

Sunday, June 29, 2014

What's Your Take?

You've probably seen the tweets, etc. about the paper, Experimental evidence of massive-scale emotional contagion through social networks.  This was a study conducted by the:

Core Data Science Team, Facebook, Inc., Menlo Park, CA 94025;
and Departments of Communication and Information Science, Cornell University, Ithaca, NY 14853

From January 11-18, 2012, Facebook adjusted its news feed algorithm so that 689,003 users received either less positive emotional content, or less negative emotional content, from friends. Then they looked at what people posted in response.

They found that less positive feed content yielded less positive posts, and less negative content yielded less negative posts. If that sounds confusing, they tried to make people either sadder or happier. The ones they tried to make sadder, by giving them less happy stuff to read, got sadder. And the ones they tried to make happier, by giving them less sad stuff to read, got happier.

They used linguistic software to determine the happiness or sadness of an individual post.

The paper was reviewed and edited by Susan T. Fiske, a professor of Psychology and Public Affairs at Princeton. It was published in the Proceedings of the National Academy of Sciences of the United States of America.

Facebook always has a news feed filtering system-they claim there would just be too much stuff to read in the feed, otherwise. In the case of the study, they simply adapted the filtering system to randomize users to happy or sad arms, and they claim that this is, "...consistent with Facebook's Data Use Policy, to which all users agree prior to creating an account on Facebook, constituting informed consent for this research."

Their goals seem to have included demonstrating that online interactions can have significant emotional impact, and debunking the theory that people get sad when they see how happy all their friends are on Facebook.

Well, I guess this is a powerful use of big data, but I just wish they had asked first. They claim they did, that informed consent was implicit in the Facebook user agreement. I think that's pushing it.

I happen to know a depressed adolescent (not my patient), a big user of Facebook, who was hospitalized a couple weeks after this experiment. Am I claiming this is why he was hospitalized? No. Could it have influenced his need for hospitalization? Maybe. Does an adolescent need a parent to sign informed consent? Could be.

It's a complicated issue. Every advertiser on the planet tries to manipulate people's emotions, so how is this different? Because Facebook wasn't trying to sell anything, it was just manipulating emotions to see what would happen? I don't know if that makes it better or worse.

An inquiry was made to Dr. Fiske about IRB approval. Her response:

Would it have adversely affected their data if they had done a mass posting?:

We interrupt this waste of time to bring you an important news bulletin! You may be randomized to participate in a study of your emotions. If you experience prolonged and unremitting sadness for more than 4 hours, please seek emergency medical assistance. If you wish to opt out of this experiment, click HERE.

I don't know. What do you think?

Saturday, June 28, 2014

A Bridge to Cross

The Golden Gate Bridge has been approved for a $76 million suicide safety net. As I recall, installing a protective structure has been in discussion for a lot of years. Families of people who have jumped off the bridge are understandably happy about it. I can certainly see how they'd want to do something proactive to prevent the kind of suffering they and their loved ones have experienced.

But I have a problem with it, and I hope this isn't interpreted as a lack of empathy towards those families, or towards Kevin Hines, who jumped off the bridge in 2000, at age 19, and miraculously survived.

The statistic in the linked article, which is consistent with my understanding, is that 1400 people have died jumping off the "bridge of death" since it opened in 1937. That's roughly 18 people per year. Again, I don't want to minimize the suffering involved, but to put it in perspective, according to the American Suicidology Association, 39, 518 people killed themselves in 2011, the most recent year for which statistics were available on the site. In other words, 0.05% of all suicides in 2011 were committed by jumping off the Golden Gate Bridge.

What I'm curious about is how much money the federal government devotes to suicide prevention. I poked around online, and I found out the the NIH spent $21 million on suicide prevention in 2013, with a projected spending of the same amount for each of 2014 and 2015.

In 2012, the National Strategy for Suicide Prevention Plan devoted $55 million dollars in federal funds to state, tribal and community prevention efforts.

I found a document, I believe from 2001, with some relevant financial figures:

In 2002, the NIMH offered $2.5 million for stigma-related research.

"SAMHSA provide(d) $5.4 million for a three-year collaborative effort with states to develop and evaluate public education approaches for overcoming barriers to mental health treatment and encouraging community participation for persons with psychiatric disabilities."

