures on violent prisoners as a means of social control. So it became a big issue in some circles. I was at some neuroscience meetings that discussed the biology of aggression, and people came in and broke up the meeting and demanded time on the program.

STAY FREE!: Was there any truth to the rumors that lobotomy was being performed in prisons? “

(Stay Free!)

This devastating piece by The Nation‘s Tom Englehardt dissects the failures of current Iraq reporting, now that we are familiar with the NY Times‘ and Washington Post‘s mea culpas for their pre-war coverage. Englehardt catalogues the aspects of the war discussions of which are missing in action in the major media:

• Al-Sadr’s fighters are called ‘cowardly’ for taking refuge in a holy shrine, but the real cowardice lies in the increasing resort of the US military to devastating air power
• “…If you don’t grasp that, from the beginning, the Pentagon was planning a major string of “enduring camps” in Iraq, then you really can’t grasp why the Bush administration had no exit strategy from that country — because, of course, it had no plans to depart”.
• When Baghdad fell without a struggle, those who had worried that US forces would be bogged down in street-to-street urban guerrilla warfare were dismissed and the subject forgotten. Now, in a range of Iraqi cities from the north to the south, the US and British forces’ worst nightmare is largely coming to pass, only nobody takes note of the fact that we told you so.
• After the handover of power to the Allawi government at the end of June, the US plan to get the American strategists of the occupation behind the lines in the Green Zone to become invisible has largely worked. The combination of coverage of Iraqi government statements and the US military policy of emphasizing that they are doing Allawi’s bidding whenever questioned (e.g. on the run-up to the Najaf offensive) go unquestioned, but it is “obvious to any sane observer that the Americans are still in charge and that American strategic decisions are largely being implemented by Americans, not Iraqis”
• While the Imam Ali Shrine is routinely referred to as “holy” in all coverage of the current fighting in Najaf, American ignorance about Islam and Shi’ism has not been countered with sufficient background about how centrally holy it is to that faith and why the American threat to the mosque is so unnerving and enraging to Muslim and other observers around the world. “It matters that we, who simply read about this, can’t even begin to put ourselves in the shoes of Iraqis experiencing it — although this should at least give us insight into why American policy makers and military men, no less ignorant than the rest of us, can make such staggering tactical blunders.”
• The administration’s characterization of the elements of the Iraqi uprising against the occupation as outlaws, terrorists, ex-Ba’athists and foreign elements (and, I might add, the rhetorical tactic of contrasting them with ‘Iraqis’ and ‘the Iraqi people’) goes largely unquestioned. In fact, it is the US that is more in the role of the Saddam-era ‘Ba’athist’ counter-revolutionary crushing of popular resistance to its rule. In a similar vein, al-Sadr is perennially labelled a ‘rogue cleric’ and his forces always referred to as a ‘renegade militia’, Allawi’s puppet regime in Baghdad inevitably gets described as a ‘fledgling government’.

Note the emphasis on language. The cruelest confirmation of the Whorfian hypothesis is in political reporting — what you call something imposes subtle but firm constraints on how you think about it. (Serendipitously related: this New Scientist article). Englehardt concludes (in the should-go-without-saying category), “How the naming of embattled reality is brokered in our newsrooms and how it changes is a fascinating subject, though one you’re unlikely ever to find discussed in the press itself.”

The first part of Englehardt’s piece, from last week, is also quite worth reading if you missed it:

This is written by a professor of law and an ‘advisor to the MIT Security Studies Program’, whatever that is. The only problem is, they sound like they did not consult a psychiatrist or neuroscientist before going off halfcocked. The lie-detecting functions of brain imaging techniques which they describe are quite fanciful, whether the Pentagon is funding research into their interrogation applications or not. And the SSRI antidepressants do not do anything to ‘reduce…the urge to deceive’ as they assert! Far from it; they probably improve a subject’s resistance to fear-based interrogation techniques and give the subject a higher pain threshold. Moreover, if they could do what the authors assert they do, the ethical dilemma would be much like that around ‘kinder gentler’ ways of executing condemned prisoners which require physicians to violate their Hippocratic oath against “first doing no harm”. The techniques the authors allude to would, in my opinion, undermine American values no less than the torture and abuse American interrogators currently use. Finally, there is nothing to indicate that the jingoistic thug types who conduct debriefings of the demonized adversaries we come up against, when faced with a spectrum of choices of techniques, would choose the less abusive, less invasive ones for any reason. After all, new interrogation methodologies do not supplant old ones….

