This is a republication of an essay submitted last summer after my personal loss. I am happy to offer it again since I think the SIN series is important. Religion and church attendance are useful to the religious for more than worship. The fellowship of congregations provides support during life passages, births, holidays, weddings and funerals. I found a great deal of support from my secular community.

“No one here gets out alive.” – Jim Morrison

Maybe a hundred years ago, maybe even in my own lifetime, it was more common for people to die at home, and for family members to see firsthand the process of dying. But since the mid 20th century, except for health professionals, military personnel and witnesses to violent crimes, I think few of us ever see anyone die, let alone see anyone die at home of natural causes.

By chance I happened to be listening a couple of weeks ago to This American Life podcast, an episode called Death and Taxes. It brought to mind an article I’d read in The New Yorker in 2010, “Letting Go” by Atul Gawande. Both the podcast and the article were about hospice care – end of life decisions that are not easy for anyone to contemplate for their own lives or for the lives of those we love. The podcast reminded me that maybe I ought to review my mother’s advance directive, and review the New Yorker article, because she was growing older and more fragile. When I phoned the gerontology clinic to have a little chat with the social worker there, she said she was glad I called if I had questions, that most people wait too long to ask about hospice.

Advancing Age

My mother was diagnosed with dementia associated with her age about five years ago. Her demeanor was about the same as always, but she’d begun making little mistakes. She’d always been a good driver, but one day, about 20 years ago, when I was a passenger in her car, she changed lanes without looking and cut off another driver. I didn’t think too much about it at the time, but as I look back on it, it was the first in a gradual spiral of changes in her that constituted her decline into what used to be called senility.

When I realized she didn’t know what financial records she was supposed to give the tax accountant, I offered to help with that annual chore, and gradually I took over as her “secretary.” She added me to her checking account, and I paid her bills, including insurance premiums. This is relevant. She’d had a persuasive insurance broker who sold her two Long Term Care insurance policies. That was long before she needed them, but they turned out to be wise investments.

We, her family, live in a cluster within a couple of miles of each other in a suburb of Los Angeles. We helped her move closer to us so it would be easier to visit her often. We took turns having dinner with her, celebrating holidays and birthdays at her house, and doing her shopping. It wasn’t always easy – negotiating with each other over what nights we needed for other activities, the strain of being away from our partners at dinner time at least twice a week, the double duty taking care of our own lives, and simultaneously taking care of her was hard, but we kept her in her own home, and she was mostly happy.

I was describing her problems with memory to a fellow skeptic, and he encouraged me to take her to a specialist, a gerontologist. I followed that advice, and the clinicians administered a battery of tests to get a baseline of her mental state, and the series of tasks was maddeningly revealing. One of them, the clock face, was startling. The doctor placed a sheet of paper in front of her that had a circle printed in the middle, and asked her to draw the numbers on a clock. In my mind, it was easy: 12 at the top, 3 on the right side, 6 on the bottom and 9 on the left; then fill in the other numbers. She couldn’t do it. She bunched all the numbers from one to twelve on the righthand side of the circle. It makes tears well up in me to this day. I wondered when this change had occurred, and what kind of brain damage causes one to lose that ability.

The diagnosis was mild dementia. In those days, the only way Alzheimers could be diagnosed was a postmortem examination of the brain. Dementia is a catchall phrase for several kinds of mental changes associated with advanced age.

The social worker had a talk with me and explained that it is a progressive disease. That means that the symptoms were going to get worse, and if I had questions, I could always call on her. Social workers know a lot of stuff – I did call on her, and was grateful every time.

Taking care of business

My mom had been living alone; I figured I’d better find out about the provisions of those long term care insurance policies. One of them would pay the same amount every day for the rest of her life and the caregivers were required to come from an agency. I don’t think they even sell those anymore. The other paid roughly the same amount per day, but only for two years, but didn’t have the requirement for an agency. It would pay anyone but a family member. I invoked the lifetime policy and found an agency that provided caregivers. I asked for someone to come four hours a day to get my mom used to having a caregiver in her house, and I wanted someone to stay with her for the rest of her life. I thought it would be better if the caregiver could always remember my mom when she could still talk, instead of seeing her for the first time, possibly unconscious. My mom didn’t want a caregiver, and getting someone to stay with her for the rest of her life was – problematic.

The social worker explained that because my mom couldn’t remember what she couldn’t remember, as far as she was concerned, there was nothing wrong. Dementia is a lot harder on the family and friends of the patient than it is on the patient. They don’t think anything’s wrong, and they think they can take care of themselves, all the way to the end when they can’t even take themselves to the bathroom.

We had a security system installed in my mom’s house that had cameras recording five rooms in the house that I could access with an app on my smart phone. I wanted to make sure nobody was hurting my mom when I wasn’t there. That turned out to be a non-issue – but I’d read horror stories of elder abuse, and the security system turned out to be useful in other ways.

When my mom fell in the night, we realized we couldn’t leave her alone at night anymore. My mom’s housekeeper was about 70 years old, and the income for staying overnight was definitely interesting to her. My best friend, Heather, was between jobs, and I asked if she’d take turns with the housekeeper, and it worked out well. My mom and Heather loved each other, and my mom was always happy to see her. I invoked the other insurance policy. We supplemented the security system with a motion detector that would wake the overnight caregivers if my mom tried to get up in the night. But one day she fell and broke her foot, and that was the beginning of a steeper downward spiral.

Adding injury to injury

A broken fifth metatarsal requires avoiding placing weight on the injured foot. For seniors, every day of inactivity, not getting up to walk from one room to another, is like three weeks for a healthier younger person. The muscle atrophy is much more severe and rapid. If the bone didn’t heal right, she would have required foot surgery, but not walking was also bad for her. There was no middle ground.

There is a high burnout rate among caregivers. The ones that are attractive and young and strong are also the demographic that has families of their own, children to care for and other responsibilities. We liked many of the caregivers, but finally, after over three years of mostly good experiences with caregivers for my mom, we had the perfect combination. One young woman from the agency for daytime Monday through Friday, another for daytime on the weekends, and the two friends of the family for overnights. These are the people who stayed by my family after my mom’s sudden and unexpected illness.

I guess I’d begun to think that besides my mom’s dementia, she was otherwise healthy. I could see that she was not as strong as she’d been before the broken foot, but one night she threw up. At the emergency room, the doctors said that it appeared there was a mass in her bile duct (translation: a blockage that was causing bilirubin to back up in her bloodstream, and causing jaundice). The recommendation was to do a “procedure” – without going into detail, it was supposed to be quick and easy, and in fact was an outpatient procedure in younger patients. It didn’t work. The recommendation was to try again, this time with a doctor who had more experience with this problem. He also failed; hospital personnel were assuring me that if they did not operate, my mom would die. That’s when I began to ask about hospice.

Hospice, not homicide

Hospice care is completely covered under the Medicare Act. The provisions are that the patient is suffering from a terminal illness, is seeking comfort and not a cure. There are  agencies that provide personnel who have experience in providing equipment and medicines to assure a minimum of pain, and assistance for the family of the dying patient. I learned a lot.

I was startled when the hospice liaison said there would be no IV fluids – only food and drinks that my mom could take by mouth. She could have a catheter, and disposable underwear, and pain killers that are considered controlled substances, but no life prolonging medicines. All she had was sublingual drops of morphine, Ativan and atropine. The morphine controlled pain – I know it works because I had a dose of it when I had a broken leg once. The Ativan was to control agitation – it helped her sleep. The atropine is normally used to help clear up eye infections, but sublingually, it helps clear the lungs; it stops the “death rattle,” a symptom of lung congestion after the patient can’t swallow anymore.

