Self-Esteem (II)

Here’s my first post about the book. I was disappointed by some of the chapters in the second half of the book and I think a few of them were quite poor. I have been wondering what to cover from the second half, in part because some of the authors seem to proceed as if e.g. the work of these authors does not exist (key quote: Our findings do not support continued widespread efforts to boost self-esteem in the hope that it will by itself foster improved outcomes) – I was thinking this about the authors of the last chapter, on ‘Changing self-esteem through competence and worthiness training’, in particular; their basic argument seems to be that since CWT (Competence and Worthiness Training) has been shown to improve self-esteem, ‘good things will follow’ people who make use of such programs. Never mind the fact that causal pathways between self-esteem and life outcomes are incredibly unclear, never mind that self-esteem is not the relevant outcome measure (and studies with good outcome measures do not exist), and never mind that effect persistence over time is unknown, to take but three of many problems with the research. They argue/conclude in the chapter that CWT is ’empirically validated’, an observation which almost made me laugh. I’m in a way slightly puzzled that whereas doctors contributing to Springer publications and similar are always supposed to disclose conflicts of interest in the publications, no similar demands are made in the context of the psychological literature; these people obviously make money off of these things, and yet they’re the ones evaluating the few poor studies that have been done, often by themselves, while pretending to be unbiased observers with no financial interests in whether the methods are ‘validated’ or not. Oh well.

Although some chapters are poor (‘data-poor and theory rich’, might not be a bad way to describe them – note that the ‘data poor’ part relates both to low amounts of data and the use of data of questionable quality; I’m thinking specifically about the use of measures of ‘implicit self-esteem’ in chapter 6 – the authors seem confused about the pattern of results and seem to have a hard time making sense of them (they seem to keep having to make up new ad-hoc explanations for why ‘this makes sense in context’), but I don’t think the results are necessarily that confusing; the variables probably aren’t measuring what they think they’re measuring, not even close, and the two different types of measures probably aren’t remotely measuring anything similar (I have a really hard time figuring out why anyone would ever think that they do), so it makes good sense that findings are all over the place..), chapter 8, on ‘Self-esteem as an interpersonal signal, was however really great and I thought I should share some observations from that chapter here – I have done this below. Interestingly, people who read the first post about the book would in light of the stuff included in that chapter do well to forget my personal comments in the first post about me having low self-esteem; interpersonal outcomes seem to be likely to be better if you think the people with whom you interact have high self-esteem (there are exceptions, but none of them seem relevant in this context), whether or not that’s actually true. Of course the level of ‘interaction’ going on here on the blog is very low, but even so… (I may be making a similar type of mistake the authors make in the last chapter here, by making unwarranted assumptions, but anyway…).

Before moving on, I should perhaps point out that I just finished the short Springer publication Appointment Planning in Outpatient Clinics and Diagnostic Facilities. I’m not going to blog this book separately as there frankly isn’t enough stuff in there for it to make sense to devote an entire blog post to it, but I thought I might as well add a few remarks here before moving on. The book contains a good introduction to some basic queueing theory, and quite a few important concepts are covered which people working with those kinds of things ought to know about (also, if you’ve ever had discussions about waiting lists and how ‘it’s terrible that people have to wait so long’ and ‘something has to be done‘, the discussion would have had a higher quality if you’d read this book first). Some chapters of the book are quite technical – here are a few illustrative/relevant links dealing with stuff covered in the book: Pollaczek–Khinchine formula, Little’s Law, the Erlang C formula, the Erlang B formula, Laplace–Stieltjes transform. The main thing I took away from this book was that this stuff is a lot more complicated that I’d thought. I’m not sure how much the average nurse would get out of this book, but I’m also not sure how much influence the average nurse has on planning decisions such as those described in this book  – little, I hope. Sometimes a book contains a few really important observations and you sort of want to recommend the book based simply on these observations, because a lot of people would benefit from knowing exactly those things; this book is like that, as planners on many different decision-making levels would benefit from knowing the ‘golden rules’ included in section 7.1. When things go wrong due to mismanagement and very long waiting lists develop, it’s obvious that however you look at it, if people had paid more attention to those aspects, this would probably not have happened. An observation which is critical to include in the coverage of a book like this is that it may be quite difficult for an outside observer (e.g. a person visiting a health clinic) to evaluate the optimality of scheduling procedures except in very obvious cases of inefficiently long queues. Especially in the case of excess capacity most outsiders do not know enough to evaluate these systems fairly; what may look like excess capacity to the outsider may well be a necessary buffer included in the planning schedule to keep waiting times from exploding at other points in time, and it’s really hard to tell those apart if you don’t have access to relevant data. Even if you do, things can be, complicated (see the links above).

Okay, back to the self-esteem text – some observations from the second half of the book below…

“low self-esteem is listed as either a diagnostic criterion or associated feature of at least 24 mental disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV- TR). Low self-esteem and an insufficient ability to experience self-relevant positive emotions such as pride is particularly strongly linked to depression, to such a degree that some even suggest conceptualizing self-esteem and depression as opposing end points of a bipolar continuum [] The phenomenology of low self-esteem – feeling incompetent and unworthy, unfit for life – inevitably translates into experiencing existence as frightening and futile. This turns life for the person lacking in self-esteem into a chronic emergency: that person is psychologically in a constant state of danger, surrounded by a feeling of impending disaster and a sense of helplessness. Suffering from low self-esteem thus involves having one’s consciousness ruled by fear, which sabotages clarity and efficiency (Branden, 1985). The main goal for such a person is to keep the anxieties, insecurities, and self-doubts at bay, at whatever cost that may come. On the other hand, a person with a satisfying degree of self-respect, whose central motivation is not fear, can afford to rejoice in being alive, and view existence as a more exciting than threatening affair.” [from chapter 7, on ‘Existential perspective on self-esteem’ – I didn’t particularly like that chapter and I’m not sure to which extent I agree with the observations included, but I thought I should add the above to illustrate which kind of stuff is also included in the book.]

