In an installment of Slate‘s “Hot Documents” series, a 2001 memo from Lilly’s marketing department lays out the battle plan for marketing the antipsychotic medication Zyprexa (Lilly’s brand of olanzapine). It is commonplace to observe that the health of the American people is hostage to Big Pharma these days; several important aspects of just how this has been brought about are highlighted here.

The major therapeutic advances in psychopharmacology during my professional career in psychiatry have been the development of new types of two classes of medications, antidepressants and antipsychotics, the rationale for developing which has been the notion that they are less prone to cause side effects than older antidepressants or antipsychotics, and thus far more tolerable and less complicated for our patients to take. Eli Lilly has been at the forefront of these developments with its products Prozac (fluoxetine), the first of the SSRI antidepressants, and Zyprexa (olanzapine), one of the first two new-generation “atypical” antipsychotics.

I have long ranted about prescribing trends in psychiatric medications which follow from these developments. The vast expansion in prescribing of these classes of drugs, often for inappropriate or marginal indications, and decreasing intensity of followup and supervision of their use, leads to rampant problems. These have included the highly-publicized seeming association between antidepressant prescribing and suicidality and (to a lesser extent) incidents of violence and rage; the discomfort associated with discontinuing antidepressants too rapidly; and, as the current article highlights, the epidemic of serious and supposedly unanticipated metabolic complications emerging with the use of the atypical antipsychotic medications.

A more pervasive and perhaps more serious complication than these has been the changing message we are giving our patients — that reaching for the prescription pad can replace the careful crafting of a relationship with an afflicted individual that allows them to come to grips with their life problems; that people do not need to be seen as individuals but rather merely instances of a diagnostic class; that an external agent (a doctor; a medication) can fix them with little effort on their part; that they are passive witnesses rather than active agents in their recovery and, by extension, in their lives; that there is less and less room for personal responsibility in life; that there is little value to careful diagnosis and little distinction between diseases requiring treatment and “cosmetic” personality variants one must either accept or modify slowly and painstakingly.

The leaked memo confirms what I have assumed — that Big Pharma has had deliberate and explicit strategies to persuade less qualified practitioners to prescribe these medications; to prescribe them with less care and supervision; to prescribe them for a broader range of conditions for which they are less appropriate; and to disregard the serious complications they can cause.

All of these, of course, have one goal and one goal only — to maximize profit and commodify already horribly disenfranchised patients with mental health problems. And, when the medications rather than the marketing practices are blamed for the complications and adverse outcomes that follow, mental health treatment is vilified, psychiatric illnesses further stigmatized, and suffering individuals dissuaded from seeking appropriate care that could alleviate their serious distress.

Havidol is “the first and only treatment for Dysphoric Social Attention Consumption Deficit Anxiety Disorder (DSACDAD)…” [via boing boing]

Jan Morris: “The American swagger has become bombast, the cocky GI a bully. But with luck the pendulum may be ready to swing back…” (Guardian.UK)

I am not sure if the napping is the independent variable here. It may be that people who take naps take better care of themselves in general, are less driven and more relaxed, etc. Correlation is not causation.

It is incredible that the dysadministration be allowed to get away with this yet again. First of all, the proportion of the IED-related casualties arising from the supposedly-Iranian devices is miniscule. Secondly, even if the devices in question originate in Iran, there is no evidence that Iranians have brought them into Iraq or that their use is state-sponsored. They may just as well have been bought on the black market. And wouldn’t it be in the interests of at least some of the Iraqi insurgents to turn the US’ attention in the direction of Iranian meddling? Encouraging the extension of armed conflict to Iran would further diffuse American power, bog us down even more severely and create the opportunity for a humiliating American defeat an even more humiliating American defeat than we are undergoing now.

This is one in my continuing series of posts objecting to the medicalization of everyday life, which is particularly rampant in the mental health field. Psychiatrists are taught, as the writer above alludes to, to avoid passing moral judgment on others’ souls, but what if the only other way to validate your perceptions of or reactions to the way someone does business with you is to diagnose them with a disorder?

One of my particular interests in my work is the treatment of irritability and interpersonal violence, some of which is attributable to personality disorders and some to brain pathologies. Some, but not most…

The duty of the psychiatrist is as much to know when not to treat as to treat. We have to be very careful not to contribute to the epidemic of erosion of personal responsibility for behavior in modern society. Giving someone a diagnosis can serve to let them “off the hook”; this is a relief and a service when it is appropriate but a travesty when it is not, as it often is not. How many times have I heard a patient say, “I can’t help it. They tell me I’ve got a chemical imbalance” or the like?