The hospice liaison was trying to talk with my mom in the hospital – she was yelling, as a matter of fact. I said she didn’t have to yell, that there was nothing wrong with my mom’s hearing – but that I doubted she could hear anything anyway. The liaison started talking about my mom’s spiritual journey – and my daughter was standing behind me motioning to the woman to stop talking about those things (making a horizontal motion with her finger under her throat), but I could barely wait to put a status update on Facebook asking if any of my friends knew whether patients near death can still hear what’s being said around them.

The last thing my mom said to me that I could understand was that she wanted to go home. I told her we were taking her home in the afternoon. My sister waited to receive the hospital bed and other equipment – my mom rode in an ambulance and was carried on a gurney in the elevator to her apartment. Our daytime nurse offered to stay with us for the rest of my mom’s life, and Heather offered to stay every night because the other overnight caregiver doubted her ability to handle this crisis, although she came every day to sit by my mom, crying frequently.

The Vigil

Heather and my daughter and I camped in my mom’s room every night. We had to get tough with the hospice service on only two occasions: they for some reason had a contract with a pharmacy that was not open weekends, and we were afraid of running out of the drugs; and we didn’t like one of the hospice nurses. We discovered the family is in charge, and they accommodated us, apologizing repeatedly.

In the movies, people die fast. Not so much in real life. In the movies, people die quietly. Not so much in real life (or death, in this case). At first we could give my mom little sips of water by creating a little vacuum in a straw, but we couldn’t even do that after she couldn’t swallow anymore. The last solid food she had was ice cream my sister fed her with a spoon – I’m glad she enjoyed that. Her breathing was noisy and irregular, sometimes with long pauses between breaths. I would hold my breath to see if this was her last one – and then sigh with relief as she inhaled again. She slept with her mouth open, convenient when the drops of medicine had to be put under her tongue, but it looked uncomfortable. We found a list of the symptoms of death online – some of it was useful, some of it was bordering on woo, but it was a useful resource because I could tick off the symptoms my mom seemed to show.

Not knowing how long it was going to take, we cleared our calendars, and stayed in her room, except for zooming home to shower and get clean clothes. We just needed to be there. Finally, one morning I was asleep when my daughter and Heather got up to give my mom her two hour dose of medicines, when she seemed to stop breathing for real. My daughter woke me up – Heather suggested getting a stethoscope. I ran to get a knife to hold under my mom’s nose – there was no fog on the knife. My daughter was about to go get the stethoscope out of her car, but I suggested the blood pressure monitor – it has a little gauge to read the pulse. She wrapped the cuff around my mom’s arm, and at first there was a beating heart on the readout, indicating a pulse. She pumped up the cuff again, and the monitor gave an error reading. She let it deflate, then pumped it up again, and there was no reading at all.

We cried, we called the hospice to send a nurse to pronounce her, and Katie and Heather picked up bagels and coffee. Hospice was not what I expected, but I am proud that we brought my mom home instead of subjecting her to surgery. She would not have understood post surgical pain – she would not have benefitted by having her life prolonged at the expense of the quality of that life. All I was doing was following the precise conditions set forth by my mom in her advance directive. I am eternally grateful that she left that trail of crumbs for me to follow. I had checked with her about two years ago – she did not believe in life after death. I think we took good care of the one we knew about.

The post SIN Series – Death: The Vigil appeared first on Healthy Skepticism.

If you have children, there’s a good chance you’ve had experience with head lice. Head lice affects as many as 12 million people in the US each year, mostly children. Compared to other health conditions, it is a trivial problem; but it is common and annoying. It can cause itching, notes sent home from school, and often a strong “yuck” reaction. Fortunately, several effective treatments are available, including enough “natural” options to please any critic of Big Pharma.

Pediculosis humanus var capitis is a bloodsucking parasitic insect specific to humans. It is 2.5-3 mm long and flattish. It can’t jump or fly or even walk efficiently, but is easily transferred, usually by head-to-head contact with an infected person or less often with an infected person’s headgear, comb, towel, or other object. Infestation is not a sign of poor hygiene. Lice bite and suck blood 4-5 times daily, injecting an anti-coagulant in their saliva. Mommy lice live for up to 3 months and lay up to 300 eggs at a rate of 3-4 a day. They glue the eggs individually to a hair shaft, usually close to the scalp but in warm climates as far as 6 inches from the scalp. They hatch in 6-10 days, after which the empty egg cases move further and further from the scalp as the hair grows out. The diagnosis can be made by seeing live, moving lice and finding nits (the egg or young lice) on the hair. The best place to look for them is behind the ear and at the nape of the neck. Nits can be confused with dandruff and debris, but these can usually be brushed away while nits remain firmly stuck to the hair shaft. Nits alone are not enough to make the diagnosis of active infestation. They may be either alive or dead: empty or nonviable egg cases may still be present long after the infestation has resolved.

Non-drug treatments

Combing . Removal by wet combing with a fine-toothed lice comb every 3 days for at least 2 weeks produces reported cure rates of 47-75%. Downside: time-consuming, especially if hair is long and thick. Upside: no risks, quality time with kids, satisfies primate grooming urges (chimps pick lice for social bonding and they eat what they find). Shaving the head also reliably removes lice, but it is a rather drastic solution that few people would choose.

Desiccation. Hot air kills both lice and eggs. A study of hot air devices found that the LouseBuster was the most effective: a single 30 minute session was well-tolerated and essentially 100% effective. Only one treatment is needed, and the lice aren’t likely to develop resistance. The device is expensive and requires special training; using a regular blow dryer is not recommended because it can propel live lice airborne to infest other people.

Suffocation. If you can block its air intake, the critter dies. Nuvo lotion was 95% effective in a study that was questioned because it was non-randomized, uncontrolled, unblinded, and had other design flaws. It turns out the doctor who headed the research was re-packaging Cetaphil Skin Cleanser and selling a $10 product under a new name (Nuvo) for $285. That means he’s sneaky, but it doesn’t mean it doesn’t work. More studies are needed.

Home remedy suffocants have included Vaseline, mayonnaise, olive oil, and almond oil. Vaseline and mayonnaise are no longer recommended because they are messy and hard to wash out. Essential oils have also been used, including tea tree oil, lavender oil, neem oil, clove oil, eucalyptus oil, aniseed oil, cinnamon leaf oil, red thyme oil, peppermint oils, and nutmeg oil. There have been a few promising pilot studies of some of these treatments, but the studies have not been replicated; the research is far from conclusive and success rates have been as low as 3.3%.

Drug treatments

Most effective drugs are neurotoxic, designed to paralyze and kill the lice. They do not reliably destroy the eggs, so repeat treatment is typically needed after 7-10 days. Available neurotoxic options include ivermectin, lindane, malathion, permethrin, and pyrethrins. Since 2006 a prescription suffocant, 5% benzyl alcohol lotion, has also been available. The drug of choice today is permethrin; lindane is discouraged because of neurotoxicity concerns but is a good second-line choice in areas where lice have become resistant to permethrin and pyrethrins.

