Noteworthy News Articles on Mental Health Topics, January 10-19, 2010 If there is a bright spot in the data, it's that in 2007 veterans in the group who used VA health care were less likely to commit suicide than those who did not. That's a change from 2005. In recent years, the VA has hired thousands of new mental health professionals and established a suicide hot line credited with ''rescues'' of nearly 6,000 veterans and military members in distress. The military has also struggled with an increase in suicides, with the Army seeing a record number last year. While the military frequently releases such data, it has been more difficult to track suicide information on veterans once they've left active duty. The VA calculated the numbers using Centers for Disease Control and Prevention numbers from 16 states. In 2005, the rate per 100,000 veterans among men ages 18-29 was 44.99, compared with 56.77 in 2007, the VA said. It did not release data for other population groups. At a suicide prevention conference on Monday in Washington, VA Secretary Eric Shinseki said his agency needs to do a better job understanding what led to each suicide. He said he'd also like to see more stringent protocol put into place at VA facilities about how to handle a potentially suicidal veteran, similar to what's done with someone who's having a heart attack. He noted that of the more than 30,000 suicides each year in America, about 20 percent are committed by veterans. ''Why do we know so much about suicides but still know so little about how to prevent them?'' Shinseki said. ''Simple question, but we continue to be challenged.'' On the Net: Mental Health: Deficiencies in Treatment of Depression Roni Caryn Rabin, New York Times- 1/11/2010 Researchers reported last week that antidepressant drugs seemed to be effective mainly in people with severe depression, not those with milder forms. Now another study is reporting that only about half of all Americans with depression receive treatment of any kind. Moreover, only 1 in 5 are getting care — talk therapy, medication or both — that conforms to American Psychiatric Association guidelines, according to the study, which appears in the January issue of Archives of General Psychiatry. The findings were based on nationally representative surveys of 15,762 adults from February 2001 to November 2003. Over all, more patients used talk therapy (44 percent) than drug therapy (33 percent). Mexican-Americans and African-Americans were less likely than other groups to receive treatment of any kind. “For minorities especially, psychotherapy may be more acceptable than antidepressants,” said the lead author of the study, Hector M. González, assistant professor of family medicine and public health at Wayne State University in Detroit. “The take-home message is that maybe we should be trying to reach out to these particular minorities more with psychotherapy.” Benedict Carey, New York Times- 1/11/2010 Dr. Herbert Spiegel treated pain, anxiety and addictions by putting people into a trance. Broadway actors sought his help to overcome stage fright, singers to quit smoking, politicians to overcome fear of flying. For years he had a regular table at Elaine’s, as well as his own place on the national stage. A New York psychiatrist, Dr. Spiegel, who died on Dec. 15 at the age of 95, was far and away the country’s most visible and persuasive advocate for therapeutic hypnosis, having established it as a mainstream medical technique. Beginning in the 1950s, he described the technique, both its uses and misuses, in magazine articles and in courtrooms. In the 1960s, he developed the first quick and practical test for individual susceptibility to hypnosis; it is still widely used. In later decades he appeared on television programs like “60 Minutes” and he helped treat the woman known as Sybil, whose controversial case became the subject of a book and inspired two television movies. In a famous course at Columbia University, Dr. Spiegel taught generations of doctors the art and science of hypnosis — how concentrated relaxation and suggestion can have a powerful effect on thinking and behavior. His son, Dr. David Spiegel, a psychiatrist at Stanford University, said his father had died in his sleep at his home on the Upper East Side of Manhattan, not far from Elaine’s, where Dr. Herbert Spiegel’s regular table was near Woody Allen’s at what was a fixture of the New York intellectual and creative scene in the 1960s and ’70s. A trained Freudian analyst, Dr. Spiegel came to see traditional, open-ended psychoanalysis as too costly and meandering for many patients — and hypnosis as a way to accelerate healing, effecting change in some people even in a single session. As Dr. Spiegel’s reputation grew, performers and politicians in New York and prominent people from around the world made their way to his office in Manhattan. It was in the early ’60s that he filled in for Dr. Cornelia B. Wilbur, the therapist who had been treating a troubled woman named Shirley Mason, who appeared to communicate through several distinct personalities. Her case became the basis for the popular 1973 book “Sybil,” by Flora Rheta Schreiber, and two television adaptations, one in 1976 with Joanne Woodward and Sally Field and the other in 2008 with Jessica Lange. Critics later challenged Dr. Wilbur’s methods, saying they had encouraged the woman’s behavior. Dr. Spiegel agreed. He argued that Sybil had disassociation disorder, not multiple personalities, and he voiced his reservations when the book became part of a debate in recent years over the causes of such disorders. Yet more than anything, it was Dr. Spiegel’s rigorous studies of hypnosis, as well as his easygoing, matter-of-fact presence, that most impressed other doctors and patients. “He wasn’t Svengali-like; he didn’t have this Mesmer voice,” said Dr. Philip R. Muskin, a psychiatrist at Columbia. “He was a regular guy with this Midwestern accent who explained in a very straightforward way that hypnosis was something you could learn that’s useful. He really took the techniques out of the dark alleys, out of Hollywood and the world of the circus, and moved them into mainstream medicine.” Many therapists now use hypnosis to aid treatment, and the National Institutes of Health have financed dozens of studies of the technique to reduce pain and accelerate healing. Herbert Spiegel