"SAMHSA provides funding support to Signs of Suicide (SOS), a peer program that teaches students to recognize depression in peers..." (no figure provided)

"By providing $3.0 million in funding annually over three years, SAMHSA sponsors the Hotline Evaluation and Linkage Project (HELP)."

"SAMHSA is overseeing the launch of the National Suicide Prevention Technical Resource Center in late 2002. Funded at $7.5 million over its first three years, the Center will be dedicated exclusively to suicide prevention..."

"Several HHS operating divisions fund technical assistance efforts aimed at suicide prevention." (no figure)

It was hard to find more information about funding. When I googled, the main link was to the Golden Gate Bridge story.

A few more stats:

At the upper end, there were 19,990 suicides by firearms in 2011. At the lower end, 354 suicides by drowning. And a total of 3996 suicides in California.

And in 2011, there were 987,950 non-fatal suicide attempts in the US.

So this is my problem. The federal government is handing over $76 million to build a net that will prevent roughly 18 people per year, NOT from committing suicide, but from committing suicide by jumping off the Golden Gate Bridge.

I think a lot has to do with the iconic nature of the bridge. As it turns out, about 6 people per year jump off the George Washington Bridge. But no one cares about the GW because it's a rubbish bridge.

A jump from the Golden Gate is dramatic, no doubt. I don't quite understand how people get there on foot. There's Golden Gate Park on one side, and Sausalito on the other, and it's been a while since I've been in the Bay Area, but I think you pretty much have to drive to get close. What I'm trying to say is that it takes some planning.

I just think they're building the wrong kind of net. It's a dramatic gesture for a dramatic structure, but I doubt it'll accomplish much. I think the money would be better spent on catching people before they purchase guns, or down a bottle of pills, or set foot on the Golden Gate, or any other bridge.

Thursday, June 26, 2014

The Subway System Ucs

In my recent post, The Core, I mentioned that I was reading a book about Antisocial Personality Disorder (ASP), Bad Boys, Bad Men, by Donald Black. I also mentioned that I had taken the book out of the library.

Well, today, as I got out of the downtown station near my office, I realized I had left the book, along with a pair of shoes, in a bag, on the train.

Yup. I lost a library book. Never happened before. In fact, I never even return a book late. And I've never left anything on the train before, either.

That's not precisely true. A couple years ago I was crocheting on my way to work, and the train jostled, and the ball of yarn fell down. I went to pick it up, but then the train stopped and jostled again, and the door opened, and the ball of yarn rolled out the door onto the tracks. And I sat there for a stop or two afterward watching my hard work unravel and get dragged away. Not my best commute.

But this is different. Oh, I can explain it away. On crowded trains, I usually put any bag I'm holding on the floor between my feet, but my back went out last week and I couldn't sit like that, so I put the bag on my lap, and then the train was slow and weird, and I had to switch to the express quickly, etc.

Can't be. Something's up. I don't know what, but I'm gonna try a little free association (minus any awkward references to toilet training or primal scenes or other stuff that really has no business on this blog).

I was planning to write a post about the book. My impressions, what I learned, what I question. I was going to include other perspectives on ASP. I had in mind the chapter entitled, Impulsive Styles: Variants, Some Psychopathic Traits, from David Shapiro's, Neurotic Styles. Maybe Freud's bit on The Exceptions. And most importantly, the sections from the Psychodynamic Diagnostic Manual (PDM): P103. Psychopathic (Antisocial) Personality Disorders, with P103.1 Passive/Parasitic and P103.2 Aggressive.

This was important to me. To introduce the PDM. I think a lot of people aren't familiar with it, but it's a great alternative to the DSM, especially when it comes to personality disorders.  It goes beyond the symptom clusters characteristic of the DSM and ICD systems (it references DSM-IV), and elaborates on the patient's internal experience of his symptoms, since it's usually a patient's subjective suffering that brings him to treatment.

