So what do we know about depression anyway?

Drugs Raise Risk of Suicide (washingtonpost.com)

A meta-analysis is reported to claim that the SSRIs increase suicide risk. This WaPo article didn't mention the effect size, but suicide is, in technical terms, a "hard end point". It can be measured fairly clearly. If the suicide-outcomes are unclear then that's important. The study suggests the SSRIs are not dramatically lowering suicide risks compared to placebo. I doubt this study really answers questions; but it may tell us we know even less than we thought we did.

This doesn't mean, but the way, that non-SSRI anti-depressants are safer. Maybe they increase suicide rates too compared to placebo. I remember 20 years ago that my teachers warned of "activation" during early treatment being associated with suicide. (As soon as the depressed patient gets more energy, they get around to actually getting something done -- but that something is suicide.)

At the end of the day the main lesson is that we (meaning the quite corrupt government that we electand reelect) let the pharmas get away with selective publication of efficacy and safety data. As a result we lack important answers. That has to change.

Another lesson concerns all the beatings primary care physicians get about "undertreating depression". I've long been skeptical of those studies because:

1. Even when primary care docs treat depression payor rules and patient preferences often mean euphemistic ICD-9 codes are used.
2. I've not felt comfortable about the data we had on the disorder. I don't feel we understand the disorder(s) or the therapies very well -- especially outside of referral clinics treating depression with psychotic features.

This doesn't mean I or my primary care colleagues did a great job with depression. Instead I'd say more humility is needed from every quarter.

By the way, we also need to do something about corruption in government.

Gwynne Dyer's site has 8 new articles

2005

The eccentric web site of Gwynne Dyer, an iconoclastic journalist and military historian, suddenly has 8 new articles to read from his Jan/Feb publications. All are worth reading. I'd quote and blog from a few but the odd web pages confound the BlogThis! bookmarklet.

I tried to get the webmaster to complement the site with an RSS feed, but s/he really didn't understand what I was writing. I am curious as to why Dyer does it this way. Heck, I'd make him a better site for free! I can only guess it's done by a relative.

Free business ideas: outsourcing claims processing for patients AND a web site for business idea distribution and related services

For various reasons we spend a fair bit of time in our household dealing with errors in healthcare claims processing. (See also my prior post!)

Both providers and payors commonly make errors in healthcare claims processing. It's a complex process in which failure is not merely an accident, it's an emergent property of the system. Ultimately we (ok, my wife) is called upon to resolve the errors.

The work of error resolution is tedious and time consuming. We would like to outsource it; we'd be willing to pay a good amount per claim to have someone else track payment, make calls, resolve complaints. I think this could be a viable business. A reasonably well designed set of processes could probably turn a tedious chore for a person into a routine 5-15 minute task for a well run business. At $15 per managed error each worker could bring in about $90 an hour. Increased automation could improve that earnings stream substantially.

Perhaps some enterprising bookkeeper, working at home, would want to launch such a business. If they kept costs low they could grow it off cash flow (early profitability) while gaining expertise and scaling upwards.

Anyone want to try? No rights reserved on this idea!

PS. Here's another business idea. Set up a web site where one could submit requests for new businesses. Charge $2 to people who want to outline a business they'd like someone to deliver. Then support the site by advertising and on revenue for business requests. All ideas would enter the public domain. For an extra fee charge would-be entrepreneurs for business-process patent searches around the business ideas. Then grow the web site with additional services around implementing the business proposals. This business could be fairly big and interesting -- except the barriers to entry are low so the competition would be significant. Maybe eBay or Amazon would buy a well run startup.

I come up with business ideas all the time. They're all for things I'd like to have. I'm happy to give them away. So here are two business ideas for today. No rights reserved, but if they're not patented I've just placed them in the public domain. So don't try to patent them.

Aggregate databases: what my shadow medical profile will look like

In an earlier post I noted the inevitable rise of the "total information awareness" "shadow profile", the picture of a person that emerges when one aggregates data across a diverse set of databases with a variety of primary purposes: Faughnan's Notes: The national identification card and database.