At staged “Ask President Bush” events, audience members have to pledge their allegiance to his reelection to gain admission. Bush has forgotten who’s sovereign in America. — Sidney Blumenthal (Salon)

Programs that may behave differently in Windows XP Service Pack 2: Many who use WinXP can be forgiven for the temptation to apply Service Pack 2, especially if they are reading any of the media paeans to how indispensible it is. The Washington Post technology pundit went so far as to proclaim that any computer manufacturer who doesn’t upgrade the Windows installs they provide with new machines to SP2 isn’t fit to market PCs. What SP2 is supposed to do is largely to close interconnectivity security holes (it turns on the Microsoft firewall by default… duh!) and (finally! they decry) add popup-blocking to Internet Explorer. However, before you decide to apply SP2, read the list of programs which may ‘behave differently’ (read: ‘stop working’?) afterwards. While there are alot of games on the list, such heavyhitters as Symantec and McAfee products, Nero Burning ROM, the ZoneAlarm woftware firewall, Adobe Pagemaker, and many of Microsoft’s own Office components can also be found there. So I don’t think I’ll be applying the upgrade after all, especially since I already use effective ways of protecting myself in the manner Microsoft boasts of doing with SP2 — the aforementioned ZoneAlarm (plus a hardware firewall) , both server- and client-based spam blocking, and the built-in pop-up blocking in the Mozilla and Firebird browsers. No matter how improved Internet Explorer is, why bother?

And the reports that will emerge of what Microsoft has inevitably ‘broken’ in implementing this ‘fix’ are probably just beginning. [Yes, yes, I know, this whole discussion is really irrelevant, since the real issue is that Microsoft’s OS is such an imperfect creature overall, and those of you out there using Linux or OS-X are sitting there smirking smugly…]

Agre goes on to elucidate the deceptions at the core of conservatism, which become increasingly desperate and at times subtle in a society predisposed toward egalitarianism. I particularly like his take on the ‘mockery of conscience.’ Agre’s laundry list of how to defeat conservatism deserves to be studied by anyone with any interest (read it in full; he elaborates convincingly on every point):

• Rebut conservative arguments
• Benchmark the Wall Street Journal
• Build a better pundit
• Say something new
• Teach logic
• Conservatism is the problem
• Critically analyze leftover conservative theories
• Ditch Marx
• Talk American
• Stop surrendering powerful words
• Tipper Gore is right
• Assess the sixties
• Teach nonviolence
• Tell the taxpayers what they are getting for their money
• Make government work better for small business
• Clone George Soros
• Build the Democratic Party

Apparently, security screeners on the Staten Island Ferry are trying to confiscate ‘inappropriate’ books as security threats. As did the writer, perhaps you ought to put the ACLU’s phone numbers in your phone book and carry a printout of relevant parts of the Bill of Rights…and pray things are different after Inauguration Day. But at least for those of you in the New York area, expect the ridiculousness, outrage and offense quotient to rise at least until after the Republican convention.

Glad I’m a fountain pen devotee. (The Economist)

‘Gene banking and cloning of exceptional pets’; they claim their first two cloned cats were born in June, 2004, and predict dog cloning will be available next year. Before you ask, yes, I and my family are fervent lovers of dogs and cats and always have any number of each around, but I join adam, who sent me this link, in thinking this is an extraordinary waste of resources.

Craig is back (and he still has that picture of Warren Zevon up next to his own at the top of the page!).

Kristof suggests four things we should be doing about this:

• secure fissionable nuclear materials around the world
• a serious commitment to nonproliferation. With regard to North Korea and Iran, where the danger is greatest and where it mihgt be too late, extreme concessions are necessary to bribe them into giving up their nuclear aspirations
• vigorous and targeted ‘homeland security’ measures to prevent the smuggling of nuclear weapons or their components into the US
• “Finally, Mr. Bush needs to display moral clarity about nuclear weapons, making them a focus of international opprobrium. Unfortunately, Mr. Bush is pursuing a new generation of nuclear bunker-buster bombs. That approach helps make nukes thinkable, and even a coveted status symbol, and makes us more vulnerable.”

Kerry’s comment that he would wage a “more sensitive” war on terrorism came in for ridicule from Bush’s attack dogs, especially Cheney and his wife. Yet Kerry was prepared with chapter and verse of Bush’s own references to the need for sensitivity in prosecuting the war. (Washington Post) Two of Bush’s comments struck me. First, there is this, from 2001:

“Precisely because America is powerful, we must be sensitive about expressing our power and influence. Our goal is to patiently build the momentum of freedom, not create resentment for America itself.”

