The Blog

Can cancer be funny?  Should it be funny?  Some people may find an illness they or a loved one have demeaned if someone sees humor in it.   Psychological research shows us that a sense of humor is an extremely effective coping mechanism under stress, but there are diseases so frightening, so deadly and so close to home (add HIV to the list) that even comedians shy away from them.  This great episode of On The Media takes a look at this phenomenon, and includes an interview with SNL’s Jane Sweeney that is definitely worth a listening.  

Let’s Think Psychologically: when is it okay for painful, sensitive subjects to be sources of humor?  Think beyond disease–think racism, think terrorism, because I suspect there’s not a lot of difference between these subjects. 

Funny, but unfair.  The profits made off of psychotropic medications VASTLY exceed the profits made off of psychotherapy.  Pharma companies make billions off of psychotropics.  Hospitals make billions off of inpatient care.  Psychiatrists make 2-3 times more on average a year than psychologists, and of course masters level counselors make less than that.  Also, to defend both medication and therapy, there is an overall cost savings to the treatment of depression which, untreated, can lead to far more costly problems down the road.  Disappointing–I generally expect more objectivity from the Onion.  ;)

“Many Americans apparently are convinced of a fact that it is utterly wrong.” says this article, referring to the idea that China owns over 50% of American debt and will use that leverage to somehow take over America.  Here’s the terrible thing about the psychology of mistaken beliefs–by even mentioning this false belief, even though I clearly say it is FALSE, I will be inadvertently contributing to the perpetuation of the belief among people who read this. Why?

Here’s how it may work–first, people are very prone to biases  in their thinking, so we may be inclined to believe information that SEEMS true rather than IS true.  Hearing about the rise of China’s wealth and power (true) lends more credence to the idea that China SEEMS to have more power over us, for example (not necessarily true).  

But we are also not very good at remembering context.  So after reading this post, you may go about your day and much later on someone may say something to you about China owning 50% of America’s debt, and you may remember hearing something about that in the past, but you may not recall the context of that information, which in this case was a discussion of popular mistaken beliefs.  All you may remember is that you heard it, not whether it was right or wrong.  Therefore, you are more likely to agree with your mistaken friend, even though you were told that the information was false.  

This is why it can be so very hard to correct popular misconceptions, and why we need to hold our leaders and experts to very high standards of accuracy and truthfulness (I’m looking at you, Michele Bachmann).  Once a mistaken belief gets out, it’s very hard to put away, because even if there is a concerted effort to correct the misinformation (think about all experts during the Ebola scare who came on TV to remind us that we’re not all going to die) it is of limited benefit because simply mentioning the false belief, in any context, puts it in peoples’ memory and makes them more likely to believe that information is true.  

Thus, the best way to correct popular misbeliefs is to not mention them at all, and only reference correct information.      Speaking of which, China only owns about 10% of our public debt.  

Listen to the first segment of this Radiolab episode.  They’re talking about what I was addressing in my last blog post, the hard decisions that have to be made about what we’re willing to pay for healthcare.  They posit a number of real and likely scenarios–what if there was a cure for diabetes that cost roughly a $100,000 but cured it forever–given the millions of people with diabetes it would bankrupt the nation!  And yet, the lifetime cost of only managing diabetes, not curing it, may be far more than $100,000.  So how do we decide how to pay for this treatment?  Who gets it?  Who doesn’t?  What about the relative worth of a cancer treatment drug that costs a fortune yet provides only minimal benefits?  Are we obligated to help pay for any and all treatments available, no matter the cost?  We couldn’t afford to even if we wanted to, so where do we draw the line? 

These are answerable questions.  If you surveyed a thousand people about any of these healthcare cost questions you would get a thousand different answers, but if you plotted the answers on a graph they would likely cluster around a certain range–not a very scientific or deliberate process, granted, but my point is we can easily figure out how much healthcare is worth to us, and who should receive the limited dollars available.  Ask a life insurance company how much a year of extra life is worth, and you’ll get a much more precise, statistical answer.  These are not unanswerable questions, they can and will be answered.  We have to acknowledge that hard choices must be made.

