Google Searches Reveal Seasonal Trends in Mental Illnesses

It’s easy to appreciate the seasonality of winter blues, but web searches show that other disorders may ebb and flow with the weather as well.

Google searches are becoming an intriguing source of health-related information, exposing everything from the first signs of an infectious disease outbreak to previously undocumented side effects of medications. So researchers led by John Ayers of the University of Southern California decided to comb through queries about mental illnesses to look for potentially helpful patterns related to these conditions. Given well known connections between depression and winter weather, they investigated possible connections between mental illnesses and seasons.

Using all of Google’s search data from 2006 to 2010, they studied searches for terms like “schizophrenia” “attention deficit/hyperactivity disorder (ADHD),” “bulimia” and “bipolar” in both the United States and Australia.  Since winter and summer are reversed in the two countries finding opposing patterns in the two countries’ data would strongly suggest that season, rather than other things that might vary with time of year, was important in some way in the prevalence of the disorders.

“All mental health queries followed seasonal patterns with winter peaks and summer troughs,” the researchers write in their study, published in the American Journal of Preventive Medicine. They found that mental health queries in general were 14% higher in the winter in the U.S. and 11% higher in the Australian winter.

The seasonal timing of queries regarding each disorder was also similar in the two countries. In both countries, for example, searches about eating disorders (including anorexia and bulimia) and schizophrenia surged during winter months; those in the U.S. were 37% more likely and Australians were 42% more likely to seek information about these disorders during colder weather than during the summer. And compared to summer searches, schizophrenia queries were 37% more common in the American winter and 36% more frequent during the Australian winter. ADHD queries were also highly seasonal, with 31% more winter searches in the U.S. and 28% more in Australia compared to summer months.

Searches for depression and bipolar disorder, which might seem to be among the more common mental illnesses to strike during the cold winter months, didn’t solicit as many queries: there were 19% more winter searches for depression in the U.S. and 22% more in Australia for depression. For bipolar, 16% more American searches for the term occurred in the winter than in the summer, and 18% more searches occurred during the Australian winter. The least seasonal disorder was anxiety, which varied by just 7% in the U.S. and 15% in Australia between summer and winter months.

Understanding how the prevalence of mental illnesses change with the seasons could lead to more effective preventive measures that alert people to symptoms and guide them toward treatments that could help, say experts. Previous research suggests that shorter daylight hours and the social isolation that accompanies harsh weather conditions might explain some of these seasonal differences in mental illnesses, for example, so improving social interactions during the winter months might be one way to alleviate some symptoms. Drops in vitamin D levels, which rise with exposure to sunlight, may also play a role, so supplementation for some people affected by mood disorders could also be effective.

 

The researchers emphasize that searches for disorders are only queries for more information, and don’t necessarily reflect a desire to learn more about a mental illness after a new diagnosis. For example, while the study found that searches for ‘suicide’ were 29% more common in winter in America and 24% more common during the colder season in Australia, other investigations showed that completed suicides tend to peak in spring and early summer. Whether winter queries have any relationship at all to spring or summer suicides isn’t clear yet, but the results suggest a new way of analyzing data that could lead to better understanding of a potential connection.

And that’s the promise of data on web searches, says the scientists. Studies on mental illnesses typically rely on telephone or in-person surveys in which participants are asked about symptoms of mental illness or any history with psychological disorders, and people may not always answer truthfully in these situations. Searches, on the other hand, have the advantage of reflecting people’s desire to learn more about symptoms they may be experiencing or to improve their knowledge about a condition for which they were recently diagnosed. So such queries could become a useful resource for spotting previously undetected patterns in complex psychiatric disorders.  “The current results suggest that monitoring queries can provide insight into national trends on seeking information regarding mental health, such as seasonality…If additional studies can validate the current approach by linking clinical symptoms with patterns of search queries,” the authors conclude, “This method may prove essential in promoting population mental health.”

Maia Szalavitz @maiasz

Maia Szalavitz is a neuroscience journalist for TIME.com and co-author of Born for Love: Why Empathy Is Essential — and Endangered.

 

 

Dying teen is too ill to attend prom, so it comes to her hospital bed

Fourteen-year-old Katelyn Norman doesn’t have much time left. Doctors say osteosarcoma, a form of bone cancer, will soon take the Tennessee teen’s life. But it hasn’t stolen all her chances to experience the joys of being young — including the prom.

Katelyn hoped she’d be well enough to attend a personalized prom at her school Tuesday night, but that afternoon she had trouble breathing and had to be hospitalized. Her friends and family rallied, bringing the event to her hospital room, where her date presented her with a corsage and a “Prom Queen” sash.

Katelyn insisted that the prom at school proceed without her: “She contacted me and said prom must go on — that’s her, and you can’t help but feed off that energy, that life,” said the organizer.

 

 

http://www.wate.com/story/21802744/teen-fighting-cancer-checks-prom-off-her-bucket-list?autoStart=true&topVideoCatNo=default&clipId=8713178

LAFOLLETTE (WATE) – There wasn’t a fancy dress or even a dance floor, but on Tuesday night family and friends helped cross off the number one thing on a teen with terminal cancer’s bucket list.

Katelyn Norman, 14, has been fighting bone cancer for months, last week she got word her chemotherapy treatments were no longer working. Katelyn made a bucket list that included going to prom, and the Campbell County community pitched into make it happen.

But Tuesday afternoon, Katelyn was having difficulty breathing and was rushed to Children’s Hospital. When she couldn’t go to the dance, they brought the dance to her.

In stable condition and in high spirits, Katelyn was able to have a make shift prom in her room.

The hospital staff decorated the room and her date gave her a corsage and a special sash. Family and friends gathered outside with candles.

Meanwhile, in Campbell County, the celebration of Katelyn was taking place.

The music was blaring, the decorations were hung, it was meant to be Katelyn’s perfect night, and she wanted it to go on, even if she wasn’t there.

“She contacted me and said prom must go on, that’s her, and you can’t help but feed off that energy, that life,” said Sharon Shepard, an instructor at Katelyn’s school and organizer of the prom.

The night was a celebration of Katelyn, featuring all her favorite things.  But most important, the people she loves most.

“Once you meet her your life will never be the same, she has such an impact,” Shepard said.

And despite her absence her friends passed along messages of hope and love.

“Tell her that I love her and she’s my hero,” said friend McKayla Pierce.

“If I could say anything to her I would say hold on, she’s fighting hard,” said another friend, Brandi Marsh.

Her courage even prompted the mayor to declare Tuesday Katelyn Norman day.

“We wanted to try to make this day, and this time in her life, special to her because she makes it special for people in Campbell County,” said Mayor William Bailey.

That was more evident than ever as thousands of people lined Highway 63 in honor of Katelyn.

 

“I think she’s a hometown hero for all of us and a great inspiration to everybody,” said Seirra Ames, who came to hold a candle in Katelyn’s honor.

For more than a mile, candles in hand, the Campbell County community came together to light the night all for a teen that has touched so many.

“It amazes me that an individual has that much impact on people,” Shepard said. “But that’s just Katelyn.”

 

How Nerve Cells Communicate

Our brains are better than Google or the best robot from iRobot.

We can instantly search through a vast wealth of experiences and emotions. We can immediately recognize the face of a parent, spouse, friend or pet, whether in daylight, darkness, from above or sideways—a task that the computer vision system built into the most sophisticated robots can accomplish only haltingly. We can also multitask effortlessly when we extract a handkerchief from a pocket and mop our brow while striking up a conversation with an acquaintance. Yet designing an electronic brain that would allow a robot to perform this simple combination of behaviors remains a distant prospect.

How does the brain pull all this off, given that the complexity of the networks inside our skull—trillions of connections among billions of brain cells—rivals that of theInternet? One answer is energy efficiency: when a nerve cell communicates with another, the brain uses just a millionth of the energy that a digital computer expends to perform the equivalent operation. Evolution, in fact, may have played an important role in pushing the three-pound organ toward ever greater energy efficiencies.

Parsimonious energy consumption cannot be the full explanation, though, given that the brain also comes with many built-in limitations. One neuron in the cerebral cortex, for instance, can respond to an input from another neuron by firing an impulse, or a “spike,” in thousandths of a second—a snail’s pace compared with the transistors that serve as switches in computers, which take billionths of a second to switch on. The reliability of the neuronal network is also low: a signal traveling from one cortical cell to another typically has only a 20 percent possibility of arriving at its ultimate destination and much less of a chance of reaching a distant neuron to which it is not directly connected.

Neuroscientists do not fully understand how the brain manages to extract meaningful information from all the signaling that goes on within it. The two of us and others, however, have recently made exciting progress by focusing new attention on how the brain can efficiently use the timing of spikes to encode information and rapidly solve difficult computational problems. This is because a group of spikes that fire almost at the same moment can carry much more information than can a comparably sized group that activates in an unsynchronized fashion.

Beyond offering insight into the most complex known machine in the universe, further advances in this research could lead to entirely new kinds of computers. Already scientists have built “neuromorphic” electronic circuits that mimic aspects of the brain’s signaling network. We can build devices today with a million electronic neurons, and much larger systems are planned. Ultimately investigators should be able to build neuromorphic computers that function much faster than modern computers but require just a fraction of the power [see “Neuromorphic Microchips,” by Kwabena Boahen; Scientific American, May 2005].

Cell Chatter

Like many other neuroscientists, we often use the visual system as our test bed, in part because its basic wiring diagram is well understood. Timing of signals there and elsewhere in the brain has long been suspected of being a key part of the code that the brain uses to decide whether information passing through the network is meaningful. Yet for many decades these ideas were neglected because timing is only important when compared between different parts of the brain, and it was hard to measure activity of more than one neuron at a time. Recently, however, the practical development of computer models of the nervous system and new results from experimental and theoretical neuroscience have spurred interest in timing as a way to better understand how neurons talk to one another.

Brain cells receive all kinds of inputs on different timescales. The microsecond-quick signal from the right ear must be reconciled with the slightly out-of-sync input from the left. These rapid responses contrast with the sluggish stream of hormones coursing through the bloodstream. The signals most important for this discussion, though, are the spikes, which are sharp rises in voltage that course through and between neurons. For cell-to-cell communication, spikes lasting a few milliseconds handle immediate needs. A neuron fires a spike after deciding that the number of inputs urging it to switch on outweigh the number telling it to turn off. When the decision is made, a spike travels down the cell’s axon (somewhat akin to a branched electrical wire) to its tips. Then the signal is relayed chemically through junctions, called synapses, that link the axon with recipient neurons.

In each eye, 100 million photoreceptors in the retina respond to changing patterns of light. After the incoming light is processed by several layers of neurons, a million ganglion cells at the back of the retina convert these signals into a sequence of spikes that are relayed by axons to other parts of the brain, which in turn send spikes to still other regions that ultimately give rise to a conscious perception. Each axon can carry up to several hundred spikes each second, though more often just a few spikes course along the neural wiring. All that you perceive of the visual world—the shapes, colors and movements of everything around you—is coded into these rivers of spikes with varying time intervals separating them.

Monitoring the activity of many individual neurons at once is critical for making sense of what goes on in the brain but has long been extremely challenging. In 2010, though, E. J. Chichilnisky of the Salk Institute for Biological Studies in La Jolla, Calif., and his colleagues reported in Nature that they had achieved the monumental task of simultaneously recording all the spikes from hundreds of neighboring ganglion cells in monkey retinas. (Scientific American is part of Nature Publishing Group.) This achievement made it possible to trace the specific photoreceptors that fed into each ganglion cell. The growing ability to record spikes from many neurons simultaneously will assist in deciphering meaning from these codelike brain signals.

For years investigators have used several methods to interpret, or decode, the meaning in the stream of spikes coming from the retina. One method counts spikes from each axon separately over some period: the higher the firing rate, the stronger the signal. The information conveyed by a variable firing rate, a rate code, relays features of visual images, such as location in space, regions of differing light contrast, and where motion occurs, with each of these features represented by a given group of neurons.