Can Bush really think this is what he has been doing since??

And this comment is getting alot of press, as it should:

“Now, in terms of the balance between running down intelligence and bringing people to justice obviously is — we need to be very sensitive on that.”

Don’t tell me I’m taking it out of context; there is no context that could make this comment sound coherent! Behind such disordered syntax is surely a mind that cannot get from point A to point B in a orderly and logical manner. Here we are in another Bush campaign, and I am starting to get worked up again about the fact that the American public don’t see, or are not alarmed by, Bush’s cognitive limitations. I thought I resolved that for myself during the 2000 campaign — Bush’s muddled thinking and inarticulateness appealed to American voters’ anti-intellectualism and intimidation by the complexities of most issues.

In an interesting piece in last month’s Atlantic, James Fallows analyzed the speaking styles of Bush and Kerry to give us a sense of what to expect in the Presidential debates. Fallows watched tapes of old campaign debates for each. Surprisingly, he felt the contrasts between Bush’s early presentation and his recent performances as Presidential candidate and since prove that Bush has deliberately remade himself into an “Aw, shucks”, befuddled, plainspeaking man in order to appeal more broadly, and that there is artifice and cunning in this strategy that the Kerry team had better be alert to. While it would explain alot, I just can’t see anyone crafting a sentence like the above by artifice.

Bush probably remade himself as a Texas rancher because — no offense meant to Texas — it was far easier for a dimwit who had never read a book in his life and spent his time at Harvard Business School smirking and blowing bubbles in the last row of the lecture hall not to feel outclassed on a Crawford ranch or among good ol’ boy oilmen than it was among his original Ivy League circles in New England. It seems more likely to me that the cunning was on the part of his handlers, not him, in elevating a stuporous man, who would not impede their own agenda, to the Presidency. One overriding example — the evidence is abundantly clear that the PNAC neo-conservatives had Iraq on their minds for a long time, as the lynchpin in their grandiose geopolitical agenda, and were easily able to hijack the post-9/11 War on Terror to their aims. For Bush’s part, the irresistable draw of Iraq served other purposes, largely unconscious, by the force of which he could be enlisted into the neo-con agenda. As well as the pitifully simplistic credo of enhancing democracy and freedom, there have been persistent suggestions that toppling Saddam Hussein largely addressed Bush’s Oedipal needs relating to his lifelong sense of inadequacy vis a vis his father. When unrecognized by an unsophisticated intellect (well known for his dismissal of “psychobabble” whenever asked to scrutinize his own motives), such unconscious dramas are often the major influences at work in someone’s behavior. As an aside, the other issue in which Dubya’s unconscious Oedipal urges to best his father will be put to use by his advisors to further their own aims is, of course, winning a second term, which Bush the Father could not do. As this seems less and less attainable, we will see — perhaps we already are, in the accumulating evidence that Bush is ‘losing it’ in public — the sort of pitiful psychodramatic desperation that is evident when the unconscious stakes are so high.

The contrast between his seeming mastery of the limited scope of Texas gubernatorial issues and his befuddlement at the range of Presidential issues is a matter of the Peter Principle, of his having been promoted far beyond his level of cognitive incompetency. (Fallows does suggest ways in which his dogged reduction of any campaign question in Texas to one of three canned responses could work there, while not on the Presidential stage.) Of course, one also needs to take into account the cognitive damage done by a lifetime of partying with cocaine and alcohol by a rich spoiled kid who never grew up.

When I have asked more discerning observers, some with much closer familiarity with Bush, whether they think he is intellectually dull, I have gotten two kinds of responses. Some people are evasive, feeling it is a matter of protocol not to disparage the Leader of the Free World in this manner. (This constraint has dominated journalistic considerations of Bush.) Others demur, pointing to evidence of what a cunning politician he is, as if this refutes my concerns. But being a politician is usually a matter of reductionistic simplification of complexities and manipulation of your interlocutors, rather than one of grasp of issues and sophisticated exchanges in conversations.

In anticipating the debates, my prediction is that you will see alot more of this incontrovertible incoherence, which is something altogether different from plainspeaking. Whether it will be recognized for the alarming evidence of an utter inability to function in a Presidential role is another matter. Wake up, America, you have to be able to think to run the country!

[Now, I know I seem to be at my best when I’m finding fault with others. I usually come off more like a shark excited by blood in the water than a bloodhound methodically tracking a scent, I suppose. Hey, sounds like a politician; except I’m working on it…]

If you had any doubts about whether these guys are in touch with mainstream American culture, look at this stunning list of the performers they are booking for NYC.