“Although past research has emphasized how social environments are internalized to shape self-views, researchers are increasingly interested in how self-views are externalized to shape one’s social environment. From the externalized perspective, people will use information about another’s self-esteem as a gauge of that person’s worth […] self-esteem serves a “status-signaling” function that complements the status-tracking function […] From this perspective, self-esteem influences one’s self-presentational behavior, which in turn influences how others view the self. This status-signaling system in humans should work much like the status-signaling models developed in non-human animals [Aureli et al. and Kappeler et al. are examples of places to go if you’re interested in knowing more about this stuff] […] Ultimately, these status signals have important evolutionary outcomes, such as access to mates and consequent reproductive success. In essence, self-esteem signals important status-related information to others in one’s social world. […] the basic notion here is that conveying high (or low) self-esteem provides social information to others.”

“In an effort to understand their social world, people form lay theories about the world around them. These lay theories consist of information about how characteristics covary within individuals […] Research on the status-signaling function of self-esteem […] and on self-esteem stereotypes […] report a consistent positive bias in the impressions formed about high self-esteem individuals and a consistent negative bias about those with low self-esteem. In several studies conducted by Cameron and her colleagues […], when Canadian and American participants were asked to rate how the average person would describe a high self-esteem individual, they universally reported that higher self-esteem people were attractive, intelligent, warm, competent, emotionally stable, extraverted, open to experience, conscientious, and agreeable. Basically, on all characteristics in the rating list, high self-esteem people were described as superior. […] Whereas people sing the praises of high self-esteem, low self-esteem is viewed as a “fatal flaw.” In the same set of studies, Cameron and her colleagues […] found that participants attributed negative characteristics to low self-esteem individuals. Across all of the characteristics assessed, low self-esteem people were seen as inferior. They were described as less attractive, less intelligent, less warm, less competent, less sociable, and so forth. The only time that the stereotypes of low self-esteem individuals were rated as “more” than the group of high self-esteem individuals was on negative characteristics, such as experiencing more negative moods and possessing more interpersonally disadvantageous characteristics (e.g., jealousy). […] low self-esteem individuals were seen just as negatively as welfare recipients and mentally ill people on most characteristics […] All cultures do not view self-esteem in the same way. […] There is some evidence to suggest that East Asian cultures link high self-esteem with more negative qualities”

“Zeigler-Hill and his colleagues […] presented participants with a single target, identified as low self-esteem or high self-esteem, and asked for their evaluations of the target. Whether the target was identified as low self-esteem by an explicit label (Study 3), a self-deprecating slogan on a T-shirt (Study 4), or their email address (Study 5, e.g., sadeyes@), participants rated an opposite-sex low self-esteem target as less romantically desirable than a high self-esteem target […]. However, ascribing negative characteristics to low self-esteem individuals is not just limited to decisions about an opposite-sex target. Zeigler-Hill and colleagues demonstrated that, regardless of match or mismatch of perceiver-target gender, when people thought a target had lower self-esteem they were more likely to ascribe negative traits to him or her, such as being lower in conscientiousness […] Overall, people are apt to assume that people with low self-esteem possess negative characteristics, whereas those with high self-esteem possess positive characteristics. Such assumptions are made at the group level […] and at the individual level […] According to Cameron and colleagues […], fewer than 1% of the sample ascribed any positive characteristics to people with low self-esteem when asked to give open-ended descriptions. Furthermore, on the overwhelming majority of characteristics assessed, low self-esteem individuals were rated more negatively than high self-esteem individuals”

“Although for the most part it is low self-esteem that people associate with negative qualities, there is a dark side to being labeled as having high self-esteem. People who are believed to have high self-esteem are seen as more narcissistic […], self-absorbed, and egotistical […] than those believed to possess low self-esteem. Moreover, the benefits of being seen as high self-esteem may be moderated by gender. When rating an opposite-sex target, men were often more positive toward female targets with moderate self-esteem than those with high self-esteem”

“Not only might perceptions of others’ self-esteem influence interactions among relative strangers, but they may also be particularly important in close relationships. Ample evidence demonstrates that a friend or partner’s self-esteem can have actual relational consequences […]. Relationships involving low self-esteem people tend to be less satisfying and less committed […], due at least in part to low self-esteem people’s tendency to engage in defensive, self-protective behavior and their enhanced expectations of rejection […]. Mounting evidence suggests that people can intuit these disadvantages, and thus use self-esteem as an interpersonal signal. […] Research by MacGregor and Holmes (2007) suggests that people expect to be less satisfied in a romantic relationship with a low self-esteem partner than a high self-esteem partner, directly blaming low self-esteem individuals for relationship mishaps […] it appears that people use self-esteem as a signal to indicate desirability as a mate: People report themselves as less likely to date or have sex with those explicitly labeled as having “low self-esteem” compared to those labeled as having “high self-esteem” […] Even when considering friendships, low self-esteem individuals are rated less socially appealing […] In general, it appears that low self-esteem individuals are viewed as less-than-ideal relationship partners.”

“Despite people’s explicit aversion to forming social bonds with low self-esteem individuals, those with low self-esteem do form close relationships. Nevertheless, even these established relationships may suffer when one person detects another’s low self-esteem. For example, people believe that interactions with low self-esteem friends or family members are more exhausting and require more work than interactions with high self-esteem friends and family […]. In the context of romantic relationships, Lemay and Dudley’s (2011) findings confirm the notion that relationships with low self-esteem individuals require extra relationship maintenance (or “work”) as people attempt to “regulate” their romantic partner’s insecurities. Specifically, participants who detected their partner’s low self-esteem tended to exaggerate affection for their partner and conceal negative sentiments, likely in an effort to maintain harmony in their relationship. Unfortunately, this inauthenticity was actually associated with decreased relationship satisfaction for the regulating partner over time. […] MacGregor and colleagues […] have explored a different type of communication in close relationships. Their focus was on capitalization, which is the disclosure of positive personal experiences to others […]. In two experiments […], participants who were led to believe that their close other had low self-esteem capitalized less positively (i.e., enthusiastically) compared to control participants. […] Moreover, in a study involving friend dyads, participants reported capitalizing less frequently with their friend to the extent they perceived him or her as having low self-esteem […] low self-esteem individuals are actually no less responsive to others’ capitalization attempts than are high self-esteem partners. Despite this fact, MacGregor and Holmes (2011) found that people are reluctant to capitalize with low self-esteem individuals precisely because they expect them to be less responsive than high self-esteem partners. Thus people appear to be holding back from low self-esteem individuals unnecessarily. Nevertheless, the consequences may be very real given that capitalization is a process associated with personal and interpersonal benefits”