I think I'll wait for another post to get into the PDM's approach. This is what I remember about the couple chapters of Bad Boys, Bad Men that I read. It's well-written and engaging. The author's intent seems to be to truly try to understand ASP, and not just derisively dismiss it as hopeless. He followed up on 30 year old cases, to try to see what happened to those diagnosed with ASP (or psychopathy) over time.
He describes these cases, and intersperses them with descriptions about well-known serial killers, or other well-knowns, like Mike Tyson. He repeatedly states that while he can't officially diagnose this one or that one as having ASP, their behavior is consistent with the diagnosis. I didn't like that. He kept saying that ASP is probably more common than is recognized, but you can't assume that just because someone behaves badly, they have ASP.
That probably sounds sensible, but it read more like he couldn't make up his mind. And I think that, in turn, was due to his extensive reliance on DSM criteria. It was all mushed together. ASP's are too impulsive to plan, yet many are capable of elaborate cons. They can't hold down long-term jobs, yet many are professionally successful.
It was all, Do they meet criteria? Some people are just born bad. They can't accept society's rules. This seemed to completely neglect an understanding of the phenomenon, well-described in the book, that these are usually people who have had terribly chaotic upbringings. If the first thing a child learns is that there are no rules, or any rules that exist don't protect him, and even harm him, why would he learn to think of rules as something desirable?
The book seemed to just go the DSM route and ignore the inner experiences of ASP's, while only examining their behavior. I'll allow for the fact that I didn't progress very far before I lost it, but while I was reading, I kept bristling at what I perceived as a lack of insight, and had to keep telling myself to wait and see how the book progressed, and maybe I'd learn something.

End of free association. And here's my analysis. I was going to say, "amateur" analysis, because I guess I still haven't gotten used to thinking of myself as an official analyst:

I don't like DSM. I REALLY don't like DSM 5. I've been trying very hard to completely ignore it, but now I'm faced with taking my board recert exam, which will require DSM stuff, which I find offensive because it's at best superficial, and at worst politically fabricated, and it's derisive towards the way I've chosen to practice my profession. It neglects what I consider to be the most important part of human existence, whether in mental illness or mental health, which is a person's internal experience of himself and the world. I was hopeful that Black's book would have a different perspective, but I was disappointed. I want to lose the DSM. I want it lost in the bowels of the NYC subway system, where maybe it can learn something about depth.

And for very complicated personal reasons, there are ways in which I identify with ASPs, even though I clearly don't live that way. So I don't want to be judged without regard to the reasons I do what I do, or feel what I feel. Not by the APA, or the ABPN, or insurance companies, or the world at large, or family or friends, or myself. Not even by the NY Public Library system, for losing one of their books.

PS: On a lighter note, please remember to enter my giveaway contest.

Wednesday, June 25, 2014


Guess what! I've reached my 50,000 hits mark, which isn't much, I know, but for a small niche blog that I write in addition to my day job, I'm pretty proud of it.

To celebrate, I managed to convince the wonderful people at Poppin, to donate a $25 gift card to the winner of my very first giveaway. You may recall my Pharmaphenalia and Poppin In posts, where I described some of the wonderful, colorful things I got for my office from Poppin.

My new favorite thing is the tape dispenser, but I can't decide if I prefer it in yellow:

Or Aqua:

So check out their site, decide what you'd like to get for your office, or a friend, and then comment in the entry form below. In particular, I'm interested in comments about what if anything people are looking for in a free online journal club. So make your voice heard. And as far as I can tell, it won't show anyone's contact info, but if it does, I'll try to fix it.

And once more for the road, Poppin is not paying me to do this, nor do I get any percentage of sales they happen to earn from having my readers peruse their site. I just like their stuff and they're nice.

a Rafflecopter giveaway

Monday, June 23, 2014


It's been a while now since Jim Amos, George Dawson, and I started POLL, our free online journal club, where we post an open access article, and ask for discussion.

At first, we were posting our articles on our respective blogs, but then, with some discussion and show of interest, we switched to LinkedIn as a venue, thinking it would be more professional, and could encourage a larger audience. We tried to keep up at the rate of a new article each week, with credit mostly to Jim Amos, but that was a bit much to manage. So then we moved to every other week.

Unfortunately, with the exception of one or two instances, no one was participating in the discussions. I don't know if people weren't interested in the particular articles, or the questions weren't evocative enough, or the venue wasn't working, or we weren't doing enough to promote it, or any of a number of reasons I haven't thought of.