Kevin Drum comments: “Are there any depths to which these guys won’t sink? What’s next? Alleged al-Qaeda infiltration of labor unions? Email from Osama to the NAACP?” (The Washington Monthly)

Don’t expect the sort of leniency Lindh seeks from the Bush Justice Dept. before the election.

Reason interviews Barlow, former Wyoming rancher, Grateful Dead lyricist and Electronic Frontier Foundation co-founder. Barlow talks about his upcoming stint as the star of a reality TV show, his new recommendations for ‘bohemian libertarians’, digital freedom, and his recent apprehension at San Francisco Airport as a threat to national security.

The review of this fanciful book edited by “Dr. Jeff VanderMeer & Dr. Mark Roberts”, with a remarkable density of luminaries contributing, hooked me, as a physician who has written and lectured myself on unusual and controversial syndromes.

Boing boing linked to this orthopedic warning about the effects of backpacks on back health. For those of us getting school supplies ready for our children’s September return to the classroom, it is a timely advisory that deserves to be distributed widely. Although adult backs are either stronger or already ruined, it is probably not bad advice for us grown-ups either; I routinely haul around too much stuff, mostly reading material I don’t want to be stranded without. Commonsense advice often ignored: if one has a smaller pack, one’s ability to load it up is helpfully constrained. (I learned that a long time ago with respect to my mountaineering backpacks, but it has not translated effectively to my daily urban carry.)

I am glad boing boing‘s piece addended the reader’s comment on the competing hazards of shoulder bags, which may do a different sort of damage to the back by imbalancing the bearer laterally. I first got to thinking about this imbalance issue after Carlos Castaneda described a lecture his brujo don Juan supposedly gave him in A Yaqui Way of Knowledge several decades ago. This, however, emphasized the spiritual hazards of such an ‘uncentered’ way of moving through life (also criticizing Western ‘imbalanced’ sports such as tennis in the process, if I recall).

Someone’s been having a bunch of Photoshop fun.

I heard Keyes interviewed on an NPR talk show this afternoon. He had the temerity to call Barack Obama’s stand on abortion “the slaveowners’ position” and to accuse Obama of lying about favoring civil unions over gay marriage. Keyes, one of the most polemical politicians I have ever heard speak, boasted that while others’ political positions are made via assertion, his are made via argument, and then went on to make unargued assertions on every point in his conservative platform. It may have been the fault of the cowed interviewer (who could not stand up to the withering blasts of pompous articulacy from his guest) that he did not justify, explain or argue anything, but I think Keyes is so caught up in the idea of his own brilliance that he is incapable of seeing his absurdity. Let us hope the Illinois voters can tell the difference. (The first poll after he got into the race showed him trailing Obama 67-28%).

Oh, yes, Keyes was asked to justify his carpetbagging entry into the Illinois race from Maryland in light of his oft-quoted condemnation of Hilary Clinton’s run for a Senate seat in New York. In what had to be the most entertaining moment of this galling interview, he actually invoked states’ rights and the protection of sovereignty in explaining the difference — Illinois wanted him, whereas Clinton was not New York’s choice. Uhhh, Alan, it looks like it is going to be precisely the other way around…

“The full text online of a short story by Will Self from his new collection Dr Mukti And Other Tales of Woe“. (willself.org.uk)

Leading US daily admits underplaying stories critical of White House push for Iraq war (Yahoo! News)

An interesting critique of Alan Ball and Six Feet Under from critic Dale Peck who, among other things, finds it too painful to watch the characters’ stupid choices:

“The most common criticism of the show is that such high jinks are a little too reminiscent of soap-opera plotting. The critics are right, of course, but before one acknowledges that, one should also acknowledge the fact that the characters on Six Feet Under are what pollsters call “self-selecting”; in this case, a peer group of incredibly destructive people who create most of the drama in their lives. Mr. Ball’s characters choose among potential acquaintances and mates the same way doomed heroines choose between the ax and the flashlight in horror movies: They pick up the flashlight every time, so they can shine it in the face of death as it swoops down on them. This is an expression of the form, but it’s also an expression of Thanatos, by which I mean that, yes, it’s big and Greek and a little silly, but you don’t get to have one without the other. In fact, the heroine doesn’t really choose the flashlight over the ax—vision over protection, knowledge over life. Rather, death chooses her, as it eventually chooses all of us. This is the core of Six Feet Under, clumsily driven home by the high-concept funeral-home setup, yet delicately, empathically reinforced by the continued suffering of its characters. If the show is often mawkish—especially in the more outré kill scenes, which seem culled from horror movies—it also often achieves a Weltschmerz you won’t find anywhere else on TV. By which I mean that I got mad at American Beauty because it is, ultimately, a stupid story; but I get mad at the characters on Six Feet Under because they make stupid choices. And even though I know it’ll never happen, I still hope they make the right choice at some point.” (New York Observer)