An essay such as Friedman’s is a bold affront to a worrisome facet of the medical status quo, to be heartily welcomed from one curmudgeon to another.

Point well-taken, but shouldn’t we be hearkening at least as far back as The X-Files and Millennium, if not Twilight Zone and Kolchak, with such concerns?

I am addicted to this stuff (although never a lover of American Southern fried chicken…).

The Army lieutenant who refused to deploy to Iraq did not fully understand a document he signed admitted to elements of the charges, the judge ruled. Watada was charged with conduct unbecoming and missing movement for staying behind when his brigade shipped out last June, as covered here. (I think war resisters deserve broad coverage, as I have explained.) Watada asserted that, because the war was illegal, his responsibility as an Army officer was to disobey his deployment order. Does any reader know if, under military law, he can face a second court-martial after the mistrial?

Should cut down on the incidence of brain tumors in New York as well as pedestrian-vehicle accidents [grin]…

“It’s a sad fact of military aviation that helicopters flying in combat are accidents waiting to happen.” They are slow, they fly low, and they have lots of external vulnerable targets. They can be brought down by small-arms fire. Most of the downings that the Pentagon is quick to assert did not result from hostile fire actually turn out indeed to have been shot down. The role of copters in the upcoming ‘surge’ remains to be seen… (Time)

Also: 

Copter Crashes Suggest Shift in Iraqi Tactics: “American officials say the streak strongly suggests that insurgents have adapted their tactics and are now putting more effort into shooting down the aircraft….Some aspects of the recent crashes indicate that insurgents have become smarter about anticipating American flight patterns and finding ways to use old weapons to down helicopters, according to military and witness reports. The aircraft, many of which are equipped with sophisticated antimissile technology, still can be vulnerable to more conventional weapons fired from the ground.” (New York Times )

I am puzzled by what I think is a specious distinction here. There are many ways to be a problem drinker. Alcoholism is an imprecise term that has little utility and serves to make people either defensive or self-satisfied. It is a common occurrence for people entering treatment for alcohol-related problems to bolster their denial with the assertion that, after all, they are “not alcoholic”. It is true, not all problem drinkers are alcohol-dependent, by which we mean physiologically addicted, needing to drink daily, going into withdrawal if deprived of access to alcohol, and requiring a medical detox to become sober. DSM-IV, the ‘bible’ of official psychiatric diagnoses, makes a distinction between alcohol dependence and alcohol abuse, but IMHO both qualify as “alcoholism”. Just my .02.

Four-year old Rebecca Riley was found dead on the floor of the family home in Hull on December 13. Prosecutors are charging her parents with first-degree murder for allegedly “regularly giving her drug overdoses, ostensibly to keep her calm and help her sleep”. (Boston Globe)

Rebecca had been diagnosed at age 2 1/2 [sic] with attention deficit hyperactivity disorder and bipolar disorder and was being medicated by a Tufts-New England Medical Center psychiatrist who was also prescribing nearly identical drug regimens for her older brother and sister. The medical center rushed to stand behind their clinician, stating

With the caveat that of course I don’t know the clinical details of Rebecca Riley’s case, I would have to say that there is at least one psychiatric colleague here in Massachusetts who questions the appropriateness of the care little Rebecca received. I find it difficult to imagine how any 2 1/2-year old could possibly be diagnosed with these disorders in the first place. As readers of FmH know, I think the field suffers from rampant overmedicalization of variant behaviors. In particular, I have vented my spleen about the irresponsible epidemic of diagnosing ADHD — there is not an epidemic of ADHD; there is one of diagnosing it! (Perhaps we ought to have a psychopharmacological treatment for disordered diagnostic practices among caregivers…) And childhood bipolar disorder, a controversial diagnosis which seems defined, Alice-in-Wonderland fashion, by little more than the fact that it does not present anything like the adult bipolar disorder with which we are familiar, is the newest abused diagnosis in child psychiatry. Then consider for a moment, even granting the validity of the diagnoses, whether one should ever medicate small children so heavily, or medicate them at all. The only possible consolation from this horrendous travesty of medical care will be if Rebecca’s death becomes a cause celebre that leads to earnest reform. Whatever aspersions one might cast on the parents’ role in their daughter’s death, this entire family should be considered poster children for the affront to human dignity that mental health diagnosis and treatment have become.

Your thoughts?

Hmm, sounds like it should be right up my alley, and in fact I find cognitive dissonance a psychological concept of crucial importance. We change our beliefs to avoid the distress of conflicting thoughts. Is it to salve our egos or to avoid agonizing over past mistakes, as the New York Times birthday appreciation poses the question? I actually think there is not much of a distinction. A sense of certainty allows us to have confidence in our minds, our ability to decipher the world and to act decisively. It is one of the foundations of effective functioning. As a mental health clinician, I see every day how devastating it is to lose confidence in the reliability of one’s own thought processes and the lengths to which people will go to avoid doing so.