was born on June 29, 1914, in McKeesport, Pa., one of four children of Sam and Lena Spiegel. His father ran a successful wholesale grocery business; his mother, the household. Their only son attended the University of Pittsburgh before enrolling in medical school at the University of Maryland, where he graduated in 1939. After completing his internship at St. Francis Hospital in Pittsburgh, he did a residency in psychiatry at St. Elizabeth’s Hospital in Washington, where he first learned hypnosis. But it was during World War II — Dr. Spiegel served as a battalion surgeon in North Africa from 1942 to 1946 — that the young doctor first witnessed the power of hypnosis. “I discovered that it was possible to use persuasion and suggestion to help the men return to previous levels of function” after severe combat stress, he later wrote. He used the same techniques on himself after suffering a shrapnel wound that earned him a Purple Heart. Dr. Spiegel’s first marriage, to Dr. Natalie Shainess, ended in divorce. In addition to his son, he is survived by a daughter, Dr. Ann Spiegel, a pediatrician in Phoenix; four grandchildren; and his wife, Marcia Greenleaf, a therapist who collaborated with him and who was with him at his death. Dr. Spiegel received a long list of awards and held academic appointments at a number of institutions, including John Jay College of Criminal Justice, New York University and, for more than 20 years, Columbia. His book “Trance and Treatment: Clinical Uses of Hypnosis,” written with his son, is a classic in the field. But he was, until the end, a therapist. “He saw a patient a few days before he died,” his son said. Before You Quit Antidepressants ... Richard Friedman, M.D., New York Times- 1/12/2010 Last week, The Journal of the American Medical Association published a study questioning the effectiveness of antidepressant drugs. The drugs are useful in cases of severe depression, it said. But for most patients, those with mild to moderate cases, the most commonly used antidepressants are generally no better than a placebo. For the millions of people who take these drugs, and the doctors who prescribe them, this provocative claim had to be confusing, if not alarming. It contradicted literally hundreds of well-designed trials, not to mention considerable clinical experience, showing antidepressants to be effective for a wide array of depressed patients. But on close inspection, the new study does not stand up to that mountain of earlier evidence. To understand why, it helps to look at the way it was conducted. The study is a so-called meta-analysis — not a fresh clinical trial, but a combined analysis of previous studies. A common reason for doing this kind of analysis is to discover potential drug effects that might have been missed in smaller studies. By aggregating the data from many studies, researchers gain the statistical power to detect broad patterns that may not have been evident before. But meta-analyses can be tricky. First, they are only as good as the smaller studies they analyze. And when there are hundreds of studies out there, how to decide which ones to include? For the recent analysis in the journal, the authors identified 23 studies (out of several hundred clinical trials) that met their criteria for inclusion. Of those 23, they could get access to data on only 6, with a total of 718 subjects. Three trials tested the antidepressant Paxil (a selective serotonin reuptake inhibitor, in the same class as Prozac) and three used an older drug, imipramine, in the class known as tricyclics. That is not many studies if your goal is to answer a broad question about the efficacy of antidepressants as a class. Indeed, as Robert J. DeRubeis, a professor of psychology at the University of Pennsylvania who is one of the new paper’s authors, told me, “Of course, we can’t know that these results generalize to other medications.” Admittedly, it is not easy to find studies that include large numbers of people with mild to moderate depression; most trials focus on severely ill patients. But the authors of the new analysis gave themselves an additional handicap: they decided to exclude a whole class of studies, those that tried to correct for the so-called placebo response. Researchers argue all the time about which patients to include in a study. Antidepressant studies come to such different conclusions partly because patient characteristics vary so widely. Many patients with depression — as many as 50 percent, in some studies — get better with no drug at all, just a placebo pill and attentive treatment by a therapist. For that reason, researchers often design their studies to exclude such people, to determine whether the drugs are working independent of any placebo response. An analysis that eliminates such studies is bound to show a comparatively small average difference between drug treatment and placebo treatment. Not surprisingly, this is just what happened in the recent analysis. But in randomized clinical trials that try to correct, or wash out, the placebo effect, patients with mild to moderate depression respond to antidepressants at rates nearly identical to patients with severe depression (who tend to have a much lower response to placebos). Another drawback of the study is that its conclusions are based on studies that included only two antidepressants — when there are 25 or so on the market. By contrast, when the Food and Drug Administration wanted to investigate the safety of antidepressants, it analyzed data from some 300 clinical trials, with nearly 80,000 patients, involving about a dozen antidepressants. Antidepressants are not interchangeable; studies show that a patient who fails to respond to one has about a 30 percent chance of responding to another. Still, antidepressants are not panaceas, and their advocates have sometimes been overly optimistic about their efficacy. Only about 35 percent of depressed patients will achieve remission with the first antidepressant they receive. But with sequential treatments, most can expect to feel a lot better. And the real test of an antidepressant is not just whether it can lift someone out of depression; it is whether it can keep depression from returning. For a vast majority of people with depression, the illness is chronic. Relapses and low-level symptoms between episodes are common. Scores of studies show that antidepressants are highly effective in preventing relapse; on average, the risk of relapse in patients who continue on an antidepressant is one-half to one-third of those who are switched to a placebo. Every once in a while, a landmark study comes along and overturns everyone’s cherished ideas about a particular treatment. But the current study is not one of them. So it would be a shame if it discouraged depressed patients from taking antidepressants. Experts may disagree about what constitutes the best treatment for depression, and for whom. But there is no question that the safety and efficacy of antidepressants rest on solid scientific evidence. Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College. To Treat Bed-Wetting, Healthy Doses of Patience Perri Klass, M.D., New York Times- 1/12/2010 A couple of weeks ago, I saw a 5-year-old girl who was still wetting the bed every night. It’s a common complaint: at least 15 percent of healthy 5-year-olds are not reliably “dry” at night. And bed-wetting is quite common even in older children. But what may be most surprising about primary nocturnal enuresis, to use the clinical term for urinary incontinence in a child who does fine by day but has never been reliably dry through the night, is that it is often genetically based. In other words, it is not about emotional problems, or mistakes a parent made during potty training, or laziness, which some still attribute to the bed-wetter himself. (The problem is about three times as common in boys as in girls.) Indeed, one of the worst things about bed-wetting is the stigma. Sufferers and their families have been accused of everything from poor parenting to latent criminality. (In 1945, The New York Times reported on a psychological study of the backgrounds of 500 men who got into disciplinary trouble in the wartime Navy. The most powerful predictor of failure in the Navy, the article reported, was a combination of three factors: expulsion from school, civilian arrest and enuresis beyond age 5.) Enuresis can have a number of physiological causes. Some children lack a hormone that decreases urine production at night. Others wet the bed simply because their bladder capacity is small. “Here’s the encounter I usually have when I see children in my clinic,” Dr. Jennifer Abidari, chief of pediatric urology at the Santa Clara Valley Medical Center in California, told me. “I draw a bunch of bladders, and three of them are big and one of them is very small. “I ask them which one was wetting and they’ll usually guess the smaller one, and I’ll say, ‘You’re right — you have a bladder that’s smaller than your age, and it’s not your fault.’ And I’ll see the child glance over to the parent and I’ll know there’s been a lot of conflict.” In 1995, the first news of a genetic basis for bed-wetting made headlines, after Danish researchers reported a link to Chromosome 13. “It’s very clear that there is a strong hereditary component in the course of enuresis,” said Dr. Soren Rittig, a professor of pediatric nephrology at Aarhus University Hospital in Denmark. Dr. Rittig is one of a group of researchers who have published new findings on the genetics of nocturnal enuresis, which turn out to be far from simple; linkage to three other chromosomes has been found in other families. The researchers identified several large families in which enuresis was inherited following an autosomal dominant pattern — that is, if either parent has a history of bed-wetting, a child has a 50 percent chance of inheriting it. As children grow older than my patient, behavioral and other treatments can make a big difference. Children whose bladders tend to spasm can be treated with anticholinergic drugs, and children who lack an antidiuretic hormone can take a synthetic version. But these drugs treat the symptom, not the underlying problem. “I consider enuresis to be a developmental delay which will improve by itself,” Dr. Abidari said, adding that if the medication is stopped and development has not progressed, “they will wet again.” In such cases an effective treatment is a bed alarm, which vibrates and makes a noise when a child starts to urinate. Dr. Abidari says the alarms can cure the problem but can be hard on families, especially if the child is a sound sleeper. “The alarm goes off, everybody in the household wakes up but the child is still asleep,” she said. Success, she said, requires motivation on everyone’s part. The doctors, nurse practitioners and counselors who treat enuresis can be almost messianic about the relief they can offer children and families. “The physician has to have an enthusiasm for wanting to treat wetters,” said Dr. Kenneth I. Glassberg, director of pediatric urology at Morgan Stanley Children’s Hospital of NewYork-Presbyterian. There must also be a committed staff, he added, to handle the frequent visits, phone calls and long-term support the children and their families may need. All children with wetting problems should be checked for urinary tract infections. Children who develop secondary enuresis — that is, they are fully dry for six months, then begin wetting again — may have infections, constipation (an overly full bowel can put pressure on the bladder) or a variety of other problems, including behavioral and psychological issues. My patient was also having some daytime accidents, and many specialists would want to address those even before age 5. The same bladder problems may be at work, but there can also be behavioral components. In addition to anatomical and hormonal factors, “developing continence day and night is a combination of neurological readiness, developmental readiness and the interplay between a child and his environment, whether that’s day care, parents, sibling, preschool,” said Dr. Alison D. Schonwald, an assistant professor of pediatrics at Harvard Medical School and the co-author of “The Pocket Idiot’s Guide to Potty Training Problems” (Alpha, 2006). My plan was to check the 5-year-old’s urine, just to make sure she didn’t have an infection, and to offer a referral to a pediatric urologist. Although the patient’s mother felt that the daytime problems were improving, she was happy to see a specialist. And the child herself demonstrated her bladder control by flatly refusing to urinate in a plastic cup. The Jan. 4 hanging death of Marc Biron, described by a fellow patient as "friendly and