My profile will make interesting reading. Due to an uncharacterized error in a payor's/provider manager information system a variety of claims are being directed against one of my employer's benefits program. The claims are for services are not covered by this benefit program, so the claims are being rejected.

In addition to not being covered, they are also not my claims. They belong to another person.

Depending on how the benefit program manages data associated with rejected claims, however, the diagnostic codes (ICD-9) may well be retained in the system and associated with my name. Ten years from now, the corrupted descendant of "total information awareness" will be browsing shadow profiles identifying persons to be added to various "yelllow and black and grey". This particular database will have an interesting range of ICD-9 codes in the database; a set that might put me on a "yellow" list.

I'll also be uninsurable. Chances are there won't be any way to know why I'll be rejected for insurance, or strip-searched every time I fly, and there will be no way to correct the error. The only saving grace is that a lot of people will be in the same boat. We can commiserate in the restricted areas where undesirables might be allowed to congregate..

The use of databases for purposes other than their original intent will cause no end of problems.

Godel, Newton, Pauling: betrayed by intuition?

The New York Times > Arts > Connections: Truth, Incompleteness and the Godelian Way

This NYT Connections column has the most succinct description of Godel's most famous work that I recall reading:

Before Godel's incompleteness theorem was published in 1931, it was believed that not only was everything proven by mathematics true, but also that within its conceptual universe everything true could be proven. Mathematics is thus complete: nothing true is beyond its reach. Gdel shattered that dream. He showed that there were true statements in certain mathematical systems that could not be proven. And he did this with astonishing sleight of hand, producing a mathematical assertion that was both true and unprovable.

[jf: actually if memory serves a better statement might be: "He showed that there were true statements in certain nontrivial and interesting mathematical systems that could not be proven. And he did this with astonishing sleight of hand, producing a mathematical assertion that was both true and unprovable."]

But Godel's genius came with a price:

... those leaps and connections could go awry. Godel was an intermittent paranoiac, whose twisted visions often left his colleagues in dismay. He spent his later years working on a proof of the existence of God. He even died in the grip of a perverse esotericism. He feared eating, imagined elaborate plots, and literally wasted away. At his death in 1978, he weighed 65 pounds.

Genius, connections, intuition, courage, fascination with the infinite, then madness.

Thomas Nash, a nobel prize winner disabled for many years by paranoid schizophrenia comes to mind, but Godel was old for the onset of schizophrenia. What do we know, however, of the psychiatric disorders of genius? We are much more familiar with more conventional minds. I think also of Isaac Newton, who spent the latter half of his life wrapped up in Alchemy. Linus Pauling, who's powerful but misdirected intuition made him a peculiar pusher of vitamin C.

These extraordinary minds excelled at making connections and drawing inferences, at rethinking and radical leaps. Is the price of such excellence a predisposition to leaps beyond the bounds of reason?

"Whom the gods would destroy they first make mad".

The Tsunami: Things disappear.

The New York Times > International > Asia Pacific > Nam Khem Journal: The Tsunami's Horror Haunts a Thai Fishing Village

It was fate,' said Am Changkraichok, 68, a fisherman. 'If you were meant to die, you died. People visiting here to see friends, or foreigners here on holiday, all were here because their time had come to die.'

'I've lived here all my life but I was spared,' he said. 'How do you explain that? My time had not yet come. When I think like this, it makes me feel better. Nature decides. Things come and things disappear. If you don't just let go, it can make you crazy.'

A truly useful cameraphone: document managing

The New York Times > Technology > Circuits > What's Next: Cellphones Get a New Job Description: Portable Scanner

This xerox product may come to market in 2006. Use a cameraphone to photograph a document, then server-based software does OCR and compression of a processed image.

I'd use it.

I suspect the cameraphone will need a 2mpix image and the ability to do near-focusing to be truly useful. So most of the cameraphones sold into the US market today won't work. (Korea gets all the good cameraphones.)

An early shot in the human vs. hybrid wars

U.S. Denies Patent for a Too-Human Hybrid (washingtonpost.com)

Two activists set up a patent case in order to establish that a human/chimp genetic hybrid could not be patented. Their goal was to begin to declare some work "off limits" by either removing the profit incentive or seizing the patent itself. The courts indeed ruled that human beings could not be patented and that the theoretical hybrid was "too close" to human to patent.

