7 ms·

Should Psychiatry Test for Lead More?

77 points by smackay 8y ago

conistonwater 8y ago
Link should be: http://slatestarcodex.com/2018/05/23/should-psychiatry-test-for-lead-more/ http://slatestarcodex.com/2018/05/23/should-psychiatry-test-...
pjc50 8y ago
It sounds like the whole field is contaminated with mind-body dualism. But there's a bigger problem; even once you accept that humans are fully physical, embodied minds in a sea of whatever chemicals can cross the blood-brain barrier, the scope is wider. Humans are part of a society that can harm them without effective means of redress. Also, from the original paper, via the linked LJ: https://siderea.dreamwidth.org/1388220.html https://siderea.dreamwidth.org/1388220.html "I began taking blood samples from everybody who came to the clinic. At times it seemed like Transylvania Station. The state Department of Public Health's laboratory tested blood free for anyone under the age of 12 and provided plastic pipettes, finger puncture equipment, and even mailing envelopes at no cost. So, for a while, everyone in the clinic was declared to be under 12 years of age." Both a nice public healthcare hack and a risky thing to admit in a journal article.
- pmoriarty 8y ago
  "once you accept that humans are fully physical, embodied minds in a sea of whatever chemicals can cross the blood-brain barrier" What humans are is far from settled.
  - andai 8y ago
    True, but whatever I am responds poorly to heavy metals.
- CalRobert 8y ago
  " once you accept that humans are fully physical, embodied minds in a sea of whatever chemicals can cross the blood-brain barrier" I'm not disagreeing, but is this something that everyone reasonable would agree on without any sort of support? "Humans are part of a society that can harm them without effective means of redress." Indeed. I am sad every morning I walk my child to creche and her head (in a pram) is at the same height as the exhaust pipes next to her. Yet, there's nothing to be done, apparently.
  - Iv 8y ago
    "I'm not disagreeing, but is this something that everyone reasonable would agree on without any sort of support?" We are lucky then that there is a ton of support to this claim. Some people may argue with the word "fully" but if you replace it by "in big part" I don't think one can disagree with that without throwing a century of medical research out of the window.
    - krageon 8y ago
      There is no consensus about how consciousness arises from the brain specifically, or how it works. We're pretty sure that if the brain breaks, the expression of consciousness will also break (occasionally in predictable ways). Further than that, you can make no definite statements about it and call yourself scientific. It's still mostly a philosophical problem with no clear solutions.
      - CalRobert 8y ago
        "how consciousness arises from the brain specifically" This seems like the most important question in the universe, and one not nearly studied enough. For instance, the idea that consciousness is a fundamental feature of the universe that is simply manifested in brains sounds very woo - but hasn't been falsified. The question of when an animal goes from "unconscious, animate matter" to "thinking self-aware being" seems unclear as well (and is very relevant to medical ethics w.r.t embryo experimentation, etc.) By comparison to another out-there idea, if we're willing to take the Many-Worlds Interpretation seriously (and enough well-informed scientists do) then I'm not sure it's a _completely_ settled matter that we have a good sense that humans are "fully physical, embodied minds". However, lead is bad for brains. I think we know that much.
nabla9 8y ago
If the patient is chronically not well, they will often show symptoms of depression. Diagnosis of exclusion that can't find the cause often ends with depression diagnosis. In this sense depression is a trashcan diagnosis. It's the default end for short decision tree.
- AstralStorm 8y ago
  Depression is not a diagnosis. The diagnosis is "iatrogenic depression", "substance abuse related depression", "pervasive depressive disorser", "bipolar disorder related depression", "developmental disorder related depression", "adjustment disorder" and only very finally there is the "idiopathic major depressive disorder" and a few gradations thereof, which is the trashcan. And I've probably skipped a few. (E.g. genetic folate metabolism disorder, thyroid related) Treatments are different in each. Lead, mercury and some other heavy metal exposure is one of iatrogenic. They are not commonly tested as they are rare causes and tests are not specific. (As opposed for thyroid panel and folate check which are highly specific.)
brownbat 8y ago