“Cameron (2010) asked participants to indicate how much they tried to conceal or reveal their self-feelings and insecurities with significant others (best friends, romantic partners, and parents). Those with lower self-esteem reported attempting to conceal their insecurities and self-doubts to a greater degree than those with higher self-esteem. Thus, even in close relationships, low self-esteem individuals appear to see the benefit of hiding their self-esteem. Cameron, Hole, and Cornelius (2012) further investigated whether concealing self-esteem was linked with relational benefits for those with low self-esteem. In several studies, participants were asked to report their own self-esteem and then to provide their “self-esteem image”, or what level of self-esteem they thought they had conveyed to their significant others. Participants then indicated their relationship quality (e.g., satisfaction, commitment, trust). Across all studies and across all relationship types studied (friends, romantic partners, and parents), people reporting a higher self-esteem image, regardless of their own self-esteem level, reported greater relationship quality. […] both low and high self-esteem individuals benefit from believing that a high self-esteem image has been conveyed, though this experience may feel “inauthentic” for low self-esteem people. […] both low and high self-esteem individuals may hope to been seen as they truly are by their close others. […] In a recent meta-analysis, Kwang and Swann (2010) proposed that individuals desire verification unless there is a high risk for rejection. Thus, those with negative self-views may desire to be viewed positively, but only if being seen negatively jeopardizes their relationship. From this perspective, romantic partners should signal high self-esteem during courtship, job applicants should signal high self-esteem to potential bosses, and politicians should signal high self-esteem to their voters. Once the relationship has been cemented (and the potential for rejection has been reduced), however, people should desire to be seen as they are. Importantly, the results of the meta-analysis supported this proposal. While this boundary condition has shed some light on this debate, more research is needed to understand fully under what contexts people are motivated to communicate either positive or negative self-views.”

“it appears that people’s judgments of others’ self-esteem are partly well informed, yet also based on inaccurate stereotypes about characteristics not actually linked to self-esteem. […] Traits that do not readily manifest in behavior, or are low in observability, should be more difficult to detect accurately (see Funder & Dobroth, 1987). Self-esteem is one of these “low-observability” traits […] Although the operationalization of accuracy is tricky […], it does appear that people are somewhat accurate in their impressions of self-esteem […] research from various laboratories indicates that both friends […] and romantic partners […] are fairly accurate in judging each other’s self-esteem. […] However, people may also use information that has nothing to do with the appearances or behaviors of target. Instead, people may make judgements about another’s personality traits based on how they perceive their own traits […] people tend to project their own characteristics onto others […] People’s ratings of others’ self-esteem tend to be correlated with their own, be it for friends or romantic partners”


November 12, 2014 Posted by | Books, Economics, health care, Psychology | Leave a comment

Suicide risk management: A manual for health professionals

My brief goodreads review of the book, which I read yesterday (I gave it two stars):

“Closer to one star than three. Multiple spelling errors, no inline citations, questionable coverage of the literature, the authors frequently repeat themselves. Not recommended.”

This is a poor book, and I was close to giving it one star. I was considering modifying the review above today, as I got started blogging the book; when I wrote the review I’d assumed they’d just put the sources in the back of the book because the idea never crossed my mind that somone might decide to write a book like this without providing any sources (…I mean, that would be insane – and they’re psychiatry professors..). See more details about this aspect below. Normally spelling errors don’t bother me that much, but I spotted four of them in the first 50 pages alone (plus two words that were not separated by a space) and that’s just completely unacceptable; if you make that many mistakes which make it into the final publication then you don’t care enough about your book. I have had good experiences with the Wiley-Blackwell publications I’ve read, but the fact that they allowed this book through is a strong point against them.

The book is not heavy on data, but they do talk quite a bit about various findings from the literature. The problem is that you have to take everything they talk about on faith, and I’m just not that kind of person. No specific studies are mentioned (sentences like, ‘we base this on X&Y’s publication (20XX)’ are completely absent), the number of studies used to establish the conclusions are unknown, effect sizes are rarely talked about except in a very general sense (and you’ve no idea where the numbers are coming from so often such estimates are not actually helpful), limitations of the studies on which the conclusions are based are not covered in any amount of detail. I have the distinct impression that the authors are really bad at math, due to coverage of some specific conditions and the reported risks associated with them, but I won’t go into that in detail here as I consider those specific findings uninteresting (and if they knew basic probability theory, so presumably would the authors). Some of the findings they talk about I’m sure are correct as they are well known and -established in the literature, but there are other claims in the book which contradict what has been found in studies I’ve read in the past on the topic, so I certainly see no great need to just take it for granted that the authors are right. The fact that they won’t go into the details of which studies they are basing their conclusions on and so on frankly just make them look bad, especially considering the overall data quality one has to work with in this area and the limitations imposed by this data quality problem – basically what they’ve ended up with is a book filled with postulates. They don’t even include a literature overview in the final pages of the book, like say in an appendix – the book has an index, but no literature list, so basically they just decided to publish a book in which they don’t even tell you which sources they’re basing their conclusions on. From the point of view of someone who’d only consider evidence which you can test/verify to be valid, this book would be completely worthless as they may just have made it all up. I’m sure they haven’t, but this approach really stinks. One might argue that given that the book’s main focus is on the clinical perspective (how to deal with patients), not epidemiology, lack of sourcing may not be that big of a deal – one major problem here, however, is that writing textbooks this way certainly isn’t the way to promote evidence-based approaches in the future. Given the problematic history of mental health care, this is sure as hell not an area where you get points in my book for not dealing with the data in some detail and dealing with questions related e.g. to how we know what we know, and how and why those conclusions we’ve drawn may be wrong.