Debra J. Dickerson, author of The End of Blackness and An American Story, argues that Obama is “black” rather than black, as he cannot claim ancestry from African slaves.

I have written before, here (“A New Way to be Mad”; scroll down or use your browser’s search function to find ‘apotemnophilia’) (2000) and here (“Costing an Arm and a Leg”; ditto) (2003), about apotemnophilia. It is back in the news because of this Guardian article, but it seems it has a less tongue-tying name now — BIID or body identity integrity disorder. Here are a spate of recent references (Google) under the new name. [“Squick!” — acm]

This Vancouver office building is less than 6′ wide [via digg]

“Insomniacs can take heart from a new drug that makes the brain enter a state similar to narcolepsy.” In narcolepsy, people suddenly fall asleep, probably because neurons that normally release orexins, proteins that promote the waking state, are defective. Swiss researchers have developed an orexin-receptor blocking drug which, in preliminary tests, promotes sleepiness in laboratory animals and human subjects. As opposed to current sedative-hypnotic drugs, this sleep would be more physiological, i.e. natural: “Unlike other sleeping pills, the drug also increases the time spent in REM sleep, when the brain is thought to organise memories, so it may not cause the forgetfulness and memory disruption linked to regular sleeping pill use.” (New Scientist)

“This is a list of lists of unsolved problems in various subjects” (Wikipedia). Just choose your discipline, devote the major part of your creative years to one of these questions, and retire on your Nobel Prize proceeds.

From Cognitive Daily via kottke

My family and I never tire of these, having visited a number of such sites (Roadside America ) in the US (as well as abroad). I always detour if one is within reach of our road trip route. (By the way, I subscribe to the theory that these are not-very-mysterious optical illusions.)

A weblog about mental healthcare from an investigative journalist who has been a mental health consumer.

The test is not yet commercially available, and take note that the detection rate is only around 2/3 although there is a negligible false positive rate. But it is far safer than amniocentesis as a first screen.

And:

Doctors Without Borders: “The humanitarian crises that the media isn’t covering, but should be.” (via Utne Reader)

“Scientists from across the world gathered Monday to hammer out the final details of an authoritative report on climate change that is expected to project centuries of rising temperatures and sea levels unless there are curbs in emissions of carbon dioxide and other gases that trap heat in the atmosphere.” (New York Times) The central consensus is that carbon dioxide levels in the atmosphere are reaching twice preindustrial levels as a result of human activities, and that this will result in a 3-8 degree (F) increase in ambient temperatures. Where the consensus founders is on the extent of sea level rise and coastal impact. Some climate scientists fear that existing models are too conservative, in light of recent findings about the instability of Antarctic and Greenland ice caps. Competing agendas have led to leaks of information from the upcoming reports designed to be either as frightening or reassuring as possible. (Which would you rather hear?)

Wake up and smell the coffee, Nancy: ‘In an interview, Pelosi also said she was puzzled by what she considered the president’s minimalist explanation for his confidence in the new surge of 21,500 U.S. troops that he has presented as the crux of a new “way forward” for U.S. forces in Iraq.

“He’s tried this two times — it’s failed twice,” the California Democrat said. “I asked him at the White House, ‘Mr. President, why do you think this time it’s going to work?’ And he said, ‘Because I told them it had to.’ ” ‘ (The Politico) When has Bush’s rationale for any Presidential decision ever gone beyond groundless confidence and infantile willfulness?

In the wake of the insurgent downing of a Blackwater helicopter and the execution-style killing of its crew hours before the State of the Union address, Democracy Now! interviews Jeremy Seahill, author of a forthcoming book profiling Blackwater . Does Bush’s call for a troop surge obscure a more substantial but undeclared private mercenary surge in Iraq?