Fair warning, this is a bit of a comment trap, insofar as the post is less about lead per se, and more about a class of decision-making problems involving the allocation of scarce resources and massive uncertainty. But incidentally, public health and governing bodies should definitely work to reduce lead in communities, regardless of the duty of psychiatrists. And maybe some researcher should improve chelation? But there are other things to work on, and that might be simply intractable, so maybe not.
- koboll 8y ago
  It would be nice if HN had an all-around light moderation policy, with the sole exception that commenters who clearly haven't read the article and are debating with the title be barred from commenting for a certain period of time.
- criddell 8y ago
  Whenever I see a title that's posing a question, I like to immediately assume the answer is "no". It makes the headline seem pretty ridiculous.
  - severine 8y ago
    Betteridge's law of headlines: Betteridge's law of headlines is an adage that states: "Any headline that ends in a question mark can be answered by the word no." It is named after Ian Betteridge, a British technology journalist, although the principle is much older. As with similar "laws", it is intended to be humorous rather than the literal truth.
lostlogin 8y ago
Surprised it hasnt been mentioned yet, but just in case there is a HN reader who hasn’t read the lead article by Drum - it’s good. https://www.motherjones.com/environment/2016/02/lead-exposure-gasoline-crime-increase-children-health/ https://www.motherjones.com/environment/2016/02/lead-exposur...
- staz 8y ago
  Thanks
amelius 8y ago
Why don't doctors give patients a choice? Some people may wish to pay for more extensive testing.
- dsr_ 8y ago
  Two important details: 1. Doctors don't appear to even think about lead poisoning unless you give them big fat clues like "My job is scraping lead paint off a bridge." What they don't think about, they don't ask about, just like everyone else. 2. The patients presenting with psychiatric symptoms that could be caused by lead poisoning are much more likely to be near the poverty line than a random sampling of people with stress and depression. Insurance companies are not likely to pay for lead blood tests unless they see a good reason to do so, and poor people are much less likely to have insurance in the first place.
  - amelius 8y ago
    True. But the article speaks of more than just lead poisoning. > And when you’ve answered that, what about copper? Omega-3/omega-6 ratio? Vitamin D levels? Cortisol? Magnesium balance? The methylation cycle? Cortisol? Mitochondrial function? Inflammation? Covert viral infections? Covert autoimmune disorders? Paraneoplastic syndromes? Allergies? Light exposure? Circadian rhythm? Selenium? Lithium levels in your local water supply? Insulin resistance? Gut microbiome? PANDAS? FODMAPs? Structural brain abnormalities? And that’s not even getting into the psychosocial stuff! I want my doctor to tell me what tests have what probability of being positive, and the cost, so I can make an informed decision.
    - AstralStorm 8y ago
      Half of the things do not require tests at all. E.g. light exposure and circadian rhythm are answered in a questionnaire. (And sleep quality - clue to sleep apnea.) Likewise allergies and their medication or major gut diseases. Water sample is less useful as many people use enough bottled water and diffuse sources (out of home) to make test at any one location pointless. Leave it to epidemiology. Just ask if the person is taking lithium. Insulin resistance is done with the standard metabolic and blood panel. These are best done as screening regularly. (But nobody wants to pay for that.) Since you will be checking thyroid why not extend. Gut microbiome is speculative. We do not even have tests. Brain abnormalities? Either it is in history (major surgeries, seizures) or we don't even know what they are. Vitamins and microelements are also speculative.
narrator 8y ago
Heavy metal poisoning is a cause of mental illness that is reversible and does not require the patient to take drugs for the rest of their lives. We like selling drugs to people for the rest of their lives in this country.
- losvedir 8y ago