But I’ll say again–managing the exploding cost of healthcare must not be a burden placed only on the public, we need to first rein in the greed running wild in the healthcare industry.  Profit motivations and healthcare do not mix well–at best profit motivation can drive innovation, but when it drives every sector of the industry it leads to corruption and exploitation.  Free markets are not the solution, and the past 50 years proves the point.  

How do we reduce the costs of health care?  Our current path is unsustainable, we know, but what to do?  Mental health care is less than 1% of the total expenditures on care insurance companies have to make.  That means we have to look to physical health to cut costs.  Half the battle is restraining hospitals, drug and medical device companies, and specialists who charge insanely huge amounts of money to keep profits high and have no incentive to reduce the fee because the bill gets sent to gargantuan insurance companies and not people like you and me.  But the other half of the battle is having serious, sober discussions about cost effectiveness.

This opinion piece is by a physician making a case for reducing costs by using cost effectiveness formulas to estimate how much value a given treatment has in terms of adding years to life or increasing quality of life, and then considering that in light of the cost of treatment.  Think talking about a single payer system is difficult?  Try talking about what procedures we won’t pay for!  The author acknowledges as much, but disagrees that such discussions inevitably lead to “death panels” where heartless bureaucrats decide not to pay for procedures that save lives.  

The reality is that the vast majority of the money we spend on health care gets spent on the very young and the very old.  Children born prematurely are often the ones responsible for massive health care expenses, while at the other end of the timeline the treatments used to extend life by a few days, weeks, or months is also extremely expensive. And, increasingly, elderly people in particular are making more of these “cost effectiveness” decisions already–maybe not thinking in terms of financial cost, but in terms of whether the treatments are worth whatever benefit to extending life or quality of life.  People increasingly write living wills that dictate what treatments they want under what circumstances, recognizing that some treatments simply don’t seem…. worth it.  

In the same way, we need to acknowledge that there are many treatments that offer little benefit but are extraordinarily expensive, and are just… not worth it.  Adopting an attitude of “if there’s a treatment, we’ll pay for it!” may be very popular, but it ignores reality and contributes to the bankrupting of America.  This does mean that people will be denied treatments, but the intent is not to deny treatments just because they are expensive, but because they are expensive AND have little value.  

We can’t, morally, have a conversation like this without first tackling the bottomless greed of our current healthcare system.  It makes no sense to talk about cost effectiveness models while shareholders demand higher profits that in turn dictates the absurd cost of health services particularly in hospitals.  The Affordable Care Act, I believe, will not do enough to control these costs because it leaves the current private insurance system largely unchanged.  But, eventually, we need to have a serious talk about what we should and shouldn’t be paying for. 

This past week, a committee of the US Senate released a comprehensive report on the use of torture against alleged terrorists after 9/11.  In the report, two psychologists are identified as being instrumental in designing interrogation protocols that relied on torture.  In fact, their company allegedly was paid $81 million to develop this program, so their role was not likely minimal. Understandably, some are looking at psychologists with a suspicious eye, wondering to what extent psychology as a profession was complicit in the use of torture.  

The American Psychological Association has quickly distanced itself from the two psychologists, in this link to a letter written by the APA president, it is noted that neither psychologist was a member of APA.  Members of APA, including myself, are required to adhere to a strict code of ethics that clearly prohibits participation in torture, and on top of this APA has released statements in the past specifically condemning any connection between the profession of psychology and torture.  

Nevertheless, some within and outside psychology have questioned for years whether APA had any involvement in torture programs.  The report apparently does not implicate APA, but before the report was released APA announced the formation of an investigative task force to look into the question.  Their work is not complete, and hopefully when it is the full role of psychology (or the absence of a role) in torture will be finally understood and accepted.

While a certain degree of PR damage may be inevitable, I think it is still important for the public to hear that whatever these men were doing, collaboration in the torture of anybody, including terrorists, does not reflect the standards of our profession, and these men were not closely affiliated with our national organization.  

