14 November 2011

The Vets Are Alright (The Rest of Us Are the Problem)

This post is cross posted over at the wonderful Gunpowder & Lead blog. They're the same post.

As I read through recent stories about military veterans one thing has crystallized for me: the relentless focus on injuries, PTSD, TBI and the soldier's and veteran's general distress.

Based solely on the media's portrayal of returning soldiers and veterans one would believe them all to be fragile individuals whose lives may shatter at the slightest additional trauma. However, the vast majority of soldiers return healthy and capable, even if they are forever changed by their experience serving. That is to say, we seem to live in a world where the afflictions of soldiers are covered in the media like airplane crashes, rather than car accidents:
Page-one coverage of airplane accidents was sixty times greater than reporting on HIV/AIDs; fifteen hundred times greater than auto hazards; and six thousand times greater than cancer, the second leading killer in America after heart disease.
To be sure, PTSD, TBI, amputations, automobile accidents, plane crashes, and cancer deaths are all very real and very tragic but it's long past due that we consider the consequences of our relentless focus on the those afflicted by war because they are real as well.

While the media's predilection for rare and extraordinary stories has been well documented what's more important than the coverage itself is the nature of the coverage. For example: this October 2010 Washington Post article, Traumatic brain injury leaves an often-invisible, life-altering wound. This article is typical for its genre, coming in at nearly 3,000 words, yet devoting only a few sentences to any sort of wider context. We are told the raw number of diagnoses of TBI since 2000, then given another, larger, number from a RAND corporation study. Completely missing is any sense of scale. Do those 180,000 (or is it 300,000?) soldiers represent 1%, 10%, or 90% of individuals at-risk for TBI?

03 October 2011

Misdirection by euphemism

As I watched the news a few weeks ago waiting to see if, and then when, the state of Georgia would execute Troy Davis—a man wrongly convicted at worst, or unjustly sentenced at best—something about the images from outside the prison struck me: The innocuous and anodyne name of the prison, the Georgia Diagnostic and Classification Prison.

Naming the prison this way asserts that the public should know that this facility is where diagnosing and classifying occur. While it's undeniably true that those terms do accurately convey some of the actions that the Georgia Department of Corrections carries out there, it begs the question: Why are these functions of this prison so vital as to claim space in its very name?

George Orwell, in his famous 1946 essay Politics and the English Language said, "In our time, political speech and writing are largely the defense of the indefensible." It is a coincidence of history that only a year later the United States would consolidate the belligerently named Departments of War and Navy into the comparatively docile Department of Defense.

The labels a culture applies to its institutions serve a purpose beyond mere identification: they signal the purpose and expectations by which we should judge them. This is why those two superfluous words in the Georgia prison's name are so important. They were not chosen lightly, nor were they included in the prison's title carelessly.

Let's examine the word diagnostic closely (classification's particulars ought to be self evident afterward). Beyond its definition, the verb diagnose is notable because it is overwhelmingly used to indicates a label applied by an authority. To wit: the OED's first usage example for diagnose is, "doctors diagnosed a rare and fatal liver disease." One can easily construct other common usages, e.g., "the mechanic diagnosed the problem with the car."

No matter the usage example, they all refer to situations where higher-information individuals (or professions, or institutions) apply a label to something. To put it more simply, diagnosis is an act of profound authoritarianism. While the authoritarian implications of both diagnosis and classification are important, the more subtle endorsement is toward the medical usage. It is no accident that diagnose's usage example invokes the medical profession.

14 September 2011

One thousand and seventy words about mental healthcare

I'm currently doing a psychiatry rotation at an outpatient behavioral health clinic which primarily serves the substantial indigent population here. I've tried to sit down and write about the experience but all that comes out is a structureless jeremiad about the tragedy of a shredded safety net and those with psychiatric problems.

Rather than subject you to that I'd rather just present this chart by Bernard Harcourt (much more here):

03 August 2011

JAMA and the NYT don't understand PTSD

The New York Times has a new article about a recent study examining the adjunctive use of Risperdal in treating PTSD. Specifically, patients who were already taking a serotonin reuptake inhibitor either were, or were not, given Risperdal as well. Via a variety of metrics they were then assessed after six months to see if the Risperdal made a difference.

