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How hospitals are killing E.R. patients

“Despite increasing evidence that crowded E.R.s can be hazardous to your health, hospitals have incentives to keep their E.R. patients waiting. As a result, there has been an explosion in E.R. wait times over the past few years, even for those who are the sickest.

…E.R. boarding allows hospitals to insulate themselves from the burgeoning needs of the poor. E.R.s are safety nets: By law, we who work in them see any and all patients, regardless of their ability to pay. But as more E.R. beds are devoted to boarders, the E.R. has less space for new patients, which keeps a lid on the number of un- and underinsured. So unless you are having a heart attack and can jump the line, your emergency—though it may still be serious—may wait for so long that you give up and go home. Bad for you, good for the hospital’s bottom line. ” (Slate)

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How hospitals are killing E.R. patients

“Despite increasing evidence that crowded E.R.s can be hazardous to your health, hospitals have incentives to keep their E.R. patients waiting. As a result, there has been an explosion in E.R. wait times over the past few years, even for those who are the sickest.

…E.R. boarding allows hospitals to insulate themselves from the burgeoning needs of the poor. E.R.s are safety nets: By law, we who work in them see any and all patients, regardless of their ability to pay. But as more E.R. beds are devoted to boarders, the E.R. has less space for new patients, which keeps a lid on the number of un- and underinsured. So unless you are having a heart attack and can jump the line, your emergency—though it may still be serious—may wait for so long that you give up and go home. Bad for you, good for the hospital’s bottom line. ” (Slate)

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Exposed: Harvard Shrink Gets Rich Labeling Kids Bipolar

“Meet the man who got rich by popularizing bipolar disorder for children. Congressional investigators and the NY Times expose the scandal.” (AlterNet)

This is part of what makes me despair about my profession. From my position in the trenches in Boston psychiatry, you have to take my word for how influential Biederman’s influence has been on diagnostic and therapeutic practices… and how few clothes I have always thought the Emperor was wearing.

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The Science of Happiness: Is It All Bullshit?

Just because a Harvard academic says something is so, doesn’t mean it is. ‘A “Daily Show” interview that hit a chord for me was Jon Stewart’s conversation with Tal Ben-Shahar, who teaches “positive psychology” at Harvard and has written a self-help book. Early in the interview, a suspicious Stewart declares, “I am a psychology major, so I know a lot of it is bullshit.”

Stewart, however, politely gives Ben-Shahar a chance to explain the value of his book and his course on positive psychology. Ben-Shahar is proud that his course is the most popular one at Harvard, to which Stewart gets an audience laugh by suggesting that perhaps the real reason it is so popular is because it is easy. This results in a nervous laugh from Ben-Shahar, who retorts that his exams are “actually quite difficult.” Ben-Shahar then explains that there is now a “science of happiness” and offers a study to prove it, but an unimpressed Stewart quips, “How is that science?”

Finally, Stewart is no longer able to restrain his amazement that platitudes are considered profound at Harvard nowadays (the “Six Happiness Tips” on Ben-Shahar’s website are about acceptance of negative feelings, positive attitude, meaningful activities, being grateful, simplifying life and physical health). Stewart ends the interview in Groucho Marx fashion by saying, “It’s a fascinating subject and one that I can’t believe you are getting away with.” ‘ (AlterNet)

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Esquire Print Mag Will Use E-Ink Cover

“The [issue of Esquire that hits the newsstands in September] will have an e-ink cover. 100,000 of the total 720,000 print run will be assembled by hand, with parts criss-crossing the globe before ending up newsstands, jumping out at your eyes with shifting images.

Esquire first thought up the idea eight years ago, but the technology was still too clunky. Since then, the Kindle has gone on sale, and the same company that invented the tech used in Amazon’s device — E Ink — is making the covers. The price, although undisclosed, is prohibitive, and Ford has been brought in as a ‘sponsor’: A moving car ad will appear on the inside cover. Esquire even had to design a battery (a ‘six-figure investment’) that was small enough to fit into a magazine and keep things running until the mags are sold. The batteries will last for 90 days.” (Wired)

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Obama is saying the wrong things about Afghanistan

Juan Cole in Salon:

“Barack Obama’s Afghanistan and Iraq policies are mirror images of each other. Obama wants to send 10,000 extra U.S. troops to Afghanistan, but wants to withdraw all American soldiers and Marines from Iraq on a short timetable. In contrast to the kid gloves with which he treated the Iraqi government, Obama repeated his threat to hit at al-Qaida in neighboring Pakistan unilaterally, drawing howls of outrage from Islamabad.”
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Why you should not drive in Rhode Island