It will be interesting to see where the human/non-human boundary is. Can one patent a modified chimpanzee? If so the boundary is extremely close. If not, then what about other primates? Dolphins? Non-primates? Non-mammals?

What the heck, the hybrids will be developed in China anyway. I am positive, by the way, that someone somewhere has at some time created an embryo that was part human and part chimpanzee. It's too easy to do for humans to resist trying, even if they were never to speak of it.

This battle, of course, is only beginning. If we survive the next forty years we'll see much more of it. This "first shot", however, is an historic event.

Abused nations and abused children

Guardian Unlimited | Special reports | Iraq trapped in a terrible vice between ruthless insurgents and unloved occupiers

A Guardian reporter leaving Iraq summarizes the state of the occupation, from an admittedly limited perspective. One story he related really stood out. I doubt the Bushies understood this phenomenon:

...Then at some point Iraqis will have to become reconciled to the the crimes of the past. Giving Saddam and his deputies a fair trial in Baghdad will be a start, but not enough. The emotional and psychological cost of a dictatorship that for three decades persecuted so many is difficult to fathom.

Shortly after the war a quiet Iraqi from Hilla, Ali Abid Hassan, took me to a mass grave outside the town where he was supposed to have been killed and buried along with 3,000 others after the regime crushed an uprising in 1991. He was shot but crawled away to safety.

Among the reeds he showed me where it had happened. On a pathway we found the tokens of history: some vertebrae, a rib bone, one button and 11 long, creamy-brown teeth. A year later I went back and asked him about Saddam's brief appearance in court and he of all people was deeply troubled. "I couldn't bear to see him in such a miserable condition. He shouldn't be humiliated; after all he was our president. He was our father," he said. Then I asked if he thought Saddam should be punished. "He deserves the ultimate punishment. Yes, death. He executed many of us.

A man who ought to hate Saddam as much as any person alive, is troubled by the humiliation of "his father".

Anyone who's worked with battered women and abused children will recognize those sentiments. What a festering mess.

Iraq: worse than you think?

The Counterterrorism Blog: Iran's Great Victory

I've been following this counterterrorism blog for a while. It's not a left/democrat/liberal site, but neither is it pro-Bush. Mostly it's professional military and, as the name goes, counterterrorism journalists and hobbyists. It's rationalist/secular, so it's something I can relate to even when I may disagree.

This post includes an alleged statement by a "senior military commander". The claim is that religious Shia dominance of the new legislature may be virtually complete, with no balancing Kurdish block of significance and no significant secular block. The alleged author also describes very effective insurgent military action and implies Iraqi forces are completely penetrated by insurgent intelligence.

We'll know in a few days if the claims of the political outcome are correct.

At around the same time I read reports that the US training of Iraqi forces is failing dismally. I also see reports that the new Saudi education minister is a Wahabbi zealot who could have been appointed by bin Laden, and that the Saudis are backpedalling on their counter-terrorism initiatives.

I am very interested in what the Sunni/Wahabbi Saudis make of the rise of Shia Iraq, the rise of Shia Iran, and the fall of the Iraqi Sunni elite.

I'm also curious as to whether bin Laden is all that keen on how this is turning out; does he truly favor Iran? I'd thought the Wahabbi were always suspicious that Iran was a bit too civilized (not to mention that Zoroastrian skeleton in the closet).

The hypothesis that Iran has competely outplayed the US, and bin Laden, has not yet been disproved.

Who knows, maybe a truly dominant Iran will turn out to be a good thing. If anyone but me repeats that statement we'll know that the crisis of Iraq is plumbing new depths.

Each household borrows $3000 a year to run America

The New York Times > Week in Review > Cut Short: The Revolution That Wasn't

This is a helpful analogy.