I don't want to give up the idea of on online journal club, because I think it's a perfect venue, and a great way to demonstrate an interest in lifelong learning without shelling out thousands of dollars for meaningless CME.

So I am really, genuinely asking for people's opinions. Are you interested in an online journal club? If so, why, and if not, why not? What venue are you interested in-LinkedIn, individual blogs, twitter, a separate blog, facebook, other suggestions? What would be the function of an online journal club, for you? What topics would you like to see covered? Who would you like to see participate? Who would you like to select the articles? Would you like to be involved in selecting the articles? Should there be separate journal clubs for separate topics? What should the frequency be?

I'm not sending out another survey, because they're so sparsely responded to that it isn't useful. But I really think this is a great opportunity for people with common interests to have open discussions about important professional topics. So please make your voice heard and comment.


Thursday, June 19, 2014

The Core

Jefferson Market Branch NYPL

One of the many things I love about NYC is the public library system. It has one of the best smartphone apps I've encountered, completely intuitive and user friendly, does exactly what it should-not more, not less. There are many library  branches throughout the city, and the really wonderful thing is that you can use the app, or your computer, to search for a book, put it on hold, and have it delivered to the branch of your choosing. They email you when it gets there, and also when your books are due, and you can renew online. I love it, and if you ever have a hankering to donate some money to a worthwhile public institution, please consider the NYPL.

Today, I happily went to the branch near my office (in photo), and picked up my reserved copy of Bad Boys. Bad Men: confronting antisocial personality disorder, by Donald Black, MD. Reading is one of the few perks of my long daily commute on the NYC subway system, which is over 100 years old and boy can you tell. I started the book on the way home yesterday. 

So far, I can say that it's engaging and well written, and I'm looking forward to reading all of it. From what I can tell from the cover, Black makes a biological argument, "that some people are simply born bad."

In the Introduction, he writes," It is as if a vital part of the antisocial's character-his moral judgement, is somehow absent or underdeveloped. This essential part of our humanity makes us adhere to social rules and obligations."

This line made me recognize the perspective from which I'm approaching the book.  
I know I've already made one plug in this post, but here's another- for the value of a traditional liberal arts education. Because as little as I actually remember from college, there are some concepts that have truly influenced my Weltanschauung, concepts that were developed in intense discussions between multiple people sitting in the same room. Maybe I would have come away from a virtual classroom with the same outlook, but I doubt it.

The concept I have in mind is that of the social contract. From Hobbes' Leviathan:


The idea that I find important is that anyone can kill anyone, so in order to make this a livable world, people have agreed not to harm each other. And we've set up all kinds of rules and policing of these rules to maintain a social structure.

I think this is why the argument about how it's not morally justifiable to murder, but it is to kill someone in war, misses the point. It's not about right and wrong, it's about protecting the social structure. A murderer is a threat to that structure from within, and an enemy country is a threat to that structure from without.

 We call these our rights-to a world where one can reasonably expect to be safe, but they're only rights because as a whole, we've decided to make them so. We call these morality, but they're only a way to make it possible to function in the world. We talk about right and wrong, good and bad, but these properties are not in our nature. Spend an hour watching small children, and this becomes obvious. We have simply chosen to forego some of the options available to us so we can sleep at night and expect our children to grow up safely.

It's like the group version of Freud's reality principle. People want to maximize pleasure and minimize unpleasure. And at some point, most people realize that while they may want to take the candy bar without paying for it, if they do, they could end up with a lot more unpleasure than the pleasure they would get from the candy bar. So they concede to reality and pay for it.

I don't think a sense of right and wrong is an innate part of our humanity. I think expedience is an innate part of our humanity. Black doesn't claim that morality is innate, just that it's essential. 

Then the question I need to keep in mind, while reading his book, is, "Why do people with antisocial personality disorder lack the ability to control their behavior in ways that would benefit them?" rather than, "Why do people with antisocial personality disorder lack a sense of right and wrong?"

I'll update as I read more. 

Monday, June 9, 2014

New POLL Article: Clinical Trials and Legal Jeopardy

I was reading David Healy's recent post, Sense About Science: First Admit No Harm. In it, he references an article her wrote back in 1999 for the Bulletin of Medical Ethics called, Clinical Trials and Legal Jeopardy. I linked over to it and read it-it basically covers many of the points he makes in his book, Let Them Eat Prozac, which I've mentioned in the past.