Permethrin (Nix). Generally recommended as a first-line treatment, permethrin is a synthetic version of a natural insecticide that is more effective and less allergenic than natural pyrethrins. Advantages: the most studied pediculicide and the least toxic, reported side effects are mild (itching, redness, and swelling), low cost: $8-9. Disadvantage: resistance is increasing and treatment failures are becoming more common. For treatment failures with 1% permethrin, using a 5% solution and leaving it on the hair overnight under a shower cap may be effective.

Pyrethrins with piperonyl butoxide shampoo (Rid). A natural extract from chrysanthemum flowers, pyrethrins are less effective and more allergenic than permethrin. Advantages: sold over-the-counter, no prescription required, low cost ($5-6). Disadvantage: treatment failures are common.

Benzoyl alcohol 5% lotion (Ulesfia). This is a suffocant that is applied to dry hair, left on for 10 minutes, then rinsed; the treatment must be repeated after a week. Advantages: approved for children 6 months and older, OK for pregnant or lactating women, two double-blind studies showed it to be 75% effective, resistance is unlikely to develop. Disadvantages: not as effective as some other treatments, and higher cost than permethrin ($60).

Malathion (Ovide). An irreversible cholinesterase inhibitor, malathion is the fastest-killing, most effective head lice treatment ever marketed. Advantages: safe and effective, kills eggs, resistance has been reported in other countries but not yet in the US. Disadvantages: not recommended for children under 6 or for women who are pregnant or nursing, long application time (8-12 hours), objectionable odor, flammability, high cost ($150). An earlier version was removed from the US market by the manufacturer but a new formulation was reintroduced and approved by the FDA in 1999.

Lindane (Kwell). An organochlorine insecticide similar to DDT, lindane is stored in fat and nerve tissue. There are concerns about contamination of drinking water, rivers, and lakes, with hazards to fish and wildlife. The FDA issued a public health advisory about the risk of neurotoxicity and seizures, and lindane is banned in California. It is a shampoo applied to dry hair for 4 minutes as a single application; it costs $136. The Medical Letter cautions against its use because there are safer alternatives. It is usually safe when used as directed, but seizures and deaths have occurred with overuse, misuse, or accidental ingestion, and in rare cases death has reportedly followed a single application according to directions. It should be used with caution by those who might be more susceptible to side effects, including infants, children, women who are pregnant or breast-feeding, people who weigh less than 110 pounds, HIV-positive patients, the elderly, and patients with skin conditions like atopic dermatitis or psoriasis. It is contraindicated in premature infants and patients with seizure disorders.

Ivermectin lotion. Two double-blind studies showed this was 76% and 71% effective. It is not recommended for children under 33 lbs. or for women who are pregnant or nursing. Side effects include dizziness and itching. It costs $260.

Ivermectin pills. The pill form of ivermectin is not FDA approved for head lice, although it has been reported to be 95% effective and has been used successfully when all other therapies have failed. The tablets are taken as a single dose repeated after a week. The cost is around $10.

Spinosad (Natroba). A new neurotoxic drug approved by FDA in 2011, spinosad provokes hyperexcitation and eventually paralyzes the lice and kills them. Two comparative trials showed it was twice as effective as permethrin, and it is safe. Side effects are mild and infrequent: irritation at the application site, eye redness, dry skin, etc. It is approved for age 4 and up. It is expensive ($240) but it usually requires only one application and does not require nit combing.

Comparing effectiveness

It’s hard to draw any firm conclusions about the relative effectiveness of different treatments. Comparing results from different studies is problematic. Different endpoints are used. The incidence of treatment-resistant lice varies with geographic location. Home treatments may not be administered uniformly. Did they follow instructions precisely? Did they leave the product on for the recommended time? Did they comb out all the nits? Did the study measure clinical cure or death of lice?

Back to school

Some schools have had no-nit policies where a child couldn’t return to school until all nits were removed. International guidelines say these policies are unjust and should be discontinued because they are based on misinformation rather than on objective science. Dead nits remain after effective treatment, so finding nits in the hair doesn’t mean the child can infect others.

Conclusion

Head lice are more of an annoyance than a health problem. There is a wide choice of treatments to fit every budget, philosophy, and personal preference. Permethrin is a safe, effective first choice; other remedies can be used if treatment with permethrin fails. Even the most potentially toxic product is seldom hazardous when used as directed. The hot air treatment is a new but very promising non-drug option; I’m staying tuned.

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It’s February and my New Year’s Resolutions are already in the toilet.

The first resolution was to be slightly less Fergalicious in 2015, but there are some things you just can’t help.  I fail at this every year.

ONE DOWN.

My big skeptical resolution was to not assume, despite overwhelming, undeniable evidence, that all Americans are Taylor Swift fans. I mean she’s sold about as many songs as there are Americans buying records, so there’s pretty much irrefutable proof, but still I know there are a few outliers (but not after you watch this). I’ve already failed on this one. I know… haters gonna hate hate hate hate hate…

TWO DOWN.

At some point I’ll do an entire blog on Taylor Swift Denial, but that’s not for today.

My third and final resolution was to blog here bi-weekly, but a new job and lots of travel has cratered this one as well.

THREE STRIKES. I’ve failed, and not in the good way.

Poor excuses, I know, but it highlights the very poor record of people making clear New Year’s Resolutions. Some will tell you that those who make New Year’s Resolutions are 10 times more likely to meet them – and that’s true. It’s also true that those who predict the future by rolling chicken bones are 26 times more likely to accurately predict the future than those who don’t. (See Footnote 1)

A common resolution is to get fit… so I thought I’d address that one. It’s so easy to get busy and push off your fitness goals… and resolutions are fragile. Motivation is key, and so I present my top 5 motivating exercises. Several of these are my own term, generated to motivate me… and you should create your own terms to that end.

Each of these was completely, unimaginably unobtainable when I started. I seriously didn’t think I’d ever get to the level I’m at today and it happened over months and months with an intense goal to conquer them. Don’t rush these.

I routinely have people ask me about or watch me do these exercises, primarily due to the risk factors (see “freak-out factor” and “reason it’s cool” below).

Skull Crushers

• Common Name: Skull Crushers / Tricep Isolation
• Muscle Group: Arms / Triceps
• Freak-out Factor: 6/10
• Reason it’s cool: Risk of slamming a big heavy weight on your face.
• Comments: I just love the name and telling people that I do “skull crushers”. I do it with a dumbbell (which adds to the perception of skull crushing) on a declined bench, but there are lots of variations.
• Getting there: Start with low weight and work your way up.

Suicide Vest

• Common Name: Weighted pull-ups
• Muscle Group:  Upper body (esp. back, arms)- will give you “wings”.
• Freak-out Factor: 7/10
• Reason it’s cool: A lot of people aspire to do pull-ups well, and those who struggle will really appreciate good form with weight.
• Comments:  It doesn’t take much weight to really feel the burn – 20 lbs. will crush you. If you have good form and can complete 3 sets of 10 pull-ups (or more), this is my favorite step-up exercise. Rather than buying a vest or belt, you can bring an empty backpack to the gym, put in a plate of your choosing, and do your pull-ups (cheap & adjustable).
• Getting there: Many gyms have pull-up “assists” machines if you can’t complete a full pull-up (they effectively reduce the full weight of your body). Build this until you can do a full set of normal pull-ups, then consider adding weight. You could also put a plate/dumbbell between your legs, but then you don’t get the cool exercise name.