But his real pain is reserved for the depiction of homosexuality and the controversial third episode of this season in which David is the victim of a heinous crime. Peck both finds the violence gratuitous and opines that Six Feet Under consistently treats gay desire as acting-out and something to be punished for. All I can say, as a viewer who finds the character development on this show to be some of the most sophisticated ever on television, is that this is an incredible demonstration of Peck’s selective attention in order to spin a yarn.

“A Lebanon County man admitted that he drank a 6-pack a day. A Pa. law required PennDot to be alerted.” (Philadelphia Inquirer )This article is doing the weblog rounds as a heinous example of Big Brother coming to the doctor’s office. I beg to differ, and I am surprised that people so uncritically have that take on the issue.

Driving under the influence is a heinous offense placing the innocent public at large at enormous risk, as any number of tragic incidents should remind us. Anyone who tells you that someone who drinks 6-10 beers a day can be trusted when they assure you that they can safely avoid driving under the influence is whistling in the dark. “I’m just a regular Joe six-pack,” the article quotes this hapless Joe as saying, and then goes on to opine that a man so large can be trusted to keep his blood alcohol level within legal limits by pacing his drinking. (The rule of thumb we are taught in our medical training is that an accurate estimate of a patient’s drinking is around twice what they admit to.) This is nothing so much as colluding in the minimization and denial that accompanies heavy drinking, a world in which, if you listen to the drinkers, no one is an alcoholic or in any way impaired by their drinking.

The problem in this case is that doctors and other professionals allow a naive notion of confidentiality to reign unchallenged in the eyes of the lay public. Preserving confidentiality always take a back seat to averting an imminent harm, but doctors entering into a treatment relationship with a new patient rarely go into the nuances of the limits and exceptions to doctor-patient privilege as they should. The problem, of course, is the fear that an accurate description of the situations in which a doctor will violate her patient’s confidence will have a chilling effect on patient honesty. So what is most common, instead, is a blanket assurance that anything said in the office will remain confidential. <

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While the article takes pains to inform us that only six states have laws requiring doctors to report unfit drivers to the motor vehicle authorities, the ethical and public health burden lies no less heavily on the physicians in the other forty-four states, IMHO. To complain that including alcohol abuse as a reportable offense without adequately defining what constitutes abuse is unfair ignores the fact that this achieves precisely what it should — to allow a doctor to exercise her professional judgment on whether an impairment ensues from her patient’s pattern of use. This, I think, is far preferable to codifying inflexible criteria in nonnegotiable laws. It is pitiful to hear the psychiatrist and medical ethicist quoted in the article complain that the judgment of the individual physician opens the way to arbitrariness and relativity. It is a sorry reflection on the state of modern medicine that the call for standards is really the stalking horse for a phobic avoidance of relying on one’s own professional judgment. In this vein, those whose license is revoked can, in Pennsylvania and elsewhere, get their license back on a doctor’s say-so that they are safe to drive. The sobering (forgive me) effect of a wrongful death lawsuit if a physician restores a license to someone who later commits vehicular homicide while drunk will surely be a more effective hedge against the physician taking her obligation frivolously than many other incentives!

The other apparent failing of the physician in this case was in doing the mandatory reporting and springing the license revocation on the patient as a surprise. When I am faced with a competing harm-avoidance need that supersedes the confidentiality right of a patient of mine, the first thing to do is to talk about it with my patient, not the last! This goes a long way toward avoiding the potential sense of betrayal, enhancing the patient’s insight about the risk they are presenting and may well have been denying. Equally important, one encourages the patient to take preventive action themselves — installing a breathalyzer ignition interlock or cutting down significantly on one’s alcohol are both discussed in this article — and maintain their control and dignity, rather than making it a matter of law enforcement at all.

The situation in which violating a patient’s confidence comes up most often for me is not reporting a patient as a potentially unsafe driver but the so-called Tarasoff duty — to warn a prospective victim or take other appropriate harm-avoidance measures if I have learned in confidence that a patient of mine intends to do harm to a specific other individual. But in discussing my considering doing so, the patient will often choose to preempt my plan and take measures themselves to diffuse the risk, certainly a far more therapeutic outcome.