Information is also transmitted by relative timing—when one neuron fires in close relation to when another cell spikes. Ganglion cells in the retina, for instance, are exquisitely sensitive to light intensity and can respond to a changing visual scene by transmitting spikes to other parts of the brain. When multiple ganglion cells fire at almost the same instant, the brain suspects that they are responding to an aspect of the same physical object. Horace Barlow, a leading neuroscientist at the University of Cambridge, characterized this phenomenon as a set of “suspicious coincidences.” Barlow referred to the observation that each cell in the visual cortex may be activated by a specific physical feature of an object (say, its color or its orientation within a scene). When several of these cells switch on at the same time, their combined activation constitutes a suspicious coincidence because it may only occur at a specific time for a unique object. Apparently the brain takes such synchrony to mean that the signals are worth noting because the odds of such coordination occurring by chance are slim.

 

Electrical engineers are trying to build on this knowledge to create more efficient hardware that incorporates the principles of spike timing when recording visual scenes. One of us (Delbruck) has built a camera that emits spikes in response to changes in a scene’s brightness, which enables the tracking of very fast moving objects with minimal processing by the hardware to capture images [see box above].

Into the Cortex

New evidence adds proof that the visual cortex attends to temporal clues to make sense of what the eye sees. The ganglion cells in the retina do not project directly to the cortex but relay signals through neurons in the thalamus, deep within the brain’s midsection. This region in turn must activate 100 million cells in the visual cortex in each hemisphere at the back of the brain before the messages are sent to higher brain areas for conscious interpretation.

We can learn something about which spike patterns are most effective in turning on cells in the visual cortex by examining the connections from relay neurons in the thalamus to cells known as spiny stellate neurons in a middle layer of the visual cortex. In 1994 Kevan Martin, now at the Institute of Neuroinformatics at the University of Zurich, and his colleagues reconstructed the thalamic inputs to the cortex and found that they account for only 6 percent of all the synapses on each spiny stellate cell. How, then, everyone wondered, does this relatively weak visual input, a mere trickle, manage to reliably communicate with neurons in all layers of the cortex?

Cortical neurons are exquisitely sensitive to fluctuating inputs and can respond to them by emitting a spike in a matter of a few milliseconds. In 2010 one of us (Sejnowski), along with Hsi-Ping Wang and Donald Spencer of the Salk Institute and Jean-Marc Fellous of the University of Arizona, developed a detailed computer model of a spiny stellate cell and showed that even though a single spike from only one axon cannot cause one of these cells to fire, the same neuron will respond reliably to inputs from as few as four axons projecting from the thalamus if the spikes from all four arrive within a few milliseconds of one another. Once inputs arrive from the thalamus, only a sparse subset of the neurons in the visual cortex needs to fire to represent the outline and texture of an object. Each spiny stellate neuron has a preferred visual stimulus from the eye that produces a high firing rate, such as the edge of an object with a particular angle of orientation.

In the 1960s David Hubel of Harvard Medical School and Torsten Wiesel, now at the Rockefeller University, discovered that each neuron in the relevant section of the cortex responds strongly to its preferred stimulus only if activation comes from a specific part of the visual field called the neuron’s receptive field. Neurons responding to stimulation in the fovea, the central region of the retina, have the smallest receptive fields—about the size of the letter e on this page. Think of them as looking at the world through soda straws. In the 1980s John Allman of the California Institute of Technology showed that visual stimulation from outside the receptive field of a neuron can alter its firing rate in reaction to inputs from within its receptive field. This “surround” input puts the feature that a neuron responds to into the context of the broader visual environment.

Stimulating the region surrounding a neuron’s receptive field also has a dramatic effect on the precision of spike timing. David McCormick, James Mazer and their colleagues at Yale University recently recorded the responses of single neurons in the cat visual cortex to a movie that was replayed many times. When they narrowed the movie image so that neurons triggered by inputs from the receptive field fired (no input came from the surrounding area), the timing of the signals from these neurons had a randomly varying and imprecise pattern. When they expanded the movie to cover the surrounding area outside the receptive field, the firing rate of each neuron decreased, but the spikes were precisely timed.

 

The timing of spikes also matters for other neural processes. Some evidence suggests that synchronized timing—with each spike representing one aspect of an object (color or orientation)—functions as a means of assembling an image from component parts. A spike for “pinkish red” fires in synchrony with one for “round contour,” enabling the visual cortex to merge these signals into the recognizable image of a flower pot.

Attention and Memory

Our story so far has tracked visual processing from the photoreceptors to the cortex. But still more goes into forming a perception of a scene. The activity of cortical neurons that receive visual input is influenced not only by those inputs but also by excitatory and inhibitory interactions between cortical neurons. Of particular importance for coordinating the many neurons responsible for forming a visual perception is the spontaneous, rhythmic firing of a large number of widely separated cortical neurons at frequencies below 100 hertz.

Attention—a central facet of cognition—may also have its physical underpinnings in sequences of synchronized spikes. It appears that such synchrony acts to emphasize the importance of a particular perception or memory passing through conscious awareness. Robert Desimone, now at the Massachusetts Institute of Technology, and his colleagues have shown that when monkeys pay attention to a given stimulus, the number of cortical neurons that fire synchronized spikes in the gamma band of frequencies (30 to 80 hertz) increases, and the rate at which they fire rises as well. Pascal Fries of the Ernst Strüngmann Institute for Neuroscience in cooperation with the Max Planck Society in Frankfurt found evidence for gamma-band signaling between distant cortical areas.

Neural activation of the gamma-frequency band has also attracted the attention of researchers who have found that patients with schizophrenia and autism show decreased levels of this type of signaling on electroencephalographic recordings. David Lewis of the University of Pittsburgh, Margarita Behrens of the Salk Institute and others have traced this deficit to a type of cortical neuron called a basket cell, which is involved in synchronizing spikes in nearby circuits. An imbalance of either inhibition or excitation of the basket cells seems to reduce synchronized activity in the gamma band and may thus explain some of the physiological underpinnings of these neurological disorders. Interestingly, patients with schizophrenia do not perceive some visual illusions, such as the tilt illusion, in which a person typically misjudges the tilt of a line because of the tilt of nearby lines. Similar circuit abnormalities in the prefrontal cortex may be responsible for the thought disorders that accompany schizophrenia.

When it comes to laying down memories, the relative timing of spikes seems to be as important as the rate of firing. In particular, the synchronized firing of spikes in the cortex is important for increasing the strengths of synapses—an important process in forming long-term memories. A synapse is said to be strengthened when the firing of a neuron on one side of a synapse leads the neuron on the other side of the synapse to register a stronger response. In 1997 Henry Markram and Bert Sakmann, then at the Max Plank Institute for Medical Research in Heidelberg, discovered a strengthening process known as spike-timing-dependent plasticity, in which an input at a synapse is delivered at a frequency in the gamma range and is consistently followed within 10 milliseconds by a spike from the neuron on the other side of the synapse, a pattern that leads to enhanced firing by the neuron receiving the stimulation. Conversely, if the neuron on the other side fires within 10 milliseconds before the first one, the strength of the synapse between the cells decreases.

Some of the strongest evidence that synchronous spikes may be important for memory comes from research by György Buzsáki of New York University and others on the hippocampus, a brain area that is important for remembering objects and events. The spiking of neurons in the hippocampus and the cortical areas that it interacts with is strongly influenced by synchronous oscillations of brain waves in a range of frequencies from four to eight hertz (the theta band), the type of neural activity encountered, for instance, when a rat is exploring its cage in a laboratory experiment. These theta-band oscillations can coordinate the timing of spikes and also have a more permanent effect in the synapses, which results in long-term changes in the firing of neurons.

 

A Grand Challenge Ahead

Neuroscience is at a turning point as new methods for simultaneously recording spikes in thousands of neurons help to reveal key patterns in spike timing and produce massive databases for researchers. Also, optogenetics—a technique for turning on genetically engineered neurons using light—can selectively activate or silence neurons in the cortex, an essential step in establishing how neural signals control behavior. Together, these and other techniques will help us eavesdrop on neurons in the brain and learn more and more about the secret code that the brain uses to talk to itself. When we decipher the code, we will not only achieve an understanding of the brain’s communication system, we will also start building machines that emulate the efficiency of this remarkable organ.

 

* By Terry Sejnowski and Tobi Delbruck  

ABOUT THE AUTHOR(S)

Terry Sejnowski is an investigator with the Howard Hughes Medical Institute and is Francis Crick Professor at the Salk Institute for Biological Studies, where he directs the Computational Neurobiology Laboratory.

Tobi Delbruck is co-leader of the sensors group at the Institute of Neuroinformatics at the University of Zurich.

 MORE TO EXPLORE

Terry Sejnowski’s 2008 Wolfgang Pauli Lectures on how neurons compute and communicate: www.podcast.ethz.ch/podcast/episodes/?id=607

Neuromorphic Sensory Systems. Shih-Chii Liu and Tobi Delbruck in Current Opinion in Neurobiology, Vol. 20, No. 3, pages 288–295; June 2010. http://tinyurl.com/bot7ag8

SCIENTIFIC AMERICAN ONLINE
Watch a video about a motion-sensing video camera that uses spikes for imaging at ScientificAmerican.com/oct2012/dvs

 

Trying to Find a Cry of Desperation Amid the Facebook Drama

For adolescents, Facebook and other social media have created an irresistible forum for online sharing and oversharing, so much so that endless mood-of-the-moment updates have inspired a snickering retort on T-shirts and posters: “Face your problems, don’t Facebook them.”

But specialists in adolescent medicine and mental health experts say that dark postings should not be hastily dismissed because they can serve as signs of depression and an early warning system for timely intervention. Whether therapists should engage with patients over Facebook, however, remains a matter of debate.

And parents have their own conundrum: how to distinguish a teenager’s typically melodramatic mutterings — like the “worst day of my life” rants about their “frenemies,” academics or even cafeteria food — from a true emerging crisis.

(Dr. Megan A. Moreno has studied college students’ Facebook postings for signs of depression. Some showed signs of risk.)

Last year, researchers examined Facebook profiles of 200 students at the University of Washington and the University of Wisconsin-Madison. Some 30 percent posted updates that met the American Psychiatric Association’s criteria for a symptom of depression, reporting feelings of worthlessness or hopelessness, insomnia or sleeping too much, and difficulty concentrating.

Their findings echo research that suggests depression is increasingly common among college students. Some studies have concluded that 30 to 40 percent of college students suffer a debilitating depressive episode each year. Yet scarcely 10 percent seek counseling.

“You can identify adolescents and young adults on Facebook who are showing signs of being at risk, who would benefit from a clinical visit for screening,” said Dr. Megan A. Moreno, a principal investigator in the Facebook studies and an assistant professor of pediatrics at the University of Wisconsin-Madison.

Sometimes the warnings are seen in hindsight. Before 15-year-old Amanda Cummings committed suicide by jumping in front of a bus near her Staten Island home on Dec. 27, her Facebook updates may have revealed her anguish. On Dec. 1, she wrote: “then ill go kill myself, with these pills, this knife, this life has already done half the job.”

Facebook started working with the National Suicide Prevention Lifeline in 2007. A reader who spots a disturbing post can alert Facebook and report the content as “suicidal.” After Facebook verifies the comment, it sends a link for the prevention lifeline to both the person who may need help and the person who alerted Facebook. In December, Facebook also began sending the distressed person a link to an online counselor.

While Facebook’s reporting feature has been criticized by some technology experts as unwieldy, and by some suicide prevention experts as a blunt instrument to address a volatile situation, other therapists have praised it as a positive step.

At some universities, resident advisers are using Facebook to monitor their charges. Last year, when Lilly Cao, then a junior, was a house fellow at Wisconsin-Madison, she decided to accept Facebook “friend” requests from most of the 56 freshmen on her floor.

She spotted posts about homesickness, academic despair and a menacing ex-boyfriend.

“One student clearly had an alcohol problem,” recalled Ms. Cao. “I found her unconscious in front of the dorm and had to call the ambulance. I began paying more attention to her status updates.”

Ms. Cao said she would never reply on Facebook, preferring instead to talk to students in person. The students were grateful for the conversations, she said.

“If they say something alarming on Facebook,” she added, “they know it’s public and they want someone to respond.”

While social media updates can offer clues that someone is overwrought, they also raise difficult questions: Who should intervene? When? How?

“Do you hire someone in the university clinic to look at Facebook all day?” Dr. Moreno said. “That’s not practical and borders on creepy.”

