Seth's Blog

Marcia Angell, a former editor of JAMA, may be the most prominent critic of drug companies. The most recent two issues of the New York Review of Books contain a two-part critique by her of psychiatry. I liked Part 1 because she described the excellent work of Irving Kirsch (The Emperor’s New Drugs). Part 2, however, is a disaster.

She goes on and on about the evils of the DSMs — the diagnostic manuals of psychiatry. Improving the reliability of diagnosis is playing into the hands of the drug companies, she seems to say. She complains that the number of diagnoses is increasing. Well, yes, all diagnostic systems get larger over time. This is a good thing; if you don’t have a name for a problem, it is hard to do cumulative research about it and hard to communicate research results to everyone else. She complains, apparently, that new categories are being added:

There are proposals for entirely new entries, such as “hypersexual disorder,” “restless legs syndrome,” and “binge eating.”

She does not say why this is bad. Maybe she thinks it’s obvious. It isn’t obvious to me. Diagnostic categories help researchers and doctors and the rest of us communicate. For example, Dennis Mangan’s research shows why it is a good idea for the term restless legs syndrome to have an agreed-upon meaning.

She complains that the DSM doesn’t have enough “citations”:

There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journal articles or textbooks, statements of fact are supposed to be supported by citations of published scientific studies. (There are four separate “sourcebooks” for the current edition of the DSM that present the rationale for some decisions, along with references, but that is not the same thing as specific references.)

Please. This is clueless. A diagnostic manual is a dictionary. It assigns meanings to diagnostic categories. You can make a useful dictionary without “citations of scientific studies”. Long before you can do scientific studies about the best way to define dog you can come up with a definition of dog that is better than nothing.

She ends her review with this:

Above all, we should remember the time-honored medical dictum: first, do no harm (primum non nocere)

Gag me with a spoon. Time-honored? Doctors — with the support of JAMA, not to mention the rest of the health-care establishment — continually prescribe drugs with bad side effects and high prices and suppress innovative alternatives. (Not only that. My own surgeon recommended a dangerous surgery of no clear value.) How they can claim to do no harm escapes me.

Sure, psychiatry is awful. For a long time psychiatrists rallied around a transparent intellectual fraud (Freud and his offshoots). Now they rally around a less transparent intellectual fraud (neurotransmitter theories of mental illness). Psychotherapists and their wacky theories and no-more-effective treatments are no better so I wouldn’t blame the drug companies for the underlying problem. I put the problem like this: Our health care system consists of a very large number of people, many with very large salaries, who must get paid. Being human, they strongly oppose any progress that would reduce their salary or influence or, heaven forbid, eliminate their job. Because of them, many promising lines of research, such as prevention via environmental change or cure via nutrition, are completely or almost completely ignored. This is the fundamental reason Angell’s critique is so bad: She is part of the problem. She is very smart, but she’s been brainwashed (“primum non nocere“!). She utterly ignores the fact that we don’t know what causes depression, what causes schizophrenia, what causes autism, and so forth. Only when we learn what causes these and other mental disorders will we be in a good position to improve our mental health.

In college and afterwards, I tried to educate myself by reading well-written stuff. At first, I went through back issues of The New Yorker in the Caltech library. Later I stuck with books. For example, I learned about molecular biology by reading The Eighth Day of Creation. The Torchlight List by Jim Flynn (discoverer of the Flynn Effect, the slow increase in IQ scores) has the same underlying philosophy: a good way to learn is to read books you enjoy. (more…)

• The Burzynski Case discussed by Ben Williams in Surviving “Terminal” Cancer. Starts on page 186.
• Watching the Watchdogs at Quackwatch by Joel Kauffman
• The self-quantification movement: Implications for health-care professionals by Rajiv Mehta
• This game might be good for measuring brain function. Play for ten minutes, note average score. Later version with leaderboard and music.
• Elsevier attempts to fend off the extreme challenge posed by open-access journals such as PLoS

The more certain you are the more power you have to convince others and convince yourself. You may want to convince them that change is needed — e.g., that a polluting factory should be shut down or cleaned up. China has a huge problem with industrial pollution, as this report describes. Children are especially at risk.