kind to people," is the third since a consent judgment mandating a wide array of changes was imposed on the hospital in May 2006. In a letter to state officials that laid out specific problems at Patton, federal civil rights attorneys noted that "of great concern is the high number of suicide attempts by hanging." While the "vast majority" of suicide attempts at the facility involved hanging, the findings letter noted, the hospital failed to prevent future incidents of a similar nature because it "fails to respond effectively to identified trends." California Department of Mental Health spokeswoman Nancy Kincaid said that staff had checked on Biron between 5:30 a.m. and 5:45 a.m. and that he was asleep. At 5:45 a.m. he was in the bathroom, and when the staff next checked him he was hanging from the wardrobe in the bedroom. The hospitals are working to get rid of the wardrobes, Kincaid said, as they have been identified as a suicide risk. A number of patients at Metropolitan State Hospital have hanged themselves from bedroom wardrobes. Kincaid said the hospitals have made progress in identifying and removing materials that can be used for suicides – such as foot lockers and curtain fixtures. Patton's last suicide was one year ago, when Augie Solez hanged himself with a sheet from his bedroom door. The hinges have since been changed on the doors, Kincaid said, to avert hangings. Napa State Hospital, in Napa, which along with hospitals in Atascadero and Norwalk is also subject to the consent judgment, also lost a patient to suicide last month. Data provided by the state Department of Mental Health show that there have been nine suicides and three homicides at the four hospitals since the consent judgment was imposed on them. In a similar period preceding the consent judgment, there were 14 suicides and three homicides. Biron played guitar in a hospital band named "Barriers to Discharge," fellow patients said. They described him as respectful and kind with a good sense of humor. Kincaid said that Patton State Hospital Executive Director Octavio "Carlos" Luna led a treatment group in which Biron participated and that Luna said there were no signs he was suicidal. "The people in our care are the people who are the most ill," she said. "It is a great challenge when are dealing with someone who is focused on ending their own life. Trying to identify those individuals and head that off has been a real focus at the hospitals."
The agency, the Eastern Los Angeles County Regional Center, informed more than 100 families late last summer that the therapy — known as the DIR model, or “developmental, individual difference, relationship-based” — was being eliminated for their children because of state budget cuts. The therapy is the basis for a popular treatment known as Floortime, in which a therapist follows a child’s lead during play activities to build communication and social interaction skills. Eliminating it “threatens to condemn our clients and this group of children to a bleak future under institutionalized care,” said Laura Faer, an attorney with the Public Counsel Law Center, which filed the suit on behalf of the families in Los Angeles County Superior Court. In July, the state Legislature cut more than $300 million in services for the developmentally disabled, including experimental treatments, recreational activities and nonmedical therapies. The Eastern Los Angeles County Regional Center — which oversees state-funded services for the developmentally disabled from Highland Park to La Mirada — eliminated DIR because it “doesn’t meet the rigors of science,” said Executive Director Gloria Wong, who is named as a defendant in the suit. Attorneys for the families said DIR should not be considered experimental since it has been reported “clinically effective” and that none of the other 20 regional centers in the state had discontinued it. Although there are no controlled scientific studies on DIR, the National Research Council concluded in 2001 that it had enough in common with other, proven methods that it could be considered a valid model for treating autism. Across the country, some public agencies and school districts have funded it; others have refused. Wong estimated that the regional center was spending $4 million a year on the therapy. The law allows any family to appeal the decision and maintain the service while waiting for an administrative law judge to issue a ruling. Autism, a neurodevelopmental disorder that limits communication and social interaction, is being diagnosed at record rates. Johnson & Johnson Accused of Drug Kickbacks Natasha Singer, New York Times- 1/16/2010 Johnson & Johnson paid kickbacks to the nation’s largest nursing home pharmacy to increase the number of elderly patients taking the antipsychotic Risperdal and several other medications, according to a complaint filed Friday by the office of the United States attorney in Boston. The payments violated the federal anti-kickback statute and led Omnicare, a pharmacy company specializing in dispensing drugs to nursing home residents, to submit false claims to Medicaid, the complaint charged. The government’s civil complaint joins a whistle-blower suit against Johnson & Johnson brought by two former employees of Omnicare, which has headquarters in Covington, Ky. Johnson & Johnson said Friday it was reviewing the complaint and intended to address the government’s lawsuit in court. The complaint charges that Johnson & Johnson, based in New Brunswick, N.J., and two of its subsidiaries, Ortho-McNeil-Janssen Pharmaceuticals and Johnson & Johnson Health Care Systems, paid tens of millions of dollars to induce Omnicare to buy and recommend Risperdal for elderly patients as well as the drug maker’s prescription pain relievers Duragesic and Ultram, and the antibiotic Levaquin. The complaint charges that Omnicare’s pharmacists engaged in intensive efforts to persuade physicians to prescribe the drugs from 1999 to 2004, a period in which the pharmacy’s annual purchase of Johnson & Johnson medications nearly tripled to more than $280 million, from about $100 million. During the same period, the pharmacy’s annual purchase of Risperdal rose to more than $100 million, according to the complaint filed in United States District Court in Massachusetts. “Kickbacks in the nursing home pharmacy context are particularly nefarious,” Carmen M. Ortiz, the