 Back Extension

• Common Name: Back Extension
• Muscle Group: Lower Back (you’ll walk with perfect posture for a few days if done right) & core
• Freak-out Factor: 8/10
• Reason it’s cool: Looks preposterous with big weight
• Comments: Start with no weight and work your way up.
• Getting there: Start with no weight on the back extension machine (available in most gyms) and work your way up. When you get to 90 lbs. (2 big plates), you need to switch to deadlifts to continue improvements… which are awesome but have a lower freak-out factor and require perfect form to avoid injury. Back extensions are a little more forgiving due to the isolation of the back extension machine.

Captain Kirk Chairs

• Common Name: Captain’s Chair / High leg lift
• Muscle Group: Abdominals/core
• Freak-out Factor: 9/10
• Reason it’s cool: Anyone who’s tried the Captain’s Chair knows that it’s tough… really tough. But doing high leg lifts takes it to a whole new level that dramatically raises the freak-out factor. Will illicit double-takes.
• Comments: If you master these, you can step it up even more to hanging leg lifts. A key is not to sway… to be in total control on every rep.
• Getting there: Start by raising your knees-only to get in a tuck-position (this is already a GREAT ab exercise and exhausting if you’ve never done it). Once that’s mastered go for straight-leg lifts to a horizontal position. Next is raising your legs over your head. Note – this could take MONTHS to achieve.

Mission Impossibles

• Common Name: Double TRX Chest Fly’s
• Muscle Group: Chest / Core
• Freak-out Factor: 10/10
• Reason it’s cool: Very high chance of face plant
• Comments:  Without question, the most comments I get at the gym around my Mission Impossibles, and I routinely get people interrupting me to ask about these. If you’ve seen the original Mission Impossible movie, you know the scene. I like to do a press (suspended push-up) followed by a fly (spread-eagle). Three sets of 8 and you’re jello…
• Getting there: Start with single TRX pushups – near-vertical if necessary. These aren’t easy, since they require lots of stabilization muscles  not required by standard push-ups. Slowly lower yourself until horizontal. When you can do 3 sets of 10, start doing flys. Finally, jump to the double TRX (leg suspension). This requires still-more stabilization, but if you can do the presses and flys, it’s not a huge jump to the double TRX.

Do you have great motivational exercises with high freak-out factors?

Footnote 1) Source: Statistic completely made-up, but it doesn’t matter since people that make claims are much more likely to have their claims be both accurate and inaccurate. Which is like saying that people who make claims are more likely to make claims. It’s completely meaningless.

____________________________________________________________________________________________

Jay Diamond writes the VitaminJ blog on evidence-based fitness & bodybuilding. Jay is the founder of Reason4Reason – a skeptical activist group based in the San Francisco bay area. He holds dual masters degrees in engineering and business and has managed both startup companies and hundred-million-dollar programs for Fortune 50 companies. Growing up in Canada, he performed magic, studied science, and became aware of the skeptical movement. Jay has lectured around the world on science & technology, business, and skepticism. 

The post New Year’s Resolutions Gone Bad: Motivation appeared first on Healthy Skepticism.

People tend to limit their reading to sources that agree with their beliefs. We find ourselves mostly preaching to the choir; our message usually doesn’t reach those who most need to hear it. I recently received an inquiry from a science-based medical doctor asking how to approach others in building a bridge to clarify so much misinformation.

My first thought was that you can build a bridge but the real challenge is persuading people to cross that bridge. Like leading a horse to water…

How to approach others? That’s a tough question. The best approach varies with the individual and with where he is in his journey. Confrontation seldom works: it just makes people angry. It is counterproductive: it only serves to make them invent more rationalizations to defend their beliefs. Although sometimes anger can be a good thing. I got an e-mail from an acupuncturist who was incensed by an article I wrote saying that acupuncture was not based on good evidence. He set out to prove me wrong by looking up the evidence behind what he had been taught by his teachers about acupuncture’s efficacy for specific conditions, and when he couldn’t find any, he realized that his teachers and his textbooks had misled him with lies. He gave up acupuncture and went back to school to learn a science-based health profession.

If someone has never had his belief challenged and thinks it a universally accepted truth, it might do some good to show him otherwise. When I was in the dentist’s office earlier this week he asked me what I thought about detoxification. I told him I thought it was a pseudoscientific concept with no scientific validity, that proponents couldn’t even tell you what those “toxins” were, much less measure how much had been removed, and that there was no evidence that detox objectively benefitted patients. He had me repeat this to his assistant who was currently doing a detox. She looked at me very strangely and I may have created an enemy for life. But just possibly I may have started a small crack in her certainty that might someday widen to let accurate information seep in.

Some people respond to accurate information. I belong to the Healthfraud discussion list on Quackwatch and we have had several people thank us for providing accurate information, debunking false information, showing the fallacies in arguments for claims, and helping them learn about the scientific process. They tell us they have discarded their previous false beliefs because of what they read there.

When I spoke at a local college I mentioned that diet supplements are not regulated like FDA approved drugs and have been found contaminated with everything from insect parts to prescription drugs, and that dosages sometimes vary wildly from what the label says. One older student got very upset and said she was going right home to clean out her cabinet and throw all those products away.

I have gotten e-mails from people who decided not to waste their money at the Amen Clinics or on treatments with the DRX-9000 spinal decompression machine after reading my articles.

Unfortunately, many people do not respond to accurate information. Some people choose to form strong beliefs on hearsay or personal perceptions or ideological grounds without any input from science. Scientific information is irrelevant to them so they are not likely to change their minds no matter how much evidence from scientific studies you throw at them. It is useful to ask people what evidence it would take to change their minds. True believers frequently say nothing would change their minds: they know they are right and they are sure that testing would only serve to demonstrate the truth of their beliefs. It’s a waste of time to talk to these people.

I met a believer in dowsing and I gave him a book explaining the ideomotor effect, showing that dowsers had never been able to pass controlled tests, and debunking dowsing in detail. We held a public debate afterwards, and what he said was as if he had never read the book. He managed to just ignore everything in it: his “pro” side of the argument boiled down to two points: he’d personally seen it work and lots of people believed in it. That was enough for him.

Then there are people who are capable of responding to new information but don’t want to hear it. Don’t confuse me with the facts; my mind’s made up. It’s more comforting to have a belief and stick to it than to deal with uncertainty.

Something I haven’t tried yet but want to: ask them if they know of something that doesn’t work but that some other people believe in. Once you find something they reject, you might be able to argue that logical consistency requires that their pet remedy be rejected on the same grounds. For instance, if they reject bloodletting to balance the humors but accept reflexology, you might point out that during the many centuries bloodletting was used, there were far more testimonials from patients and doctors than there are for reflexology today. So if they accept reflexology on the basis of testimonials, they should logically accept bloodletting on the same basis. If they reject bloodletting because science showed it didn’t work, they should look more closely at what science says about reflexology.

Humor can be effective in making a point, like the comedian who said “Of course science doesn’t know everything; it KNOWS it doesn’t know everything, otherwise it would stop.” And like Mark Crislip’s “Alternative Flight.”

The best strategy would be to guide people to discover the truth for themselves and claim it as their own, but I’m afraid I don’t have the patience or the psychological acumen to carry that out. It’s too bad Socrates isn’t around to help.

I am not foolish enough to think I could ever influence true believers; but even for them, it might be possible to plant a tiny seed of doubt that might be reinforced by future experiences and might eventually grow into a plant. Dripping water can wear away the hardest stone over time. But realistically, I can only hope to reach the fence-sitters: those who have not yet irrevocably made up their mind.

