Mind Hacks

A new study has made headlines around the world that claim that internet use is linked to depression despite better evidence from previous studies that there is no substantial link.

The study itself is a fairly straightforward online survey with the key finding that out of 1,319 people who completed the questionnaires, 18 were identified as ‘addicted’ by Kimberly Young’s Internet Addiction Questionnaire and these people were more likely to score highly on the BDI – a standard questionnaire to measure depression.

The study itself was well conducted although it is not a surprising finding because Young’s Internet Addiction Questionnaire (which you can read online here) asks lots of questions about emotional distress, so it’s hardly surprising that people who say they’re distressed on one questionnaire will say they’re distressed on the other.

I have criticised the concept of internet addiction on the basis that the whole concept doesn’t make sense, but research has also shown that these ‘diagnostic’ questionnaires are not particularly reliable, meaning they not a good guide even to what they claim they’re doing.

But perhaps the most important point, is that this study is just one in a long line of studies that have looked at whether internet use is linked to changes in mood.

Recently, a type of study called a meta-analysis was published that looked at all of these previous studies to see what the overall effect was – in essence, a mathematical aggregation of all the reported findings to get at the big picture.

This meta-analysis found that there was a statistically reliable link between internet use and depression, but one so small as to be insignificant. In fact, it found that internet was responsible for between 0.02% and 0.03% of total changes in mood (stats geeks: the variance was not reported directly but I calculated it from the r by the coefficient of determination).

In other words, internet use explains so little of a person’s depression that it’s irrelevant. It’s like knowing that hypothermia is a serious medical condition and that drinking a glass of water reliably lowers body temperature, but by such a small amount as to be medically unimportant.

Interestingly, I am quoted in some of the news stories about the study. Actually, I was contacted by a BBC journalist and some other stories have seemingly just nicked the quotes (often wrongly describing me as a psychiatrist).

What’s curious is that I sent the BBC journalist a link to the meta-analysis, even explained what it found and what a meta-analysis is, and included comments about why the study doesn’t change the general conclusion.

Instead of focusing on the existing evidence, I am quoted as being a naysayer. I have not been misquoted but the most important scientific point is omitted at the expense of presenting my words. This seems to be a common pattern where news stories often privilege opinion over data, when science privileges data over opinion.

In fact, the motto of the Royal Society, the world’s oldest scientific society, translates as “on the words on no-one”, but news stories often turn the hierarchy of evidence on its head, giving a skewed impression of the most fundamental way in which science works.

In this case, to suggest that science has established that internet use is strongly linked to depression when we know that it isn’t.

Link to PubMed entry for latest study.
Link to PubMed entry for meta-analysis.

Slate has two articles on an innovative but controversial service in Vancouver, Canada, that provides injecting drug users with a place to safely inject drugs with clean equipment and medical staff on hand.

The project, ‘Insite’, is based on a ‘harm reduction‘ approach which is driven by the idea that users should be encouraged to take drugs in the safest way possible.

This is partly an admission that addiction treatment is not very successful on its own, but partly a public health measure in that injecting drug users have much higher rates of diseases such as HIV and hepatitis and are more likely to pass them on to other people.

It is also the case that one of the biggest dangers from injecting drugs is the actual practice of injecting, as unsanitary conditions, ad-hoc ‘cooking up’ and unpredictable street dope as become much more risky when the final product is injected into the bloodstream.

These services can be controversial in some places as they can be seen to be condoning drug use, although some countries are now going further and actually prescribing heroin to addicts.

One of the biggest impacts on society is not the fact that a tiny minority of people are damaging themselves with smack, but that they tend to commit crimes to feed their habit and support a violent criminal network of dealers.

Methadone is a heroin substitute that has been prescribed for years and we know that it can stabilise the lives of users and increase their chance of kicking the habit.

But it is often not what users want. It stops the withdrawals, as it’s another form of opioid drug, but it doesn’t feel the same and still has the danger of overdose. One common problem is known euphemistically in the medical literature ‘methadone diversion‘ where users sell their methadone to buy street drugs.

Several countries have trialled the prescription of heroin itself, with, it turns out, a great deal of success – including better health, a reduction in criminal activity and a higher chance of actually kicking the habit.

This may seem counter-intuitive, but one of the advantages of these projects is that the user is constantly in contact with health professionals who can provide addiction treatment.

The political and local opposition to harm reduction services is usually immense, however. Politicians want to be seen to be ‘tough on drugs’ and no-one, and I mean no-one, wants one of these clinics near where they live.