She said a student might be willing to take a concerned call from a parent, or from a professor who could be trained what to look for.

But ethically, should professors or even therapists “friend” a student or patient? (The students monitored by Dr. Moreno’s team had given their consent.)

Debra Corbett, a therapist in Charlotte, N.C., who treats adolescents and young adults, said some clients do “friend” her. But she limits their access to her Facebook profile. When clients post updates relevant to therapy, she feels chagrined. But she will not respond online, to maintain the confidentiality of the therapeutic relationship.

Instead, Ms. Corbett will address the posts in therapy sessions. One client, for example, is a college student who has low self-esteem. Her Facebook posts are virtual pleas for applause.

Ms. Corbett will say to her: “How did you feel when you posted that? We’re working on you validating yourself. When you put it out there, you have no control about what they’ll say back.”

Susan Kidd, who teaches emotionally vulnerable students at a Kentucky high school, follows their Facebook updates, which she calls a “valuable tool” for intervention with those who “may otherwise not have been forthcoming with serious issues.”

At Cornell University, psychologists do not “friend” students. At weekly meetings, however, counselors, residence advisors and the police discuss students who may be at risk. As one marker among many, they may bring up Facebook comments that have been forwarded to them.

“People do post very distressing things,” said Dr. Gregory T. Eells, director of Cornell’s counseling and psychological services. “Sometimes they’re just letting off steam, using Facebook as something between a diary and an op-ed piece. But sometimes we’ll tell the team, ‘check in on this person.’ ”

They proceed cautiously, because of “false positives,” like a report of a Facebook photo of a student posing with guns. “When you look,” said Dr. Eells, “it’s often benign.”

Dr. Moreno said she thought it made sense for house fellows at the University of Wisconsin to keep an eye on their students who “friend” them. Students’ immediate friends, she said, should not be expected to shoulder responsibility for intervention: “How well they can identify and help each other, I’m not so sure.”

Tolu Taiwo, a junior at the University of Illinois at Urbana-Champaign, agreed. “I know someone who wrote that he wanted to kill himself,” she said. “It turned out he probably just wanted attention. But what if it was real? We wouldn’t know.”

In fact, when adolescents bare their souls on Facebook, they risk derision. Replying to questions posted on Facebook by The New York Times, Daylina Miller, a recent graduate of the University of South Florida, said that when she poured out her sadness online, some readers responded only with the Facebook “like” symbol: a thumb’s up.

“You feel the same way?” said Ms. Miller, puzzled. “Or you like that I’m sad? You’re sadistic?”

Some readers, flummoxed by a friend’s misery, remain silent, which inadvertently may be taken as the most hurtful response.

In comments to The Times, parents who followed their children’s Facebook posts said they did not always know how to distinguish the drama du jour from silent screams. Often their teenagers felt angry and embarrassed when parents responded on Facebook walls or even, after reading a worrisome comment by their child’s friend, alerted the friend’s parents.

Many parents said they felt embarrassed, too. After reading a grim post, they might raise an alarm, only to be curtly told by their offspring that it was a popular song lyric, a tactic teens use to comment in code, in part to confound snooping parents.

Ms. Corbett, the Charlotte therapist, said that when she followed her sons’ Facebook pages, she used caution before responding to occasional downbeat posts. If parents react to every little bad mood, she said, children might be less open on Facebook, assuming that “my parents will freak out.”

Dr. Moreno said that parents should consider whether the posts are typical for their child or whether the child also seems depressed at home. Early intervention can be low-key — a brief text or knock on the bedroom door: “I saw you posted this on Facebook. Is everything O.K.?”

Sometimes a Facebook posting can truly be a last-resort cry for help. One recent afternoon while Jackie Wells, who lives near Dayton, Ohio, was waiting for her phone service to be fixed, she went online to check on her daughter, 18, who lives about an hour away. Just 20 minutes earlier, the girl, unable to reach her mother by phone, used her own Facebook page to post to Mrs. Wells or anyone else who might read it:

“I just did something stupid, mom. Help me.”

Mrs. Wells borrowed a cellphone from her parents and called relatives who lived closer to her daughter. The girl had overdosed on pills. They got her to the hospital in time.

“Facebook might be a pain in the neck to keep up with,” Mrs. Wells said. “But having that extra form of communication saves lives.”

Liz Heron contributed reporting.

 

 

By JAN HOFFMAN, NYT, February 23, 2012

 

 

Branding a Soldier With ‘Personality Disorder’

Capt. Susan Carlson was not a typical recruit when she volunteered for the Army in 2006 at the age of 50. But the Army desperately needed behavioral health professionals like her, so it signed her up.

Though she was, by her own account, “not a strong soldier,” she received excellent job reviews at Fort Leavenworth, Kan., where she counseled prisoners. But last year, Captain Carlson, a social worker, was deployed to Afghanistan with the Colorado National Guard and everything fell apart.

After a soldier complained that she had made sexually suggestive remarks, she was suspended from her counseling duties and sent to an Army psychiatrist for evaluation. His findings were shattering: She had, he said in a report, a personality disorder, a diagnosis that the military has used to discharge thousands of troops. She was sent home.

She disputed the diagnosis, but it was not until months later that she found what seemed powerful ammunition buried in her medical file, portions of which she provided to The New York Times. “Her command specifically asks for a diagnosis of a personality disorder,” a document signed by the psychiatrist said.

Veterans’ advocates say Captain Carlson stumbled upon evidence of something they had long suspected but had struggled to prove: that military commanders pressure clinicians to issue unwarranted psychiatric diagnoses to get rid of troops.

“Her records suggest an attempt by her commander to influence medical professionals,” said Michael J. Wishnie, a professor at Yale Law School and director of its Veterans Legal Services Clinic.

Since 2001, the military has discharged at least 31,000 service members because of personality disorder, a family of disorders broadly characterized by inflexible “maladaptive” behavior that can impair performance and relationships.

For years, veterans’ advocates have said that the Pentagon uses the diagnosis to discharge troops because it considers them troublesome or wants to avoid giving them benefits for service-connected injuries. The military considers personality disorder a pre-existing problem that emerges in youth, and as a result, troops given the diagnosis are often administratively discharged without military retirement pay. Some have even been required to repay enlistment bonuses.

By comparison, a diagnosis of post-traumatic stress disorder is usually linked to military service and leads to a medical discharge accompanied by certain benefits.

In recent weeks, questions about whether the Army manipulates psychiatric diagnoses to save money have been raised at Joint Base Lewis-McChord near Tacoma, Wash., where soldiers undergoing medical evaluations before discharge complained that psychiatrists rescinded PTSD diagnoses, leaving the soldiers with diagnoses like personality disorder that did not qualify them for medical discharges.

In a memorandum, an Army ombudsman wrote that a doctor from the base hospital, Madigan Army Medical Center, said that one diagnosis of post-traumatic stress disorder can cost $1.5 million in benefits over a soldier’s lifetime. The doctor also counseled his colleagues to be good stewards of taxpayer money by not “rubber-stamping” such diagnoses.

In the wake of those complaints, the Army has removed the head of Madigan and suspended two doctors at a special forensic psychiatric unit. It has also reviewed the cases of 14 soldiers and reinstituted PTSD diagnoses for 6 of them.

Some senior military officials have raised concerns that PTSD is overdiagnosed. Still, the Defense Department has denied that it uses psychiatric diagnoses either to weed out injured or low-performing troops, or to save money.

“Our goal is to provide the most accurate diagnosis,” said Maria Tolleson, a spokeswoman for the Army Medical Command.

On Captain Carlson’s case, the Colorado National Guard declined to comment. Officials at Womack Army Medical Center at Fort Bragg, N.C., said the psychiatrist who evaluated Captain Carlson in Afghanistan, Maj. Aniceto Navarro, was not available for an interview.

But in a statement, the hospital said: “No commander may order a credentialed clinician to make a particular diagnosis. Dr. Navarro did not feel he was being ordered by the service member’s command to make a particular diagnosis. The sentence referenced was written in terms of the commander asking to evaluate for a personality disorder, i.e. asking if one existed, not ordering to diagnose a personality disorder.”

Though it is impossible to know how many veterans are disputing their personality disorder discharges, Vietnam Veterans of America, an advocacy group, with help from the Yale veterans legal clinic, has sued the Defense Department seeking records they say will show that thousands of troops have been unfairly discharged for personality or adjustment disorder since 2001.

“We believe that many of the people who received personality disorder discharges were wrongly diagnosed and that in fact they were suffering from PTSD or traumatic brain injury,” said Thomas Berger, executive director of Vietnam Veterans of America’s health council.

Although the number of personality disorder discharges is small relative to the total number of troops who have served since 2001, Congress was concerned enough about the issue to hold hearings in 2007 after reading reports that troops with post-traumatic stress and other combat-related injuries were being discharged for personality disorder.

The Defense Department then tightened its requirements, partly to ensure that troops who had served in combat zones and had PTSD were not discharged for personality disorder. Personality disorder discharges subsequently declined, to 1,078 in 2010 from 4,264 in 2007, data obtained by Vietnam Veterans of America show.

But the Government Accountability Office said in 2010 that the Defense Department had not proved that it was in full compliance with its rules. And Captain Carlson’s case shows that the military continues to issue personality disorder diagnoses in questionable ways, according to veterans’ advocates and her lawyers, Stephen H. Carpenter Jr. and Daniel C. Russ.

Unlike the soldiers at Madigan, Captain Carlson has not been given a diagnosis of PTSD. But the personality disorder diagnosis could complicate her ability get a medical discharge for a back injury and other problems. Perhaps more significant, the diagnosis will be listed on her discharge papers, which employers typically review when they are considering veterans for a job.

“It may have a significant impact on her ability to find employment,” Mr. Carpenter said.

Captain Carlson, now 55, signed up with the Army after a co-worker at a Milwaukee trauma hospital, a surgeon in the National Guard, told her that the Army badly needed therapists and social workers. Intrigued, she got an age waiver and joined through a program that commissions officers based on their specialized training.

At Fort Leavenworth, where she served for three years, supervisors called her “highly talented,” “outstanding” and “a dedicated officer,” according to a 2008 evaluation.

After leaving active duty, Captain Carlson moved to Colorado Springs in 2010 to take a civilian job as a substance abuse counselor at Fort Carson. But she soon learned that the Colorado National Guard, which she had just joined, would deploy to Afghanistan in early 2011. She told her commander she wanted to go.

“I wanted to experience what soldiers experience,” she said in an interview.

But her problems began soon after she arrived in Afghanistan last February. She got lost outside a combat outpost and wore shorts when she should have been in combat uniform. Then a junior enlisted soldier accused her of sexual harassment, citing an off-color remark she made during a game of Scrabble with several soldiers at a combat outpost.

Captain Carlson contends the remark was innocent, but the Army sent her back to Bagram Air Base near Kabul and opened an investigation. A major general eventually gave her a memorandum of reprimand, a potentially career-ending action. But she says it was the psychological evaluation she received at Bagram that upset her the most.

In notes from that evaluation, Dr. Navarro wrote that “it is very difficult to draw absolute conclusions for a personality disorder.” But he noted that her command had asked for the diagnosis and, in his final report dated three days later, Dr. Navarro did just that.

Captain Carlson has “a very dramatic style” and “chronic difficulty in adjusting,” Dr. Navarro wrote in that report, concluding that she had “personality disorder NOS” — not otherwise specified — “with histrionic traits.” He recommended that the Army move swiftly to discharge her if she did not comply with counseling from her commander.

Experts say personality disorder is generally evident in a person’s youth, leaving a telltale pattern across failed jobs and broken relationships. For that reason, they generally recommend that diagnoses include reviews of patients’ medical records and interviews with people who have known them for years. Dr. Navarro says in his notes that he did not have access to her records.

Dr. Andrew E. Skodol, research professor of psychiatry at the University of Arizona and an expert on personality disorder who was not familiar with Captain Carlson’s case, said it would not be surprising for a person who entered the Army in middle age to have trouble adapting to the stresses of military life and deployment. But that would not necessarily qualify as a personality disorder, Dr. Skodol said.