I hope readers will share their own success stories and bridge-building ideas in the comments section.

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Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about medicine, so-called complementary and alternative medicine, science, pseudoscience, questionable medical practices and critical thinking. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel. She is an editor and one of the five MD founders of the Science-Based Medicine blog. Dr. Hall writes the SkepDoc column in Skeptic magazine, and is a contributing editor to Skeptic and Skeptical Inquirer, as well as a medical advisor and author of articles on the Quackwatch website. She recently published Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the recently released textbook “Consumer Health: A Guide to Intelligent Decisions,” and was appointed to the Executive Council of the Committee for Skeptical Inquiry.

Healthy Skepticism is republishing selections from Dr. Hall’s blog with permission. Please visit Science Based Medicine.

The post How to Build a Bridge appeared first on Healthy Skepticism.

Originally published  Sunday, Sept. 15, 2013

The post Drowning in a sea of misinformation. Part 6: The World Health Organisation, WHO appeared first on Healthy Skepticism.

This post is a correction and apology
We recently published a post in this space critical of the evidence supporting Back to Sleep from a new contributor. As skeptics, we here at Healthy Skepticism promote the thoughtful questioning of prevailing ideas, including those that might be accepted by official authorities. However, following criticism from great skeptic friends of ours, we scrutinized that post more carefully and determined that it failed to meet an adequate standard of rigor and accuracy. We conclude that it was in some aspects misleading and mischaracterized the medical consensus. I apologize for this lapse in quality, and sincerely thank the community members for their alert criticism. That post was quickly removed and this one is meant to set the record straight. Below I will review the broad medical consensus on this issue and some of the supporting evidence.
As always, Healthy Skepticism does not issue medical advice and nothing posted in this space should be regarded as such. Finally, the medical evidence will be recounted here, but the reader is always encouraged to maintain a skeptical stance insofar as one may, without being an expert.

Correlative evidence of risk of SIDS due to sleeping position
As previously noted, there are definitely several risks factors that contribute to the likelihood of a child falling victim to SIDS. This is uncontroversial, and attested-to in virtually every medical paper on the subject including a 2014 review by pathologist Henry Kous (2, 6). However, there is substantial evidence that sleeping position is a large risk factor, which is why back-sleeping for infants is officially recommended  by the  Centers for Disease Control, National Institutes of Health, US Department of Health and Human Services, the UK Department of Health, the American Academy of Pediatrics, among other groups.

• A systematic review of all available data from 1940-2002 found a strong elevated risk factor for prone sleeping and SIDS (1-7).
• Deaths from SIDS were halved following the BTS/STS campaign in the United States.
• Data from pre-campaign nations such as Hong Kong, where prone sleep was always rare showed much lower rates of SIDS
• The beneficial effects are observed in many countries including the US, Canada, the UK, Sweden, The Netherlands, New Zealand, Hong Kong, and Tasmania (4,5).
• Apparent beneficial effects observable when education and outreach efforts applied to low SES and minority groups. Such a program dropped SIDS deaths in Mississippi by more than half between 2006 and 2012 (7). This can’t be attributed to broader trends or cause-of-death classification changes made around 1999.
• There is mounting physical evidence that the prone sleep position is associated with reduced cerebral tissue oxygenation which may be one mechanism involved in SIDS deaths (8).

SIDS – Known Risk Factors
According to the National Institute of Child health and Human Development-lead Safe to Sleep campaign,

Babies are at higher risk for SIDS if they:

• Sleep on their stomachs
• Sleep on soft surfaces, such as an adult mattress, couch, or chair or under soft coverings
• Sleep on or under soft or loose bedding
• Get too hot during sleep
• Are exposed to cigarette smoke in the womb or in their environment, such as at home, in the car, in the bedroom, or other areas
• Sleep in an adult bed with parents, other children, or pets; this situation is especially dangerous if:
  • The adult smokes, has recently had alcohol, or is tired.
  • The baby is covered by a blanket or quilt.
  • The baby sleeps with more than one bed-sharer.
  • The baby is younger than 11 to 14 weeks of age.

Further reading

Safe to Sleep Public Education Campaign
Centers for Disease Control
Mayo Clinic

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Citations

1. Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position Task Force on Infant Sleep Position and Sudden Infant Death Syndrome Pediatrics 2000; 105:3 650-656

2. Risk Factor Changes for Sudden Infant Death Syndrome After Initiation of Back-to-Sleep Campaign Felicia L. Trachtenberg, Elisabeth A. Haas, Hannah C. Kinney, Christina Stanley, and Henry F. Krous Pediatrics 2012; 129:4 630-638; published ahead of print March 26, 2012, doi:10.1542/peds.2011-1419

3. Infant sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002. Ruth Gilbert, Georgia Salanti, Melissa Harden, and Sarah See. Int. J. Epidemiol. (August 2005) 34 (4): 874-887.

4. Wigfield RE, Fleming PJ, Berry PJ, Rudd PT, Golding J. Can the fall in Avon’s sudden infant death rate be explained by changes in sleeping position? BMJ. 1992;304:282-283.

5. Dwyer T, Ponsonby A-L, Blizzard L, Newman NM, Cochrane JA. The contribution of changes in the prevalence of prone sleeping position to the decline in sudden infant death syndrome in Tasmania. JAMA. 1995;273:783-789.

6. Krous, Henry. “Sudden Infant Death Syndrome (SIDS), Sudden Unexpected Death in Infancy (SUDI), and Sudden Unexplained Death in Childhood (SUDC).” Forensic Pathology of Infancy and Childhood (2014): 193-206.

7. Scott, Stacy. “Transferring partnership-building strategies from Mississippi to Arkansas to reduce sleep infant deaths.” 142nd APHA Annual Meeting and Exposition (November 15-November 19, 2014). APHA, 2014.

8. Gazit, Avihu Z., and James S. Kemp. “Cerebral Tissue Oxygenation Index and SIDS.” Pediatrics 134.3 (2014): 598-599.

The post Back to Sleep/Safe to sleep saves children’s lives appeared first on Healthy Skepticism.

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Exorcisms versus Psychotherapy by Sarah Stice

The belief in exorcisms and demonic possessions has been an integral part of our society and the world for centuries. Today, it is evident that our world’s fascination with these subjects has not lost steam. Many of the horror movies that have been released for the last decade have centered on demonic possession. Just think about it! We have had The Rite, The Exorcism of Emily Rose, The Devil Inside, The Unborn, The Omen, The Possession, Paranormal Activity, and the list just goes on. Seriously, enough with the demons, and let’s get back to good old-fashioned hack and slash (props to Freddy and Jason).Anyways, with this increase in horror films centered on demons, there are questions that plague skeptics and psychologists. Why is the public drawn to this kind of subject matter? Why do some people believe that demonic possessions are real? Better yet, why do some people seek out individuals that specialize in exorcising said demons?

First off, it may be good to examine the exorcism practitioners’ training. Catholic exorcists typically are not specially trained while they attend seminary school. They are usually educated about the devil, manifestations of evil, and evil’s consequences, but most of their exorcism training comes from their experience as priests. They can also learn the prayers and steps of exorcisms from the Roman Catholic Rite of Exorcism document. There are also exorcism organizations (e.g., International Association of Exorcists) that print newsletters where exorcists can communicate and pass along their “tricks of the trade.” Otherwise, this is as much educational training as appointed exorcists get, and it is severely lacking compared to the amount of training psychiatrists, clinical psychologists, physicians, and counseling psychologists receive.