United States attorney for Massachusetts, said in a statement Friday. In return for Omnicare’s efforts, the drug maker allegedly paid the pharmacy company kickbacks in the form of rebates based on the market share of some Johnson & Johnson drugs, sponsorship of Omnicare meetings, grants and payments for Omnicare data, like the prescribing habits of doctors, of the kind that Omnicare had previously provided the drug maker for free, the complaint said. “When it comes to the sometimes questionable practice of promoting brand-name drugs to doctors and their patients, this case represents the lowest of the low,” Senator Herb Kohl, the Wisconsin Democrat who is the chairman of the Senate Special Committee on Aging, said in an e-mail message sent Friday in response to a reporter’s question. “Nursing home residents comprise a vulnerable population that should be able to trust that their physician’s advice is based on medical expertise, not financial self-interest.” Although the events described in the complaint took place several years ago, Mr. Kohl wrote that the aging committee was continuing to investigate the issue of the overuse of antipsychotic drugs in nursing homes. Johnson & Johnson issued an e-mail statement in response to a reporter’s question. “We believe airing the facts will confirm that our conduct, including rebating programs like those the government now challenges, was lawful and appropriate,” the statement said. “We look forward to the opportunity to present our evidence in court.” Omnicare, with a market capitalization of about $3.1 billion, serves more than 1.4 million residents of nursing homes, assisted living and other health care facilities in 47 states and Canada, according to the company’s Web site. Last November, Omnicare paid $98 million to settle civil charges by the government that it had violated the False Claims Act for engaging in kickback schemes with Johnson & Johnson and a smaller drug maker. The settlement agreement did not include any finding of wrongdoing or any admission of liability by Omnicare, the company said in a statement issued in November. Omnicare denies the contentions of the federal complaint settled last fall and denies any liability related to those contentions, the statement said. The government has regulations in place to protect nursing home residents from medication mismanagement, like being sedated with psychiatric drugs for the purposes of discipline or convenience. The Department of Health and Human Services requires nursing homes to arrange for an outside consulting pharmacist to review a patient’s medication regimen at least once a month. These outside pharmacists have a duty to report any irregularities to the attending physician; the pharmacists also have the ability to recommend that a physician remove, change or add medications to a patient’s drug regimen, the complaint said. But the government’s complaint in the Johnson & Johnson case raises the question of whether some companies have used the consultant pharmacists — the very people entrusted by the government with safeguarding the integrity of nursing home drug prescriptions — for corporate gain. In this case, according to the complaint, Omnicare’s consultant pharmacists worked to increase Risperdal’s market share. “If true, these allegations represent a cynical manipulation of the laws intended to protect nursing home residents, as well as yet another rip-off of the Medicaid program,” Senator Charles E. Grassley, the Iowa Republican who has investigated the corporate conduct of certain drug makers, said in a statement Friday in response to a reporter’s question. “If consultant pharmacists aren’t independent, both the patient and the taxpayer lose.” In one company document among the court exhibits, for example, Omnicare said that its efforts generated a record market share high of 55.5 percent for Risperdal in the first quarter of 2000. “This market share represents Omnicare’s ability in persuading physicians to write Risperdal in the areas of behavioral disturbances associated with dementia,” the Omnicare document said. But Risperdal, which is approved by the Food and Drug Administration to treat schizophrenia and bipolar disorder, is not specifically approved to treat behavioral problems in elderly people with dementia. In fact, in 2005 the F.D.A. required that the labels of certain antipsychotic drugs, including Risperdal, carry a black box label warning that elderly people with dementia-related psychosis treated with such drugs were at an increased risk of death compared with those taking a placebo. In the e-mail message to a reporter, Mr. Kohl noted that the government’s complaint was not the first charge against a drug company for improperly marketing antipsychotic drugs to aging populations. Last January, the drug maker Eli Lilly pleaded guilty to a misdemeanor and paid $1.415 billion to settle criminal and civil charges that the drug maker had marketed its antipsychotic Zyprexa for the treatment of elderly people with dementia. The exhibits attached to the complaint depict the efforts of Omnicare and Johnson & Johnson to increase market share for Risperdal against competing antipsychotics like Zyprexa and Seroquel from AstraZeneca. In an Omnicare letter to Johnson & Johnson in 2001, an executive wrote that the pharmacy planned to spend about $173 million on Johnson & Johnson products. The executive wrote in capital letters, “We are selling more high-priced drugs (read Risperdal here) for the pharmaceutical industry!!”