...To most Americans, the federal budget, more than 2,000 pages of fine print, is hard to grasp; it isn't easy to summon a mental image of $2.57 trillion. One way to look at it is to consider how much the government spends per household. In the 1990's, the figure held steady at about $18,000, according to Brian M. Riedl, a budget analyst for the Heritage Foundation. But last year, it exceeded $20,000, adjusted for inflation, the highest amount since World War II. But the government only takes in $17,000 for each household. 'So right there,' Mr. Reidl said, 'we're borrowing $3,000 per household.'

We borrow from other countries, but mostly we borrow from the future. This is not necessarily irrational -- assuming the money is used wisely and that our future selves can afford the cost. Unfortunately we are borrowing more than the near future will likely repay.

I used to belong to the Concord Coalition. Then I switched to organizations fighting corruption in government. Lastly I made a very strong effort for Kerry. All of these failed.

I figure all I can do now is buckle our life jackets and wait for the ship to run aground.

Arranged marriages for the wealthy unmarried

The New York Times > Magazine > The New Arranged Marriage

Janis Spindel arranges mergers and acquisitions for wealthy unmarried men:

... Janis Spindel Serious Matchmaking Incorporated's fees begin -- begin! -- at $20,000 for an initiation fee, plus $1,000 for a one-year membership that includes 12 dates.... An out-of-town client must fly Janis and an assistant first class and put them up in a hotel for the home visit. Additionally, a marriage bonus is expected -- sometimes it's a car or extravagant jewelry; other times it's cash. She has received gifts in the $75,000-to-$250,000 range.

Gorgeous [the prospect] tries to negotiate the price, but Janis flatly refuses. Then he says he's uncomfortable with the general idea of paying for dates and wonders what kind of women would date a man who needs to pay to find her. He doesn't want to be set up with ''shrews'' or women who are interested in him because he owns a successful business.

This strikes me as an extremely realistic concern. How else to describe the women who, Janis says, pay $750 for a 30-minute meeting to audition for her databank of women (6,800 of them, Janis claims) who want to marry a man rich enough to pay for her services?

As a young man I traveled the world as a Watson Fellow. I spent about 8 months in Bangkok in 1981; I've not been back since, but I'm told it's a different city now. In those days mergers and acquisitions were a common arrangement for visiting executives, executed with a mercenary understanding of power, advantage, and mutual benefit. To paraphrase Churchill, only the price has changed.

Dean as National Democratic Committee Chairman

The New York Times > Washington > Democrats Elect Dean as Committee Chairman

I'm glad Dr. Dean was chosen. He was widely smeared during the campaign, not only by the usual suspects but also by the NYT. I'm looking forward to his next steps.

Rural suicide - anything to do about it?

The New York Times > Health > Social Isolation, Guns and a 'Culture of Suicide'

When Professor Branas examined data from the federal Centers for Disease Control and Prevention, he found that the risk of dying by gunshot was the same in rural and urban areas from 1989 to 1999, findings that were published in The American Journal of Public Health. He has also concluded that in the most rural counties, the incidence of suicide with guns is greater than the incidence of murder with guns in major cities.

The article doesn't say which of the three alleged factors is the larger contributor to the high suicide rates. Suicide rates are also high in many scandinavian nations; I think guns less accessible there. Isolation is not only a part of most rural areas, it's a feature. Would more mental health workers really drop the suicide rate? It would be useful to have some data.

Maybe we could do something about the romanticization of suicide. In 20 years I've walked out of one movie -- The Dead Poets' Society. The romantic portrayal of the senseless suicide of the teen protagonist was infuriating. That's an uphill battle however.

We know there's a problem worth studying, but we've got a lot of work to figure out if there's anything to do about it.

Who will defend freedom? It's not illegal to take pictures of subways.

Shooter.net: Attack of the SF Muni Fare Inspectors

It's commonly believed that after 9/11 it became illegal to take pictures in subways and of public transit structures. This is an urban myth, but it's a myth accepted by many transit workers and some police. This post tells the story of a San Francisco photographer who persists in taking pictures and is first threatened by transit workers, then harassed by police.

This is how freedom goes away, one step at a time.

Once upon a time this story would have brought a mass of americans to the subway to snap pictures. I now fear that most of us lack the energy even for such a minor defense. I know many of my friends, post Nov 2nd, have withdrawn from the world of politics and discourse.