Let's begin where the article does, with its headline, "Drugs Found Ineffective for Veterans’ Stress". First of all, the study only examined one drug (granted, it did so in conjunction with a myriad of others, but its findings all relate to one drug), making the Times' use of the plural deeply wrong. In case you want to excuse the writer (Benedict Carey) and just blame the editor for a careless headline, here's the first sentence, which abuses the plural as well, "Drugs widely prescribed to treat severe post-traumatic stress symptoms for veterans are no more effective than placebos and come with serious side effects, including weight gain and fatigue, researchers reported on Tuesday."

Not only does the sentence abuse its subject to over sensationalize the story, the entire second half exaggerates the research findings upon which this article is based. The research author's only comments on the side effects of Risperdal were, "Adverse events associated with risperidone were not serious."

24 May 2011

Why we all want to justify rape (sometimes)

In the wake of Dominique Strauss-Kahn's arrest on attempted rape charges last week a furor arose over apologia written by Ben Stein and Bernard-Henri Levy. (In case you're wondering why I didn't write about this sooner… I had finals and an ACLS class, oh and I have a board exam in a month.)

Occasionally mentioned—usually in passing—as this saga has unfolded is the (United States') general media portrayal of rape. In particular there have been a few mentions of this (recently notorious) NYT story on the vicious gang rape of an eleven year old girl by eighteen men. As Roxane Gay at The Rumpus did a masterful job dissecting the story I will just quote one of Gay's paragraphs that synopsizes the NYT's troubled reporting.
The overall tone of the article was what a shame it all was, how so many lives were affected by this one terrible event. Little addressed the girl, the child. It was an eleven-year-old girl whose body was ripped apart, not a town. It was an eleven-year-old girl whose life was ripped apart, not the lives of the men who raped her. It is difficult for me to make sense of how anyone could lose sight of that and yet it isn’t.
As usual I find the the way these events were reported on interesting. However, I find why they were reported this way to be a lot more interesting.

06 May 2011

Why properly understanding how stuff works is important

Constitutionally I can only handle studying for so long at a stretch without going crazy. However, with board exams looming nearer every day I shifted my normally wide ranging leisure reading to focus on things that are medically relevant and help to reenforce many of the bits of information and/or concepts that I'll be tested on.

Which is why I'm currently reading The Excellent Powder: DDT's Political and Scientific History. The third chapter entirely pertains to widespread misunderstanding among policy makers of how DDT works. To quote the chapter summary:

04 May 2011

The myth of Muslim conspiracy theories

In the wake of Osama bin Laden's death the media can't say enough about conspiracy theories: how our actions are creating them, what they are, who believes what, and so on. Strangely absent from their fascination is their own role in their creation and persistence. Dutifully playing along is Matthew Gray, a writer at Foreign Affairs, who brings us a backgrounder on what is already a growing trend—Muslim conspiracy theory spotting. His piece will likely set some of the terms for the future conversation because he goes one step further and, as his subtitle indicates, purports to explain, "Why falsehoods flourish in the Muslim world."

The piece is not devoid of value; however, it's impossible to talk about who is susceptible to a "conspiracy theory" without clarifying what you mean by the term, as well as the more straightforward "conspiracy." Take, for instance, this assertion of Mr. Gray's:
One reason the region is so susceptible to conspiracy theories is that it has been subject to an unusually high number of actual conspiracies in the past.
What Mr. Gray is referring to here is not the disproportionate number of conspiracies that have taken place in the Middle East, instead he is referring to the number of coups that have occurred. Even more specifically though, he is referring only to coups engineered by foreign governments. This is all well and good in that foreign operatives (particularly those of clandestine services) engineering coups provide solid examples of one type of conspiracy.

14 April 2011

Irrational decision making in healthcare

Paul Ryan's budget plan as sparked a widespread conversation about the nature of Medicare benefits (and to a lesser degree, Medicaid). I want to focus on an issue that seems incredibly obvious to me, yet seemingly eludes clever economists like Tyler Cowen, Matt Yglesias, and Paul Krugman.

One of the biggest problems regarding the provision of health care, and the design of a system to do so in a "cost effective" fashion is the cognitive and temporal disconnect between decision making and the consequences thereof. The trio of economists I mentioned above have all, at various times, reflected on the moral hazard of bailing out banks that are too big to fail. For the most part they regard this as a Bad Thing.

19 March 2011

Opium addiction and cultural imperialism ch. II

This time the nonsense comes from The New Republic. As a refresher, CNN ran a piece back in January about how opium addiction was an un(der)reported scourge affecting destitute Afghanis. I wrote about the flaws of that piece. Unsurprisingly, many of the same flaws are evident in the New Republic dispatch from Anna Badkhen. Badkhen does CNN writer Arwa Damon one better and opens her story with an infant who has an overdose of opium, rather than just an infant being fed it.