Most previous popular treatments of subliminal forces haven’t been data driven. Vedantam, who until recently wrote the Department of Human Behavior column for The Washington Post, hopes to fill that gap. His entertaining romp through covert influences on human behavior began as a series of columns, and true to its genesis, it reads as vivid reportage overlaid with a sampling of science. Ranging widely from the role of social conformity in violence to snapshots of racial and gender prejudice, Vedantam draws expansive arcs between findings from social psychology and the nation’s sensibilities and voting patterns. “Unconscious bias reaches into every corner of your life,” he writes, thanks to a “hidden brain” generally inaccessible through introspection. As with crop circles, all we see are the traces left by covert attitudes, never the perp at the scene of the crime. Colorful characters form the backbone of the narrative; we meet a bickering, long-married academic couple, a rapist with great teeth, a woman working the night shift at a tire factory, a woman suffering from a rare form of dementia and a cult member. What binds this motley crew together? All are victims of some form of irrationality — those imperceptible forces that often prompt our actions in the real world, the ones that are at odds with our ideals. Most of us assume that honesty and generosity are personality traits polished over a lifetime of social interaction. But Vedantam shows how imperceptible social signals determine, for example, how deeply you’ll dig into your pocket. In offices with an honor system for coffee, people are more likely to pay on days when a photograph of human eyes is discreetly posted above the coffee machine, according to one British study. They’re more prone to cheat if a still life of daisies is pasted there instead — even if they say they’re unaware of either picture. Another experiment demonstrates that you’re likely to give a handsome tip to a waiter who repeats your food order verbatim. In fact, you’ll tip an average of 140 percent more than you would if he just paraphrases it. It’s all about social mimicry, apparently, our hidden ability to sync our behavior with the group’s. While social cues grease the wheels of interaction in subtle ways, they can also create hazards. In a gripping chapter on disasters, Vedantam describes the snap decisions made by employees of one brokerage firm in the south tower of the World Trade Center in the crucial minutes after the first plane hit on Sept. 11. The group on the 89th floor reached the consensus that they were not in danger — and perished. The group on the 88th floor ran for the stairs and survived. While everyone felt they were making autonomous decisions, the decisions were really made by the group. “Group decisions provide us with a signal,” Vedantam writes. “The details about individuals — who did what, who felt what, who thought what — is noise.” He cites another analysis, of response to the 1993 World Trade Center bombing, in which two different groups escaped at different rates. What mattered wasn’t what floor the groups were on but how large they were. “Groups seek to develop a shared narrative as an explanation for what is happening,” Vedantam writes. “The larger the group, the longer it took to arrive at a consensus.” His conclusion? “People can undermine themselves — and reduce the overall survival rate — by trying to help one another.” The crisis vignettes are skillfully spun out, Grisham style. Vedantam presents a fresh, bracing case for the dangers of group-think. But he sometimes extends his lessons too far. While Vedantam is right that large groups tend to produce fewer good Samaritans, studies of social networks show they can also mobilize quite effectively. After Hurricane Katrina, an impromptu “Cajun navy” rescued thousands of stranded residents. And a number of sociologists have documented how hundreds of thousands of people were evacuated from Lower Manhattan on Sept. 11 by another spontaneous armada. In a chapter on the psychology of suicide bombers, Vedantam draws parallels among obsessed sports fans, a Jonestown crackpot, violent extremists and striving executives. “The hidden brain’s drive for approval and meaning, and the ability of small groups to confer such approval and meaning, is what is common to the world of” all four, he writes. Social “tunnels,” which block out input from the outside world, direct some people toward public service and heroism, others toward violence. True, we all want to belong. But the evidence Vedantam offers for his claims is often too scant or streamlined, with contradictory or ambiguous results and dissenting interpretations left out. Meanwhile, the biggest bias of all — confirmation bias, which makes us notice only what supports our own opinions and tune out everything else — hardly gets a mention. All this secret stuff can be very disconcerting. But we need more than we get here to know if it is true. Narrowing an Eating Disorder Abby Ellin, New York Times- 1/19/2010 The year was 1988, and I was a college student on my junior year abroad, traveling aimlessly through the Middle East and Europe. My backpack was crammed with shorts and T-shirts, bathing suits and sarongs, my Walkman and Grateful Dead tapes. And oh, yes, a scale, buried deep beneath layers of socks. Having been a chubby adolescent — and having spent six summers at fat camp — I was terrified of gaining weight. Unfortunately, nothing gave me as much pleasure as eating, which I did with abandon. To maintain some semblance of control, I divided my eating into Food Days and Nonfood Days: that is, days when I consumed vast amounts, and days when I policed my caloric intake with military precision. The routine kept my weight in check, more or less. Never mind that it was insane. No one at my college health center knew what to do with me. Clearly, I wasn’t anorexic; I was slightly round, in fact. I didn’t purge, so bulimia was out. To my distress, the counselors told me there was nothing they could do for me and sent me on my way. Today, I would probably qualify for a diagnosis of “eating disorder not otherwise specified,” usually known by its acronym, Ednos. In the current edition of the Diagnostic and Statistical Manual of Mental Disorders, it encompasses virtually every type of eating problem that is not anorexia or bulimia. Though its name is less familiar, it is diagnosed more often than those two disorders — in 4 percent of American women each year, according to the National Eating Disorders Association. (The association does not have statistics on men.) Subsets of Ednos include binge eating disorder, purging disorder, night eating syndrome, chewing and spitting out food, and even picky eating. But the diagnosis baffles many clinicians, who call it ambiguous, vague and unwieldy. And so the American Psychiatric Association is overhauling its definition of Ednos for the next edition of the diagnostic manual, known as D.S.M.