by crissly | Jan 17, 2023 | Uncategorized
“Everyone’s so gung ho about therapy these days. I’ve been curious myself, but I’m not ready to commit to paying for it. A mental health app seems like it could be a decent stepping stone. But are they actually helpful?”
—Mindful Skeptic
Dear Mindful,
The first time you open Headspace, one of the most popular mental wellness apps, you are greeted with the image of a blue sky—a metaphor for the unperturbed mind—and encouraged to take several deep breaths. The instructions that appear across the firmament tell you precisely when to inhale, when to hold, and when to exhale, rhythms that are measured by a white progress bar, as though you’re waiting for a download to complete. Some people may find this relaxing, although I’d bet that for every user whose mind floats serenely into the pixelated blue, another is glancing at the clock, eyeing their inbox, or worrying about the future—wondering, perhaps, about the ultimate fate of a species that must be instructed to carry out the most basic and automatic of biological functions.
Dyspnea, or shortness of breath, is a common side effect of anxiety, which rose, along with depression, by a whopping 25 percent globally between 2020 and 2021, according to a report from the World Health Organization. It’s not coincidental that this mental health crisis has dovetailed with the explosion of behavioral health apps. (In 2020, they garnered more than $2.4 billion in venture capital investment.) And you’re certainly not alone, Mindful, in doubting the effectiveness of these products. Given the inequality and inadequacy of access to affordable mental health services, many have questioned whether these digital tools are “evidence-based,” and whether they serve as effective substitutes for professional help.
I’d argue, however, that such apps are not intended to be alternatives to therapy, but that they represent a digital update to the self-help genre. Like the paperbacks found in the Personal Growth sections of bookstores, such apps promise that mental health can be improved through “self-awareness” and “self-knowledge”—virtues that, like so many of their cognates (self-care, self-empowerment, self-checkout), are foisted on individuals in the twilight of public institutions and social safety nets.
Helping oneself is, of course, an awkward idea, philosophically speaking. It’s one that involves splitting the self into two entities, the helper and the beneficiary. The analytic tools offered by these apps (exercise, mood, and sleep tracking) invite users to become both scientist and subject, taking note of their own behavioral data and looking for patterns and connections—that anxiety is linked to a poor night’s sleep, for example, or that regular workouts improve contentedness. Mood check-ins ask users to identify their feelings and come with messages stressing the importance of emotional awareness. (“Acknowledging how we’re feeling helps to strengthen our resilience.”) These insights may seem like no-brainers—the kind of intuitive knowledge people can come to without the help of automated prompts—but if the breathing exercises are any indication, these apps are designed for people who are profoundly alienated from their nervous systems.
Of course, for all the focus on self-knowledge and personalized data, what these apps don’t help you understand is why you’re anxious or depressed in the first place. This is the question that most people seek to answer through therapy, and it’s worth posing about our society’s mental health crisis as a whole. That quandary is obviously beyond my expertise as an advice columnist, but I’ll leave you with a few things to consider.
Linda Stone, a researcher and former Apple and Microsoft executive, coined the term “screen apnea” to describe the tendency to hold one’s breath or breathe more shallowly while using screens. The phenomenon occurs across many digital activities (see “email apnea” and “Zoom apnea”) and can lead to sleep disruption, lower energy levels, or increased depression and anxiety. There are many theories about why extended device use puts the body into a state of stress—psychological stimulation, light exposure, the looming threat of work emails and doomsday headlines—but the bottom line seems to be that digital technologies trigger a biological state that mirrors the fight-or-flight response.
It’s true that many mental health apps recommend activities or “missions” that involve getting off one’s phone. But these tend to be tasks performed in isolation (pushups, walks, guided meditations), and because they are completed so as to be checked off, tracked, and subsumed into one’s overall mental health stats, the apps end up ascribing a utility value to activities that should be pleasurable for their own sake. This makes it more difficult to practice those mindfulness techniques—living in the moment, abandoning vigilant self-monitoring—that are supposed to relieve stress. By attempting to instill more self-awareness, in other words, these apps end up intensifying the disunity that so many of us already feel on virtual platforms.
by crissly | Jan 11, 2023 | Uncategorized
Shortages persist because of complex structural problems. Take, for instance, one that the pandemic briefly made visible: the reality that many American medications are manufactured somewhere else, at the end of long supply chains. In some cases, the raw materials, known as active pharmaceutical ingredients, or API, come from offshore, primarily India and China. In others, the entire drug—raw materials mixed with other ingredients into a finished product—is made abroad by a contract manufacturing organization. “It’s possible that, even though there are three products on the market with three labels, it’s all coming from the same facility,” says Michael Ganio, a clinical pharmacist and ASHP’s senior director of pharmacy practice and quality. “There also could be three manufacturers that are all sourcing from the same API manufacturer. The transparency is not there.”