I don't mean to diminish the tragedy or heartbreak attendant to infant deaths and near misses. Any death, particularly a child's is dreadful. However, consider the words of Dr. Mohammad Akbar whom Badkhen interviewed:
Every month we receive two or three babies like this, not breathing, overdosed,” he said. “It is very common for people in this area to give opium to children when they cry. If he had gotten here twenty minutes later, he wouldn’t have lived. Last year, we had three children who were brought here dead.
This terrible epidemic is killing… three children per year. Wait, what? Here's the worst part, Badkhen's description of just who Dr. Mohammad Akbar is, "Dr. Mohammad Akbar, the sole pediatrician here, told me the hospital receives approximately 1,000 child patients each year." To recap, the sole pediatrician at the sole hospital north of Balkh sees three deaths from opium overdose per year.

10 March 2011

Hospitals are not like airports; patients are not like airplanes

In writing blog posts that are critical of other writing one of my goals is not to point to the specific flaws of any particular article. No one has time to discredit all of the specious and nonsensical things that get posted, even by reputable outlets, to the internet each day. One of the things I try, and you can let me know if I'm failing, is to point out some of the tricks used to manipulate and/or mislead readers.

Which brings me to the false dichotomies. For an excellent example there's this piece in the Washington Monthly. You don't even have to read past the subhead to find the comparison:
Last year there wasn’t a single fatal airline accident in the developed world. So why is the U.S. health care system still accidentally killing hundreds of thousands? The answer is a lack of transparency.
I've added emphasis on a particularly important part here, and I'll get back to it in a bit.

14 February 2011

How problems in WTUs are like drug interaction deaths

Medical issues in the military seem to be getting a lot of press attention these days, so I feel it's important to take a look at the genesis of these problems, specifically the polypharmacy issue and the troubles with Warrior Transition Units (WTUs). The policies leading to these problems have been well intentioned, yet there seems to be little thought or care for how and why they've gone so far astray, although there is plenty that they have gone astray.

Before delving into the issues I mentioned above, let's use a more well known example of these "second order effects." During the toughening of drug sentences in the late 1980s the Anti-Drug Abuse Act made prison sentences proportional to the quantity of illicit substance that a dealer was holding when arrested. The thinking behind such laws is straightforward: stiffer sentences for bigger time drug dealers. At first blush this sounds like a solid enforcement strategy; however, both in theory and in practice these laws had the unintended consequence of incentivizing dealers to hold smaller quantities while still being able to meet demand. Dealers responded to this by placing a new premium on purity. If they could sell their customers half the weight for the same price, they faced a lighter sentence if/when they were arrested. In this way drug laws that were designed to curtail large scale drug dealing had the perverse effect of increasing drug purity, which itself has many second order consequences (higher overdose rates, increased addiction potential, etc).

12 February 2011

Opinion as journalism in the NYT

The NYT has an opinion piece (although it's filed as news) decrying the ideological dominance of the social sciences by liberals. Fortunately for ivory tower liberals everywhere, the piece would be bad as opinion. It's truly awful as journalism. Let's begin where the article does:
“Anywhere in the world that social psychologists see women or minorities underrepresented by a factor of two or three, our minds jump to discrimination as the explanation,” said Dr. Haidt, who called himself a longtime liberal turned centrist. “But when we find out that conservatives are underrepresented among us by a factor of more than 100, suddenly everyone finds it quite easy to generate alternate explanations.”
People do often jump to discrimination as a default explanation for gender discrimination (particularly in graduate schools). However, as the article itself goes on to explain statistics demonstrate that the disproportionate number of men in graduate studies actually represents discrimination against the men, since women are, as compared to the percentage of applicants, overrepresented.

08 February 2011

You do not understand what a p-value is (p < 0.001)

I'm sure it's only a matter of weeks (months at most) before every "news" publication in this country runs a story on the pitiful state of statistical rigor in research. Most of them will probably point to one of a handful of studies that pick apart the various statistical methods used in studies. None of them will point out the fundamental statistical misunderstanding that undergirds 99% of the medical literature: the p-value and what it means. The p-value is so misunderstood, and the misunderstanding so widespread, that my medical school class was taught the wrong definition.