Now, it is time to move onto what exactly is involved in an exorcism (personally, I would be terrified if I were you). An exorcism usually involves a priest dressed in a surplice and a purple stole (the usual white gown and purple shawl). The priest recites prayers during the ritual, which can be broken down into formulas. The first formula is termed the “imploring formula,” which involves the priest asking God to free the person from suffering, or in this case demon(s). The second formula is termed the “imperative formula,” which is when the priest orders the demon(s) to leave the person’s body, and return from where it came from. See, I told you exorcisms were terrifying… terrifyingly simple! Moving on, the person who has received the exorcism usually reports feeling better, although most do not have any significant psychological improvement. This typical response should sound familiar because it is none other than the placebo effect, and it is no wonder why scientists have had difficulty tracking the effectiveness of exorcisms.

Exorcisms, or the belief in their efficacy, are not well acknowledged or supported in the realm of psychotherapy. The general consensus among the psychology community is that exorcisms are filled with autosuggestion, misdiagnosis, and manipulation (Wilkinson, 2007). Essentially, people who suffer from mental illness may be more easy to manipulate and more sensitive to the power of suggestion than other groups. Other factors supported by psychologists and physicians include hysteria and unconscious role-playing (Wilkinson, 2007). Also, people with schizophrenia and anxiety disorders are more susceptible to seeking out priests for “treatment,” rather than seeing a medical doctor or psychiatrist (Pfeifer, 1994). An even bigger component to this is the possessed person’s belief in exorcism effectiveness. The stronger the belief in exorcism effectiveness, the more likely the person will report it worked (Pfeifer, 1994).There is the placebo effect again! No wonder so many people who strongly subscribe to these beliefs request exorcisms instead of psychotherapy.

Sadly, there have not been many, if any, studies done concerning the effectiveness of exorcisms versus psychotherapy. One sociologist, Michael Cuneo, observed over 50 exorcisms, and stated that he saw no demon(s) that could be visibly identified via exorcism. Cuneo (2001) also concluded that most of the people who reported that the exorcism worked for them had symptoms that could be easily explained in psychological, medical, cultural, and social terms. Incredibly, or not incredibly, most of the evidence that has shown support for exorcisms has come from anecdotes from people who supposedly witnessed an exorcism, or had the ritual performed on him or herself.

Amazingly, despite all the scientific evidence to the contrary, 42 percent of people in the United States that believe in demonic possession. They truly believe that the only way they can be “saved” from their so-called demon(s) is by having an exorcism performed. However, some of these believers display symptoms, or they have been diagnosed with schizophrenia (various types), bipolar I disorder, depression, possibly dissociative identity disorder, epilepsy, Tourette’s syndrome, alcoholism, and drug abuse – many of which are helped by evidence-based therapies and medications.

It is even more upsetting that the symptoms displayed by these individuals match the criteria for the Roman Catholic Church’s criteria for demonic possession. Case in point, some of the Church’s criteria include supernatural physical strength, speaking in tongues unfamiliar to the possessed person, evident negative responses to prayer, holy water, and priests. It is clear that it may be difficult for individuals that subscribe to these beliefs to understand the real cause of their suffering, and they may resort to possibly dangerous treatments to have their “demon(s)” removed. This is where things get a bit more dicey.

Thankfully, the Roman Catholic Church has become more vigilant, and has passed numerous new guidelines about performing exorcisms, but these measures cannot erase the harm exorcisms have done. For instance, a 23-year-old woman, Anneliese Michel, died after receiving 67 exorcisms in a year. Her death was unfortunate because she suffered from psychiatric illnesses (e.g., depression, epileptic seizures, hallucinations) for seven years prior to receiving her first exorcism, and all of these events stemmed from her parents’s belief that she was possessed (on a side note, Michel’s story was the inspiration for the film The Exorcism of Emily Rose). There have been numerous other instances of exorcisms gone wrong including an incident in 1995 where Pentecostal ministers beat a woman to death, a woman was strangled to death by a church minister in New Zealand, and a case where two children were stabbed to death during an exorcism. Exorcisms do not seem so harmless now, do they? Unfortunately, there is not much that can be done to stop these incidents from happening (even with the strict guidelines and education), and it is even more difficult since 70 percent of people in the United States believe in the devil. The only advice that this article can hopefully provide is to be careful about who you talk to concerning mental distress, and be vigilant about the placebo effect.

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I have bad news. You’ll probably never be a professional contortionist.

I laugh when I see good skeptics selectively choose to pick apart sci-fi or fantasy movies while giving a “pass” to other works in the genre for which they have fondness. The issues cited are normally silly, fallible humans doing silly, fallible things or simply bad science, but the beloved films are similarly flawed (Harry Potter, Star Wars, and Star Trek come to mind). In the right context, suspension of disbelief is healthy and fun.

Unfortunately silly, fallible humans also love to suspend disbelief outside of the movies – in real life, without realizing that they are doing it. Wouldn’t it be great if you were actually gaining benefit from the things you thought were giving you benefit? What a concept…

In my youth, I ran track & field (I was terrible) and was a diver (less terrible, but still bad), learning all kinds of great warm-ups, which I practiced well into my adult life. The warm-up is a source of great confusion, a lot of ritual, and even more superstition and pseudoscience.

I was the poster-boy for warm-up self-delusion.

The warm-up was all about stretching, more specifically static stretching, and that method was taught and used by generations of athletes. When I started working out 5 years ago, I couldn’t touch my toes. Not even close. Embarking on a path of methodical self-improvement, I started the static stretching routines from my youth, which involved sitting on a mat and reaching as far as I could for my toes. And I was getting better. After 6 months of doing this every day I could touch my toes. Clearly projecting forward, in 5 years I’d be a professional contortionist.

Except that I’m not a contortionist today (at least not a professional).

I plateaued at reaching my feet… it became less painful to stretch, but I’d clearly reached some kind of physical limitation. But that was my warm-up, so I kept doing it… for years, thinking that I was improving my flexibility, reducing the chance of injury. Then science told me that I was deluding myself.

I’m often asked about warming up – what to do and when to do it. I’ve had people authoritatively tell me to stretch before the workout to prevent injury. I’ve heard people authoritatively tell me that stretching after your workout is optimal because it “seals in” all your hard work. I’ve had people authoritatively tell me both. And it’s all wrong.

All of this started with the assumption that limber = good.

This seems reasonable, but is it true? In fact, the research says that less limber runners are generally faster… and studies show that static stretching actually reduces power and efficiency (as much as 30%). It also doesn’t seem to help injuries (from large-scale studies on military recruits).

That’s not to say that you should be a sloth… there’s definitely an advantage to having enough flexibility. There’s a great variance in people’s flexibility, much of which is determined by genetics. Very flexible for one person may not be for another, and static stretching will definitely get you from nothing to enough. Beyond that, it appears that you’re actually conditioning your tolerance for discomfort to accept more pain in stretching rather than actually conditioning the muscles and tendons to stretch farther.

So what should I do and when?

Dynamic stretching, or doing a light version (or a simplified derivative) of the exercise that you’re about to perform seems to have the best results, and today that’s the regimen for elite athletes. This does 2 important things: increases your range of motion by loosening muscles & tendons, and primes the cardiovascular system with increased blood flow and body heat.

Even better, there is growing evidence that dynamic stretching reduces injury… which was my youthful but erroneous expectation of static stretching. These are all motivating reasons that most high-level athletic organizations now encourage active stretching prior to exercise – across most activities.

