Anyway.  Here’s an interesting article: What don’t we know about the pharmaceutical industry? A Freakonomics Quorum. From Freakonomics (as you might guess) at the New York Times.

The first and last author describe pharmaceutical  industry practices that I think a lot of people actually do know about.  The other three involve chain pharmacies making huge profits off generics (surprise to me), and market forces and incentives for research and development of new drugs (two authors, both pharmaceutical employees, you might consider reading them nonetheless).

The anti-vaccine movement comes in part from anecdotes of kids regressing at about the time they get the MMR vaccine. That’s actually accurate; when I was taking a cognitive development graduate class, the percentage estimated to regress in that way was about 25%. There was some speculation at the time that it’s due to kids’ brains undergoing a major reorganization at (coincidentally) about the same time they get the MMR.

(Kids make a bunch of neuronal connections, then prune out the less useful ones, and the speculation was that the children who lost language and social skills had not pruned as extensively. There was some research on head circumference at the time looking at whether kids with autism had greater head circumference – kind of a crude measure if you ask me but it did seem to be panning out.)

My own impression is that the anecdotes about regression after vaccine (but not anecdotes about regression before vaccine) kick off contamination fears in some people. In the literal “we have a mental faculty that’s highly alert to dangerous contamination by non-visible substances” sense. Which then kicks off a search for an essentialized underlying substance that will explain/justify their intuitions (also an extremely common thing for people to do).

What I’m getting at is that thimerosol isn’t a trigger for concerns, thimerosol-in-vaccines is an explanation for them. It’s the endpoint of a search. Why doesn’t it generalize from there? My speculation is that vaccines are required by authority and contact lens solution etc is not, and stories about having dangerous things forced on you are much more mentally catchy and conducive to righteous indignation and fear than are stories about stuff you can voluntarily avoid. So a lot of people don’t know about it, and it’s not that their lack of concern comes from lack of knowledge, but that their lack of knowledge comes from fears of thimerosol-in-household-products never taking root strongly enough to become widespread.

And a good point.  This is a basic tenet among the people who study end users of software and web applications, who do user-centered design, human-computer interaction, usability studies, etc:  You have to design your approach for what people are going to do.  Designing (whether it be software/web applications or any kind of information delivery) for what you think they ought to do is an approach destined for failure.

And you can’t stop the Internet.  It spreads information, and misinformation, like nothing else.

(On the other hand, calling doctors who don’t get this – like the article does – ow.  Good way to piss people off.  Doctors are end users of information, too, and starting off your approach with an insult, maybe not so effective.)

Let’s say you have a dog (let’s make him a mutt) named Barky (your six-year-old named him, not you).  You’ve had him for five years, you love him and your kid does too, and you know quite well that lying in one place, resisting going out into the sunshine for walks, and eating very little is not at all normal behavior for rambunctious, cheerful Barky.  He’s more than unhappy and you know him well enough to know that this is well outside the normal.  You take him to the vet and nothing’s physically wrong, but the vet suggests that he’s depressed and might benefit from Reconcile, the Prozac for dogs.

What do you do?  Your options include (this is not a complete set): reject the option because he’s a dog, not a human, and only humans feel real emotional pain and/or deserve treatment; reject the option because you ask about the side effects and decide they would be worse for Barky than how he appears to feel now; or accept the suggestion because you think that reducing pain, even animal pain, is desirable, and can be helped by medication. You can also go home and make fun of it. I know what I’d choose to do for someone I cared about, even if they weren’t human, or weren’t adults, or whatever we choose as the boundary line between living beings whose pain matters, and those whose pain we don’t consider real enough to matter.  It wouldn’t necessarily be to give them psych meds (that really would depend on the expected benefit and side effects), but I wouldn’t reject it based on the notion that dogs cannot have serious problems or painful emotional experiences.

The availability of Prozac for dogs is unquestionably an attempt for Eli Lilly to expand their market.  This is not different from other companies.  When you see an ad for life-saving drugs, it’s because they want more people to get those drugs.  When you see an ad for a new sports drink, it’s because they’re trying to get more people to buy it.  And so on.

The question here isn’t whether drug companies are exploitative – we already know they are, so that’s not really a question – but whether we want to use their products to reduce suffering.

1) Look for therapists affiliated with hospitals, they tend to have more experience with psych patients.

2) Be leery of anyone who makes a big deal out of “situational” versus “chemical” depression.  It’s all chemical; it all happens in your brain and body.  Peter Kramer, a psychiatrist who is pro-therapy and writes books about therapy and books about medication, argues that research shows that depression triggered by repeated situational events comes to look no different from depression with a heavier genetic component.  It’s just that some people start higher or lower down the slope.

Those who start further down the slope – who some people would say have “chemical” depression – can still be helped by therapy.  For example, people who are more prone to depression following negative life events can learn to better anticipate and/or avert those events, and cognitive therapy can help people interpret those events in ways that are less damaging.  It’s not always enough, but it can be very helpful.