The article’s conclusion is further confused, suggesting that the incident led the man to cut down on his alcohol abuse “not just to get (his) license back” but for his health. While this may have been a by-product of the situation described, I hope the reporter who wrote this story is not suggesting that the benefits to the man’s health justified the means. The end that justifies the means here is the enhancement of public health and safety, not that of the individual.

What may hang in the balance is literally nothing less than whether talk therapy survives as an accepted treatment for emotional distress. Increasingly, the insurance companies that pay for treatments demand “evidence-based” proof of their efficacy, and research into the effectiveness of psychotherapy over the past decade has led to the ascendency of cookbook approaches which are easily standardized and controlled. The increasing penetration of this instruction-manual approach, even into some topnotch clinical psychology training programs, has stimulated outrage.

“Some therapists say that the healing they offer in their offices every day is too complex to be captured in standard studies, and that having to justify it to a third party is a breach of patient privacy. They argue that to insist on proof that a therapy works denies many people adequate treatment, or the forms of treatment that they most need.”

The empiricists insist that the move to evidence-based treatment has augmented the credibility of the field. Indeed, to the extent that it serves as a basis to differentiate reputable treatment from fringe therapies promising miraculous and instant results, it is tempting to agree. But the more crucial threat of evidence-based treatment is that it will take the art, the inspiration and inventiveness, the empathy and sensitivity out of treatment techniques that depend on them. The more crucial differentiation it achieves, at least in the eyes of the third-party payors, is from the open-ended exploratory treatment such as psychoanalysis, already a dying art because the only clientele who can afford it are the worried affluent self-paying. While various psychotherapeutic approaches — from the interminable self-indulgent open-ended to the structured problem-centered evidence-based to the brief and ultrabrief focused interventions to the unsuitability for any psychotherapy at all — ought to be stratified by the nature of the patient’s clinical presentation, severity and desire to change, insted they are coming to be stratified entirely by ability to pay and extent of insurance coverage.

Some therapists worry about the threat of lawsuits if they depart from “accepted” techniques. How about the threat of lawsuits if they refrain from using their inventiveness and creativity and tailoring the treatment to the unique requirements of each therapy client? There are precedents for a malpractice judgment when a therapist does not utilize a technique which is the standard of care for a given mental health problem. Studies cited in the article are only a small sampling of what used to be the consensus (in a generation of psychotherapy outcome studies designed by thoughtful ingenious competent researchers rather than beancounters) that it is the therapist’s competence, rather than anything about the specific technique she uses, that most closely correlates with therapeutic success. Instead, the new paradigm threatens to impose techniques, in the interest of being able to measure and replicate success, which mitigate against success. But at least the insurers will be able to economize on mental health treatment.

And, turning from psychotherapy to the care of the severely, chronically, mentally ill, here is an example of society’s treatment of them. (New York Times ) Believe me, obtaining redress as some of the clients mentioned in this story do is by far the exception.

The wonderful but, of course, quite fanciful Capitol Hill Blue is reporting that Bush is taking ‘powerful anti-depressant drugs’ to control his erratic behavior, depression and paranoia.’ The source of the report is not made clear beyond citing unnamed ‘White House sources’, but the ‘powerful’ drugs have reportedly been prescribed by Presidential physician Col. Richard Tubbs MD after the July 8th debacle, which I mentioned here, in which Bush stormed off stage after reporters questioned him about his relationship with the indicted Kenneth Lay. Added details of that incident are offered:

“Keep those motherfuckers away from me,” he screamed at an aide backstage. “If you can’t, I’ll find someone who can.”

This piece suggests that the unidentified drugs “can impair the President’s mental faculties and decrease both his physical capabilities and his ability to respond to a crisis, administration aides admit privately.”

The article draws heavily on the armchair diagnosis of Bush offered by psychiatrist Justin Frank in his recent book, Bush on the Couch: Inside the Mind of the President, which I have criticized and others have more thoroughly savaged. Frank’s book and the comments of several prominent psychiatrists who share his concerns about the President’s mental stability are the closest the article comes to citing an authoritative source. But, notice, those sources have nothing to say about the drug prescriptions. All that Frank is ‘confirming’, in the words of the article, are ‘increasing concerns’ about Bush’s ‘mood swings’ and outbursts.