“The attempts of brain damage victims to imagine falter thanks to an inability to marshal the places of the past.” (Scientific American) Bilateral damage to the hippocampus is known to cause amnesia. Now a study from the University of London found deficiencies in the abilities of five amnesiac men, compared with matched subjects, to imagine. It points to a greater role for the hippocampus in adding a temporal dimension to our experience; without its functions we exist in a timeless present. It makes a sort of sense that if you cannot have the experience of remembering a time gone by, you cannot imagine a time when the present moment will have passed. And one FmH reader [thanks, Joel] noted the resonance with T.S. Eliot:

And right action is freedom
From past and future also. (The Dry Salvages)

Steve Silberman:

In a major scoop, Silberman, who has become one of the best-informed and best-sourced reporters about neuroscience and medical topics, exposes an epidemic of multiply resistant Acinetobacter baumannii infecting wounded troops in the ‘evacuation chain’ from field hospitals in Iraq through medevac facilities to civilian hospitals in Europe and the US; it has already spread to civilian patients in those hospitals. Although the US government long maintained that the organism originated in Iraqi soil and infected soldiers wounded by IEDs, it is clear that the real culprits are the unsterile conditions and unrestrained use of broad-spectrum state-of-the-art antibiotics in US field hospitals in Iraq. Silberman does a good job of laying out the factors that continue to prevent an effective response to these issues. These include, of course, Rumsfeld’s doctrine of fighting the war on a shoestring and the military’s misuse of medical resources to keep casualties on the front lines as long as possible.

Silberman’s story is one of the Huffington Post’s “most huffed stories.” Huffit is HuffPo’s new Digg-like feature in which readers register which stories they feel are most newsworthy.

Multiply-resistant strains of bacteria are becoming a fact of life. As a physician working in a medical hospital, I am dealing with increasing regularity with patients with MRSA or C. difficile. The situation is only going to become worse as resistant bacteria’s sharing of drug resistance genes (a process which Silberman aptly likens to sharing open source software code) accelerates and we enter a fallow period in antibiotic development. There has always been an ‘arms race’ (another apt metaphor) between infectious disease organisms and medical tactics, and medicine is losing out. Could the Iraq war end up playing a major role in the end of the era of medical ascendancy over infectious disease?

After a patient who had had a stroke that damaged his insula readily and abruptly quit smoking, researchers at the University of Iowa looked at a number of other stroke victims and found that those with insular damage often quit smoking effortlessly and suddenly. (Forbes)

The emerging neurobiology of addictions (both behavioral and substance) emphasizes a two component system, one of which controls cravings and the other the satisfaction or reward associated with the addictive behavior. Separate and complementary interventions target these two components; for example, the concurrent use of the medications acamprosate and naltrexone to assist relapse prevention in recovering severely alcohol-dependent patients. The insula seems to be instrumental to the craving component.

Neuroscientists have long relished studying patients with circumscribed lesions in specific brain areas, to see which functions those areas subsume. Far more precise knowledge can be derived than the newer brain imaging techniques to study regional activation during certain mental tasks.

Rarely Seen Sea Monster Captured, Then, Following Script, Dies: “Yet another rare-freaky sea creature has made a rare-freaky video appearance — courtesy Japanese marine researchers — before being promptly declared dead.” (New York Times )

A report from Cambridge University researchers suggests that people lease clothes instead of buying them, in light of the resource impact of the textile industry. New York Times readers respond. The point seems to be to encourage reuse rather than discarding clothes. If leasing caught on, it would essentially be a piece of jiu jitsu to achieve an expansion of the second-hand clothes market. My guess is that tying the concept of leasing to the resource reuse meme will actually do little to promote it, given the intimate relationship most people have with their clothing. A P.R. campaign about the ludicrousness of buying clothes in response to everchanging notions of style foisted on consumers by the clothing industry (whether we are talking about high-end couturiers or The Gap), rather than durability and serviceability, would be energy better spent. Along with this should come efforts to encourage donation of used clothes or even the implementation of frank recycling systems similar to those in place for other resource-intensive genres of waste.

Dartmouth-Hitchcock Medical Center was overrun by the most disruptive and extensive of an increasing number of pseudo-epidemics caused by faith in rapid screening tests that ultimately turn out to be false positives — sensitive but not particularly specific.

The so-called epidemic of pertussis at Dartmouth turned out to be a spate of run-of-the-mill respiratory infections. Specific, but slower, tests failed to find any pertussis in any of the affected individuals. Proponents of the rapid tests argue that there is no way to be prepared for a potentially devastating pandemic without the risk of false positives from the rapid tests.

Researchers at Duke University have shown with functional MRI that the degree of activation of the posterior superior temporal sulcus [PSTS], a brain region activated when people observe others’ actions but not perform them themselves, correlated with personality ratings of subjects’ degree of altruism. (Hindustan Times ) This has some relationship to the ‘mirror neurons’ with which I have been fascinated and about which I have written repeatedly in FmH, which I think of as the neurophysiological basis for interpersonal empathy and — to extrapolate — socialization.