After leaving Afghanistan last year, Captain Carlson went to Joint Base Lewis-McChord, where a psychiatrist gave her a diagnosis of adjustment disorder, her lawyers said. That psychiatrist has since been suspended as part of the Army’s investigation into Madigan.

It will be up to the Colorado National Guard to decide how Captain Carlson will be discharged, a process that could take months. At the least, Captain Carlson wants the personality disorder diagnosis removed from her record.

“It’s a bad label,” she said. “I’m a broken soldier. I’m old. And they just want to get rid of me.”

 

By JAMES DAO, NYT, February 24, 2012

 

 

 

Following a Script to Escape a Nightmare

Her car is racing at a terrifying speed through the streets of a large city, and something gruesome, something with giant eyeballs, is chasing her, closing in fast. It was a dream, of course, and after Emily Gurule, a 50-year-old high school teacher, related it to Dr. Barry Krakow, he did not ask her to unpack its symbolism. He simply told her to think of a new one.

“In your mind, with thinking and picturing, take a few minutes, close your eyes, and I want you to change the dream any way you wish,” said Dr. Krakow, founder of the P.T.S.D. Sleep Clinic at the Maimonides Sleep Arts and Sciences center here and a leading researcher of nightmares.
And so the black car became a white Cadillac, traveling at a gentle speed with nothing chasing it. The eyeballs became bubbles, floating serenely above the city.
“We call that a new dream,” Dr. Krakow told Ms. Gurule. “The bad dream is over there” — he pointed across the room — “and we’re not dealing with that. We’re dealing with the new dream.”

The technique, used while patients are awake, is called scripting or dream mastery and is part of imagery rehearsal therapy, which Dr. Krakow helped develop. The therapy is being used to treat a growing number of nightmare sufferers. In recent years, nightmares have increasingly been viewed as a distinct disorder, and researchers have produced a growing body of empirical evidence that this kind of cognitive therapy can help reduce their frequency and intensity, or even eliminate them.
The treatments are controversial. Some therapists, particularly Jungian analysts, take issue with changing nightmares’ content, arguing that dreams send crucial messages to the waking mind.

Nightmares are important because they “bring up issues in bold print,” said Jane White-Lewis, a psychologist in Guilford, Conn., who has taught about dreams at the Carl Jung Institute in New York.
While Dr. White-Lewis acknowledged that she does not treat patients suffering from severe trauma, she said that if a nightmare is eliminated, “you lose an opportunity to really get some meaning out of it.” Changing eyeballs into bubbles, she added, might have robbed Ms. Gurule of the chance to find out what the eyeballs were trying to tell her.

Nightmares have fascinated and perplexed people for centuries, their meaning debated by therapists and analysts of all schools of thought, their effects so powerful that one terrifying nightmare can affect a person for a lifetime.

A nightmare is “a disturbing dream experience which rubs, bites and sickens our soul, and has an undercurrent of horsepower, lewd demons, aggressive orality and death,” Dr. White-Lewis wrote in “In Defense of Nightmares,” her contribution to a 1993 book of essays about dreams.
From 4 to 8 percent of adults report experiencing nightmares, perhaps as often as once per week or more, according to sleep researchers. But the rate is as high as 90 percent among groups like combat veterans and rape victims, Dr. Krakow said. He said treatment for post-traumatic stress needed to deal much more actively with nightmares.

He and other clinicians are increasingly using imagery rehearsal therapy, or I.R.T., to treat veterans and active-duty troops in the Iraq and Afghanistan wars. Last month, Dr. Krakow conducted a workshop on imagery rehearsal and other sleep treatments for 65 therapists, sleep doctors and psychiatrists, including many working with the military. And the technique has drawn more attention from other researchers in the last several years. Anne Germain, an associate professor of psychiatry at the University of Pittsburgh School of Medicine, is comparing two treatments — behavioral therapy, including imagery rehearsal, and the blood-pressure drug prazosin, which has been found to reduce nightmares.

Preliminary results from a study of 50 veterans showed that both treatments were effective in reducing nightmares and symptoms of P.T.S.D., she said, though they differed from patient to patient. She is continuing to study what factors may lead to those differences.
Deirdre Barrett, a psychologist at Harvard Medical School who is an expert on dream incubation, inducing dreams to resolve conflicts , and on the connection between trauma and dreams — said she was struck by the growing interest in nightmares as a result of war trauma and torture.
“Within the community of psychologists who have put an emphasis on dreams it used to be about interpretation,” she said. “And now therapists are getting the message that you can influence dreams, ask dreams about particular issues and change nightmares.”

And Hollywood has just produced its own spin on the idea of controlling dreams, with the release earlier this month of “Inception” a thriller whose plot swirls through the darkest layers of the dream world. Underlying the story is the concept of lucid dreaming, another technique used by clinicians to help patients afraid of their dreams understand that they are dreaming while a dream is in progress. Dr. Barrett supports the use of Dr. Krakow’s technique, although she said that ideally the nightmare work should be integrated with psychiatry and behavioral therapies to treat the underlying condition.

Still, Dr. Barrett said, “Barry has made a huge contribution by getting the numbers, getting the statistics and getting the proof that it can work.”
Dr. Krakow’s nightmare therapy typically includes four sessions of group treatment and between one and ten individual sessions, though Dr. Krakow said between three and five sessions are usually effective. (The clinic visits are covered by insurance.)

Patients participate in sleep studies as needed, and do considerable work on their own, using a manual he published to guide them, “Turning Nightmares Into Dreams.”
At the clinic here, some patients, like Ms. Gurule, come in for severe snoring and daytime sleepiness and discover they are suffering from trauma-induced nightmares. Others come with a diagnosis of post-traumatic stress or simply report recurring nightmares and discover they also have other sleep disorders.
Dr. Krakow’s latest research, which was presented last month at the annual meeting of the Associated Professional Sleep Societies, found a striking connection between P.T.S.D. and a variety of sleep disorders. In an analysis of the sleep studies conducted on more than a thousand patients with varying degrees of post-traumatic stress, he found that 5 to 10 other sleep problems may be involved. High rates of sleep apnea, for example, were found even in patients with moderate symptoms of post-traumatic stress. “In the world of P.T.S.D. and sleep, no one is making these connections,” Dr. Krakow said.

He refers to his small clinic, in an office park here, as a “bed-and-breakfast without the breakfast.” It has four small bedrooms, with pastel-colored bedspreads and cheerful, serene paintings of fish and beaches. Before bed, the technicians place sensors on the patients to track sleep, breathing and movement.
Dr. Krakow, 61, started out as an internist and then practiced emergency medicine before studying nightmares and possible treatments with colleagues at the University of New Mexico in the late 1980s. With financing from the National Institute of Mental Health, he conducted his first major research between 1995 and 1999, looking at the effect of imagery rehearsal on 168 sexual assault survivors who suffered from nightmares.
The results of a randomized controlled trial were published in a 2001 paper in the Journal of the American Medical Association. Of the subjects, 95 percent had moderate to severe P.T.S.D., 97 percent had experienced rape or other sexual assault, 77 percent reported life-threatening sexual assault and 58 percent reported repeated exposure to sexual abuse in childhood.

The treatment group, 88 women, participated in three sessions of imagery rehearsal therapy, while the control group, 80 women, was on a waiting list and continued with whatever treatment they had been undergoing. Of the 114 that completed follow-up at three or at three and six months, those in the treatment group had “significantly” reduced the nights per week with nightmares and the number of nightmares per week, the paper said. The control group showed small, “nonsignificant” improvement on the same measures. And symptoms of post-traumatic stress decreased in 65 percent of the treatment group, while they either remained unchanged or worsened in the control group, according to the findings.

Along with other researchers, Dr. Krakow has continued to publish further studies on imagery rehearsal, finding that of hundreds of patients treated, about 70 percent have reported significant improvements in nightmare frequency after regularly using the treatment for two to four weeks.
Roberta Barker, 55, was one of Dr. Krakow’s first patients and a participant in the research published in JAMA. Ms. Barker says she was kidnapped in Japan, where she had gone to teach English, and was raped and tortured for three days before escaping. (She suffered extensive physical injuries and now survives on a government disability pension.)

Her nightmares, replaying the horror over and over, were so frightening she could barely sleep. Medications did not seem to work. She was on the verge of suicide.
“I drank enough coffee to float a battleship,” she said in a recent visit to Dr. Krakow’s clinic. “A few times a week I was reliving the entire set of days in one night.”
When Dr. Krakow told her that nightmares can be a learned behavior and that she had the power to stop what had essentially become a habit, she was highly skeptical.
He explained that she could come up with another dream and practice it and that it was possible for her to no longer have the nightmares of the kidnapping and rape.
“No, it’s too easy,” she recalled telling him. “It can’t work.”

Some patients work to change the plot of their dreams; a rape victim who was receiving treatment with Ms. Barker decided to script a dream about confronting her rapist with a baseball bat. But Ms. Barker said she felt she had to come up with an entirely new dream. So she chose birds.
“I’ve always loved birds, wild birds, doves and pigeons and starlings, mountain blue jays,” she said. “I had fed birds, the images were solid, I could hear them flying and talking. Now, instead of waking up screaming, I wake up knowing I’ve dreamed of birds.”

By SARAH KERSHAW (July 2010)

 

A Soft Spot for Circuitry

Nothing Eileen Oldaker tried could calm her mother when she called from the nursing home, disoriented and distressed in what was likely the early stages of dementia. So Ms. Oldaker hung up, dialed the nurses’ station and begged them to get Paro.

Paro is a robot modeled after a baby harp seal. It trills and paddles when petted, blinks when the lights go up, opens its eyes at loud noises and yelps when handled roughly or held upside down. Two microprocessors under its artificial white fur adjust its behavior based on information from dozens of hidden sensors that monitor sound, light, temperature and touch. It perks up at the sound of its name, praise and, over time, the words it hears frequently.
“Oh, there’s my baby,” Ms. Oldaker’s mother, Millie Lesek, exclaimed that night last winter when a staff member delivered the seal to her. “Here, Paro, come to me.”
“Meeaakk,” it replied, blinking up at her through long lashes.

Janet Walters, the staff member at Vincentian Home in Pittsburgh who recalled the incident, said she asked Mrs. Lesek if she would watch Paro for a little while.
“I need someone to baby-sit,” she told her.

“Don’t rush,” Mrs. Lesek instructed, stroking Paro’s antiseptic coat in a motion that elicited a wriggle of apparent delight. “He can stay the night with me.”
After years of effort to coax empathy from circuitry, devices designed to soothe, support and keep us company are venturing out of the laboratory. Paro, its name derived from the first sounds of the words “personal robot,” is one of a handful that take forms that are often odd, still primitive and yet, for at least some early users, strangely compelling.

http://video.nytimes.com/video/2010/06/29/us/1247468152153/bonding-with-paro.html

For recovering addicts, doctors at the University of Massachusetts are testing a wearable sensor designed to discern drug cravings and send text messages with just the right blend of tough love.

For those with a hankering for a custom-built companion and $125,000 to spend, a talking robotic head can be modeled on the personality of your choice. It will smile at its own jokes and recognize familiar faces.

For dieters, a 15-inch robot with a touch-screen belly, big eyes and a female voice sits on the kitchen counter and offers encouragement after calculating their calories and exercise.

“Would you come back tomorrow to talk?” the robot coach asks hopefully at the end of each session. “It’s good if we can discuss your progress every day.”
Robots guided by some form of artificial intelligence now explore outer space, drop bombs, perform surgery and play soccer. Computers running artificial intelligence software handle customer service calls and beat humans at chessand, maybe, “Jeopardy!”

Machines as Companions
But building a machine that fills the basic human need for companionship has proved more difficult. Even at its edgiest, artificial intelligence cannot hold up its side of a wide-ranging conversation or, say, tell by an expression when someone is about to cry. Still, the new devices take advantage of the innate soft spot many people have for objects that seem to care — or need someone to care for them.

Their appearances in nursing homes, schools and the occasional living room are adding fuel to science fiction fantasies of machines that people can relate to as well as rely on. And they are adding a personal dimension to a debate over what human responsibilities machines should, and should not, be allowed to undertake.
Ms. Oldaker, a part-time administrative assistant, said she was glad Paro could keep her mother company when she could not. In the months before Mrs. Lesek died in March, the robot became a fixture in the room even during her daughter’s own frequent visits.