As usual when reading this kind of material, I was mildly annoyed by the fact that the authors take for granted the view that all suicides should be prevented. There’s such a thing as a good suicide. I’m not exactly surprised that this notion is absent from the book, but I am still a bit annoyed.

Some observations from the book below:

“based on available data, globally suicide is believed to account for an average of 10–15 deaths for every 100 000 persons each year, and for each completed suicide there are believed to be up to 20 failed suicide attempts.” [believed by whom, you ask? I have no idea] […] “in the USA and many other countries (particularly in wealthy or developed states), suicide continues to be one of the three leading causes of death in young people between the ages of 15 and 24.” […]

“The majority of studies on risk factors for suicide have been conducted in developed countries using the psychological autopsy methodology. Psychological autopsy studies in the West have consistently demonstrated strong associations between suicide and mental disorder, reporting that 90% of people who die by suicide have one or more diagnosable mental illness […] Using the same type of psychological autopsy methodology, studies conducted in developing countries have not demonstrated as robust an association between suicide and mental disorder as purported in the West.” […] Other identified significant risk factors include current or past suicide behaviour, availability of and access to lethal means, exposure to trauma or abuse, severe psychosocial stressors, interpersonal loss, family history of suicide and mental disorder, alcohol and drug misuse, lack of significant relationships and social isolation, chronic physical illness, disabling pain, lack of internal coping abilities, and lack of access to health and social services and supports.” […]

“In North America, studies indicate that the majority (up to two-thirds) of those who die by suicide have had contact with a health care professional for various physical and emotional complaints in the month before their death. […] individuals at risk are often never identified” […]

“In many parts of the world mental illness fails to be recognized as a legitimate health disorder and people with mental illness continue to be misunderstood as weak, lazy, attention seeking, crazy or stupid. Fear of being thought of or being labelled as mentally ill and fear of the ridicule, discrimination, social exclusion, loss of friends, loss of employment or loss of opportunity that may result likely contributes to the secrecy and silence that keeps people from reaching out and receiving help. […] Regardless of the reasons, many of those who die by suicide do not seek help and do not inform others of their plans. Moreover, some who are contemplating suicide or who are committed to completing suicide may not reveal their thoughts or plans even when directly asked.” […]

“Protective factors are those factors and experiences that are believed to reduce the risk for suicide and suicide behaviours and increase a person’s ability to cope with and manage stress and face life’s challenges. […] Protective factors are less well established than are risk factors and the scientific data to support their notation is generally not very strong. […] In the opinion of the authors of this manual, these factors have not been adequately demonstrated to prevent suicide. Many of them are simply negative restatements of known risk factors” […]

“A number of risk factors have been strongly linked to both suicide and suicide behaviours. Distal risk factors can be understood as predisposing factors that may increase a person’s vulnerability to suicide. […] Proximal risk factors include factors which augment current vulnerability for suicide as well as factors which may precipitate or trigger suicide or suicide behaviours.” […]

“In North America, Western Europe (including the UK) and most other countries for which data are available, suicide rates generally increase with increasing age. Projected on top of this trend are three peaks representing periods of increased risk: adolescence/young adulthood, middle age and old age. In general, suicide rates rise sharply in late adolescence and early adulthood, before leveling off through early midlife, then rising again in middle age and then again after age 70. In developed countries the highest suicide rates are found in the elderly. […] In general, suicide behaviours in the elderly are more likely to be lethal as compared to younger age groups. […] In most countries, suicide deaths occur more frequently in men than in women. In the United States, suicide rates are four times higher in men. […] In many Asian countries, including India for example, the rates of suicide death, particularly in rural areas, are almost equal for men and women. In China, female suicide rates are 25% higher than male suicide rates.” [Considering the kind of data likely to be available, I don’t trust this finding very much but I thought the observation was still interesting. Cultural factors causing differences in reported rates is one of many potential drivers here which should at least be considered a potentially contributing factor (e.g. greater shame associated with the suicide of a son (/an heir) than a daughter).] […]

“Suicidal ideation refers to thoughts, fantasies, ruminations and preoccupations about death, self-harm and self-inflicted death. Suicidal ideation can be both ‘passive’ and ‘active’. A person who is actively thinking about killing themselves and is having thoughts of initiating a suicide process that will lead to their death is experiencing active suicide ideation. A person who has thoughts about wanting to ‘disappear’, wishing they could just go to sleep and never wake up, or thoughts that they would rather not be alive, but who does not have thoughts of actively initiating a suicide process that would lead to their death, is experiencing passive suicide ideation. Active suicide ideation confers greater risk than passive suicide ideation and the greater the magnitude and persistence of the suicidal thoughts, the higher the risk for eventual suicide. […] Suicide ideation occurs along a continuum of frequency (fleeting to persistent), intensity (manageable to intolerable or uncontrollable), duration (chronic to acute) and persistence (intermittent to persistent), and can be associated with different levels of intent (no wish or desire to die to strong desire to die) as well as motivation.” […]

“In general, men tend to choose more violent means and women less violent means. Globally, hanging, firearms and poisoning are the most common lethal means for suicide – hanging being the most common in both genders. […] In developing countries, particularly in agricultural areas, ingestion of pesticides is the most common method of suicide. […] an estimated 30% of suicide deaths globally are attributable to the ingestion of pesticide.” […]

“Suicide attempts are 10–20 times more prevalent than completed suicides and up to 50% of those who die by suicide have made at least one previous attempt. These figures are likely underestimates of the true prevalence of suicide attempts as many attempts likely go undetected […] past suicide attempts are a major risk factor for suicide death. Up to one-fifth of people who attempt suicide will reattempt (most within a year) and reattempts are often associated with more lethal means, lower chance of rescue and survival, and higher likelihood of serious medical consequences.” […]

“the suicide rate among single adults is twice that of married adults, and rates among those who are divorced, separated or widowed are four to five times higher than those for married individuals.” […]

“Identification of ‘suicide risk factors’ does not allow a completely accurate prediction of when or if a specific individual will in fact die by suicide. Thus, suicide assessment scales that rely on the cataloguing of patient risk factors, although a useful clinical aid in the assessment of suicide risk, cannot by themselves be used successfully to predict who will commit suicide. […] It is the weighting and confluence of specific suicide risk factors rather than the number of risk factors present that must be considered in determining risk” […]