Those who start further up the slope can still be helped by medication.  It looks the same as more genetically triggered depression, particularly once you’ve had it enough…and it can be helped by the same things.  Medication can also help people be in good enough shape to better deal with situations.

It’s also true that situations are not feasible to change.  If you are depressed because you are dealing with a live-in parent with Alzheimer’s that you can’t afford to put into a nursing home, a daughter who has become addicted to drugs, a neighborhood full of violence, and a difficult job you can’t afford to lose but are going to lose unless you start performing at your normal levels, it’s considerably more humane to offer you medication than to tell you that you that you get to be depressed until you’re able to fix all those things.  Likewise, if you’re so depressed by losing a long-term relationship that was everything to you that you can’t get out of bed to go to therapy, medication might be very helpful.

The important thing is not that we divide up depression into “situational” and “chemical” so that we can make sure that people with “situational” depression don’t get drugs (or that people with “chemical” depression don’t get effective therapy), but that we treat depression with whatever approach(es) will help a person most effectively deal with their minds and their lives both short-term and long-term.

None of this is easy to do when things get rough, but many of these suggestions are minor time commitments that can make a huge difference.

1. Decide on your major goal

If you are clear on what you want, it will be easier to decide what to do while things are going south. If your major goal is to get a good education, get a good job, or go to graduate school, your top priority should be using relevant resources (including those related to mental illness). If your major goal is to avoid treating your mental illness (or using accommodations, extensions etc), evaluate what you are willing to sacrifice (grades, time, extracurricular activities, your job, future salary, etc) and plan what you will sacrifice when.

See the bottom of this entry for my opinionated take on this.

2. Know your available resources

If your school has a students with disabilities service, a counseling center, or a health services, and you are not already using them, look them up and find out what they offer.

3. Know your course policies

Take time out of your day to go over your syllabuses with a fine-tooth comb. You need to know your teachers’ policies about emergencies, grade appeals, accommodations, and extensions/make-ups. Plan to make use of these where they can help you.

4. Stay in touch

Many teachers will make arrangements for minor life emergencies if (and only if) you contact them before the assignment due date / the exam date. One of the worst things you can do in a course or a job is to simply stop showing up. You do not have to give them all the details. Some things you might consider asking for extensions/accommodations for include: medical emergency; inability to concentrate due to medication side effects; recently diagnosed and have started accommodations process; etc.

If you have a major emergency – for example, being hospitalized for a week without forewarning – teachers are generally more lenient.

If you go to talk to a teacher about an extension/accommodation/etc and they’re an jerk about it, it doesn’t mean you did something wrong. Some teachers are just jerks. See section on escalation below.

5. Plan ahead

Sometimes talking to your teacher is sufficient. Sometimes they’ll want a doctor’s note, so make sure to get one. Sometimes they’ll want documentation from the disabilities office (especially for ADD, since jerks who do not have ADD sometimes try to abuse the system).

With accommodations, teachers often have a policy of “the first X weeks of the semester” or “X days prior to the exam”. The actual policy may be more lenient – for example at my university we’re required to give accommodations up to the exam itself. But it is very difficult to accommodate people on the spot if they need resources (like an extra classroom) that are not easily available.

6. Know your school policies

Like drop/withdrawal deadlines and tuition refunds for different dates of drop/withdrawal, and any policies for medical leave. Put those deadlines in your calendar. Nobody wants to drop or withdraw from a course or a semester, but should it come down to it, failing grades on your transcript look way worse than a withdrawal. A failing grade communicates “I screwed up and didn’t handle it in time” (even, unfortunately, if that’s not the case); a withdrawal says “things got really bad and I’ll need to give you a good excuse as to why, but I recognized what was going on and handled it as well as I could”. Don’t be too proud to take a needed break to get your shit together.

7. Track your grades

If you don’t know how much trouble you’re in, you won’t know what steps you need to take next. If the grade calculations are confusing, go to office hours and ask for help. If you can’t make office hours, contact your teacher to see if you can set up an appointment.

8. Escalate if necessary – and do so politely

For example, if you ask a graduate student teacher for an extension for medical reasons, and you don’t have a doctor’s note, and he/she turns you down, you can go to the professor supervising him/her. The professor may back them up; he/she is not necessarily obligated to reverse a decision. Keep in mind that the professor and graduate students are usually in communication over issues that come up, and will tend to support each other, so being polite to all involved will help your case.

If a teacher gives you grief over accommodations, document it and go to whoever manages accommodations at your school.

If a teacher is being an jerk to you in general, and your school has an ombudsman, they may be able to help you, or at least give you advice.