“He likes to lie on my left arm here,” Mrs. Lesek would tell her daughter. “He’s learned some new words,” she would report.
Ms. Oldaker readily took up the game, if that is what it was.
“Here, Mom, I’ll take him,” she would say, boosting Paro onto her own lap when her mother’s food tray arrived.

Even when their ministrations extended beyond the robot’s two-hour charge, Mrs. Lesek managed to derive a kind of maternal satisfaction from the seal’s sudden stillness.

“I’m the only one who can put him to sleep,” Mrs. Lesek would tell her daughter when the battery ran out.
“He was very therapeutic for her, and for me too,” Ms. Oldaker said. “It was nice just to see her enjoying something.”
Like pet therapy without the pet, Paro may hold benefits for patients who are allergic, and even those who are not. It need not be fed or cleaned up after, it does not bite, and it may, in some cases, offer an alternative to medication, a standard recourse for patients who are depressed or hard to control.
In Japan, about 1,000 Paros have been sold to nursing homes, hospitals and individual consumers. In Denmark, government health officials are trying to quantify its effect on blood pressure and other stress indicators. Since the robot went on sale in the United States late last year, a few elder care facilities have bought one; several dozen others, hedging their bets, have signed rental agreements with the Japanese manufacturer.
But some social critics see the use of robots with such patients as a sign of the low status of the elderly, especially those with dementia. As the technology improves, argues Sherry Turkle, a psychologist and professor at theMassachusetts Institute of Technology, it will only grow more tempting to substitute Paro and its ilk for a family member, friend — or actual pet — in an ever-widening number of situations.

“Paro is the beginning,” she said. “It’s allowing us to say, ‘A robot makes sense in this situation.’ But does it really? And then what? What about a robot that reads to your kid? A robot you tell your troubles to? Who among us will eventually be deserving enough to deserve people?”
But if there is an argument to be made that people should aspire to more for their loved ones than an emotional rapport with machines, some suggest that such relationships may not be so unfamiliar. Who among us, after all, has not feigned interest in another? Or abruptly switched off their affections, for that matter?
In any case, the question, some artificial intelligence aficionados say, is not whether to avoid the feelings that friendly machines evoke in us, but to figure out how to process them.

“We as a species have to learn how to deal with this new range of synthetic emotions that we’re experiencing — synthetic in the sense that they’re emanating from a manufactured object,” said Timothy Hornyak, author of “Loving the Machine,” a book about robots in Japan, where the world’s most rapidly aging population is showing a growing acceptance of robotic care. “Our technology,” he argues, “is getting ahead of our psychology.”
More proficient at emotional bonding and less toylike than their precursors — say, Aibo the metallic dog or the talking Furby of Christmas crazes past — these devices are still unlikely to replace anyone’s best friend. But as the cost of making them falls, they may be vying for a silicon-based place in our affections.

Strangely Compelling
Marleen Dean, the activities manager at Vincentian Home, where Mrs. Lesek was a resident, was not easily won over. When the home bought six Paro seals with a grant from a local government this year, “I thought, ‘What are they doing, paying $6,000 for a toy that I could get at a thrift store for $2?’ ” she said.
So she did her own test, giving residents who had responded to Paro a teddy bear with the same white fur and eyes that also opened and closed. “No reaction at all,” she reported.

Vincentian now includes “Paro visits” in its daily roster of rehabilitative services, including aromatherapy and visits from real pets. Agitated residents are often calmed by Paro; perpetually unresponsive patients light up when it is placed in their hands.

“It’s something about how it shimmies and opens its eyes when they talk to it,” Ms. Dean said, still somewhat mystified. “It seems like it’s responding to them.”
Even when it is not. Part of the seal’s appeal, according to Dr. Takanori Shibata, the computer scientist who invented Paro with financing from the Japanese government, stems from a kind of robotic sleight of hand. Scientists have observed that people tend to dislike robots whose behavior does not match their preconceptions. Because the technology was not sophisticated enough to conjure any animal accurately, he chose one that was unfamiliar, but still lovable enough that people could project their imaginations onto it. “People think of Paro,” he said, “as ‘like living.’ ”

It is a process he — and others — have begun calling “robot therapy.”
At the Veterans Affairs Medical Center in Washington on a recent sunny afternoon, about a dozen residents and visitors from a neighboring retirement home gathered in the cafeteria for their weekly session. The guests brought their own slightly dingy-looking Paros, and in wheelchairs and walkers they took turns grooming, petting and crooning to the two robotic seals.

Paro’s charms did not work on everyone.

“I’m not absolutely convinced,” said Mary Anna Roche, 88, a former newspaper reporter. The seal’s novelty, she suggested, would wear off quickly.
But she softened when she looked at her friend Clem Smith running her fingers through Paro’s fur.
“What are they feeding you?” Ms. Smith, a Shakespeare lover who said she was 98, asked the seal. “You’re getting fat.”
A stickler for accuracy, Ms. Roche scolded her friend. “You’re 101, remember? I was at your birthday!”
The seal stirred at her tone.

“Oh!” Ms. Roche exclaimed. “He’s opening his eyes.”

As the hour wore on, staff members observed that the robot facilitated human interaction, rather than replaced it.
“This is a nice gathering,” said Philip Richardson, who had spoken only a few words since having a stroke a few months earlier.
Dorothy Marette, the clinical psychologist supervising the cafeteria klatch, said she initially presumed that those who responded to Paro did not realize it was a robot — or that they forgot it between visits.

Yet several patients whose mental faculties are entirely intact have made special visits to her office to see the robotic harp seal.
“I know that this isn’t an animal,” said Pierre Carter, 62, smiling down at the robot he calls Fluffy. “But it brings out natural feelings.”
Then Dr. Marette acknowledged an observation she had made of her own behavior: “It’s hard to walk down the hall with it cooing and making noises and not start talking to it. I had a car that I used to talk to that was a lot less responsive.”

Accepting a Trusty Tool
That effect, computer science experts said, stems from what appears to be a basic human reflex to treat objects that respond to their surroundings as alive, even when we know perfectly well that they are not.
Teenagers wept over the deaths of their digital Tamagotchi pets in the late 1990s; some owners of Roomba robotic vacuum cleaners are known to dress them up and give them nicknames.

”When something responds to us, we are built for our emotions to trigger, even when we are 110 percent certain that it is not human,” said Clifford Nass, a professor of computer science at Stanford University. “Which brings up the ethical question: Should you meet the needs of people with something that basically suckers them?”
An answer may lie in whether one signs on to be manipulated.

For Amna Carreiro, a program manager at the M.I.T. Media Lab who volunteered to try a prototype of Autom, the diet coach robot, the point was to lose weight. After naming her robot Maya (“Just something about the way it looked”) and dutifully entering her meals and exercise on its touch screen for a few nights, “It kind of became part of the family,” she said. She lost nine pounds in six weeks.

Cory Kidd, who developed Autom as a graduate student at M.I.T., said that eye contact was crucial to the robot’s appeal and that he had opted for a female voice because of research showing that people see women as especially supportive and helpful. If a user enters an enthusiastic “Definitely!” to the question “Will you tell me what you’ve eaten today?” Autom gets right down to business. A reluctant “If you insist” elicits a more coaxing tone. It was the blend of the machine’s dispassion with its personal attention that Ms. Carreiro found particularly helpful.
“It would say, ‘You did not fulfill your goal today; how about 15 minutes of extra walking tomorrow?’ ” she recalled. “It was always ready with a Plan B.”
Aetna, the insurance company, said it hoped to set up a trial to see whether people using it stayed on their diets longer than those who used other programs when the robot goes on sale next year.

Of course, Autom’s users can choose to lie. That may be less feasible with an emotion detector under development with a million-dollar grant from the National Institute on Drug Abuse that is aimed at substance abusers who want to stay clean.
Dr. Edward Boyer of the University of Massachusetts Medical School plans to test the system, which he calls a “portable conscience,” on Iraq veterans later this year. The volunteers will enter information, like places or people or events that set off cravings, and select a range of messages that they think will be most effective in a moment of temptation.

Then they don wristbands with sensors that detect physiological information correlated with their craving. With a spike in pulse not related to exertion, for instance, a wireless signal would alert the person’s cellphone, which in turn would flash a message like “What are you doing now? Is this a good time to talk?” It might grow more insistent if there was no reply. (Hallmark has been solicited for help in generating evocative messages.)
With GPS units and the right algorithms, such a system could tactfully suggest other routes when recovering addicts approached places that hold particular temptation — like a corner where they used to buy drugs. It could show pictures of their children or play a motivational song.
“It works when you begin to see it as a trustworthy companion,” Dr. Boyer said. “It’s designed to be there for you.”

By AMY HARMON (NYT. July 4, 2010)

 

Graphic Humor 157

 

15 Medical Tests Every Man Should Have

Medical screening tests are a great way to keep on top of your health. Think of them as basic maintenance, just like checking the oil and tire pressure to keep your car safe on the highway. To keep it simple, we’ve compiled a list of the most important medical tests every man should have—along with what age to start and how often to repeat. Here’s to routine maintenance for your health.

1. Cholesterol screening/lipoprotein profile
Cholesterol is a type of fatty protein in your blood that can build up in your arteries, so knowing how much cholesterol is present is a good predictor of your risk for heart disease. There are two kinds of cholesterol: HDL, or high-density lipoproteins, and LDL, or low-density lipoproteins. Confusingly enough, HDL is “good” and protects against heart disease, while LDL is “bad” and poses a risk to your heart.
Your total cholesterol reading combines the measures of both and is used as an overall reading; 220 is the magic number that you want to stay beneath. In addition, the profile measures triglycerides, which are fats in the blood that can also block arteries; you want them below 150 milligrams per deciliter.
What Are the New Cholesterol Tests?
What it is: A blood test for cholesterol, measured in milligrams per deciliter of blood (mg/dl); usually measures triglycerides at the same time
When to start: Age 20
How often: Every five years. If testing reveals your levels are high, your doctor will recommend retesting every six months to one year. If you have risk factors for heart disease in your family, the regular cholesterol test may not be specific enough; ask your doctor for an additional test called the lipoprotein subfraction test. It’s more sensitive and checks the size of the cholesterol particles as well as the amount.

2. Blood pressure check
It seems simple, but checking your blood pressure regularly is one of the most important things you can do to protect your present and future health. One in every five adults, totaling 50 million people, has elevated blood pressure, also known as hypertension. When your blood pressure readings are higher than the cutoff of 140/90, it puts stress on your heart, leaving you at risk for heart attack and stroke. Many experts believe 120/80 is a healthier target to shoot for.
What it is: A physical reading using an arm cuff
When to start: Any age; best to begin during childhood
How often: Once a year if readings are normal; your doctor will recommend every six months if readings are high or if you’re taking medication to control hypertension.

3. Diabetes screening
To check your risk for diabetes, doctors check your tolerance for glucose absorption, which means how readily your body digests sugar.
What it is: A blood draw performed after drinking a sugary drink; a fasting glucose tolerance test requires you not to eat for nine hours prior to the test.
When to start: At age 45 if you have no risk factors or symptoms. If you’re significantly overweight, have high blood pressure, or have other risk factors for diabetes, such as family history of the disease, it’s a good idea to get tested younger. If your insurance doesn’t cover it, free testing is available at most major chain drugstores.
How often: Every three years

4. Bone density test
The loss of bone strength, called osteoporosis, afflicts nearly 10 million people every year, according to the National Osteoporosis Foundation. Surveys show that men see osteoporosis as a “woman’s disease,” but this is a misconception. After age 50, 6 percent of all men will break a hip and 5 percent will have a vertebral fracture as a result of osteoporosis. As we age, minerals such as calcium begin to leach from bones, weakening them and leading to osteoporosis, which literally means “porous bone.”
What it is: A specialized X-ray called a DXA (dual-energy X-ray) screens your spine, hips, and wrists as you lie on a table.
When to start: At age 65, everyone should have a DXA. But men who have risk factors for bone loss, such as being thin, taking corticosteroids, or having a history of fractures, should talk to their doctor about being screened now.
How often: Every five years

5. Vitamin D test
Recently, doctors have realized that vitamin D is a key nutrient that helps maintain strong bones and protect against cancer, infection, and other health conditions. For example, a study last year found that men with low levels of vitamin D had a higher incidence of heart attack. Most men have no idea if they’re D-deficient or not, though a simple blood test can tell. If you live in a northern climate, work indoors, or don’t drink a lot of milk, chances are your vitamin D level is low. If so, your doctor will recommend taking a vitamin D supplement.
What it is: A blood test, often done along with the cholesterol and lipid panel, to check the level of vitamin D in your blood. You want your reading to be between 30 and 80 nanograms per milliliter, though some experts argue that 50 nanograms should be the lowest level considered normal. Many experts recommend the 25(OH)D3 test as providing the more accurate measurement.
When to start: Age 40; sooner if you have signs or risk factors for osteoporosis. As we age, our bodies become less efficient at synthesizing vitamin D from the sun, so after the age of 40 it’s more likely that you’ll become D-deficient. Also, if you have any signs of low bone density, such as a fracture, your doctor will want to test your vitamin D along with your bone density.
How often: Although vitamin D testing isn’t yet required or listed on the official schedule of recommended tests, more and more doctors are recommending it as an annual test after age 45.