Here's what the p-value is not: "The probability that the null-hypothesis was true." I didn't choose this definition out of thin air to beat up on, it was the correct answer on a test I took asking, "Which of these is the definition of a p-value?" Beyond that it's what most people think a p-value is.

29 January 2011

Why nearly everything Newsweek writes about medicine is wrong

Newsweek has an article about Dr John Ioannidis and his work discrediting many medical studies. Incidentally The Atlantic wrote about him and his work back in November as did The New Yorker in December. All of these articles highlight Ioannidis' findings that many studies are flawed, but take different approaches, and draw different conclusions from his work. Newsweek's take is by far the worst and most harmful.

25 January 2011

Amy Chua and the stereotype ladder

The amount of ink spilled over this Amy Chua WSJ excerpt is threatening to break BP's recent record for noxious black liquids we wish would go away. The problem with all of this blogging and emailing and tweeting and editorializing about her is that it misses the point.

Before I get to my big reveal and tell you what that point is I want to list some assorted facts about the Chua family.
  • Amy Chua is a professor at Yale
  • Jed Rubenfield (her husband) is also a professor at Yale
  • The family has two Samoyeds named Coco and Pushkin
  • Chua's Wikipedia page has 1,500 words about Battle Hymn of the Tiger Mother

24 January 2011

The future of the Army's suicide & PTSD problems

Part II: Where do we go from here?

A few days ago I told you what the Army's latest data says. Now I will tell you some things that people are looking at, what those things mean, and some options for getting the suicide and PTSD epidemics under control.

The first, most important piece of this puzzle, is a study out this month that assessed the effectiveness of mental health screening prior to their Iraq deployment. Screenings were conducted on three brigades, and three unscreened brigades served as the controls. There were 10,678 soldiers in the screened brigade, of those 347 were taking a psychiatric medication at the time of their screening.1 Of those on medications 74 (0.7%) were not cleared to deploy immediately and 96 (0.9%) received waivers to deploy on time. Among those not cleared for immediate deployment, 26 were delayed for 1-2 months to allow their medications to stabilize, 32 were not cleared for deployment because they were unlikely to stabilize quickly, and 16 were not cleared for deployment because of a psychotic or bipolar disorder diagnosis.

23 January 2011

Opium addiction in rural Afghanistan is not a big deal

CNN has a heart wrenching story about Afghan infants being fed pure opium. Or at least that's what the headline says. Aside from one anecdote early in the article there's nothing else in it about children, it's all about how widespread opium addiction is in rural Balkh. Moreover, it mentions "health risks" and that opium is addictive but does not elaborate.

First of all, opium is the raw paste harvested from slit seed poppies of Papaver somniferum, but also other poppies. It is composed of a variety of substances, but the pain killers are morphine, codeine, and thebaine. Most important is morphine which typically constitutes 10-15% of the raw latex paste. It also contains codeine (1-3%) and thebaine (<%5)1. The composition matters because morphine and thebaine get extensively metabolized when you ingest them orally and only a small amount of codeine will even end up as a bioactive compound (on its own it is inert).

20 January 2011

Breaking down the Army's suicide data

Part I: What does the data say?

There's a lot of grist to Wednesday's news briefing with Gen. Chiarelli on the 2010 Army suicide statistics. As usual, everything I write is my own opinion, unvarnished.

Looking past the headlines telling you some suicides were up and some where down I want to point out an underemphasized point that Gen. Chiarelli made during his briefing:
So the numbers [...] have really only focused on this group, both the Army Reserve and the Army National Guard, to collect this data for about five years.

17 January 2011

The geography of mental health

Over at The Atlantic there is an article mapping the geography of gun deaths. They go one step further and create the below list of correlates with deaths from gun violence that I added a big red box to for you.

What's going on here? Didn't I make a big fuss about there being a real correlation between mental illness and violent crime? Yes, and I am still correct. First of all, they're comparing gun deaths, not violent crime. More importantly though, the article is the bar room equivalent of blindfolding yourself, and spinning around while throwing darts wildly in the hope that a few hit the board.

Ike's other warning

In this day and age everyone knows Eisenhower's warning regarding the growing military-industrial complex. His lesser known, but equally important, fear bears mention on the 50th anniversary of his famous farewell address.
Today, the solitary inventor, tinkering in his shop, has been over shadowed by task forces of scientists in laboratories and testing fields. In the same fashion, the free university, historically the fountainhead of free ideas and scientific discovery, has experienced a revolution in the conduct of research. Partly because of the huge costs involved, a government contract becomes virtually a substitute for intellectual curiosity. For every old blackboard there are now hundreds of new electronic computers.
The prospect of domination of the nation's scholars by Federal employment, project allocations, and the power of money is ever present and is gravely to be regarded.
Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific-technological elite.