Healy is very passionate in his beliefs, and I think this sometimes detracts from his arguments. His writing often sounds like he's so indignant he's just generating data for his version of the story, just as he's claiming "the opposition" does.

But he makes a lot of good points. Significantly, for me anyway, this was written in 1999, and despite his legitimate concerns, we're still not much better at getting full data from pharmaceutical companies. (See all kinds of posts from 1 Boring Old Man, David Healy, and others).

The legal jeopardy part of the article is that many medications, Prozac in the case of the article, must be prescribed by a physician (or other qualified prescriber). This principle rests on the assumption that physicians are well-informed, and that we use the information we have to make the best possible clinical recommendations for our patients. So adverse events become the physician's responsibility, not that of the pharmaceutical company. But if the pharmaceutical company in question is withholding adverse event data, then physicians can't be well-informed, even though we think we are, putting us in a legally tenuous position.

Something else I found interesting is his pointing out that there were not a lot of follow-up studies on the issue of prozac-induced akathisia/suicide attempts, despite all the data that came out about akathisia, and the use of benzodiazepines in the early trials to control agitation/akathisia. Healy reasons that if the problem was just with prozac, other companies with SSRIs in the pipeline at the time would have pounced on this fact to make their own drugs look better. But they didn't.

I'll include one quote, and corresponding references, from the article, to whet your appetite:

"As of 1986, Lilly's clinical trial base was showing rates of 12.5/1000 patients attempting suicide on fluoxetine versus 2.5/1000 patients on placebo and 3.8/1000 patients on reference antidepressants. This data remained unpublished and unreported to the FDA. There are other unpublished studies consistent with this finding, in addition to one published set of figures."

Lilly Memo re suicides and suicide attempts October 1986. Forsyth v Eli Lilly, Plaintiff's exhibit 73.
Kasper S. The place of milnacipran in the treatment of depression. Human Psychopharmacology (1997), 12 (suppl 3):s135-141.

What do you think? Is Big Pharma truly hiding adverse event and outcome data under the guise of commercial confidentiality to make unimpressive or even harmful drugs look better, or are they merely protecting patient privacy, and their investment, while providing a public service by producing useful products?

Read the article, hop on over to POLL, and comment!

Sunday, June 8, 2014


Lately, I feel like I'm being bullied.

First, I was told by Practice Fusion that I need to send an e-prescription or I'll lose my
e-prescribing privileges. Well, I sent one. Took me 20 minutes to get it done. As opposed to the 30 seconds it would have taken me to write the thing.

I wanted to balk and not do it, but then I'm going to have to start e-prescribing, whether I like it or not, beginning in March, and I don't want the process to be made more difficult because I let it slide a few months earlier.

Second, I got a survey from the HHS, about my use of EHR's. Ironically, it's a paper survey, and there doesn't seem to be any option to fill it out online. It's supposedly voluntary, but it's not anonymous. I haven't decided yet if I'm going to fill it out. I'm torn between, "Why are you wasting my time with this nonsense" and, "Yeah, I'll fill it out, and tell you how stupid, useless, and sometimes harmful EHRs are."

If I want to work toward some kind of change in EHR requirements, the former is obviously not going to help. But neither is the latter.

A week after I got the survey, I got a postcard reminding me to fill out the survey and send it in. But no pressure.

And finally, on May 23rd, I got The Email. The ABPN email reminding me that my board certification will expire on December 31, 2015. Applications for the recertification exam have been available since June 3rd. If I apply online after September 1st, I pay a $500 late fee. This is in addition to the $700 application fee AND the $800 exam fee.

Remember when mail-order companies used to charge separately for shipping and "handling", and now they just charge for shipping because no one could figure out what handling was? I mean, if you're shipping something, then someone has to pick it up and put it in a package and take it to wherever it's shipped from.

Call me skeptical, but I find it hard to believe that each online application requires $700 worth of effort on the part of the ABPN. Who wrote the program, the same people who designed HealthCare.gov? And it's all ironic since I've been debating attending a Neuropsychoanalysis conference, and wondering if it's worth the money. I'm sure I'd learn more at the conference than I will for the MOC exam.