The Slate articles looks into the day-to-day running and talks to some of the clients of the Vancouver programme, and provides an insight into the challenges such services face. There’s also a gallery of photos that captures the project in action.

Link to Slate article ‘Welcome to Insite’.
Link to Slate article ‘Upstairs, Downstairs’.
Link to photos of the Insite project.

Newsweek has an excellent article that charts the rise and fall of antidepressants from their status as a wonder drug that made people ‘better than well’ to the recent evidence that suggests for many people, they’re not much better than placebo.

The piece particularly follows the work of psychologist Irving Kirsch who was the first to conduct a meta-analysis of the effects of anti-depressants back in 1998.

Titled “Listening to Prozac but hearing placebo” it suggested that the drugs were hardly more effective than placebo and, for many, marked Kirsch out as a biased and dangerous ‘anti-psychiatrist’.

However, later studies in a similar vein by both Kirsch and others have supported his original findings and many countries have now changed their treatment recommendations as a result.

The Newsweek article tracks this story but also picks up on many important subtitles in the story, notably that the research doesn’t suggest that antidepressants are useless – quite the opposite – just that their effect is only in part due to their direct chemical effect; and that many patients in trials work out that they’re not taking placebo because of the side-effects and this realisation can trigger a stronger placebo effect.

It also integrates evidence from the recent STAR*D study, one of the most complete on the best methods to treat depression.

If you want a good overview of the debate on the effectiveness of these iconic drugs, this is a good place to start.

Additionally, if you’re interested in a good analysis of the most recent study in this area, just published in the Journal of the American Medical Association, the Neuroskeptic blog has a great write-up and analysis of what this means for the concept of depression itself.

Link to Newsweek piece on antidepressants (via @DrDavidBallard).
Link to write-up of JAMA study at Neuroskeptic.

Science isn’t sure whether fear can kill but several courts have been convinced and have convicted people for murder on the basis that they caused death through fright. An article just published in the American Journal of Cardiology summarises the eight murder trials.

The cases are not, as I first suspected, where someone had deliberately tried to kill someone else using fright as a ‘weapon’ (like in the infamous scene in Belgian serial killer mockumentary Man Bites Dog – clip here – warning: not pleasant).

Instead, they typically describe where someone has died of a heart attack in the midst of an armed robbery or assault, despite not being mortally wounded.

In a similar case, State v. Edwards,10 the defendant and his accomplices entered a bar in Tucson, Arizona and committed a robbery at gunpoint. Shortly after the robbers had fled, the proprietor experienced a heart attack and died. The defendant argued that the victim’s death was accidental and unintended and could not constitute murder. Moreover, the defendant maintained that the evidence was insufficient to prove that the robbery actually caused the victim’s death.

The court disagreed on both counts, finding first that accidental, unintended consequences could form the basis of a murder conviction. Second, the court pointed to the testimony of a pathologist that the death was caused by anxiety resulting from the robbery at gunpoint. The court held that this provided adequate evidence to support causation.

However, this is not the only area where supposedly being ‘frightened to death’ has caught the interest of psychologists. There is a small psychological literature on ‘psychogenic death’ that attempts to explore reports of death after curses, spells or violation of cultural taboos.

This is from an excellent brief article from 2003, published in the journal Mental Health, Religion & Culture:

Landy (1977, p. 327) describes the phenomenon as follows: ‘a process is set in motion, usually by a supposed religious or social transgression that results in the transgressor being marked out for death by a sorcerer acting on behalf of society through a ritual of accusation and condemnation; then death occurs within a brief span, usually 24 to 48 hours’. Ellenberger (1965) distinguishes acute from slow psychogenic death. In some cases, the death can be rapid, in other cases the process occurs over several weeks where the patient sickens and dies. There has been some doubt expressed as to whether voodoo death is part of ‘colonial folklore’ only based on anecdotal reports (Williams, 1928).

Lewis (1977, p. 11) asks, ‘Is it really the case that healthy people have died in a day or three days because they know they were victims of sorcery? Who has seen this happen with his own eyes? Is there no explanation for it but sorcery?’ Yap (1977) calls for concrete findings from anthropologists and medical field workers that can be appraised critically. Questions have arisen as to whether or not these victims had pre-existent pathological conditions predisposing them to death. There is however some direct evidence for its occurrence.

The evidence is not people just dropping dead, but from several documented cases where perfectly healthy people rapidly give up eating and drinking after being ‘cursed’ and dehydration leads to death.

Link to PubMed entry for ‘Homicide by fright’ article.
Link to DOI entry and summary for ‘psychogenic death’ article.