“Suicidal thoughts are relatively common amongst adolescents. […] Suicidal ideation in and of itself does not indicate psychopathology or need for intervention in teenagers. In children, however, expression of suicidal ideation warrants serious attention. Young children may not appreciate the ‘finality’ of death and therefore may unwittingly commit suicide, not realizing that they will not come back. […] Many […] warning signs are nonspecific and ambiguous, and taken separately may be just a normal part of growing up. On the other hand, if these warning signs represent a clear change in a young person’s personality, behaviour or functioning they may be signals of a serious underlying problem.” […]

“Although many universal and targeted interventions for suicide prevention have been implemented in countries and communities around the world, few have been empirically studied and evaluated in either developing or developed countries. Of those that have been evaluated, few have been shown to impact suicide rates. […] A number of interventions popularly considered to be very effective in reducing suicide rates, including suicide telephone hotlines and school-based suicide-education programmes, have shown little or no substantial positive effect on decreasing suicide rates.” […]

“suicide does not occur in a vacuum. Once the individual ends his or her life, there are clinicians, family members, friends and communities that may require support. […] Experience of shock and disbelief is normal in the first few hours or days following the loss of a loved one. Once the initial shock of the loss has dissipated, most people slowly begin the process of recognizing and accepting the loss. Feelings of intense sadness, anger, hopelessness, helplessness and guilt often wax and wane throughout the day, with periods of extreme intensity becoming less overwhelming and less persistent over time. Thoughts about not wanting to be alive anymore, that life is not worth living, and of wanting to reunite with the deceased are not uncommon […] After six months to one year, the pain associated with the grief generally becomes less intrusive, less intense and less persistent. Although there may be reexperiencing of intense grief when confronted with reminders of the loss, and periods of feeling sad, angry and empty, these grief experiences no longer prevent the person for moving on with their life and doing what they need to do, such as returning to work, returning to school, reconnecting in their personal relationships, participating in social and recreational activities, and caring for their families and children.” […]

“Often the most meaningful way to help someone who has experienced loss is to simply listen to them. […] Acknowledge and validate their feelings. […] Do not tell them not to cry or get angry. […] Do not tell them how you think they should feel. […] Give them space and time to talk about their loss. […] Assist problem-solving around practical issues and concerns.”

November 24, 2013 Posted by | Books, health care, Psychology | Leave a comment

Handbook of critical care (II)

I finished the book. It was hard to rate, in part because I as mentioned in the first post am not exactly part of the main target audience. However I think the book is reasonably well written and it’s certainly not the authors’ fault that I couldn’t always figure out exactly what was going on because I’m an ignorant fool (compared to most people who’ll read this). I ended up giving it four stars.

I covered the first chapters in my first post about the book, but I’ll not cover the rest of the book in as much detail as I did the first part. Topics covered in the remaining chapters were acute renal failure, neurological emergencies, the endocrine system, gastrointestinal disorders, infection and inflammation, hematologic emergencies, nutritional support, physical injury (including things like burns and electrical injuries, as well as near-drowning, hypothermia and heat stroke – which is incidentally quite a bit more dangerous than I’d imagined), toxicology, a chapter on scoring systems used to assess severity of illness among patients in the ICU, and lastly a brief chapter about obstetric emergencies (pre-/eclampsia and HELLP-syndrome). So a lot of ground is covered here, meaning of course also that they do not go into as much detail in many of these chapters as they did in some of the first ones from which I quoted earlier.

I think reading a book like this may cause your viewing experience associated with watching medical dramas to change at least marginally. Some stuff from the remaining part of the book, as well as some comments:

“Traumatic brain injury
Primary brain injury occurs on impact and is considered irreversible. Secondary brain injury […] results from processes initiated by primary insult that occur some time later and may be prevented or ameliorated. Management of traumatic brain injury (TBI) aims to prevent secondary brain injury.”

“Management of organ donors
Once a potential organ donor has been identified, the regional transplant coordinator should be contacted, but he or she should not be involved in the process of diagnosing brain death or obtaining consent for organ donation. In general, the following features exclude eligibility for organ donation: malignancy (except for primary cerebral, skin, or lip), HIV, hepatitis, intravenous drug abuse, active tuberculosis, and sepsis. However, the regional transplant coordinator should make the determination of eligibility. Once brain death has been declared and the family has consented to organ donation, an aggressive approach to preservation of organ function is crucial.”

“Management of hyponatremia
Correction must not exceed 20 mol/L per 48 h and generally at a rate of no more than 0.5 mmol/L per h.” I was curious to know why, so I looked it up – it turns out that really bad things can happen if adjustment is too fast – this may lead to CPM (central pontine myelinolysis). It’s a recurring theme in the book that adjustment speeds matter, and that optimal treatment does not always imply fast adjustment; to give but one other example this is also the case when it comes to treatment of DKA (“The initial aim is to inhibit ketogenesis, which is achieved with modest doses of insulin. Rapid reductions in blood glucose should be avoided”).

“Within 24 h of admission the majority of critically ill patients will develop stress-related mucosal damage. Clinically relevant bleeding causes hematemesis and/or melena; hypotension, tachycardia, or anemia occurs in 1–4% of patients. Those who develop stress-related mucosal disease, endoscopic signs of bleeding, or clinically important bleeding have a higher risk of death. […] Maintenance of an elevated intragastic pH has the potential to prevent stress-related mucosal disease. Studies have demonstrated that a pH of more than 4.0 is adequate to prevent stress ulceration. However, a pH greater than 6.0 may be necessary to maintain clotting in patients at risk from rebleeding in peptic ulcer disease. […] There are, however, concerns that the elevation in pH in patients may lead to increased episodes of pneumonia.”