Transparency could begin to solve the problem. More information is a necessary first step for forecasting shortages and building a resilient system that can blunt their impact. It’s especially important because most shortages don’t occur among new blockbuster drugs, but among older ones that sell on thin profit margins. The supply of those drugs is most likely to be disrupted by contamination, mechanical breakdowns, or other production problems—because while the FDA requires manufacturers to keep production lines safe, it doesn’t require them to reinvest in equipment on any particular schedule to keep those lines running. The business case for investing in a legacy product is a lot less compelling than for a high-earning breakthrough one.
Advance warning that a production line is coming down, due to materials supply or manufacturing problems, could help regulators balance the market. But that kind of disclosure would require companies to divulge proprietary information. “It’s hard to legislate the free market, and most of the problems that need to be solved have some element of the free market,” says Erin Fox, who is senior director of drug information at University of Utah Health Care and leads a research team that supplies information on shortages to ASHP.
Fox is also part of a committee at the National Academies of Science, Engineering and Medicine that proposed reforms in a report last year. It lays out a series of prompts for federal actions, such as enlarging the National Strategic Stockpile, which currently holds bioterror-defense drugs, and carving out international trade compacts to preserve an uninterrupted flow of ingredients. It also proposes developing a federal rating system that scores companies on resiliency planning and disclosure. (A quality-rating system has been endorsed by an FDA report as well.)
For companies, the National Academies report recommends carrots rather than sticks, acknowledging that firms can’t be compelled to release private information and recommending incentives to persuade them to be more forthcoming. Those federal ratings, for instance, could be used by health care organizations to justify paying slightly higher prices for drugs’ as a reward for transparency.
Adoption would be challenging. “We’re constantly battling increasing drug costs,” Ganio says. “So it’s not easy to go to a hospital CFO or director of pharmacy and say, ‘Hey, we’re going to buy a product that’s costs a little bit more, but we think it’s a good investment.‘”
But, he points out, shortages already force health care organizations to pay more, directly in labor costs and indirectly in hits to patient safety. A 2019 study by the consulting firm Vizient estimated that US hospitals spend an additional $359 million per year on staff time and overtime to cope with shortages. That same year, Australian researchers identified 38 studies that found that shortages harm patients through longer waits for treatment, longer hospitalizations, bad reactions to substitute drugs, surgical complications, and in some cases preventable deaths.
Health care personnel think tackling the challenge would be worth it, to avoid the chaos that grips their systems whenever shortages arrive. “Every time, we have to come up with a protocol for what we’re going to use instead,” says Melissa Johnson, a professor of medicine at Duke University and president of the Society of Infectious Diseases Pharmacists. “What don’t we have this week? Can we identify alternate sources? Do we have to compound our own?”
Maintaining the status quo means failing to address the problem, and letting the burden of drug shortages fall on frazzled pharmacists—and sick children and panicked parents who can do nothing but wait.
by crissly | Jan 1, 2023 | Uncategorized
James Clear, author of Atomic Habits, adds that looking at data can be a good starting point. “For fitness habits, it could be things like your Apple Watch or Whoop band or MyFitnessPal. There are many different ways to get data,” he says. “It also can be true for habits that maybe you wouldn’t think about tracking.” For example, looking at your calendar for the past year to determine whether you spent enough time at home with your family, or whether you were traveling for work too much. “If you’re so busy that you never give yourself time to think about what you’re doing … it’s really hard to improve, because you’re just busy repeating the same thing again and again. You don’t have a chance to look at the bigger picture.”
Picking Your Habit, Digging Deeper, and Creating a Plan
Once you’ve done your review of the habits you’d like to break, you should pick one of them to start with.
“I look at a number of the challenges a patient is facing and then ask myself, ‘Which one is in the driver’s seat?’” says Mendelsohn. “Meaning if I tackle one of these problems, are the rest of them likely to get better?”