R.I. police say man had 0.491 blood alcohol level… reportedly the highest ever recorded in someone who was not dead highest ever recorded in Rhode Island in someone who was not dead. (SFGate via boing boing)

Effects of alcohol in terms of blood alcohol concentration (BAC) (drugrecognition.com)

* 0.03 BAC – Slowed reaction time.
* 0.04 BAC – Federal prohibited limit for commercial drivers license.
* 0.05 BAC – Increased risk taking and American Medical Association recommended prohibited limit.
* 0.08 BAC – Recommended prohibited limit for criminal charges and impaired vision.
* 0.10 BAC – Poor large muscle control, loss of balance, and prohibited limit in most states.
* 0.17 BAC – National average blood alcohol level of drivers in a fatal crash.
* 0.19 BAC – National average for first time DUI offender and of persons who have killed police officers.
* 0.20 BAC – Loss of emotional control.
* 0.22 BAC – National average for repeat DUI offenders at time of arrest.
* 0.30 BAC – Loss of orientation as to time and place.
* 0.35 BAC – Blackouts and stupor.
* 0.50 BAC – Published overdose level leading to death.
* 0.74 BAC – Highest recorded blood alcohol level by a US hospital.
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Jenny Diski Tries to Stay Awake

“If you set aside the incomparable cruelty and stupidity of human beings, surely our most persistent and irrational activity is to sleep. Why would we ever allow ourselves to drop off if sleeping was entirely optional? Sleep is such a dangerous place to go to from consciousness: who in their right mind would give up awareness, deprive themselves of control of their senses, volunteer for paralysis, and risk all the terrible things (and worse) that could happen to a person when they’re not looking? … Apart from the dangers of letting your guard down, there’s the matter of time. Instead of trying to extend the life of human bodies beyond their cellular feasibility, the men and women in lab coats could be studying ways to retrieve all the time we spend asleep.” (London Review of Books)
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The social psychology revolution is reaching its tipping point

“…[A]n intellectual revolution is under way that will change the way we think about public policy just as the free market economists did in the 1980s. I wonder whether one day soon a future party leader will turn round to his agent and say: “Finally, I’ve got it! Human behaviour.”

Those who doubt that there is something going on in the world of ideas should get themselves a publisher’s catalogue. One month there is a book called Nudge, the next a book called Sway. A volume called Predictably Irrational follows another called Irrationality. Since the success of Malcolm Gladwell’s Tipping Point, books on tipping points have reached a tipping point.

Behind this publishing explosion, with its PR hoopla, is real and solid intellectual progress. It comes from two streams of thought, developing alongside each other. The first is the idea of evolutionary psychology… The second stream of thought is behavioural economics. For twenty years now, some economists have been looking at the psychology of economic decision-making. Instead of seeing humans as rational calculating machines, behavioural economists have been conducting experiments to assess how real choices are made…” (Times of London)

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Gone, and Being Forgotten

“How is it that Freud is not taught in psychology departments, Marx is not taught in economics, and Hegel is hardly taught in philosophy? Instead these masters of Western thought are taught in fields far from their own. Nowadays Freud is found in literature departments, Marx in film studies, and Hegel in German. But have they migrated, or have they been expelled?” (The Chronicle of Higher Education)
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Admit it, you’re as bored as I am

Joe Queenan: “Having spent most of the last century writing music few people were expected to understand, much less enjoy, the high priests of music were now portrayed as innocent victims of the public’s lack of imagination.” (Guardian.UK)

Queenan objects. I pity him his boredom…

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Reentry

Reversing Mass Imprisonment: “For the first time in decades, political leaders seem willing to consider the toll of rising incarceration rates. In October last year, Senator Jim Webb convened hearings of the Joint Economic Committee on the social costs of mass incarceration. In opening the hearings, Senator Webb made a remarkable observation, “With the world’s largest prison population,” he said, “our prisons test the limits of our democracy and push the boundaries of our moral identity.””(Boston Review)
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The motivation for blocking investigations into Bush lawbreaking

Glenn Greenwald writes in Salon: “With regard to illegal Bush programs of torture and eavesdropping, key Congressional Democrats were contemporaneously briefed on what the administration was doing (albeit, in fairness, often in unspecific ways). The fact that they did nothing to stop that illegality, and often explicitly approved of it, obviously incentivizes them to block any investigations or judicial proceedings into those illegal programs.”
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Pathologists Believe They Have Pinpointed Achilles Heel Of HIV

It would be very nice if this pans out: “Human Immunodeficiency Virus (HIV) researchers at The University of Texas Medical School at Houston believe they have uncovered the Achilles heel in the armor of the virus that continues to kill millions.