The danger to those in power posed by self-tracking — in particular, blood tests that measure lead — is shown by this quote from the report:

Even parents who were able to access [lead] testing for their children reported difficulties in obtaining the results of the tests conducted. Many parents in Yunnan and Shaanxi reported that test results from their children’s lead tests were withheld completely. Some parents in Yunnan and Shaanxi told Human Rights Watch that they never saw any test results. Others were allowed to see the results from initial testing but were prevented from seeing the results from follow-up testing.

My daily arithmetic tests (how fast can I do simple arithmetic, such as 3 + 5) have the same purpose as the lead tests: to assess the quality of the environment. If my scores get worse, it may reflect poisoning. Comparison with a blood test for lead highlights strengths and weaknesses of my arithmetic test.

Strengths

1. Sensitive to many things. Can detect any bad influence on the brain, not just lead.

2. Free in the sense that the cost is zero (so long as you have a laptop).

3. Unrestrictable. No one can deny you access.

4. Fast. You get the results immediately.

5. Great sensitivity. You can test yourself as often as you want. The more tests you do the more easily you can detect a change.

6. Variability known. By looking at a graph of your data (score vs. day) you can judge the natural variability — essential for judging the importance of a deviation. With lab tests, the variability is rarely known to the person whose blood was tested or the doctor that reviews the results.

7. Measures what you care about. You care about health. Brain health is part of that. Sure, high levels of lead are bad, but what about low levels? Is there a hormetic effect? The dose-response function isn’t obvious.

Weaknesses

1. Unconventional. A lead test is easier to understand.

2. Unspecific. If a score is bad (= if I get slower) it isn’t clear why. If you have too much lead in your blood the cause is likely to be obvious (e.g., polluting factory, lead in food).

3. Sophistication needed. The arithmetic test is sensitive to hundreds of environmental factors, I’m sure, so identifying the cause of any change inevitably requires sophistication. For example, perhaps you need to control the time of day. Another example is that you need to control/allow/adjust for practice effects.

If the Chinese parents were able to measure their children’s brain functions themselves, they might be far more outraged — and therefore far more powerful.

Re-reading an old post recently, I found this comment by Tucker Max:

I took four tablespoons [of flaxseed oil] a few hours ago, instead of the regular two, thinking that maybe I could load up and it might help me get back to normal quickly. The pain is pretty much the same, and I just brushed and my gums bled, so obviously the flaxseed oil takes more than a few hours to affect those problems. But–and I haven’t measured this with reaction tests like you do–I feel considerably more mentally alert right now. I don’t know if I felt like this before, and maybe I didn’t notice it because it came on slowly, or maybe I need four tablespoons at once to see a difference, but I really do feel the difference.

By coincidence I had noticed the same thing the day before: I was distinctly sharper than usual a few hours after drinking flaxseed oil (two tablespoons), as measured by my arithmetic test. I had noticed the same thing twice before — years earlier — but had decided not to study it in detail because it was much easier to study the long-term effects of flaxseed oil.

I wrote Tucker to say he had been right. He replied:

Yeah, there’s zero doubt in my mind now that fish oil/omega 3 is crucial to brain function. If I don’t take it, I can’t write effectively.

That’s very interesting. Sure, drugs have short-term effects. If you ingest caffeine, for example, it will make you more awake for a few hours. But drugs are dangerous. The notion that a necessary nutrient has benefits that last only a few hours is new. (The notion that a necessary nutrient can make us distinctly sharper will also be new to most people, but not to readers of this blog.) Perhaps we should eat omega-3 every few hours. You’ve heard of RDAs (Recommended Daily Allowances). Perhaps the future will contain RHAs (Recommended Hourly Allowances).

If you haven’t been reading this blog for several years, see these posts for background. Flaxseed oil also will make you smarter long-term, e.g., the next day. The short-term effect is in addition to the long-term effect.