So a light jog before a hard run, some squats and lunges before tennis, a few spider-walks before curling should be enough to get the body primed for exercise.

The bad news is that you’ll probably never be a professional contortionist.

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Jay Diamond writes the VitaminJ blog on evidence-based fitness & bodybuilding. Jay is the founder of Reason4Reason – a skeptical activist group based in the San Francisco bay area. He holds dual masters degrees in engineering and business and has managed both startup companies and hundred-million-dollar programs for Fortune 50 companies. Growing up in Canada, he performed magic, studied science, and became aware of the skeptical movement. Jay has lectured around the world on science & technology, business, and skepticism. 

The post Warm Up to Facts appeared first on Healthy Skepticism.

I’ve taken a few months off… off the gym, off this blog. Nice to take a break for a while, nice to be back. It’s always hard to get back into the gym when you’ve been out for a while, and that’s the subject of this blog. Rebuilding…

Over the last year, I’ve been doing much more Olympic-style weight lifting… bigger weights, free weights, and solid technique (built up from no weight). That’s been putting more stress on my body than ever before in my life, so when I started having pain in one hand, I started adjusting. Then one day, I noticed a protruding bump on one knuckle.  A trip to the doctor and an x-ray later revealed something my friends have been telling me for year… that I had a screw loose.

I mean I literally had a screw loose.

A clean break more than 20 years ago resulted in surgery and 2 screws in a finger. The top one had started to work its way out, presumably exacerbated by the increased joint stress. I’m inclined to believe that my body has become so strong that it was pushing all of that weak stuff (like steel) out of my body.

That’s my story, I’m sticking with it. Once the screws were removed, two holes were left in the bone. The human body has an amazing capacity for repair, and 6 weeks later enough bone has grown in to begin weight-bearing exercise again, so the rebuilding process begins.

Redoing anything is difficult, but as anyone who’s lost a file due to a computer crash can attest, rebuilding the file is easier the second time. You’ve already thought-through the process, you’ve made and corrected some mistakes, and so the new process is much more efficient. Bodybuilding is no different. It’s difficult – but it should always be difficult since that’s what builds muscle. You cannot pick up right where you left off, forcing you to take a step back, drop some weight, shorten your workouts, and start climbing the ladder again. The good thing is that you can rebuild differently, fixing the weaknesses, building new strengths.

Going through the process, I’m reminded that you don’t actually need to take a break to do any of this. You can use a logical construct known as “the outside view”.

A strategic inflection point in the history of Intel Corporation acts as a great example. Andy Grove and Gordon Moore were managing a sinking company in the 80s. The Japanese were killing Intel’s primary business – memory chips, with a price war. It was clear to everyone that the business was in trouble, but companies have a very difficult time walking away when most of their revenue comes from a single product, even if the fate of that product is inevitable.

Grove looked out of his Silicon Valley window one day and asked “If the board threw us out and brought in new management, what would that new management do?” That was the impetus to get out of the memory business and into the microprocessor business, which eventually turned Intel into the biggest semiconductor company in the world. (You can hear Grove and Moore talking about their experience here). They did it by stepping out of their shoes, looking at themselves as if outsiders.

That logical shift is not only valuable in business but in many aspects of our personal lives. We all get stuck in ruts, know it, but can’t shake the comfort of familiarity. The outside view can be used in bodybuilding to get to the next level of fitness.

That’s where I am today- rebuilding. Back extensions are at about half the weight when I stopped…  but I’m back to walking tall. It’s a struggle to get through 3 sets of 10 TRX pushups, but I see improvement every time. Dumbbell chest presses are shaky, but I’m back to doing peck-pops. I’m working on form over weight – something that was getting sloppy when I took my break, and adding a few new exercises to fill some gaps (like wrist curls). My workouts are down to an hour, after which I’m exhausted.

I feel the strength coming back quickly and it feels great to be back in the gym… and back on this blog.

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Jay Diamond writes the VitaminJ blog on evidence-based fitness & bodybuilding. Jay is the founder of Reason4Reason – a skeptical activist group based in the San Francisco bay area. He holds dual masters degrees in engineering and business and has managed both startup companies and hundred-million-dollar programs for Fortune 50 companies. Growing up in Canada, he performed magic, studied science, and became aware of the skeptical movement. Jay has lectured around the world on science & technology, business, and skepticism. 

The post Re. Built. appeared first on Healthy Skepticism.

Depression affects approximately 10% of Americans. It can be fatal; I found estimates of suicide rates ranging from 2-15% of patients with major depression. When it doesn’t kill, it impairs functioning and can make life almost unbearably miserable. It is a frustrating condition because there is no lab test to diagnose it, no good explanation of its cause, and the treatments are far from ideal.

Jonathan Rottenberg is a psychologist and research scientist who began to study depression after his own recovery from a major depressive illness. He teaches psychology at the University of South Florida, where he is the director of the Mood and Emotion laboratory. He has launched the Come Out of the Dark campaign to start a better, richer national conversation about depression. In a new book The Depths: The Evolutionary Origins of the Depression Epidemic, he reviews insights from recent experiments and asks a number of difficult questions, such as why humans evolved to be subject to incapacitating depressions. He comes up with some startling hypotheses, including the idea that evolution favored depression because of its survival value and that depression is essentially a good thing. He offers his ideas as the basis of a paradigm shift.

Is there an epidemic of depression? Rates of depression have been rising in most but not all countries. Is it a real epidemic, or might we be seeing the influence of increased awareness through the media and better diagnosis? I’m not sure we have enough evidence to be certain at this point.

What is depression? Is it:

• A defect in brain chemistry? This is the basis of drug therapy. The chemistry imbalance hypothesis is simplistic, misleading, and essentially wrong. Antidepressants do indeed alter brain chemistry as they relieve symptoms, but that doesn’t necessarily mean that a chemical imbalance caused the problem, and it doesn’t explain what caused the imbalance or why it happened when it did.
• A defect in thoughts? This is the basis of cognitive behavioral therapy (CBT). Is mere thinking enough to think yourself into a depression or out of one? The evidence suggests otherwise.
• A defect in childhood experience? This is the basis of psychoanalysis. Freud’s theories have been largely discredited, and people with the most appalling childhoods can have normal adulthoods.
• Not a defect at all? This is what Rottenberg proposes.

Evolution did not design us to be happy. It designed us to survive and reproduce. The function of mood is to integrate internal with external information to enhance fitness. Mood affects behavior: an anxious mood focuses attention on threats; a good mood broadens attention and leads people to seek out variety; and a negative mood first mobilizes effort, then eventually de-escalates effort when a task proves hopeless, conserving resources that can later be used to better purpose. Our moods occur first: we feel happy or sad, we feel a need to explain why we feel that way, and we think of a reason that would explain the mood. The reasons we come up with are not necessarily the right ones, and often they are mere confabulations.

Low mood has its benefits. Non-depressed people tend to overestimate their abilities, are prone to positive illusions, and demonstrate overconfidence and blindness to faults. When depressed, people are more realistic; they are more deliberate, skeptical, and careful in processing information from the environment.

Low mood can be triggered in animals and humans by factors such as separation from the group, removal to an unfamiliar environment, the inability to escape from a stressful situation, the death of a significant other, scarce food resources, prolonged bodily pain, and social defeat. Low mood serves as an alarm system. It gets our attention and lets us know something is wrong. Depression allows us to stop, retreat to an emotional cocoon, analyze what went wrong, and hopefully change course to avoid future calamities.