-5, to be published in 2013. “The consensus is that Ednos is ‘too big,’ meaning it is being used more frequently than is desirable, as that label does not convey much specific information,” said Dr. B. Timothy Walsh, a professor of psychiatry at Columbia who is chairman of the eating disorders work group for the new manual. Dr. Walsh said the panel was “considering a range of ways to reduce the frequency with which that very broad category is used.” For now, though, Ednos remains the nation’s most common eating disorder. A September 2009 study in The International Journal of Eating Disorders found that Ednos was often a way station between an eating disorder and recovery or, less commonly, from recovery to a full-blown eating disorder. “The eating has to be disordered in some way, as does the behavior relating to eating,” said Ruth H. Striegel-Moore, a professor of psychology at Montana State University. “Also, it has to lead to some kind of impairment. For instance, some women will not go to parties because they’re worried about eating. “If you’re restricting yourself so much that it affects your work negatively, you would meet the criteria for Ednos.” Even so, many clinicians say the diagnosis is just too roomy. “One of the difficulties with Ednos is that there’s a lot of diversity within that category,” said Craig Johnson, director of the eating disorders program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla. “Because there are different presentations that not all clinicians are familiar with, there’s a risk that people who have disordered eating who could benefit from clinical attention won’t know that they have a problem.” Indeed, one reason the panel wants to change the guidelines is to help patients with eating problems recognize them even if they do not exhibit any of the traditional symptoms. Kris Shock, for example, used laxatives and restricted her food for years, but she never threw up or binged, and her weight was average. She did not seek psychiatric help for what she and her husband called her “eating problem” until age 31, when she became addicted to the diet pill ephedra, she said in a recent interview. Now 37 and the director of a child care center in Atlanta, Ms. Shock said that when she finally got her diagnosis of Ednos, “it was like, ‘Ah, I am sick enough to get help and have the recovery experience.’ ” Most health insurance policies do not cover Ednos. (Ms. Shock refinanced her home to pay for her week-and-a-half-long stay at a residential treatment center.) Yet people with it are at risk for many of the same medical problems that afflict anorexics or bulimics, including osteoporosis, heart attacks, hormone imbalance and even death. A study in the Oct. 15 issue of The American Journal of Psychiatry reported that the mortality rate associated with Ednos exceeded that for anorexia nervosa and bulimia. With that in mind, many doctors blur the diagnostic lines just so their patients can get insurance coverage. A chewer and spitter might be classified as bulimic, Dr. Striegel-Moore said; an almost-anorexic would fall under binge eating disorder. Clinicians say patients like these often need to feel they have a “real” eating disorder.“A lot of patients feel this stigma if they know they’re diagnosed with Ednos: ‘Obviously, I’m not good enough to be anorexic,’ ” said Nicole Hawkins, director of clinical services at Center for Change, an eating disorder treatment center in Orem, Utah. “I’ve had many patients feel that they need to lose more weight so they lose their period so they can change the diagnosis. Patients really feel they have to get ‘better’ at their eating disorder to deserve treatment.” That is how Stacey Taylor felt. Ms. Taylor, 26, a prekindergarten teacher in Alexandria, La., said she had been dieting since age 7; at 16, she lost 70 pounds, and from then until age 25 she purged and abused diet pills, diuretics and laxatives. Although she vomited 3 to 11 times a day, she was never classified as bulimic because she did not binge, and her weight was never low enough to be anorexic. “The doctors would look at me and say, ‘You don’t look like you have an eating disorder — go home and get something to eat,’ ” she recalled, adding that she didn’t think she was “sick enough” to need help, either. Some doctors say weight requirements should be eliminated for all eating disorders in the new diagnostic manual. Deb Burgard, an eating disorder specialist in Los Altos, Calif., notes that people of any weight and body mass index may binge, purge or diet excessively. “I have worked with plenty of restricting average-sized and fat patients who really should be diagnosed with anorexia nervosa,” said Dr. Burgard, a founder of Health at Every Size, an approach that focuses on health rather than weight. “But there is confusion based on the current D.S.M. whether they meet the criteria for the diagnosis if they are not at a low B.M.I. — even if their current weight is extremely low for them individually and they’re showing signs of starvation.” Perhaps the most difficult part of treating Ednos is that “normal” eating is such an elusive concept. Thinness tends to be the ideal, no matter what lengths people go to get there. “What Ednos really demonstrates,” said Dr. Johnson, at Laureate in Tulsa, “is that we don’t have empirically derived diagnoses in psychiatry. “Think about the diagnosis of depression. When does someone have a clinical syndrome versus a mood fluctuation? At what point should it be regarded as a condition that needs treatment? When you talk about food habits, it becomes extraordinarily complicated, because everybody has a relationship with food, and it’s usually a somewhat complicated one.” Deficiencies in the Treatment of Depression Roni Caryn Rabin, New York Times- 1/19/2010 Researchers reported last week that antidepressant drugs seemed to be effective mainly in people with severe depression, not those with milder forms. Now another study is reporting that only about half of all Americans with depression receive treatment of any kind. Moreover, only 1 in 5 are getting care — talk therapy, medication or both — that conforms to American Psychiatric Association guidelines, according to the study, which appears in the January issue of Archives of General Psychiatry. The findings were based on nationally representative surveys of 15,762 adults from February 2001 to November 2003. Over all, more patients used talk therapy (44 percent) than drug therapy (33 percent). Mexican-Americans and African-Americans were less likely than other groups to receive treatment of any kind. “For minorities especially, psychotherapy may be more