They've reduced the number of required SA credits from 40 to 24, so I'm kicking myself for having paid for that 1 extra SA credit, bringing me to 43 total.

Also, "Beginning in 2014, diplomates are required to use only ABPN-approved products for self-assessment and performance in practice activities."

To me, that means more money.

For the 2015 exam, they'll only use DSM-5 diagnoses that haven't changed since DSM-IV. In other words, if it's in DSM-5 but not IV, like Hoarding disorder, it won't be on the exam. And if it's in IV, but completely gone from 5, it won't be there either.

More bullying, as far as I'm concerned, because I don't buy into the whole DSM system, to begin with, and now I'm going to have to simply buy the DSM system.

Funny, the same day I got the ABPN email, I got an email from Mass General Hospital Psychiatry Academy:

The study tools are the full length online mastery course, for $495, and the update and question book for $88.99 ($59.99 on kindle). The info seems to point to the fact that the course is intended for residents. I can't figure out if I should sign up for the course, or just use the review book.

More money.

Thus begins my quest to register, study for, and take the recertification exam, next February. Hmm, just before I have to start e-prescribing.

Tuesday, June 3, 2014

Further ERx Thoughts

I got an email notice from Practice Fusion, letting me know that my e-prescribing privileges would be deactivated, "in accordance with Surescript's policy" if I don't send an e-Rx within a month.  It actually used the word, "month", didn't give me a specific date, which I find curious.

I guess I haven't e-prescribed in a while. I'm assuming 6 months, since that was the initial time I was allowed before losing my privileges.

The thing is, I don't really want to e-prescribe. You may recall, I signed up for Practice Fusion for the sole and explicit purpose of using their free eRx service.  I was under the impression that e-prescribing would be required by 2015, and I wanted to make sure I didn't have to scramble, or pay a fortune, at the last minute.

But I don't like picking medications, along with their forms and strengths, from a drop down menu. Why people think this is less likely to lead to error than writing down exactly what you mean is beyond me. Something as simple as a mild tremor could lead to an error.

I don't like checking the system for the auto-refill requests. I don't like the "refill as needed" option, which I still don't understand (it allowed for no refills). I don't like the formatting of the EHR, with pop up windows covering up important information unless you upgrade to a paid version. And I don't like having my patients' information floating through the cloud. I try to limit the amount of that information-name, DOB, phone number, and the actual Rx, and NO diagnosis-but I still don't trust it. Maybe it's no different than any other way a pharmacy can access a patient's data, but it seems like it's not just the pharmacy that has it. It's out there in the cloud.

I'm confused about the requirement for e-prescribing. Lately I've been wondering if it only applies to Medicare providers, like the meaningful use requirements. When I poke around online, I still find this:

"As of March 27, 2015, all prescriptions (including prescriptions for controlled substances) issued in New York State must be electronically transmitted, with certain limited exceptions."

The same page also reminds readers that as of March 27, 2013, controlled substances can be electronically prescribed, provided that,

"The practitioner and pharmacy...use a certified software application that is consistent with all federal security requirements to process electronic prescriptions for controlled substances."

Supposedly, the security requirements can be accessed through this link:


But there's a lot of information on that page, with a lot of links, and the most recent "clarification" update is from October of 2011. It's confusing.

There's also the following, that's specific to NY State law:

"New York State regulations also require each pharmacy and practitioner to register their certified software application with the Department of Health, Bureau of Narcotic Enforcement (BNE). Please visit BNE's webpage at www.health.ny.gov/professionals/narcotic for additional information."

THAT page has a blurb about what the BNE does, and a bunch of links, none of which led me to where I could register.

Now, the reason I'm so interested in e-prescribing controlled substances is that if I'm going to keep my privileges with Practice Fusion, I need to eRx something soon. And since I write for refills on most of the non-controlled meds I prescribe, the prescription I'm most likely to write next is for something controlled.

The underlying assumption here is that I want to keep my e-prescribing privileges. If I let them lapse, then supposedly it will be harder to have them reinstated. But I don't see how I can be refused the option of e-prescribing at the same time that I'm being required to e-prescribe. And that idea assumes that I WILL be required to e-prescribe, starting in March of next year.

But will I? ICD-10 is being pushed off a year. Why not this?