“Hypergastrinemia from a gastrinoma tumor causes Zollinger–Ellison syndrome (ZES) leading to gastric acid hypersecretion. Gastrin leads to hypertrophy and hyperplasia of the parietal cells which, in turn, also results in gastric acid hypersecretion. Although a rare disease, it is life threatening. […] ZES can be cured in 30% of patients by surgical resection. More than 50% of patients with control of acid hypersecretion who are not cured will die of tumor-related causes. Surgical resection should, therefore, be pursued whenever possible.” (‘More than 50% of patients with control of acid hypersecretion who are not cured will die of tumor-related causes’ – I’m starting to like my diabetes…)

In chapter 8 it’s noted that 50% of acute liver failure cases in the UK are caused by acetaminophen overdose, and that the various forms of viral hepatitis are behind another 40% of cases.

“Severe infection is not only a common cause of admission to intensive care, but also the most common complication suffered by critically ill patients. […] Hospital-acquired pneumonia (HAP) is defined as a pneumonia diagnosed 48 h or more after admission, which was not incubating at the time of admission. In contrast to the hospital population as a whole (in whom urinary tract and wound infections are more frequent), it is the most common infection in the critically ill, and is associated with a mortality rate of up to 50%.”

No, these are not all caused by the poor hand hygiene of nurses and doctors; 10 specific risk factors are listed and it’s made clear that:

“Although community-acquired pathogens can cause HAP, there is a much higher incidence of infection caused by aerobic Gram-negative bacilli. This is possibly the result of overgrowth of the stomach with intestinal bacteria, or the direct vascular spread of organisms that have translocated across the intestinal wall into the circulation.” On a related note, “There is no clear evidence that duration of residence in itself increases the risk of [nosocomial] bacteremia.” The chapter has some great (and/but brief) descriptions of various antibiotics, antivirals and antifungal medications. Some of the descriptions make it very obvious why such drugs are not always as great as they tend to be made out to be – here’s a presumably well-known example:

“Vancomycin inhibits cell wall synthesis. It is the drug of choice in the treatment of MRSA and coagulase-negative staphylococci that are resistant to meticillin.” Sounds great. But here’s the next sentence: “However, it is nephrotoxic and ototoxic, and serum levels must be monitored carefully.” (To those who don’t speak medical textbook, vancomycin may cause kidney failure and cause you to go deaf.)

“Respiratory function is often compromised in patients with cervical cord injury […] The level of injury critically influences the effect on ventilation […] Patients with lesions above C5 (unable to move hands or arms) usually require ventilation. Patients with intact C5 innervation (can shrug shoulders and externally rotate arms) may maintain adequate respiratory function in the absence of any other pulmonary insult. Patients with lesions at C6 will usually manage without ventilatory support in the acute phase.” Spinal cord damage can cause a lot of ugly stuff to happen besides ‘just’ being unable to move limbs – there may also be systemic problems such as various gastrointestinal problems, bladder distension and urinary retention, and loss of ability to regulate normal body temperature (Poikilothermia) as well as other metabolic problems.

“Supportive care is the basis of all treatment in poisoned patients. A medical history and physical examination can help direct which toxins or poisons are involved. It is important to seek out all sources of information because obtaining a history from an attempted suicide patient may be difficult. There may be deliberate misinformation in this setting. One must always assess for coingestions, as most patients who attempt suicide will use two or more toxins. […] Specific poison assays are often unhelpful as absorption is variable and a poor guide to prognosis. […] There are a limited number of poisons that have specific antidotes […] Many antidotes are toxic in their own right and should be reserved for life-threatening poisonings.”

August 26, 2013 Posted by | Books, health care, Infectious disease, Medicine, Microbiology, Nephrology, Neurology, Pharmacology | Leave a comment

Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis

You can buy the book here, though I should note that I’m certain that free versions of the book are also available online. I started reading it yesterday and I completed it today.

The book consists of two parts: Part one deals with “Methods for Generalized Cost-Effectiveness Analysis” and part two consists of “Background Papers and Applications”. If you’re weird, like me, (or if you’re a researcher in the field…) you’ll want to read both parts. They write in the introduction that: “The main objective of this Guide is to provide policy-makers and researchers with a clear understanding of the concepts and benefits of GCEA [generalized cost-effectiveness analysis]. It provides guidance on how to undertake studies using this form of analysis and how to interpret the results.” As mentioned the book has two parts. It’s very clear that part one is written mainly for the politicians and that part two is written for the researchers – and good luck finding a politician who’ll actually read part 2 (/or part 1..?). I like to think that part one can be read and understood by most people, including certainly most readers of this blog, and I do not believe it requires a lot of knowledge about statistics or mathematics; some papers in part 2 on the other hand require math beyond the level I’ve taken for the reader to understand all the steps taken (here are a few wikipedia articles I had a look at while reading this part of the book). They repeat themselves a bit here and there, but it’s not hard to just skim passages containing stuff you’ve already dealt with elsewhere.

It should be noted that although some of it is a bit technical, there’s some good stuff in part 2 as well – for instance I really liked this table (from the fourth study in part 2, Econometric estimation of country-specific hospital costs):

Table 3
Click to view full size. The obvious conclusion to draw here is that costs do not vary much across countries – no, they definitely do not… Actually I was very surprised to learn that there’s a huge amount of variation even within countries – in the same article they note that: “it must be emphasized that there is wide variation in the unit costs estimated from studies within a particular country […] These differences are sometimes of an order of magnitude, and cannot always be attributed to different methods. This implies that analysts cannot simply take the cost estimates from a single study in a country to guide their assessment of the cost-effectiveness of interventions, or the costs of scaling-up. In some cases, they could be wrong by an order of magnitude.”

In the first chapter they state that:

“It appears that the field can develop in two distinct directions, towards increasingly contextualized analyses or towards more generalized assessments. Cost-effectiveness studies and the sectoral application of CEA [cost effectiveness analyses] to a wide range of interventions can become increasingly context specific—at the individual study level by directly incorporating other social concerns such as distributional weights or a priority to treat the sick and at the sectoral level by developing complex resource allocation models that capture the full range of resource, ethical and political constraints facing decision-makers.
We fear that this direction will lead ultimately to less use of costeffectiveness information in the health policy dialogue. Highly contextualized analyses must by definition be undertaken in each context; the cost and time involved as well as the inevitable complexity of the resource allocation models will limit their practical use. The other direction for sectoral cost-effectiveness, the direction that WHO is promoting […] is to focus on the general assessment of the costs and health benefits of different interventions in the absence of various highly variable local decision constraints. A generalized league table of the cost-effectiveness of interventions for a group of populations with comparable health systems and epidemiological profiles can make the most powerful component of CEA readily available to inform health policy debates. Relative judgements on cost-effectiveness—e.g. treating tuberculosis with the DOTS strategy is highly cost-effective and providing liver transplants in cases of alcoholic cirrhosis is highly cost-ineffective—can have wide ranging influence and, as one input to an informed policy debate, can enhance allocative efficiency of many health systems.”