I will reiterate that, while I feel diagnosis of a public figure without having a treatment relationship with that individual is irresponsible and unethical, I feel that expressing concern from a professional vantage point, from which certain signs of instability may be clearly recognizable, is abidingly in the public interest. What this calls for is transparency about the mental health of a leader such as the President, much as his physical health is a matter of public record. Of course, we are vanishingly far from that transparency, and left to vain speculation.

I can say as a psychopharmacologist that, if these reports are true rather than scurrilous propaganda, the article is painting certain unwarranted and irresponsible implications. First of all, if it is really an anti-depressant that is being prescribed, these medications do not impair one’s mental faculties or ability to respond in a crisis except in very limited respects:

• Some are sedating and sleep-inducing; while the anti-depressant benefit exerts itself round the clock, the sedation only occurs for a limited time after a dose is taken. The sleep improvement and overall benefit from an effective anti-depressant actually usually enhances daytime cognitive efficiency.
• Some SSRI antidepressants have been described as causing a tongue-tied feeling or word-finding difficulties. How one would know in George Bush’s case is a real question…
• Certain anti-depressants, by figuratively giving the user a thicker skin and stopping things from getting to them quite so much, can reduce motivation in someone who is largely driven by perfomance anxiety. Do we really think it is plausible that Bush is worried by not doing a good job?

No medical professional would describe one anti-depressant as more ‘powerful’ than another; it is simply not an adjective that is usually applied to this class of medications. All are equally ‘powerful’ when used correctly. None are second-rate in comparison to othes that are first-rate. And while one should properly refrain from using other medications with addiction and abuse potential (such as anti-anxiety medications) in those with a history of alcohol abuse and other substance abuse problems such as Bush’s, this is not a concern with anti-depressants.

If the term ‘paranoia’ is being used in an accurate clinical sense, this is not something that would be benefited by an anti-depressant either. Perhaps the President is being given an anti-psychotic (instead or in addition?), which would be the proper medication to target a psychotic symptom such as frank paranoia and which would more warrant the concerns about impairing mental capacities and responsiveness. Or perhaps he is receiving a benzodiazepine (Valium-like) anti-anxiety medication, although these would tend to disinhibit rather than contain his outbursts? Or a mood stabilizer, which might benefit emotional reactivity, impulsivity, irritability and outbursts, but might also dull mental acuity at least at the outset.

In any case, my suspicion all along has been that Bush is a figurehead, a creature of his handlers. This rumor, if true, may be just the latest technique of a vast repertoire being used to manage a puppet who was never qualified to rule and has never been leading in reality. If so, we need not worry about any further impairments in his mental acuity or capacity to handle crises. They will continue to be handled by the people behind the scenes just as well as they have been since his Cabal seized power three years ago.

The Revival of Disgust and Shame in the Law: While the effort is made to make the law impartial and unprejudicial, that does not mean that some emotions — e.g. compassion — do not have a role in legal affairs. Emotion is not inherently opposed to reason insofar as it is in the service of evaluation. But the role of some emotions — notably disgust and shame — in the law is more controversial, while enjoying a remarkable revival in our society.

Penalties based on shaming encourage stigmatization of offenders by encouraging us to view them as “disgraced or disgraceful.” This is in contrast to other democratic trends which discourage stigmatization and guard against shame, typified by the treatment of people with disabilities. Should the law protect people from insults to their dignity or shame them? Do criminals forfeit their right to these human dignities?

Disgust serves as the primary or sole reason to make some acts illegal; many standards for obscenity, for example, depend on the disgust of the average viewer, and similar principles underlie laws against homosexual relations between consenting adults. Disgust of the judge or jury also acts as an aggravating factor, and the disgust of the perpetrator as a mitigating factor, in considering penalties for acts already illegal on other grounds.

The theoretical grounds for these expanded roles for disgust and shame are scant. Shame-based penalties are frequently defended as expressions of shared values. This leaves much room to target people who make the dominant majority uncomfortable. Making acts illegal simply because of the disgust of the majority is justified, mostly but not exclusively by social cosnservatives, as defending society’s integrity against threat. [This explains — but does not justify, of course — the otherwise puzzling assertions of opponents of gay marriage that they are defending the institution against destruction.]

Disgust, although a primitive and evolutionarily conserved emotion which defended our forebears against noxious environmental threats, is nevertheless greatly shaped by social training and cognitive set. Nussbaum states that the essence of disgust is “shrinking from animality and mortality”. It is distinct from the merely dangerous — dangerous things can be tolerated and not abhorred if one stays clear of the danger, and disgusting things remain disgusting even when their danger is removed (Most people would not eat a sterilized cockroach; would you?). If what we are disgusted by serves to define our humanity as distinct from the animal, it has been used historically to define certain groups — Jews, women, foes during wartime — as subhuman.