The next step is to decide how you’re going to go about breaking the habit you’ve chosen, based on your history with it and the context or cues that lead to you performing the behavior. Here are a few examples:
Spending Too Much Money
Say you spend too much money and this is the habit you would like to stop. You’ve determined that you started overspending when you added your credit cards to your Apple Wallet or PayPal. This then made it extremely easy to buy things when you saw an ad on social media or a friend sent a link to something they thought you would like. “You want spending money to be as difficult and thoughtful as possible,” Wood says. “Putting all your credit cards on your phone that you carry everywhere is counterproductive—you are further automating the process of spending money.” To fix this, you decide to remove your cards from all online payment services so each time you want to buy something, you have to physically go and pull out the card, which then gives you a bit more time to think about the purchase itself. You could also ask friends not to send you products and unsubscribe from any product marketing emails.
Checking Your Phone All The Time
If you’re trying to check your phone less often, David Kadavy, author of Mind Management, Not Time Management, suggests locking it in a lockbox for part of the day. “Make it as hard as possible to actually perform the habit,” he says. While you’re still going to get the cue to check your phone, the effort of going to the lockbox and unlocking it can help block the behavior from triggering. Or, say you’re trying to check social media less often: “Just delete the social media apps from your phone,” says Kadavy. “Block them with the parental controls or, at the very least, don’t have them on your home screen.”
Eating Unhealthily
Clear has a great example of a negative eating habit from his own life. In the house he used to live in, there was a McDonald’s right after the highway exit on his way home. He found himself stopping there multiple times a week. “I looked at myself after the last one, and I was like, ‘Am I going to do this every time I drive home? Am I just going to stop here and eat here every single time?’” he says. “Ultimately, what I decided to do was to start taking a different path home. If I went left off of the exit instead of right, it would take an extra three minutes, but I wouldn’t pass the McDonald’s. I changed the environment so that I wouldn’t be exposed to the cue. That added enough friction and enough separation that the habit would change.”
Procrastinating
“A lot of people tend to procrastinate, then rely on anxiety and fear to motivate them to get tasks done,” says Mendelsohn. “This can be effective at getting things done, but at the cost of causing unnecessary stress. Breaking tasks down into smaller ones can be a harder strategy to implement at first, but more sustainable in the long run.” To help you get started, Mendelsohn suggests writing these tasks down using a pen and paper, as it can be “really helpful for people to keep their organizational strategies separate from the digital tools we use all day.”
Sometimes, substituting a negative behavior for a more desirable one can work at blocking it—but, Wood says you have to know what the cue is, and the alternative behavior has to be both easy and rewarding. Say you’ve decided to drink a glass of water whenever you have the urge to look at your phone, instead of locking it away somewhere or putting it facedown next to you. “For most people, drinking a glass of water isn’t going to be as interesting as looking at their phones, so I don’t know if that’s going to work particularly well,” says Wood.
If your chosen way to try and break your habit isn’t working, maybe it’s time to try something else. Another thing to keep in mind is that “for some specific behaviors, like quitting smoking, multiple attempts is actually a good thing,” Wood says. “Because most people who ultimately quit have to keep trying until they figure out the right thing that will work for them.”
So don’t get discouraged if it’s taking a while to break your habit. Sometimes you just need to approach it a different way or dig deeper into the context or cues that lead you to perform it in the first place.
by crissly | Nov 3, 2022 | Uncategorized
In November 2021, when the psychedelics company Compass Pathways released the top-line results of its trial looking at psilocybin in patients with treatment-resistant depression, the stock of the company plunged almost 30 percent. The dive was reportedly prompted by the somewhat-middling results of the research—but also because of the scattering of serious adverse events that occurred during the trial.
Amid the psychedelic renaissance, bringing up their potential harms has been somewhat of a taboo. The field, vilified for decades, has only just recently reentered the mainstream, after all. But as clinical trials get bigger—and the drugs are increasingly commercialized—more negative outcomes are likely to transpire. With the Compass trial results hinting at this, arguably now’s the time to open up the dialog about psychedelics’ potential adverse effects—even if it means tempering the hype that has built up.
Those results, now published in full in the New England Journal of Medicine, represent the largest randomized, controlled, double-blind psilocybin therapy study ever done. The participants—233 of them, across 22 sites in 10 countries—were split into three roughly equal groups. One group received 1 milligram of COMP360, Compass’s synthetic psilocybin, a dose so low it served as the placebo. The next group received 10 mg and the last group 25 mg. Psychological support was also offered alongside the treatment.
The results were promising, if not painting the picture of a miracle cure. In the 25 mg group, 29 percent of patients were in remission after three weeks compared to just 8 percent in the placebo group. After time, the positive effects waned: After 12 weeks only 20 percent of the high-dose patients were still responding—an improvement over the placebo group that wasn’t statistically significant.