6. Colonoscopy or sigmoidoscopy
Colorectal cancer, which is cancer of the lower part of the intestines, is curable in 90 percent of all cases—as long as it’s caught early. And screening tests that look inside the colon, called colonoscopy and flexible sigmoidoscopy, are the secret to catching it early.
Unfortunately, this still isn’t happening as often as it should. Currently, 39 percent of cases are already stage III or IV when discovered. This test is considered so lifesaving that news anchor Katie Couric allowed hers to be presented on live TV as an educational campaign to raise awareness after her husband died of colorectal cancer. Colorectal cancer is the third leading cause of death from cancer for men, after lung and prostate cancer, so it’s important to take it seriously.
What it is: An examination of your colon using a tiny scope and camera, which are inserted through the rectum. A colonoscopy can see the whole colon, while a sigmoidoscopy can see only the sigmoid, or lower section of the colon.
When to start: Age 50 for those with no risk factors. If, however, you have a first-degree family member who’s had colon cancer before the age of 50, begin colonoscopy screening when you’re 10 years younger than the age at which your family member was diagnosed. If a family member was diagnosed at 45, for example, you should have your first screening at 35.
How often: Flexible sigmoidoscopies should be repeated every five years, and a colonoscopy should be repeated every 10 years. A computerized imaging technique called virtual colonoscopy is gaining popularity at some medical centers, but many doctors still consider it experimental and some insurers, including Medicare, don’t cover it.

7. Fecal occult blood test (FOBT)
Although it sounds otherworldly, the word occult simply refers to the fact that this test checks for blood in the stool that’s not visible to the eye. This is the least invasive screening tool available. A chemical solution is used to test a stool sample for the presence of blood, which can indicate intestinal conditions such as Crohn’s disease and ulcerative colitis, or colorectal cancer.
Colorectal cancer still strikes more men than women—more than 50,000 men are diagnosed with the disease every year.
What it is: A stool sample test that looks for blood in the stool using a chemically treated pad that turns blue in the presence of blood. Three stool samples are collected on consecutive days, since cancer and other conditions may not bleed consistently.
When to start: At age 50; your doctor may suggest it earlier if there’s cause for concern about intestinal conditions.
How often: Yearly after age 50

8. Skin cancer screening
Skin cancer, while less deadly than some, is the No. 1 cancer diagnosed among Americans. And men are at higher risk for skin cancer than women, something most men don’t know. While most types of skin cancer are easily treated, one type, melanoma, can be deadly. Skin cancer is relatively easy to detect as long as you bring any suspicious areas to the attention of your doctor.
What it is: An examination of your skin, particularly moles, lesions, or other areas that are changing or growing.
When to start: Any age
How often: Experts recommend conducting a personal “mole check” once a month in the shower to look for unusual growths or changes to existing moles. If you notice anything suspicious, call your doctor. Many communities offer free skin cancer screenings, usually held at drug stores or clinics. They’re often held in May, just as the summer season begins and people start to expose more skin.

9. Eye exam and vision screening
Whether you have problems seeing at a distance or close up, you need regular eye exams as you age to check the overall health of your eyes. The American Academy of Ophthalmology says that by the year 2020, 43 million Americans will have some type of degenerative eye disease, yet surveys show that more than a third of adults fail to get regular eye exams.
What it is: A vision screening tests how well you can see; an eye exam checks for glaucoma, macular degeneration, retinopathy, and other eye diseases. Make sure you’re having both kinds of exams.
When to start: Age 18
How often: Every one to three years between the ages of 18 and 61, says the American Optometric Association; after that, as often as your doctor thinks is necessary depending on what’s happening with your vision. If you have diabetes, you’re at much higher risk for eye problems and should be checked more often.

10. Hearing test (audiogram)
Fourteen percent of adults between ages 45 and 64 have hearing loss, and by the age of 60 one in three adults is losing hearing. Men are at highest risk for all types of noise-induced hearing loss, the most common type. Yet many men go years before getting tested, primarily because hearing tests are voluntary. You and your doctor have to decide that you need a hearing test and request one.
If you notice problems following conversations, missed social cues, or an inability to distinguish people’s speech from background noise, ask for a referral to an otolaryngologist to check the condition of your ears, and an audiologist to check your hearing.
What it is: A series of tests to assess different aspects of hearing. Tone tests are used to measure your overall hearing, while additional tests check inner- and middle-ear function and evaluate your ability to register speech.
When to start: When you or others notice problems
How often: Hearing tests are voluntary, but the American Speech-Language-Hearing Association recommends hearing tests every 10 years for adults up to the age of 50. After that, experts say, you should have a hearing test every three years.

11. Thyroid test
The thyroid, a small gland in your neck, regulates your body’s metabolic rate. If your thyroid is overactive, a condition known as hypothyroidism, your metabolic rate is too high. Symptoms include insomnia, weight loss, and overactive pulse. If you’re hypothyroid, it means your thyroid is underactive and your metabolism will be slow and sluggish. This usually leads to fatigue, constipation, and weight gain. While more women than men are hypothyroid, that doesn’t mean men can’t be—and in men, hypothyroidism can cause some upsetting side effects, such as erectile dysfunction, low sex drive, and ejaculation problems.
What it is: The most common test, the TSH test, is a blood test that measures the level of thyroid-stimulating hormone. The desired level is between 0.4 and 5.5. However, many experts believe testing thyroxine (a hormone made by the thyroid) directly with what’s called the T4 test is a more accurate way to assess thyroid function.
When to start: Age 35
How often: Once a year, says the American Thyroid Association. Other doctors don’t recommend a thyroid test for midlife adults unless you have symptoms of hypothyroidism or hyperthyroidism. After the age of 60, thyroid testing is usually conducted annually.

12. Screening for metabolic syndrome
Metabolic syndrome is a group of symptoms that put you at increased risk for both diabetes and heart disease. The screening involves checking for a list of issues and, if they’re present, recommending additional tests. Doctors consider men to have metabolic syndrome if three of the following five risk factors are present:
Waist circumference greater than 40 inches
Low “good” cholesterol (below 40 mg/dL)
Elevated triglycerides (greater than 150 mg/dL)
Blood pressure higher thasting glucose above 100 mg/dL
If three or more of these apply, ask your doctor for an additional screening test called the C-reactive protein (CRP), which many experts think is the best way to monitor heart health risks.
What it is: A blood test that measures an inflammatory marker for plaque buildup
When to start: Age 50
How often: Every three to five years, along with cholesterol and diabetes screening

13. Testicular cancer screening
Lance Armstrong brought testicular cancer to national attention, but many men still don’t know the signs of this disease. With early detection, a man’s chances of survival go up by a whopping 90 percent, so it pays to be vigilant. While testicular cancer is rare, it’s the most common type of cancer in younger men, ages 15 to 34.
What it is: A self-exam or doctor’s exam for tumors in the testicle. The doctor (or you) rolls each testicle slowly between thumb and forefinger, looking for any hardened areas or lumps and checking to make sure there haven’t been changes in size.
When to start: All ages
How often: The Livestrong Foundation recommends that all men do a self-exam every month for testicular cancer. Sometimes a man’s partner is the first to notice signs of testicular cancer. At the first sign of concern, call your doctor and ask for an examination. Your doctor may also recommend an ultrasound or a blood test for tumor markers that can indicate testicular cancer.

14. Prostate cancer screening
Not the favorite of most men, the digital rectal exam is a lifesaver because prostate cancer is one of the most common types of cancer, affecting one in six men. A second test, called the PSA test, is used to look for elevated levels of prostate-specific antigen. While the PSA test has come under fire for producing a high number of false positives, it’s still the best first-line blood test for prostate cancer.
What it is: A digital rectal exam in which the doctor inserts a finger into the rectum to feel the prostate gland, and a blood test that measures the level of prostate-specific antigen.
When to start: Age 50, according to the American Cancer Society, unless you have symptoms such as difficulty with urination. In that case, see your doctor for a prostate cancer exam at age 45.
How often: Every year

15. Bladder cancer screening
Men, particularly Caucasian men and men who have a history of smoking, are at an elevated risk for bladder cancer. In the early stages, bladder cancer can be symptomless, and in these cases a test is the only way to detect it. There’s a good reason to be vigilant about bladder cancer: If caught while still localized, it has a cure rate of 95 percent. While routine bladder cancer screening is not yet recommended, talk to your doctor if you’re Caucasian and a smoker.
What it is: A urine test that looks for small amounts of blood in the urine not visible to the eye
When to start: Age 50, if you have a history of smoking
How often: When your doctor recommends it. Another test recently introduced checks the urine for a marker called NMP22; this test is expected to come into wider use in the next few years.

* By Melanie Haiken

 

The Doctor’s Failure to Cut Costs

On wards and in intensive care units, when doctors, nurses, patients and families find themselves at odds with one another, they inevitably turn to the experts of last resort: the bioethicists.

Regularly called upon to weigh in on issues including life support, human research, patient rights and organ transplantation, bioethicists are known for bringing clarity to situations so overwrought with opinions, values and special interests that consensus appears impossible.

Now, as the search for consensus in health care reform grinds toward the end of its first year, a national leader in bioethics has cast his critical eye on the debate. At issue, however, are not the usual moral suspects: pharmaceutical manufacturers, medical device makers and hospitals. This time it is physicians who have lapsed in their ethical responsibilities.

In an editorial in The New England Journal of Medicine, Dr. Howard Brody, professor of family medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, writes that the medical profession, unlike other groups, has made little effort to curtail future medical costs. Physicians, Dr. Brody maintains, are not “innocent bystanders” to spiraling health care costs but have been complicit in their failure to take an active role in curtailing them.
Moreover, Dr. Brody points out, certain doctors’ groups have gone so far as to make their support for reform contingent on promises that their own income would remain unaffected. “If physicians seized the moral high ground,” Dr. Brody writes in his editorial, “we just might astonish enough other people to change the entire reform debate for the better.”

I spoke with Dr. Brody recently about the ethical obligations of doctors in the health care overhaul, the role of organized medicine, his “Top Five” plan to regain medicine’s moral ground, and whether it all comes down to money.

Q. You write that doctors have an ethical responsibility to advocate health care reform. Why?
A. Doctors have two responsibilities. First, they have a moral duty as an individual advocate. A doctor has a responsibility to his or her individual patients to make them healthier and to help them live longer.
But doctors have a second moral duty: they have an obligation to the general public to be prudent stewards of scarce resources. Doctors only get about 10 percent of health care costs in their pockets, but they control about 80 percent. That isn’t our money — it’s someone else’s — and the public has entrusted us to spend it as wisely as possible.

Q. Have doctors failed in that second moral duty?
A. Unlike previous health care reform discussions where doctors were put on a pedestal, people are now turning the searchlight, appropriately I think, on the medical profession and asking if we are the problem. But rather than rising to that challenge and exercising moral leadership in health care reform, we are acting like one more special interest group. Instead of saying we care about patients enough to put our own interests on the back burner, it has been as if we were more concerned about maximizing our income.
We make so much more money than so many people in this society. To say that we are entitled to that income rather than we are privileged and should give back to society does not, and should not, win us a lot of friends.
The reason that the public gave us so much regard, trusted us, was because they saw us as willing to make that moral commitment to put the patient first. If we ever retreat from that commitment, we lose so much. I don’t even want to think what that would be like.