The capacity to have an interior experience upon watching someone else’s behavior similar to the experience of performing that behavior yourself may be a basis of the sense of inherent congruence between others’ feelings and thoughts and our own, the ability to have a so-called ‘theory of mind’, which is an important developmental achievement for humans. As suggested in the article, this body of work may help explicate the neural basis for certain conditions, in which I am interested in my work as a clinical psychiatrist, in which the capacity for empathy or mutuality break down, such as antisocial personality disorder or autistic spectrum disorders. (I am overwhelmed by the incident at Lincoln-Sudbury [MA] High School, down the road from my hospital, last Friday in which a student with a mild autistic-spectrum condition stabbed another student, apparently unknown to him, to death in one of the school restrooms.)

Here is what you come up with if you search on PSTS and ‘mirror neurons’ together. Two good starting point reviews of the nascent field of social cognitive neuroscience, which is built on these and similar observations and speculations, are these papers by Rebecca Saxe of MIT (Current Opinion in Neurobiology) and the Friths of London (Science). And, while I was browsing related materials, I came upon this paper by Chatterjee (Journal of Medical Ethics), which you might find intriguing if you are interested in this area at all.

Hillary runs for the White House as ‘new Thatcher’ (Sunday Times of London) and Bob Harris finds her ‘unelectable, and rightly so’.

or are right-wing demagogues killing two Democratic birds with one stone? (Media Matters)

According to a poll… by Fox News of all people… More Americans Dislike Bush Than … Cheney! (TPMCafe)

“Doomsday Clock” Moves Two Minutes Closer. Since 1947, The Bulletin of the Atomic Scientists has graphically gauged the world’s proximity to nuclear devastation with its famous clock, which edged as close as 3 minutes to midnight during the era of US and Soviet arms development and testing; and as far away as 15 minutes to the hour, after the nuclear test ban treaty. Now the clock edges two minutes closer to doomsday. “Reflecting global failures to solve the problems posed by nuclear weapons and the climate crisis, the decision by the BAS Board of Directors was made in consultation with the Bulletin’s Board of Sponsors, which includes 18 Nobel Laureates.”

Interesting broadening of their considerations to include the dangers posed by climate change, another global catastrophe paralleling the effects of a thermonuclear exchange, but not as far afield as it might seem, given that the devastating changes of ‘nuclear winter’ would envelop the earth after a nuclear war. Here’s a timeline of the advances and retreats of the minute hand over the past 60 years of the nuclear era.

Interestingly, the propagandistic Voice of America covers the BAS announcement. I suppose it is because the BAS decision focuses heavily on the nuclear threats posed by those the U.S. so needs to demonize, Iran and North Korea as well as the extant Soviet arsenal, thus allowing obliviousness to the fact that the US has always represented the preeminent nuclear threat to the world.

(Washington Post)

Philosophers/physicists have long drawn parallels between information theory and quantum theory. The contention that the physical world is built, ultimately, of information — that the distinction between the world and information about the world is murky — has troubled me, until I read this description of Viennese physicist Anton Zeilinger’s explanation of quantum mechanics.

Researchers identify one of the important molecular constituents of the long term potentiation process thought to underlie the deposition of memories. This has potentially monumental implications, although the reporting is restrained. (New Scientist)

With the arrival of a film adaptation of Perfume, discussion of so-called ‘unfilmable’ novels is burgeoning. Here is Screenhead‘s list of the supposedly hardest novels to film, for example, and here a discussion from Time Out London. But the adaptability of a novel is only a problem if one somehow believes that the book and the film are in some sense the same thing; this is usually the same mindset whose grasp of a work of art goes no further than what it is ‘about’; in the case of narrative arts what story they tell and visual arts what they show.

I thought the twentieth century was all about art transcending the denotative and freeing us to have a more complicated reaction to a work of art, experiencing a complex and subtle interplay between what we think and feel in the encounter. We grasp this in Literature 101 and Film 101 early in our college education, it seems to me. The experience of reading a book and that of seeing a film, even if they have the same title and even the same plot, are intrinsically and irreconcilably distinct. (In fact, one might argue, so are two different film adaptations of the same story!)

A ‘faithful’ adaptation of a novel will become a ‘movie’, not a film, which an audience receives merely as a good yarn and whose reaction begins and ends with how ‘awesome’ it was or not.

Addendum: as a counterpoint, I just came across this line from a London Review of Books review of The Prestige, based on a novel I had enjoyed several years ago.

What follows is a list of vendors with links to their 2007 DST fixes. (edgeblog)

Astronomy Picture of the Day, January 9: “The brightest comet in decades is unexpectedly now visible. The most optimistic predictions have Comet McNaught (C/2006 P1) shortly becoming one of the brightest comets of the past century. For the next few days, its short tail and bright coma can be spotted with the unaided eye close to the Sun and near the horizon in both evening and morning skies. “