acceptable than antidepressants,” said the lead author of the study, Hector M. González, assistant professor of family medicine and public health at Wayne State University in Detroit. “The take-home message is that maybe we should be trying to reach out to these particular minorities more with psychotherapy.” Estimates have obsessive-compulsive disorder afflicting anywhere from 2.5 percent to 8 percent of the human population. It shows up in behavior like excessive hand washing, repetitive checking of stoves, locks and lights, and damaging actions like pulling one’s hair out by the roots and self-mutilation. The disorder has been used in popular movies and television shows to define characters like the reclusive writer Melvin Udall, played by Jack Nicholson, in “As Good as It Gets” and Adrian Monk, played by Tony Shalhoub, in the television series “Monk.” Similar disorders are known in dogs, particularly in certain breeds, including Dobermans. Dr. Dodman and his collaborators searched for a genetic source for this behavior by scanning and comparing the genomes of 94 Doberman pinschers that sucked their flanks, sucked on blankets or engaged in both behaviors with those of 73 Dobermans that did neither. They also studied the pedigrees of all the dogs for complex patterns of inheritance. The researchers identified a spot on canine chromosome 7 that contains the gene CDH2 (Cadherin 2), which showed variation in the genetic code when the sucking and nonsucking dogs were compared. The statistical association led to further investigation to determine for which protein the gene contained instructions. It did for one of the proteins called cadherins, which are found throughout the animal kingdom and are apparently involved in cell alignment, adhesion and signaling. Cadherins have also been recently associated with autism spectrum disorder, which includes repetitive and compulsive behaviors, said Dr. Edward I. Ginns, senior author of the report in Molecular Psychiatry and director of the Molecular Diagnostics Laboratory at the University of Massachusetts Medical School. Dr. Dennis Murphy, a psychiatrist who was not associated with the study, said the results had the potential to advance understanding of obsessive-compulsive disorder. Dr. Murphy, also chief of the Laboratory of Clinical Science in the National Institutes of Mental Health’s Division of Intramural Research Program, is now working on finding and sequencing the CDH2 gene in humans to see whether it is linked to obsessive-compulsive behavior. People with obsessive-compulsive disorder often engage in normal behavior that has become extreme, ritualized, repetitive and time-consuming, and suffer from anxiety and obsessive thinking. Because the disorder involves obsessive thoughts and because of the difficulty of understanding animal cognition, the same kinds of behavior in animals has commonly been referred to simply as compulsive disorder. As scientists learn more about the underlying molecular causes of this condition, they increasingly use “obsessive-compulsive disorder” to apply to animals and people. Recent rough estimates by Dr. Karen L. Overall, a veterinarian specializing in animal behavior at the University of Pennsylvania School of Medicine, suggest that up to 8 percent of dogs in America — five million to six million animals — exhibit compulsive behaviors, like fence-running, pacing, spinning, tail-chasing, snapping at imaginary flies, licking, chewing, barking and staring. Males with the problem outnumber females three to one in dogs, she found, whereas in cats the ratio is reversed. Dr. Overall said dogs usually developed compulsive behavior between ages 1 and 4. Some of the Dobermans in Dr. Dodman’s group began earlier, with blanket sucking at around 5 months and flank sucking at 9 months. Dogs can be treated, but if they are not, compulsive behavior is one of the main reasons that people give them up for adoption or euthanasia, according to veterinary behaviorists. Dr. Overall said in an earlier paper that environmental causes might outweigh genetic factors in development of compulsive behaviors in some cases. She said the practice of “hanging” a dog up by its choke collar, a form of discipline advocated by some trainers, produced compulsive behaviors. Dogs from puppy mills or shelters, rescue dogs and those that are confined and bored dogs or anxious also seem prone to compulsive behavior, she said. Other domestic animals, notably cats and horses, as well as some of the animals at zoos, exhibit compulsive behaviors, including wool-sucking in Siamese cats, and locomotion disorders like stall walking and weaving in confined horses and pacing in captive polar bears, tigers and other carnivores used to ranging across large territories. Although antidepressants, particularly selective serotonin reuptake inhibitors and clomipramine, a tricyclic antidepressant, and behavior modification have proved effective at controlling compulsive behavior in dogs and people, they do not appear to correct underlying pathologies or causes, Dr. Ginns said. Those causes are likely to be as varied as the compulsive behaviors and as complex as the interplay of multiple genes and the environment. “Stress and anxiety, as well as physical trauma and illness, can trigger repetitive behavior that then takes on a life of its own,” Dr. Ginns said. But he believes that in many cases there is an underlying genetic predisposition that responds to environmental stimuli in such a way that once-normal behavior turns into something pathological. Those genetic dispositions may differ markedly between different behaviors. Some geneticists say that because of their detailed pedigree and the similarity of their genes to those of humans, dogs make an ideal model for studying human behaviors and pathologies, especially those involving complex patterns of inheritance. Few humans keep detailed genealogies for themselves, but they are diligent in recording every detail in the ancestry of their purebred animals. “Nick and I share an interest in pedigrees,” Dr. Ginns said in explaining how he and Dr. Dodman became collaborators with Kerstin Lindblad-Toh and her gene sequencers at the Broad Institute of M.I.T. and Harvard, the same group that sequenced the dog genome now proving so valuable to both human and canine geneticists.
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