Nobody can guarantee the same level of quality and ethical behavior of all the members of any given profession, but there are ways members of the public may be able to distinguish between a “good” and a “bad” psychologist.  For example, membership in APA and/or their state psychological association is an important indicator that the psychologist wants to be affiliated with ethical and competent members of the profession, has agreed to abide by our code of ethics, and is more likely to stay up to date on current and best practices.  Being board certified is another indicator that the psychologist tries to adhere to the highest standards of conduct, as endorsed by a committee of other board certified psychologists.  "Good" psychologists are unlikely to have many, if any, ethical complaints filed against them, and have few if any violations of state laws and regulations on their record from their state psychology board.  They are licensed and “in good standing” with their state board. Not being a member of APA or board certified is not proof of incompetency, and being a member or board certified is not proof of perfection.  But these and other markers help increase the chances that the professional you are working with is not a “quack.”

This article I’ve linked to has a very provocative premise: that comedian Robin Wiliams was taking antidepressants and that the media is ignoring the possibility that those medications may have, at least in part, led him to become suicidal.  In fairness, the article does not claim that this is definitely what happened, only that it is a possibility that must be considered, no less than if he was under the influence of illegal drugs.  

The premise may seem reasonable, but the article, in my opinion, creates the impression that these drugs are more dangerous than they are.  One of the article’s main arguments is that the drug mirtazapine, which was apparently found in Mr. Williams’ system, carries an FDA “black box warning” that the drugs causes suicidal ideation.  This is true of all antidepressants and has been since 2004, but the reality is that most psychologists and psychiatrists believe the black box warning grossly exaggerates the risks associated with the drugs.  This article, published in a well-known and peer-reviewed professional journal, (sorry I can’t post the whole thing–you know, permissions and whatnot):

“What every psychologist should know about the Food and Drug Administration’s black box warning label for antidepressants.

Rudd, M. David; Cordero, Liliana; Bryan, Craig J.

Professional Psychology: Research and Practice, Vol 40(4), Aug 2009, 321-326. ”

presents a cogent set of arguments that have been repeated by many others since the black box warning took effect.  To summarize, there are several reasons to believe that the FDA’s decision was based on little evidence and has led to more harm than good.  The decision was not made on evidence that antidepressants CAUSED suicides, rather that a relatively small number of people who happened to be taking antidepressants committed suicide, and that number was so small that it was not meaningfully higher than the rate seen in a group receiving placebo treatment.  In the data the FDA reviewed, NO children or teens on antidepressants committed suicide.  Another factor apparently ignored by the FDA is that people who are very depressed often have very low energy.  When those people start taking antidepressants, for many there is a gradual increase in energy–for some people there is a very rapid increase in energy and agitation (typically only for a few days or a couple of week).  A severely depressed person may be thinking about suicide, but not have the energy to act on the thought.  An increase in activation may lead the person to feel like they have the energy to follow through on the thought.  This is why severely depressed people should never be started on antidepressants without close follow up particularly early on, and medications generally should be combined with psychotherapy.  With these supports in place, the chances of suicide while taking the medications (already very low) become lower yet.  

The FDA surely meant well, but a consequence of the black box warning has been that fewer people take antidepressants, and the rates of suicide increased following the introduction of the black box warning and correlate with a decline in prescriptions for antidepressants.  

I am not arguing that pills are the best way to combat depression, as a psychologist I employ a far wider range of treatments, though medications can be a valuable tool to use.  And more to the point, I think this article does a disservice by assuming (not the author’s fault, to be sure), that the FDA warning means that antidepressants are more dangerous than people realize, which I would argue is not the case and the facts do not support it.  

Robin Williams’s suicide was tragic, and I have no way of knowing whether he was receiving adequate care for his depression at the time of his death, and we should not jump to any conclusions about the care he was receiving.  In my experience, these stories are often very complicated.   I suspect blaming the medications he was taking, even as partly responsible for his suicide, greatly oversimplifies what happened that led him to that decision, and the evidence simply does not support the fear that some people have about antidepressants and suicide.  It is a perfectly fair point to observe a lack of attention in the media to what prescription medications were present in his body, as that indeed may be important information.  But speaking generally, antidepressants are relatively safe medications and are much more likely to prevent suicide than to cause it (and they may not even do that.)