Nussbaum sees this at work in what she calls “the central focus of disgust in today’s United States”, male loathing of the male homosexual.

So does this give us a legitimate basis to shape laws? Given that disgust is distinct from danger and indignation, should laws really be based on “the symbolic relationship an object bears to our anxieties” rather than protection against substantive harms? or, worse yet, on a confused indiscriminate mixture of these distinct types of aversion?

Shaming, the desire to stigmatize others, arises from our own insecurities, and human insecurity is inevitable, since we are at the mercy of a world which is uncontrollable and contingent.

Feared or threatening dissident groups are often conceived of as “deviant” and seen as destabilizing core moral values, even when the dissidents do not represent a realistic threat. [Again, the debate over gay marriage is readily seen through this lens.] A society based on nonstigmatizing equality is one in which grandiose fictions of perfection and control are given up.

Yet, Nussbaum concludes, even if unattainable it can be held up as a Platonic ideal, and it is worthwhile to “make sure that our laws are the laws of that community and no other.” — Martha Nussbaum, professor of law and ethics in the philosophy department, law school, and divinity school at the University of Chicago (The Chronicle of Higher Education)

“Martin Mubanga, from Neasden, is using a mixture of slang and patois in his letters home to describe the conditions in Camp Delta.” The US is shot in the foot not only by its cultural and linguistic ignorance about the Middle East but of the “unique mixture of London street slang, Cockney, Jamaican patois and rap lyrics” used by a British Guantanamo detainee. (Independent.UK)

Thirty years since Nixon slinked off in ignomy. (Salon)

“Tips from Bobby Fischer” (Slate)

“RealPoetik is the little magazine of the vernacular, quotidian, witty and postmodern. Think of it as an attempt to invent an english lit (small e) for the last decade of the Twentieth Century. And the beginning of the Twenty First… [See archives from 1996-2003 by navigating to the site.] Send us your tired, your piss poor, your cynical, demoralizing, boring, quotidian postmodernist rants. Go ahead. Make our day.

To subscribe to the email version of RealPoetik send email to majordomo@ scn.org, no Subject:, and a single line of text which reads: subscribe RealPoetik Your Name (please note spelling of rpoetik).”

“MoveOn PAC asked their members who voted for Bush in 2000 to talk about why they are voting for Kerry in 2004. Academy award-winning documentary film director Errol Morris interviewed these former Bush voters on camera, and cut seventeen ads that tell their stories. These stories of disaffection are powerful statements about the failed Bush presidency.” You are invited to view and rate the ads for MoveOn; the highest-rated ads will be aired during the Republican convention.

It has previously been known that the male:female birth ratio increases under favorable conditions, where a population is well-nourished and without adversity, while the balance tips toward females under harsher conditions. This will be to the advantage of the survival of the population as a whole, maximizing procreative chances under stressful conditions. Having less boys than girls when one does not rate one’s chances of a long life would seem to be the psychological equivalent, or parallel, to this.

Evolutionary biologists call this the Trivers-Willard hypothesis. It suggests that when a mother feels under pressure, from anything ranging from poor health and living conditions to scarce food, it makes biological sense for her to give birth to a girl rather than a boy.

“Having females is a safe investment, in that their reproductive success is consistent,” Dr Johns said. “Boys are more risky. They are more likely to die young, and if they don’t, they have to compete for females. They could potentially provide you with lots of grandchildren, but unless you can invest in them, you run the risk of having a ‘dud’ that doesn’t produce any at all.”

But if you want to conceive a girl, should you go around meditating on a short lifespan? While there have been some studies showing that the X-chromosome-containing sperm which will give rise to a female when they fertilize an ovum are hardier than y-containing sperm, it is not as if your outlook influences which type of sperm has the swimming advantage or anything like that. It is more likely that stress levels act through producing subtle shifts in the hormonal context of the conception and gestation.

On the other hand, in the current study, it may not be that believing you will live longer produces more male offspring at all. Couldn’t it just as well be that having given birth to a boy somehow influences you in the direction of a longer estimated lifespan? In a male-centric society, moght not one unconsciously assess one’s chances of being well taken care of in old age as better if one has a son?

“What can studies of pornography, prostitutes, and seedy truck stops contribute to society?” (Discover)