The weak spot is hidden in the HIV envelope protein gp120. This protein is essential for HIV attachment to host cells, which initiate infection and eventually lead to Acquired Immunodeficiency Syndrome or AIDS. Normally the body’s immune defenses can ward off viruses by making proteins called antibodies that bind the virus. However, HIV is a constantly changing and mutating virus, and the antibodies produced after infection do not control disease progression to AIDS. For the same reason, no HIV preventative vaccine that stimulates production of protective antibodies is available.

The Achilles heel, a tiny stretch of amino acids numbered 421-433 on gp120, is now under study as a target for therapeutic intervention. Sudhir Paul, Ph.D., pathology professor in the UT Medical School, said, “Unlike the changeable regions of its envelope, HIV needs at least one region that must remain constant to attach to cells. If this region changes, HIV cannot infect cells. Equally important, HIV does not want this constant region to provoke the body’s defense system. So, HIV uses the same constant cellular attachment site to silence B lymphocytes – the antibody producing cells. The result is that the body is fooled into making abundant antibodies to the changeable regions of HIV but not to its cellular attachment site. Immunologists call such regions superantigens. HIV’s cleverness is unmatched. No other virus uses this trick to evade the body’s defenses.”…

Paul’s group has engineered antibodies with enzymatic activity, also known as abzymes, which can attack the Achilles heel of the virus in a precise way. “The abzymes recognize essentially all of the diverse HIV forms found across the world. This solves the problem of HIV changeability. The next step is to confirm our theory in human clinical trials,” Paul said. ” (Science Daily)

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Kafka Dept.

Terrorist Watch List Hits One Million Names: “The nation’s terrorist watch list has hit one million names, according to a tally maintained by the American Civil Liberties Union based upon the government’s own reported numbers for the size of the list.

‘Members of Congress, nuns, war heroes and other ‘suspicious characters,’ with names like Robert Johnson and Gary Smith, have become trapped in the Kafkaesque clutches of this list, with little hope of escape,’ said Caroline Fredrickson, director of the ACLU Washington Legislative Office.” (American Civil Liberties Union)

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eBay listing offers Bigfoot Hunting services

Bigfoot, Sasquatch, Yeti, will search for and find – eBay (item 260259571943 end time Jul-16-08 15:13:16 PDT): “With all the stories and rumors surrounding the legend of Bigfoot,I think it is time to have the right person hunting (searching) for the real answers.Most of the Tv shows,books,and articles covering the search for Bigfoot are a joke.Nothing but pure amatuers.Most searches involve people setting up trail cameras,etc.,in stationary settings,this is totally the wrong approach.My methods would be covering lots and lots of territory in very remote country.I have been a big game hunter nearly all of my life and am an experienced big game hunting guide and am currently employed by a big game hunting outfitter in Wyoming.Contact me if you would be interested in funding an expedition that will get results.” [via boing boing]
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In Japan, Buddhism May Be Dying Out

“The Japanese have long taken an easygoing, buffetlike approach to religion, ringing out the old year at Buddhist temples and welcoming the new year, several hours later, at Shinto shrines. Weddings hew to Shinto rituals or, just as easily, to Christian ones.

When it comes to funerals, though, the Japanese have traditionally been inflexibly Buddhist — so much so that Buddhism in Japan is often called “funeral Buddhism,” a reference to the religion’s former near-monopoly on the elaborate, and lucrative, ceremonies surrounding deaths and memorial services.

But that expression also describes a religion that, by appearing to cater more to the needs of the dead than to those of the living, is losing its standing in Japanese society.” (New York Times)

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The Outquisition: Post-apocalypse without the militias

Cory Doctorow: “WorldChanging’s Alex Steffen and I sat down last week for a cup of coffee and got to talking about post-apocalyptic life. I noticed that while there’s a whole ton of stories — and people who emulate them — about heavily armed survivalists bravely holding off the twilight of civilization after the Big One, there are damned few stories about super-networked post-apocalyptic Peace Corps who respond to the Great Fall by figuring out how to put it all back together. I even came up with a name for it: the Outquisition; the opposite of the Inquisition — missionaries who come to your town to remind you of how awesome it can all be, leave behind a bunch of rad, life-improving systems and tools, and generally get on with the business of being happy, well-fed and peaceful.