Q. But are you referring to individual doctors or to organized medicine? Some doctors would argue that the opinions of organized medicine are not representative of doctors as a whole. Take the American Medical Association, for example; it counts only about 30 percent of licensed doctors as members.
A. Over the years I’ve met doctors from virtually every specialty who firmly place the good of the patient ahead of their own personal income and who have made personal sacrifices in their own income in order to practice the best medicine. But there are certain things that can only be accomplished by professional medical societies, things that doctors as individuals could never do.
I firmly believe that if a professional medical society came out and said, “This is our prescription for health care reform, even if it costs us money,” that would get attention.

Q. So is it all about the money?
A. No. It’s an unfortunate joining of money with other issues and motives. We have an American public that generally believes more is better. And rather than giving up bad habits, exercising and eating right, they would rather believe that the answer to health is in high technology.
When you combine this love affair with high technology with a reimbursement system that pays so much more for technology — and less for thinking and sitting and talking with patients — you end up with an expensive kind of medicine, which, when practiced by doctors, puts more money into their pockets.
In actual fact, there’s such a low chance that technology will help all these patients.

Q. How does your “Top Five” solution work?
A. The basic idea is that each specialty would decide on the top five procedures or diagnostic studies that are done commonly but only really help a small fraction of patients. These are things like arthroscopy for osteoarthritis of the knee or MRI’s and CAT scans, all of which are massively overused, not because they help but because of our enthusiasm regarding high technology.
Once each specialty has gone through the research evidence and decided on its “Top Five,” the respective professional organizations would take a public stand, issuing guidelines and recommendations against overuse of those “Top Five” procedures or studies.
By taking a public stand and making it harder for individual doctors to say, “Oh, I know better,” we could build real momentum for cost containment. And we would ultimately all benefit because we don’t need all that technology. You can still be as healthy without it.

By PAULINE W. CHEN, M.D. (March 3, 2010-NYT)

 

Doctors Without Morals

AFTER five years of investigation, the Justice Department has released its findings regarding the government lawyers who authorized waterboarding and other forms of torture during the interrogation of suspected terrorists at Guantánamo Bay and elsewhere. The report’s conclusion, that the lawyers exercised poor judgment but were not guilty of professional misconduct, is questionable at best. Still, the review reflects a commitment to a transparent investigation of professional behavior.

In contrast, the government doctors and psychologists who participated in and authorized the torture of detainees have escaped discipline, accountability or even internal investigation.

It is hardly news that medical staff at the C.I.A. and the Pentagon played a critical role in developing and carrying out torture procedures. Psychologists and at least one doctor designed or recommended coercive interrogation methods including sleep deprivation, stress positions, isolation and waterboarding. The military’s Behavioral Science Consultation Teams evaluated detainees, consulted their medical records to ascertain vulnerabilities and advised interrogators when to push harder for intelligence information.

Psychologists designed a program for new arrivals at Guantánamo that kept them in isolation to “enhance and exploit” their “disorientation and disorganization.” Medical officials monitored interrogations and ordered medical interventions so they could continue even when the detainee was in obvious distress. In one case, an interrogation log obtained by Time magazine shows, a medical corpsman ordered intravenous fluids to be administered to a dehydrated detainee even as loud music was played to deprive him of sleep.

When the C.I.A.’s inspector general challenged these “enhanced interrogation” methods, the agency’s Office of Medical Services was brought in to determine, in consultation with the Justice Department, whether the techniques inflicted severe mental pain or suffering, the legal definition of torture. Once again, doctors played a critical role, providing professional opinions that no severe pain or suffering was being inflicted.

According to Justice Department memos released last year, the medical service opined that sleep deprivation up to 180 hours didn’t qualify as torture. It determined that confinement in a dark, small space for 18 hours a day was acceptable. It said detainees could be exposed to cold air or hosed down with cold water for up to two-thirds of the time it takes for hypothermia to set in. And it advised that placing a detainee in handcuffs attached by a chain to a ceiling, then forcing him to stand with his feet shackled to a bolt in the floor, “does not result in significant pain for the subject.”

The service did allow that waterboarding could be dangerous, and that the experience of feeling unable to breathe is extremely frightening. But it noted that the C.I.A. had limited its use to 12 applications over two sessions within 24 hours, and to five days in any 30-day period. As a result, the lawyers noted the office’s “professional judgment that the use of the waterboard on a healthy individual subject to these limitations would be ‘medically acceptable.’”
The medical basis for these opinions was nonexistent. The Office of Medical Services cited no studies of individuals who had been subjected to these techniques. Its sources included a wilderness medical manual, the National Institute of Mental Health Web site and guidelines from the World Health Organization.

The only medical source cited by the service was a book by Dr. James Horne, a sleep expert at Loughborough University in Britain; when Dr. Horne learned that his book had been used as a reference, he said the C.I.A. had distorted his findings and misrepresented his research, and that its conclusions on sleep deprivation were nonsense.

Dr. Horne had used healthy volunteers who were subject to no other stresses and could withdraw at any time, while C.I.A. and Pentagon interrogators used a broad array of stresses in combination on the detainees. Sleep deprivation, he said, mixed with pain-inducing positioning, intimidation and a host of other stresses, would probably exhaust the body’s defense mechanisms, cause physical collapse and worsen existing illness. And that doesn’t begin to acknowledge the dire psychological consequences.

The shabbiness of the medical judgments, though, pales in comparison to the ethical breaches by the doctors and psychologists involved. Health professionals have a responsibility extending well beyond nonparticipation in torture; the historic maxim is, after all, “First do no harm.” These health professionals did the polar opposite.

Nevertheless, no agency — not the Pentagon, the C.I.A., state licensing boards or professional medical societies — has initiated any action to investigate, much less discipline, these individuals. They have ignored the gross and appalling violations by medical personnel. This is an unconscionable disservice to the thousands of ethical doctors and psychologists in the country’s service. It is not too late to begin investigations. They should start now.
Leonard S. Rubenstein is a visiting scholar at the Johns Hopkins Bloomberg School of Public Health. Stephen N. Xenakis is a psychiatrist and a retired Army brigadier general.

Text  By LEONARD S. RUBENSTEIN and STEPHEN N. XENAKIS
March 1, 2010
Op-Ed Contributors-New York Times

 

How Cocaine Scrambles Genes in the Brain

It’s hardly a secret that taking cocaine can change the way you feel and the way you behave. Now, a study published in the Jan. 8 issue of Science shows how it also alters the way the genes in your brain operate. Understanding this process could eventually lead to new treatments for the 1.4 million Americans with cocaine problems, and millions more around the world.

The study, which was conducted on mice, is part of a hot new area of research called epigenetics, which explores how experiences and environmental exposures affect genes. “This is a major step in understanding the development of cocaine addiction and a first step toward generating ideas for how we might use epigenetic regulation to modulate the development of addiction,” says Peter Kalivas, professor of neuroscience at the Medical University of South Carolina, who was not associated with the study. 

Though we think about our genes mostly in terms of the traits we pass on to our children, they are actually very active in our lives every day, regulating how various cells in our bodies behave. In the brain this can be especially powerful. Any significant experience triggers changes in brain genes that produce proteins — those necessary to help memories form, for example. But, says the study’s lead author, Ian Maze, a doctoral student at Mount Sinai School of Medicine, “when you give an animal a single dose of cocaine, you start to have genes aberrantly turn on and off in a strange pattern that we are still trying to figure out.”
Maze’s research focused on a particular protein called G9a that is associated with cocaine-related changes in the nucleus accumbens, a brain region essential for the experience of desire, pleasure and drive. The role of the protein appears to be to shut down genes that shouldn’t be on. One-time use of cocaine increases levels of G9a. But repeated use works the other way, suppressing the protein and reducing its overall control of gene activation. Without enough G9a, those overactive genes cause brain cells to generate more dendritic spines, which are the parts of cells that make connections to other cells.
Increases in the number of these spines can reflect learning. But in the case of addiction, that may involve learning to connect a place or a person with the desire for more drugs. Maze showed that even after a week of abstinence, mice given a new dose of cocaine still had elevated levels of gene activation in the nucleus accumbens, meaning G9a levels were still low. It is not known how long these changes can last. Maze also showed that when he intervened and raised G9a levels, the mice were less attracted to cocaine.
It’s a big leap from a mouse study to a human study, of course — and an even bigger leap to consider developing a G9a-based treatment for addiction. The protein regulates so many genes that such a drug would almost certainly have unwanted and potentially deadly side effects. But a better understanding of the G9a pathways could lead to the development of safer, more specific drugs. And studying the genes that control G9a itself could also help screen people at risk for cocaine addiction: those with naturally lower levels of the protein would be the ones to watch. Still, there’s a lot to be learned even from further mouse studies — particularly if the work involves younger mice, unlike the adults used in Maze’s research. (See the top 10 medical breakthroughs of 2009.)

“We know that the greatest vulnerability [to addiction] occurs when adolescents are exposed,” says Dr. Nora Volkow, director of the National Institute on Drug Abuse, which funded the study. “Would you see the same results in adolescent [mice]? And what happens during fetal exposure?”
New treatments are definitely needed for cocaine addiction: there are helpful medications for addiction to heroin and similar drugs, but so far, none are particularly useful against stimulants like cocaine and methamphetamine. And with federal reports now showing that more than two-thirds of all cocaine in the country is cut with a veterinary deworming drug called levamisole, which can cause potentially fatal immune-system problems, the risks from cocaine are greater — and the search for new answers more urgent than ever.

 

* By Maia Szalavitz Friday, Jan. 08, 2010

 

Hospitals May Face Severe Disruption From Swine Flu

Swine flu may hospitalize 1.8 million patients in the U.S. this year, filling intensive care units to capacity and causing “severe disruptions” during a fall resurgence, scientific advisers to the White House warned.

Swine flu, also known as H1N1, may infect as much as half of the population and kill 30,000 to 90,000 people, double the deaths caused by the typical seasonal flu, according to the planning scenario issued yesterday by the President’s Council of Advisers on Science and Technology. Intensive care units in hospitals, some of which use 80 percent of their space in normal operation, may need every bed for flu cases, the report said.

The virus has sickened more than 1 million people in the U.S., and infections may increase this month as pupils return to school, according to the Centers for Disease Control and Prevention in Atlanta. If swine flu patients fill too many beds, hospitals may be forced to put off elective surgeries such as heart bypass or hernia operations, said James Bentley with the American Hospital Association.
“If you have 1.8 million hospital admissions across six months, that’s a whole lot different than if you have it across six weeks,” said Bentley, a senior vice-president of the Washington-based association, which represents 5,000 hospitals.
The scenario projections were “developed from models put together for planning purposes only,” said Tom Skinner, a spokesman for the CDC, at a briefing in Atlanta today. “At the end of the day, we simply don’t know what this upcoming flu season is going to look like. It could be severe, it could be mild, we just don’t know.”

Past Pandemics
The models were based on past pandemics, and the CDC is working on new projections based on the latest data gathered from swine flu patients, Skinner said. Those estimates should be available “soon,” he said, without further specifying.
President Barack Obama was urged by his scientific advisory council to speed vaccine production as the best way to ease the burden on the health care system. Initial doses should be accelerated to mid-September to provide shots for as many as 40 million people, the panel said in a report released yesterday. Members also recommended Obama name a senior member of the White House staff, preferably the homeland security adviser, to take responsibility for decision-making on the pandemic.
“This isn’t the flu that we’re used to,” said Kathleen Sebelius, U.S. health and human services secretary. “The 2009 H1N1 virus will cause a more serious threat this fall. We won’t know until we’re in the middle of the flu season how serious the threat is, but because it’s a new strain, it’s likely to infect more people than usual.”

Clinical Trials
Data from clinical trials to assess the safety and effectiveness of swine flu vaccines will start to become available in mid-September, health officials reported Aug. 21. Full results from the two-dose trials won’t be available until mid-October.
“We are making every preparation effort assuming a safe and effective vaccine will be available in mid-October,” Sebelius said today at the CDC’s Atlanta offices.