—————-

My advice for people unsure of whether they should seek treatment/accommodations/extensions/etc:

1. Employers want someone who performs well, not someone who sacrifices good performance in order to not treat medical problems

You are preparing for a job or an advanced degree. A good grade says that you are capable of handling any problems that might make you a poorer employee/grad student; a bad grade says that you did not (or were not able to) handle your problems. A withdrawal looks a lot better than an F.

Employers and schools want to hire someone who values performance over pride. They are not interested in whether you pulled off D’s because you “valued overcoming your ADD through willpower”; they are interested in hiring people who will do what they need to perform well. (And it’s often a bad idea to tell them about any mental illnesses you have, anyway.)

2. You are an investment and you are expected to make use of available resources in order to pay the investment off

You get help every time a teacher chooses a textbook for you or gives a lecture, and every time an administrator does anything that makes your life easier. You or someone is giving the school money on your behalf, but that money *is not enough* to pay for all the services you receive.

So who’s paying for the rest of it? The government (sometimes), grant funders (at research universities), and alumni donations (at all schools). Why? Because you’re an investment. They’re investing in you because they think you will give them a good return, by learning as much as you can and then going and doing good stuff with it after you graduate.

Counseling and health services, and disability services, if your school has them, are getting funded this way too. They’re part of the investment and part of what you pay for, both with money and with your blood, sweat, and tears. You’re not accepting free help. You’re using available resources intended for you to use when they will be helpful.

If you’re refusing or putting off going to counseling services or health services or the students with disabilities office, or refusing to ask for / accept extensions or other accommodations, you’re not doing anyone any favors by making yourself a poorer investment for all the people who pay for your available resources, and you’re not doing anyone any favors by giving yourself a poorer education.

“There’s not much research, but the two studies I’ve found on autism and celiac did not find a link, except for this one quack guy,” I say, meaning Andrew Wakefield.

“Okay,” my mom says.  “So they haven’t done the research confirming it yet.”

“No,” I say.  “There are two existing studies that have looked, and they did not find evidence of a link.  I’m looking on pubmed, so if there were more studies they would very likely be there.”

“Ah,” my mom says. “So all we’ve got now to go on is anecdotal evidence.”

“No,” I say again.  “Studies looked.  They looked for a link, and they didn’t find a link, suggesting there’s not a link.”

I think at that point we detected mutually incompatible approaches to uncovering truth, and dropped the conversation.

——–

It’s a normal human thing to figure out what you believe is true (often by assuming anecdotes are representative of overall reality), and then seek out social back-up to help convince others of it.  In this approach to truth (which drives scientists up the wall), if science is used, it is used to support one’s own truth claims to others.  If someone is not trying to make truth claims to others, then there is no need for science; it doesn’t tell you anything you don’t already know.

In contrast, the role of science as-generally-agreed-upon is to test what we believe to be true to see whether it really is true. In this approach to science, science can disconfirm anecdotes, and its role is to drive what people believe, not just to back what they already do believe.  So it’s much less useful for normal human goals.

Frustrating, that.   Also frustrating that we don’t have much research on a lot of things.  It could be true that the two studies on autism and celiac disease didn’t pick up on an actual connection…but the point is, two studies that show no connection are a lot more meaningful than no studies that show no connection.

Searching for similar diagnoses through DNA testing

The article stresses both the relief families find at meeting other families with similarly affected kids, and the distress they experience at seeing the degree of impairment that older children with the same problems (still) have. And there’s a demonstration of the way gender roles play in to who can back out of their responsibilities and who can’t – note the one father who decided to pick up and leave a week after a conference for families with affected kids, leaving the mom to raise their affected daughter alone.

ADHD kids have higher levels of lead in their blood than normal kids – even though their levels are higher than “safe” levels.

It would be great if  ADHD turned out to have an avoidable (or at least reducible) cause.  Seriously great.

Some stuff we still need to know (and the kind of questions you should ask yourself whenever you see a claim about etiology (cause of a disorder) based on a correlational study):

Is it causation: Are kids with ADHD more often from homes with lead-based paint?   (Or lots of toys from China, maybe?) If not, that suggests some other cause for higher levels of lead in their blood.  For example, they may be more likely to lick the walls.  (Not joking – kids with ADHD, at least those who are hyperactive, tend to seek stimulation.  And a major cause of higher lead levels in blood is licking lead paint because it tastes good.)

Are there kids with ADHD who don’t have higher levels of lead in their blood: It could be a cause, but not *the* cause.  It’s entirely possible ADHD has more than one cause.  As a quick analogy, take pneumonia – it’s a condition that can be caused by bacteria, viruses, physical injury…  We only have so many pathways in the body (including in the brain), and pathways can be interrupted by more than one cause.

And, of course, does it replicate?

We tend to use technology for the same old human kinds of things.  Staying in touch with each other; hurting each other; scamming each other; etc.  Technology facilitates some ways of doing these things, but the real problem is not kids using technology, it’s abuse and lack of social support for victims.