I’m not a health economist so I have no idea which way the field has developed since the book was written. The book isn’t exactly brand new (it’s from 2003) and so I figured one way to probe whether the recommendations have been followed in the years after the book was published was to try to figure out the extent to which one of the big ideas here, the use of Stochastic League Tables in CEAs, has been implemented. So I went to google scholar and searched for the term – and it gave me 7400+ results (and 589 since 2012). It seems to me that the use of these things at least have caught on. I incidentally have no idea to which extent researchers have now moved towards the use of GCEAs and away from the previously (?) widely used ‘incremental approach’ studies when performing these analyses. I posted the long quote above also to caution people unfamiliar with the literature against complaining about CEAs which are ‘not specific enough’ (a complaint I’ve made myself in the past…) – it may make a lot of sense to not make a CEA too specific, in order to make it more potentially useful to decisionmakers. A related point is that the idea of using CEAs in a formulaic way to decide which health interventions ‘pass the bar’ and which do not, and thus base decisions such as which health interventions should receive government support only on the outcome of CEAs, do not have much support in the field – as they put it in Murray, Lauer et al. (study 7 in the second part):

“The results of cost-effectiveness analysis should not be used in a formulaic way—starting with the intervention that has the lowest cost-effectiveness ratio, choosing the next most attractive intervention, and continuing until all resources have been used (10). There is generally too much uncertainty surrounding estimates for this approach; moreover, there are other goals of health policy in addition to improving population health. The tool is most powerful when it is used to classify interventions into broad categories such as those we used. This approach provides decision-makers with information on which interventions are low-cost ways of improving population health and which improve health at a much higher cost. This information enters the policy debate to be weighed against the effect of the interventions on other goals of health policy.”

(They also emphasize this aspect in the first part of the book). I could quote a lot of stuff from the book, but if you’re interested you’ll read it and if you’re not you’d probably not read my quotes either. If you’re interested in cost-effectiveness analyses, I think you should probably read this book – or at least the first part which is relatively easy and does not take that long to read. If you’re not interested in this stuff you should definitely stay away from it. But I think the book is a good starting point if you seek to understand some of the main concepts, issues, and tradeoffs involved when doing and interpreting CEAs.

One last thing I should note, primarily to the people who will not read the book: Many people think of the people doing stuff like cost-effectiveness analyses in this field as the bad guys. That’s because they’re the ones who keep reminding us that we can’t afford everything. When it comes to health care we don’t like to be reminded of this fact, because sometimes when it’s been decided by decisionmakers that public money should not be spent on X it means that someone will die. What I’d like to remind you of is that resource constraints don’t go away just because people prefer to ignore them; rather, when people disregard cost-effectiveness it may just mean that fewer people will be helped and more people will die than if a different course of action, perhaps the one suggested by a CEA, had been taken. CEAs may not provide the complete answer to how we should do these things and they have some limitations, but we should all keep in mind that it matters how we spend our money on this stuff, and that completely ignoring the resource constraint isn’t really a solution to the problems we face when dealing with these matters.

January 30, 2013 Posted by | Books, Economics, health care, Health Economics | Leave a comment

Random stuff from the net, links, wikipedia…

1. RAND: Living Well at the End of Life (via Razib Khan). Here’s a link to one of the sources, a book which deals with some of the same questions: Approaching Death: Improving Care at the End of Life. Looks interesting, don’t have time to read it at the moment.

2. Fatal familial insomnia. “Fatal familial insomnia (FFI) is a very rare autosomal dominant inherited prion disease of the brain. It is almost always caused by a mutation to the protein PrPC, but can also develop spontaneously in patients with a non-inherited mutation variant called sporadic Fatal Insomnia (sFI). FFI is an incurable disease, involving progressively worsening insomnia, which leads to hallucinations, delirium, and confusional states like that of dementia.[1] The average survival span for patients diagnosed with FFI after the onset of symptoms is 18 months.”

Sleep’s important.

3. False consensus effect.

“In psychology, the false consensus effect is a cognitive bias whereby a person tends to overestimate how much other people agree with him or her. There is a tendency for people to assume that their own opinions, beliefs, preferences, values and habits are ‘normal’ and that others also think the same way that they do.[1] This cognitive bias tends to lead to the perception of a consensus that does not exist, a ‘false consensus’. This false consensus is significant because it increases self-esteem. The need to be “normal” and fit in with other people is underlined by a desire to conform and be liked by others in a social environment.

Within the realm of personality psychology, the false consensus effect does not have significant effects. This is because the false consensus effect relies heavily on the social environment and how a person interprets this environment. Instead of looking at situational attributions, personality psychology evaluates a person with dispositional attributions, making the false consensus effect relatively irrelevant in that domain. Therefore, a person’s personality potentially could affect the degree that the person relies on false consensus effect, but not the existence of such a trait.

The false consensus effect is not necessarily restricted to cases where people believe that their values are shared by the majority. The false consensus effect is also evidenced when people overestimate the extent of their particular belief is correlated with the belief of others. Thus, fundamentalists do not necessarily believe that the majority of people share their views, but their estimates of the number of people who share their point of view will tend to exceed the actual number.

This bias is especially prevalent in group settings where one thinks the collective opinion of their own group matches that of the larger population. Since the members of a group reach a consensus and rarely encounter those who dispute it, they tend to believe that everybody thinks the same way.

Additionally, when confronted with evidence that a consensus does not exist, people often assume that those who do not agree with them are defective in some way.[2] There is no single cause for this cognitive bias; the availability heuristic and self-serving bias have been suggested as at least partial underlying factors.