H1N1 has already reached more than 170 countries and territories in the four months since being identified, the Geneva-based World Health Organizationsaid. Swine flu causes similar symptoms as seasonal strains. It has so far resulted in worse than normal flu seasons, with increased hospitalizations and cases of severe illness, the WHO said in an Aug. 12 release.
New Zealand and Australia, in the midst of their normal flu seasons, have reported intensive care units taxed to capacity by swine flu patients. The experience provides clues to what the U.S., Europe and Japan may see when the H1N1 virus returns.

President’s Advisers
The president’s advisory council describes as a “plausible scenario,” that 30 percent to 50 percent of the U.S. population will be infected in the fall and winter. As many as 300,000 patients may be treated in hospital intensive care units, filling 50 percent to 100 percent of the available beds, and 30,000 to 90,000 people may die, the group’s report said.

“This is a planning scenario, not a prediction,” according to the report. “But the scenario illustrates that an H1N1 resurgence could cause serious disruption of social and medical capacities in our country in the coming months.”
Peter Gross, chief medical officer at Hackensack University Medical Center in New Jersey, said if the group’s scenario comes true, “I think every hospital in America is going to be in a crunch. We’ll be hard pressed to deal with those predictions,” he said.

‘Overblown’ Estimates
The estimates seem “overblown,” Gross said, given that swine-flu outbreaks in 1968 and 1957 failed to cause as many deaths, even with medical technology and disease surveillance less advanced than today.
“Influenza, you can make all the predictions you want, but it’s more difficult than predicting the weather,” Gross said yesterday in a telephone interview, after the advisory report was made public. “If influenza was a stock, I wouldn’t touch it.”
The 775-bed hospital is planning for an outbreak, upping its order of flu medications and discussing where to put patients if the worst occurs, Gross said.

The President’s Council of Advisers on Science and Technology is chaired byJohn Holdren, the director of the White House Office of Science and Technology, Eric Lander, the head of the Broad Institute of Massachusetts Institute of Technology and Harvard University in Cambridge, Massachusetts, and Harold Varmus, the chief executive officer of Memorial Sloan-Kettering Cancer Center in New York.
The 21-member group of scientists and engineers, created by Congress in 1976, advises the president on policy involving scientific matters.

New Estimates
Seasonal flu usually kills about 36,000 Americans, Skinner said. Swine flu causes more severe illness needing hospitalization among younger people than seasonal flu, while leaving people 65 and older relatively unscathed, saidMike Shaw of the CDC.
The median age of those with the pandemic virus has been 12 to 17 years, the WHO said on July 24, citing data from Canada, Chile, Japan, U.K. and the U.S.
“We don’t know whether the number of severe illnesses will be much greater, but we do know that it’s a new virus and therefore people are very vulnerable,” said Anne Schuchat, director of the CDC’s Center for Immunization and Respiratory Diseases, in an interview yesterday.

Disease Burden
About 100 million people in the U.S. get the annual flu shot, Schuchat said. Pregnant women, who have “a disturbingly high burden of disease” from swine flu, only get vaccinated for seasonal flu about 15 percent of the time. Pregnant women are a top priority for vaccinations, she said.
Seasonal flu usually kills about 36,000 Americans. Swine flu causes more severe illness needing hospitalization among younger people than seasonal flu, while leaving people 65 and older relatively unscathed, said Mike Shaw, associate director of laboratory science at the CDC’s flu division.
The median age of those with the pandemic virus has been 12 to 17 years, the WHO said on July 24, citing data from Canada, Chile, Japan, U.K. and the U.S.
“People who get infected with this strain happen to be the healthiest members of our society,” said Shaw in a presentation yesterday at the agency.
The H1N1 strain is genetically related to the 1918 Spanish Flu that killed an estimated 50 million people. Variations of the Spanish Flu circulated widely until about 1957, when they were pushed aside by other flu strains. People whose first exposure to a flu virus was one of those Spanish Flu relatives may have greater immunity to the current pandemic, Shaw said.

* Text by Tom Randall and Alex Nussbaum, August 25, 2009

 

Graphic Humor 149

 

The Many Hidden Costs of High-Deductible Health Insurance

IS your medical insurance bad for your health? If you have a high-deductible plan, the answer may be yes.

The investment firm Fidelity recently surveyed employees at various companies who had opted for a high-deductible health plan linked to a health savings account. About half of those workers said they or a family member had chosen not to seek medical care for minor ailments as many as four times in the last year to avoid paying the out-of-pocket expenses.

As any doctor will tell you, small health problems left untreated can become big problems, warns Kathleen Stoll, director of health policy at the health care advocacy group Families USA. “This is just one of the many high-deductible pitfalls consumers need to watch out for,” Ms. Stoll said.

High-deductible health plans are essentially insurance policies that charge lower monthly premiums than traditional plans because the consumer is responsible for paying the first $1,000 to $5,000 or more in medical bills before the insurance kicks in. The plans, sometimes called catastrophic insurance, are often used in conjunction with a health savings account.

With these accounts, earnings on savings are allowed to accumulate tax free and roll over year to year, as long as the money is ultimately used to pay for medical expenses. To qualify for one of these tax-sheltered savings accounts, an insurance plan must have a deductible of at least $2,300 for families and $1,150 for individuals.

A person can put up to $3,000 annually in these accounts, or $5,950 for a family.

People who can best take advantage of this tax break are those who can afford to contribute the maximum but do not spend it all on health care. The idea is that the money accumulates over the years, providing a cushion down the road when health problems or the need for long-term care arise.

To encourage employees to choose a high-deductible option, many employers put money into employees’ accounts or match part of the workers’ contributions. High deductibles, though, can pose problems for people who cannot afford the out-of-pocket costs associated with the plans. For a low-income family earning $25,000 a year, for example, the out-of-pocket costs of a high-deductible plan would eat up an estimated 15 percent of the annual household budget, according to a Kaiser Family Foundation report.

What’s more, low-income families don’t benefit from the tax breaks associated with health savings accounts the way middle- and high-income earners do.

Even if you can afford the costs, the loopholes that insurers often weave into these plans to reduce premiums can mean that even after your deductible is met, you may not have the coverage you need to handle a serious illness or accident.

“For most people, a high-deductible plan is basically a bet against yourself,” said Ms. Stoll. “You’re betting that you won’t get sick and you won’t have an accident. But isn’t that exactly what insurance is supposed to be? A bet that something might happen, and if it does you’ll be protected?”

Whether you are considering a high-deductible policy because you are healthy and don’t think you need much coverage or you want the tax-sheltered savings account or you simply cannot afford anything else, you need to carefully consider the following.

WHY IS THE PREMIUM SO LOW?

It is not always simply because the deductible is high. There may be other cost-reducing limitations on the plan as well. If the premium looks too good to be true, look for one of these lurking loopholes:

A cap on lifetime coverage. It is hard to even estimate what you will need over your lifetime in health care coverage. But when you are looking at this number, keep in mind that the average hospital charge for an appendectomy is $22,000, and the average charge for a hip replacement is $40,000. You do not want a lifetime coverage cap that is going to be exhausted quickly by one or two long hospital stays or by extended outpatient care for a chronic illness.

A cap on doctor visits. Some severely restrictive plans will cover only a handful of doctor visits a year after the deductible is met. Others charge a big co-payment for every doctor visit. Still others will not even start to cover doctors’ visits unless they occur after a hospitalization — which, as Gary Claxton, a vice president at the Kaiser Family Foundation, points out, is basically a hospital-only policy.

A cap on hospitalization costs. Again, consider those hospital costs. Is the policy you are considering going to get you through? Mr. Claxton has seen policies that so severely restrict hospitalization that they will not pay for the first day you are admitted. “That’s the day when you’re most likely to have the most costs,” he said. “Think of it: You’re admitted to the E.R., you have surgery and you spend the night in the I.C.U., and none of it is covered.”

Other high out-of-pocket costs. Just because you have met your deductible doesn’t mean you are done spending money. High co-payments of 20 percent or more on doctors’ visits, prescription drugs and hospitalizations can add up quickly. With some of these policies, Mr. Claxton says, you will pay an extraordinary amount in out-of-pocket costs, sometimes as much as $10,000.

LEARN MORE

Consumers need to read the policies carefully. “But it’s not easy to know what is adequate coverage and what isn’t,” Mr. Claxton said. “I’ve been in this business for years, and I still wouldn’t know what, say, a reasonable cap on physical therapy for a stroke victim would be, or what a cap on radiation services would mean for a cancer patient.”

If you use a Web site like ehealthinsurance.com, you can find out more about each price quoted by clicking on “plan details” and reading carefully, looking for the categories listed above. If you do not find the specifics you need, call the insurer’s customer service department and ask.

In addition to researching and comparing policies on the Internet and by phone, Ms. Stoll suggests enlisting the help of a well-recommended insurance broker or agent who specializes in high-deductible plans, to help you wade through the really fine print. If you are comparing plans offered by your employer, your benefits department will be able to answer questions and provide copies of the policies.

DON’T OVER-APPLY

Your goal is to apply only for the policy you think you are most likely to get. The drawbacks to being turned down are too great to submit applications to many insurers, hoping for the best deal.

The prices you see on the Internet or hear quoted by an agent are not necessarily the premium you will pay. To get that number, the insurance company needs to know your age, weight and other personal details and look at your medical history — a process known as underwriting.

If you are turned down for a policy for any reason, that information can be shared among insurers and be used to deny you future coverage. The more policies you apply for, the more likely you are to be turned down by at least one of them, and the more likely you are to have the damaging information in your files. Avoiding this trap is good advice, says Ms. Stoll, whether you are applying for high-deductible or traditional health insurance.

IS THERE A SAVINGS PLAN?

High-deductible plans that can be linked to a health savings account must adhere to federal regulations that include limits on out-of-pocket costs and the amount of the deductible. It is usually clear on most insurance Web sites whether a plan is eligible for linking to a savings account. If you have any doubts, call the insurance company’s customer service department and ask.

PREVENTIVE CARE

Because people with high deductible plans are less likely to seek routine preventive treatment — risking costly problems later on — some insurers have included basics like an annual physical and certain preventive prescription drugs.

These plans often come with slightly higher premiums, though. So you will need to calculate whether the extra coverage is cheaper than what you would pay out of pocket for preventive care.

* By WALECIA KONRAD; May 30, 2009

 

Murder in Kansas

The murder of Dr. George Tiller, who was shot to death as he stood in the foyer of his church in Wichita, Kan., on Sunday morning, was a reprehensible act of domestic terrorism directed toward the dwindling cadre of physicians who risk their safety to perform legal medical procedures.

Dr. Tiller’s death, the fourth killing of an American abortion provider since 1993, was the first since 1998 when a sniper gunned down Dr. Barnett Slepian in his home in the Buffalo area. For Dr. Tiller, and physicians like him, the threatening protests and incidents of violence and harassment never really stopped.
For his principled devotion to women’s health and constitutionally protected rights, Dr. Tiller was the target of protests at his clinic, his house and his church. In 1986, his clinic was bombed, and, in 1993, an abortion opponent shot him in both arms. He was forced to fend off trumped up legal challenges aimed at shutting down his operations. Last month, vandals attacked his clinic. Nevertheless, he somehow persevered in a state that is one of the battlegrounds in the fight to restrict abortion.
Responding to Dr. Tiller’s slaying, President Obama expressed shock and outrage and said that profound differences over issues like abortion “cannot be resolved by heinous acts of violence.” Mr. Obama recently called for Americans to find common ground on reducing the need for abortions. In that spirit, abortion opponents should refrain from the “baby killer” rhetoric that inflames an already heated debate.
Attorney General Eric Holder says the United States Marshal Service will begin protecting certain abortion clinics and doctors. Mr. Holder should consider taking the additional step of revitalizing the National Task Force on Violence against Health Care Providers that former Attorney General Janet Reno established during the Clinton years. There must be a sustained focus by federal and state officials to prevent further acts of violence and intimidation. If it turns out that additional laws are needed, Congress should take action.

Over time, the combination of anti-choice restrictions and ongoing harassment by protest groups even short of violence have served to make abortions harder and harder to obtain. That trend must be stopped.

* EDITORIAL New York Times (NYT), June 2, 2009