11 January 2011

Jenny McCarthy is killing kids

Amazingly, on the same day that the Huffintgon Post runs a piece about cooling down political rhetoric they run a(nother) tragically misinformed, catastrophically misleading, and generally stupid piece from Jenny McCarthy. Message received, when the victims of your rhetoric blast to the front page of the paper because of a tragedy, we all must take note. When your rhetoric quietly sickens tens of thousands of people, most of them children, your platform will not be taken away, no matter the nonsense you shout from it.

09 January 2011

Mental illness, crime, and statistics

There was a tragedy yesterday. Because of the perpetrator's YouTube page and reports from people who knew him, the call is going out that he is "mentally disturbed," thus we have our explanation for the shooting. (Assuming you claim that national partisanship also had something to do with it.)

Not so fast warns Vaughan Bell at Slate, taking the misuse of statistics to new heights. He cites a meta-analysis of people with schizophrenia and/or bipolar disorder and concludes, "it's likely that some of the people in your local bar are at greater risk of committing murder than your average person with mental illness." Leaving aside the bizarre semantic construction of people being "at risk" to commit an act, what he says is half-true, but only because he's answering an unimportant question.

08 January 2011

Fraud and science, part II

There are reports all over (they're actually just disguised pressers since that's all the journalists read) about a new study in a journal no one reads (Pharmacoepidemiology and Drug Safety; it's the fourth google result when searching its title...). That antipsychotics are being prescribed off label in ever increasing amounts with scant data to support doing so. The actual study (gated, natch) is not linked to by a single one of those articles.

It does not reflect well on the PR acumen of Science (capital S) or scientists that the article was first "published" and the presser released on a Friday. It's as though they're undermining their own cause by ensuring that no one will read this article. (What possible incentive could they have for that? See III.)

07 January 2011

Statistics, antidepressants, and suicide

Statistics is hard. At this point the, shall we say, flexibility of statistics is well worn (even high schoolers have heard that there are, "Lies, damn lies, and statistics."). Why statistics is hard is an important, but rarely asked question. One of the reasons is because statistics sits at the intersection of quantification and inquiry. Anyone can count how many M&Ms are in the package, but first they have to ask how many there are. In any statistical venture it is very important to keep one foot firmly rooted in this initial inquiry, no matter where the mathematical convolutions take you. Which leads to the question: Is an increased suicide rate a side effect of antidepressants? The FDA think so. But they're wrong.

Fraud and science

Everyone else is writing about it, so I may as well too. Everyone is reporting that not only does the MMR vaccine not cause autism, but the data purporting to show that it did was fraudulent.

While everyone seems terribly outraged by this, they also seem to be treating the whole thing as some sort of crazy anomaly -- the scientific equivalent of that high school reunion your wife couldn't go to and where you had a bit too much to drink and the (still) hot girl you pined for long ago is now impressed at what you've become and somehow you end up with her panties in your luggage. I mean, why tell your wife? It'll turn both your lives upside down, hurt everyone involved, and it was just a once in a lifetime confluence of alcohol, chance, and reminiscence...

06 January 2011

PTSD and Canadian snipers

Up front: If you have not read Jim Gourley on what PTSD is stop reading this and go there now. This will be here when you get back.

What Gourley nails that is often missed is the import uncertainty plays in inducing PTSD (both as a chronic condition and acute attacks). Another way to think about this uncertainty is to couch it in terms of control. Soldiers have profoundly little control on their environment and this is a fact made nakedly apparent to them every single day they are down range (and many they are not). Here are two passages from Sebastian Junger's War that evince this:

05 January 2011

Identity Assault

And how in the world can the words that I said

Send somebody so over the edge

That they’d write me a letter sayin’ that I better

Shut up and sing or my life will be over


Here's how: You tell someone something that challenges their conception of self. Music, sports, and religion are a few of the existential things we use as signs to mark out our own identity, as well as signal that identity to others. Largely because existential objects are hard to display we create concrete ones to denote particular aspects of ourselves and display them to the world.

When you challenge one of these identity symbols someone is displaying, or force them to rethink (read: reject) it they will reflexively attack. You’re seen as a threat to their core being and in today’s America no one has the right to question your identity, much less make you question your own.