But low mood has its costs, too. Whatever the benefits, there are plenty of negative effects like distorted thinking, delusions, suicide, difficulty in concentrating and functioning, and weakened executive functions in the brain.

A shallow depression can be adaptive, but a deep depression is maladaptive. There’s a continuum, and any cut-off point to divide normal from abnormal is arbitrary. Rottenberg thinks low moods used to be helpful in the environment where humans evolved, but that the environment has changed in ways that make low moods less advantageous today.

He describes animal and human experiments that shed light on depression. Animals show signs of depression too. Animals often act as if they are mourning after they lose a significant other. In the “tail test,” rats suspended by their tails conserve their resources better if they give up quickly and stop struggling. Their low mood resolves quickly when the stress is over. Adolescent girls who had depressive symptoms became more disengaged from goals over time, but the more disengaged they were, the better off they were in later assessments, reporting lower levels of depression. In another study, a negative mood was found to enhance the quality and concreteness of persuasive arguments. In a starvation experiment, subjects developed the signs of depression as their bodies reacted to conserve the insufficient calories. Their energy and concentration diminished, they lost all interest in sex, and they ruminated obsessively about food. By preventing action they couldn’t afford, depression contributed to their survival on scanty rations. Their depression lasted longer than the experiment; Rottenberg hypothesizes that this strategy is effective because it holds behavior in place until depleted resources can be rebuilt.

How does this normally-resilient mood system fall into deep depression? Prolonged shocks produced helpless behavior in dogs, so they didn’t even try to escape from shocks when it was possible to escape. Chronic mild stress in rats reduces their pleasure-seeking behavior for months afterwards; their responsiveness to rewards returns when they are given antidepressants. Undergoing several stressors at once increases the likelihood of depression in both animals and humans. Not every animal shows prolonged depression, just as not every human becomes depressed under equivalent stresses. Genetic variation is likely the reason: it has been estimated that 30-40% of susceptibility to depression in humans is genetic.

Some kind of loss is always present in depression, whether it be the death of a child or an imagined loss of status. Bereavement is one kind of depression, once thought to be a separate entity but now considered to be part of the same continuum.

How long do minor depressions last? There are no good treatments for minor depression, and doctors often resort to “watchful waiting.” This may be a mistake: a study showed that after a month, only 6% of patients had recovered. Another study found that 72% of people who had a minor depression were still bothered by one or more symptoms of depression when interviewed a year later. At any given time, 22% of the population has at least one significant symptom of depression. Mild depressions outnumber deep ones six to one. Low-level sadness is so ordinary it is often overlooked. But having a mild depression quintuples the risk of a later major depression.

Depression can be triggered by events, temperaments, and routines such as sleep patterns, night shifts, and artificial light. Fish with different temperaments have different success in different environments; the bold fish are more likely to enter a trap, while wary fish are slower to adapt to changing conditions. Humans have an additional problem: Rottenberg says “Homo sapiens has the distinction of being a species that can become depressed without a major environmental insult.” We think our way into deeper depressions by rumination and self-flagellation. We worry about remote or nonexistent possibilities. When we are depressed we think we ought to be able to fix ourselves; but we can’t, and that makes us even more depressed.

Sometimes depressed people can’t even get out of bed. This reflects a lack of goals. They don’t see any good reasons that would motivate them to get up. Humans can set goals in abstract domains where progress is hard to measure. When they hold on to failing goals, they become depressed. They need to disengage from the failing goals. Self-help books and the ideals of happiness in our society create high expectations and perceived failures. In the West the idea of happiness usually involves high levels of arousal like enthusiasm and excitement; in general, those who place the highest values on that kind of happiness tend to be the least happy. Asians tend to place greater value on low arousal states like calm and serenity.

According to Rottenberg, depression arises not from a defect, but from what we do well: thinking, using language, holding onto ambitious goals, and even our drive to be happy. Rottenberg says “The picture of depression that emerges is richer, more interesting, and in some ways more troubling than defect-model approaches would allow.”

He offers clues about how low moods can be better managed: appreciating the costs of thinking, sometimes accepting a low mood with equanimity, aiming for goals that are high but not too high, knowing when it is time to give up on a goal, and realizing that happiness is not itself a goal but “a fleeting byproduct of progress towards other goals.” Despite the evolutionary directive to become depressed, we retain a margin of control to shape its course.

We have learned that depression comes on more gradually and lifts more gradually than we once thought. We can’t predict whether a patient will respond to any treatment, but that doesn’t mean we shouldn’t keep trying. We used to think antidepressants took 6 weeks to show an effect, but we often see patients improving in the first two weeks, even those taking a placebo! Early improvement doesn’t predict final outcome. Early improvers may face fewer life problems, have an innate resilience, or maybe they are just lucky. Recovered patients may still have some residual depression and fear that a relapse could happen any time. A deep depression can re-program our mood system so that it favors a return to low mood states; but the same brain plasticity also allows for re-re-programming to a more normal state with treatments like mindfulness-based cognitive therapy, which attempts to disconnect sad moods from negative thoughts about the self. Mood can be rebuilt by changing the way we think, our environment, our relationships, and our health habits like sleep, diet, and exercise.

“Just like hunger or pain, moods are survival-relevant mental states that can bind together thoughts, feelings, and memories [and] change our mental priorities.” But they lead to mood-congruent memory, where we retrieve memories that match our current mood and are unable to call up contradictory memories. This can fortify us to change our situation, but it also tends to deepen the depression and makes us mentally less nimble.

Depression can be viewed as an opportunity. Rottenberg describes a patient who used her depression as a lens to re-evaluate everything in her life and re-set her priorities. Her life was better after the depressive episode than before.

Conclusion

Rottenberg calls his ideas the “mood science approach” to depression. He says:

The evolutionary perspective asks us to be patient, to learn to tolerate some degree of low mood, and to listen to what it is that low mood can tell us.

I don’t think his approach qualifies as a “paradigm shift,” but he does provide some valuable insights about this frustrating condition. Some of these insights are speculative, but most are based on recent animal and human research.

I used to try to reduce the stigma and guilt of obesity by telling obese patients that their tendency to store calories as fat was not a bad thing per se: it would give them a survival advantage over thinner people in a starvation environment or an environment of alternating feast and famine. But in our modern environment, where food is plentiful, the survival advantage is with the non-obese. I don’t think what I said made them lose weight more successfully, but I hope it provided some degree of comfort and reduced guilt. In the same way, Rottenberg’s concepts may help destigmatize depression. Depressed patients may feel better about their condition if they are told that it is a result of evolutionary traits that are basically good for us but that sometimes overdo it. If nothing else, the ideas and the experimental evidence Rottenberg presents provide plenty of food for thought.

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Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about medicine, so-called complementary and alternative medicine, science, pseudoscience, questionable medical practices and critical thinking. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel. She is an editor and one of the five MD founders of the Science-Based Medicine blog. Dr. Hall writes the SkepDoc column in Skeptic magazine, and is a contributing editor to Skeptic and Skeptical Inquirer, as well as a medical advisor and author of articles on the Quackwatch website. She recently published Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the recently released textbook “Consumer Health: A Guide to Intelligent Decisions,” and was appointed to the Executive Council of the Committee for Skeptical Inquiry.

Healthy Skepticism is republishing selections from Dr. Hall’s blog with permission. Please visit Science Based Medicine.

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