At the same time, 179 of the 233 patients in the trial reported at least one adverse event, like headaches, nausea, fatigue, or insomnia—uncomfortable, sure, but not a huge cause for concern. But 12 patients experienced serious adverse events. These were defined as displays of suicidal ideation, including self-harm. Five of the patients in the highest-dose group were reported to have displayed suicidal behavior, as well as six in the 10 mg group. This was compared to just one in the placebo group.
“Is this expected in a trial like this? To some degree, yes,” says Natalie Gukasyan, assistant professor and medical director for the Johns Hopkins Center for Psychedelic & Consciousness Research. When you’re working with a patient group as vulnerable as those with treatment-resistant depression, higher rates of suicidal ideation are to be expected. But it’s worth noting, she says, that there were higher rates of these events in the higher-dose group, which brings up the question of whether the drug played a role. One thing she thinks would have been helpful to include in the study was the lifetime history of previous suicide attempts in the participants, which is an important predictor of future suicidal behavior.
But given the general reticence to dwell on psychedelics’ downsides, the fact that Compass was upfront about the adverse events is a good thing, says Joost Breeksema, a PhD candidate who studies patient experiences of psychedelics at the University Medical Center Groningen in the Netherlands. In August 2022, Breeksema published a review that looked at how adverse events in psychedelics research have been flagged, and found that they have been inconsistently and probably underreported. Many of the trials Breeksema looked at reported no adverse effects whatsoever—an unlikely reality. The Compass Pathways research “reported adverse effects more rigorously than many of the other trials in our systematic review,” he says.
by crissly | Sep 20, 2022 | Uncategorized
Though Bd swept through Central America from the 1980s to the 2000s, the analysis that demonstrated its effect on human health could be accomplished only recently, says Michael Springborn, the paper’s lead author and a professor and environmental and resource economist at UC Davis. “The data existed, but it wasn’t easily obtainable,” he says. Over the years, though, county-level disease records were digitized at the ministries of health in Costa Rica and Panama, providing an opportunity to combine that epidemiology in a particular statistical model with satellite images and ecological surveys revealing land characteristics and precipitation, as well as with data on amphibian declines.
“We always thought if we could link [the die-off] to people, more people would care,” Lips says. “We were pretty sure we could quantify changes in bugs, or frogs, or the water quality, or fish or crabs or shrimp. But making that connection to people was so difficult, because the effect was so diffuse, and it happened across such a large area.”
But precisely because Bd swept through Central America in a specific pattern, from northwest to southeast—“a wave that hit county after county over time,” Springborn says—it created a natural experiment that allowed the researchers to look granularly at Costa Rica and Panama before and after the fungal wave arrived. In the health records, they could distinguish that malaria rates were flat in counties (called cantons or distritos) before the Bd fungus tore through, then began to rise afterward. At the peak of the disease surge, six years from the arrival of Bd in an area, malaria cases rose five-fold.
And then they began to fall off again, beginning about eight years after the lethal fungus arrived. Researchers aren’t sure why, because most amphibian populations haven’t bounced back from the fungal onslaught. Though some populations appear to be developing resistance, most have not recovered their density or diversity. Since the fungus lingers in the environment, they remain at risk.
There’s a missing piece in the researchers’ analysis, which is that there is no contemporaneous data to prove that mosquito populations surged in a way that promoted malaria. The surveys they needed—of mosquito density during and after Bd’s arrival, in the 81 counties in Costa Rica and 55 in Panama—simply don’t exist. That makes it difficult for them to determine why malaria fell off again, particularly since frog populations haven’t revived. Springborn theorizes it might be due to human intervention, like governments or organizations noticing the malaria spike and spraying insecticides or distributing bed nets. Or it might be that ecosystems recovered even though the frogs did not, with other predator species taking advantage of the emptied niche to keep mosquito counts down.
But the fact that malaria rates came back down again doesn’t invalidate the findings’ importance. “For the most part, Bd has been a story of the consequences for amphibians, basically: Isn’t it too bad to lose this charismatic group of organisms?” says James P. Collins, an evolutionary ecologist and professor at Arizona State University. (Collins has some connection to this research; he oversaw a grant that the National Science Foundation made to Lips in the 1990s.) “It’s been an embedded assumption that reducing the world’s biodiversity is bound to be harmful. Connecting the dots to real implications for humans is a nice piece of evidence for understanding the consequences.”
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