The false consensus effect can be contrasted with pluralistic ignorance, an error in which people privately disapprove but publicly support what seems to be the majority view (regarding a norm or belief), when the majority in fact shares their (private) disapproval. While the false consensus effect leads people to wrongly believe that they agree with the majority (when the majority, in fact, openly disagrees with them), the pluralistic ignorance effect leads people to wrongly believe that they disagree with the majority (when the majority, in fact, covertly agrees with them).”

4. Malthus, An Essay on the Principle of Population. Salman Khan recently made a video on the subject, here’s wikipedia.

5. Marital Rape License (warning, tvtropes link).

“Only a few decades ago, it was legal for a man to rape his wife. Sweden was the first country to explicitly criminalize it in 1965, and it has only been illegal in all fifty US states since 1993. Fifty-three countries around the world still don’t consider it a crime.

In some old patriarchal systems, a woman belonged first to her father (or closest living male relative if the father was dead) and then to her husband. Once married — and in some systems she could be married off without her consent to some old man she despised or had never met — her husband had a legal and “moral” right to her body whether she liked it or not. It gets even creepier when the bride is underage.”

We tend to take a lot of stuff for granted. Another reason why you should read Nothing To Envy.

6. Schema (psychology)

“A schema (pl. schemata or schemas), in psychology and cognitive science, describes any of several concepts including:

*An organized pattern of thought or behavior.
*A structured cluster of pre-conceived ideas.
*A mental structure that represents some aspect of the world.
*A specific knowledge structure or cognitive representation of the self.
*A mental framework centering on a specific theme, that helps us to organize social information.
*Structures that organize our knowledge and assumptions about something and are used for interpreting and processing information.

A schema for oneself is called a “self schema”. Schemata for other people are called “person schemata”. Schemata for roles or occupations are called “role schemata”, and schemata for events or situations are called “event schemata” (or scripts).

Schemata influence our attention, as we are more likely to notice things that fit into our schema. If something contradicts our schema, it may be encoded or interpreted as an exception or as unique. Thus, schemata are prone to distortion. They influence what we look for in a situation. They have a tendency to remain unchanged, even in the face of contradictory information. We are inclined to place people who do not fit our schema in a “special” or “different” category, rather than to consider the possibility that our schema may be faulty. As a result of schemata, we might act in such a way that actually causes our expectations to come true.”

7. Koch Snowflake Fractal (a structure with infinite perimeter but a finite area). Couldn’t remember if I’ve already blogged this at one point, but no harm done in case I have:

January 3, 2012 Posted by | Books, Genetics, health care, Khan Academy, Mathematics, Psychology, Wikipedia | Leave a comment

Terry Pratchett: Shaking Hands with Death

You should watch this:

Also, this.

November 4, 2011 Posted by | health care, Terry Pratchett | Leave a comment

Danish death panels

Mostly to the non-Danish readers. It seems there’s recently been a story about widespread use of secret DNR-codes by Danish doctors, I haven’t been able to find an article about it in English but here’s google translate. The doctors apparently systematically write in the journals of some sick people that nurses and staff should not try to save the individual in case they have a heart attack. In some cases, the code states that they shouldn’t be put in intensive care.

There’s been zero debate about this before this story broke, it was just something doctors did. A study from 2007 that apparently now has come to some journalist’s attention found that whereas almost all departments use the ‘no resuscitation in case of heart attack’ (natural enough, some people want to avoid becoming a living vegetable and people are given the choice) one third of all medical departments (n= 138) use these codes in secret, where the doctor makes the decision, often without informing the patient. 38 percent of the departments uses the codes in cases where the individual is not terminal.

Another article – which google translate translates into something that makes absolutely no sense – makes it clear that the practise is illegal, as it’s currently (on paper) illegal to decide whether a patient should be attempted resuscitated or not without informing the individual. The doctor actually can decide you should not receive treatment, but he has to inform you about the decision and your response to the decision should be put into the medical chart. I didn’t know that you could be denied resuscitation attempts but it doesn’t surprise me.

I think the health care system is one of those places where people sometimes can convince themselves that it’s better just to pretend tradeoffs don’t exist, because then they don’t have to deal with the ethical dilemmas which are all over the place. But the tradeoffs don’t go away by pretending they do, and somebody has to make some hard choices at some point. If nobody else do, the doctors have to; if everybody else just ignore the incompatibility of the current political demands (the laws) regarding medical service provision and the ressource constraints that exist in the field, well, the doctors are pretty much left with the bag.

January 17, 2011 Posted by | health care | Leave a comment

Demand: 80.000, potential supply: 300.000.000

Yet a shortage still exists in the US – and most other places too. Yes, we are of course talking about kidneys.

I’ve said it before, I’ll say it again: The current policy kills. Read Virginia Postrell’s (very long and informative) article on the subject here.

Currently, 500-600 Danes are waiting for a kidney.

(An aside to Danish readers: Det tager kun et minut eller to at tilmelde sig donorregistret her. Uanset hvordan man har det med det nuværende system, vil denne simple handling en dag kunne redde et eller flere liv)

July 12, 2009 Posted by | health care | 2 Comments

A thought

Robin: A thought occurred to me about medical spending. There exists a classic economic model that would be consistent with medical spending being completely uncorrelated from health outcomes – that of a monopoly with the ability to implement price discrimination. (In other words, it’s exactly what you’d expect if people paid widely varying amounts of money for the same average quality of treatment.)

Doug S., in a comment here. I’d never thought of it like that, but now that the idea has been formulated, I wonder how close to the truth this is.

Robin Hanson’s idea about health care spending is, in case you didn’t know, that appr. half of all US health care spending is pure waste with no measurable effect on outcomes. This link provides a graph that illustrates the cost-effectiveness (or lack thereof) of the US health care system by plotting per-capita-spending and longevity for different countries.

October 27, 2008 Posted by | health care, USA | Leave a comment

Well, it’s a theory…

One reason we might have a “health care crisis” and rising medical costs is that we turn away almost 97% of the applicants to medical schools.

Here’s the link.

July 16, 2008 Posted by | health care, Random stuff | Leave a comment