Alex wrote up a great post about this and 24 hours later, some WorldChanging readers created Outquisition.org. I’m not sure what they’ll do there, but in my dreams, they’re off building a non-secret society of emergency-preparedness Nice People who think that the response to catastrophe isn’t lifeboat rules and militias, but humanitarian aid and kick-ass tools.” (Boing Boing)

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Rethinking psychosis

The disadvantages of a dichotomous classification now outweigh the advantages. “Recent molecular genetic findings have demonstrated very clearly the inadequacies of the dichotomous view, and highlighted the importance of better classifying cases with both psychotic and affective symptoms.” (PubMed abstract)

As readers of FmH know, I have always been a psychiatric classificatory skeptic. In particular, the attempt to decide whether a patient presenting with psychotic symptoms has a schizophrenic disorder or an affective psychosis has always seemed flawed to me. Rarely have I seen a patient present as a pure, unmixed exemplar of one of those categories. The central distinction between ‘thought disorder’ and ‘affective disorder’ may be specious. (Should we, in fact, rethink our dichotomization of ‘thoughts’ and ‘feelings’?)

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Prescription Narcotic Consumption

This interactive map from the Las Vegas Sun accompanies a feature article on Nevada’s no.-1 ranking in national rates of narcotic abuse. You can pick a narcotic medication and a year since 1997 and see the relative rates of consumption in the 50 states. (NB: although the map accompanies an article about drug abuse and the data on which the map is based came from the D.E.A., it details consumption and as far as I can tell does not distinguish licit from illicit use.) Some who pointed me to this map were intrigued by the regional differences in choice of particular narcotic drug. This is probably a function of regional prescribing differences among physicians, marketing and distribution decisions by drug manufacturers, and the shaping of consumer preferences largely by word of mouth. What is more interesting is the overall increase across the years listed. Is this a function of increasing abuse or dramatic increases in rates of legitimate prescribing? (All the medications listed are manufactured pharmaceuticals, not cooked up in backyard home labs.)

It would be more interesting to see this type of data for other classes of drugs of abuse as well — cocaine, amphetamines, benzodiazepines, barbiturates, hallucinogens, ‘club drugs’ etc., as well as heroin. In addition to reflecting differences in distribution patterns, such a comprehensive map might have something to say about regional lifestyle and temperamental differences. (Pet peeve of mine: many people use the term ‘narcotic’ broadly, and inaccurately, as a synonym for illicit drugs in general, or for drugs with addictive potential in general. The term means neither of these; it is synonymous with ‘opiates’.)

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‘Don’t Get in Your Patient’s Boat’

I was pointed to this New York Times article on the pitfalls of psychotherapy with the superrich from kottke. As a psychiatrist myself (who never, alas, treats the superrich), I was interested by the number of notable psychiatrists who seem to be making it their niche. True, treating the superrich overlaps with the issues, long considered very challenging in psychotherapy, of treating the very narcissistic. But the article is, I think, too polite about what I assume are added ingredients of a mix of therapists’ voyeuristic and purely mercenary interests in taking on the extremely wealthy in particular. The patients and their struggles are not inherently more interesting; in fact, they are probably less so, on the whole, despite the pat statement quoted by a therapist of the rich that she “considered a rich person’s unhappiness or emotional anguish no less serious than anybody else’s”. As the writer correctly points out, most of these patients have less of an impetus to work things through than the rest of us, and even than the rich patients of days past, more and more insulated from a recognition of personal dissatisfaction in an ever more materialistic and spiritually vacuous society as they are. Thus, a therapist treated more often as just another member of the client’s personal entourage flirts with being readily disposed of if s/he too readily emphasizes unpleasant aspects of these clients’ lives, which is after all what therapy is all about. And if the therapist refrains. s/he of necessity becomes a sycophantic supporter of self-indulgence.

In fact, arguably, psychotherapeutic practice originated with the treatment of the affluent, and the psychoanalytic style of practice inherited by those in Freud’s lineage has remained expensive, largely unreimbursed by health insurance, and only affordable by the wealthy. (Perhaps that has shaped the compelling focus of this school of treatment on narcissism as a central issue?) Only relatively recently in the lifespan of psychotherapy has it migrated down to other strata of society, its techniques and the nature and extent of the problems upon which it focuses morphing in the process. This in large measure helps to explain the two divergent cultures of the modern practice of therapy and psychiatry — the rarefied, isolated and often interminable world of the psychoanalytic psychotherapy practice, and the urgent unsystematic intensity of community mental health aimed at the lower and middle classes. Only as psychotherapy transmuted to deal with the ‘real world’ problems of the rest of us has there been an impetus to incorporate consideration of social, economic and political factors urgently impacting on patients’ lives and welfare. Ironically, only the superrich can afford the possibility of change from lengthy depth analysis, and only they can afford not to change…

Related:  While we’re on the topic of unethical mercenary behavior among psychiatric luminaries, the name Alan Schatzberg will certainly mean something to any psychiatrist FmH readers.

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‘Don’t Get in Your Patient’s Boat’

I was pointed to this New York Times article on the pitfalls of psychotherapy with the superrich from kottke. As a psychiatrist myself (who never, alas, treats the superrich), I was interested by the number of notable psychiatrists who seem to be making it their niche. True, treating the superrich overlaps with the issues, long considered very challenging in psychotherapy, of treating the very narcissistic. But the article is, I think, too polite about what I assume are added ingredients of a mix of therapists’ voyeuristic and purely mercenary interests in taking on the extremely wealthy in particular. The patients and their struggles are not inherently more interesting; in fact, they are probably less so, on the whole, despite the pat statement quoted by a therapist of the rich that she “considered a rich person’s unhappiness or emotional anguish no less serious than anybody else’s”. As the writer correctly points out, most of these patients have less of an impetus to work things through than the rest of us, and even than the rich patients of days past, more and more insulated from a recognition of personal dissatisfaction in an ever more materialistic and spiritually vacuous society as they are. Thus, a therapist treated more often as just another member of the client’s personal entourage flirts with being readily disposed of if s/he too readily emphasizes unpleasant aspects of these clients’ lives, which is after all what therapy is all about. And if the therapist refrains. s/he of necessity becomes a sycophantic supporter of self-indulgence.

In fact, arguably, psychotherapeutic practice originated with the treatment of the affluent, and the psychoanalytic style of practice inherited by those in Freud’s lineage has remained expensive, largely unreimbursed by health insurance, and only affordable by the wealthy. (Perhaps that has shaped the compelling focus of this school of treatment on narcissism as a central issue?) Only relatively recently in the lifespan of psychotherapy has it migrated down to other strata of society, its techniques and the nature and extent of the problems upon which it focuses morphing in the process. This in large measure helps to explain the two divergent cultures of the modern practice of therapy and psychiatry — the rarefied, isolated and often interminable world of the psychoanalytic psychotherapy practice, and the urgent unsystematic intensity of community mental health aimed at the lower and middle classes. Only as psychotherapy transmuted to deal with the ‘real world’ problems of the rest of us has there been an impetus to incorporate consideration of social, economic and political factors urgently impacting on patients’ lives and welfare. Ironically, only the superrich can afford the possibility of change from lengthy depth analysis, and only they can afford not to change…

Related:  While we’re on the topic of unethical mercenary behavior among psychiatric luminaries, the name Alan Schatzberg will certainly mean something to any psychiatrist FmH readers.

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Spiritual effects of hallucinogens persist, researchers report

“In a follow-up to research showing that psilocybin, a substance contained in ‘sacred mushrooms,’ produces substantial spiritual effects, a Johns Hopkins team reports that those beneficial effects appear to last more than a year.

Writing in the Journal of Psychopharmacology, the Johns Hopkins researchers note that most of the 36 volunteer subjects given psilocybin, under controlled conditions in a Hopkins study published in 2006, continued to say 14 months later that the experience increased their sense of well-being or life satisfaction.” (PhysOrg)

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Spiritual effects of hallucinogens persist, researchers report

“In a follow-up to research showing that psilocybin, a substance contained in ‘sacred mushrooms,’ produces substantial spiritual effects, a Johns Hopkins team reports that those beneficial effects appear to last more than a year.

Writing in the Journal of Psychopharmacology, the Johns Hopkins researchers note that most of the 36 volunteer subjects given psilocybin, under controlled conditions in a Hopkins study published in 2006, continued to say 14 months later that the experience increased their sense of well-being or life satisfaction.” (PhysOrg)