  I despise this sentiment. It's one of those tired cliches like "if you're not the customer you're the product", which at first pass seems like some cute insight, but is actually awful at predicting anything about reality. This disagrees with literally everything I have ever heard or seen in the healthcare industry, whether that's from doctors (family), drug development (friends), or healthcare-focused finance (career). Everyone I've ever known or worked with in healthcare has always been 100% about trying to make people better. Yes, even in finance, where I evaluated biotech stocks to make recommendations to buy or sell. The better the the drug worked, the more excited everyone was about it. It's so hard to make a drug, that some sort of evil "let's help them but not cure them" approach isn't even possible, not that anyone I know would even want that. Yes, there was that Goldman Sachs report floating around a couple months ago about the difficulties to businesses when finding cures, but even that report's takeaway was about the need for finding companies that continue to innovate and come up with new therapies.
  - narrator 8y ago
    Except chelation uses old, cheap out of patent drugs that only have to be taken for a limited time. American industry doesn't like cheap, old drugs.
    - AstralStorm 8y ago
      Chelation is ineffective at repairing damage done by chronic heavy metal intake. It is mostly useful for acute toxicity. (And potentially cleaning up cholesterol arterial plaque, that is being investigated.) It has major side effects. Even in trial like 15% drop out rates were reported due to side effects. The main treatment if actual exposure is known and chronic is to... stop the exposure.
virmundi 8y ago
Cops should do the same test. There was an NPR story a while back about a school, mostly black, that did poorly on a standardized test. The school officials declared the test racist. The science teacher couldn’t find that from the test. He wondered about lead. Low and behold the school was full of lead poisoned children. They started treatment and the scores improved by the end of the year ( the also abated the houses with grant money). We know lead causes aggression issues. We know poor communities have higher incidence of lead in their homes. How many criminals could be prevented, or reformed with lead treatment?
- tyu100 8y ago
  The article was about why testing for lead in depression is probably not a good idea or at least not a better idea than a million other things.
  - virmundi 8y ago
    I know. Lead testing is a soap box for me. Palatka has a high crime rate. I would love to know how much of it might be solved with cops testing.
    - bblough 8y ago
      If you're in Palatka, then I'm not far from you. If you want to meet up for coffee or a meal or something, my contact info is in my profile.
  - jerf 8y ago
    The article was about the lack of utility of testing for it in individual psychiatric cases. When you have a correlated problem like an entire school underperforming for no apparent reason (that is, even by the standards of a poor school, it is exceptionally poor), the math changes a lot. You have a rational reason to suspect some sort of correlated cause.
- crankylinuxuser 8y ago
  I'd go further.. When a chemical that you were dosed with, and willingly did not and would never take, is determined that it made you do erratic and/or dangerous behavior, should the courts find you at fault? It's different when you willingly take a drug (eg: meth) and you end up hurting or killing someone on it. You chose to take the drugs which lead to violence. I know of nobody who willingly doses Pb.
pasbesoin 8y ago
Yes. They should also look at environmental toxins. "Sick" houses, etc. And physiological problems. Anecdotally, I've seen a lot of mental health treatment that went after symptoms while ignoring root causes. P.S. Over time, physically induced problems can lead to outright mental problems. PTSD, for example. Also, IANAD.

77 points by smackay 8y ago

Link should be: http://slatestarcodex.com/2018/05/23/should-psychiatry-test-for-lead-more/ http://slatestarcodex.com/2018/05/23/should-psychiatry-test-...

pjc50 8y ago

It sounds like the whole field is contaminated with mind-body dualism. But there's a bigger problem; even once you accept that humans are fully physical, embodied minds in a sea of whatever chemicals can cross the blood-brain barrier, the scope is wider. Humans are part of a society that can harm them without effective means of redress. Also, from the original paper, via the linked LJ: https://siderea.dreamwidth.org/1388220.html https://siderea.dreamwidth.org/1388220.html "I began taking blood samples from everybody who came to the clinic. At times it seemed like Transylvania Station. The state Department of Public Health's laboratory tested blood free for anyone under the age of 12 and provided plastic pipettes, finger puncture equipment, and even mailing envelopes at no cost. So, for a while, everyone in the clinic was declared to be under 12 years of age." Both a nice public healthcare hack and a risky thing to admit in a journal article.

pmoriarty 8y ago
"once you accept that humans are fully physical, embodied minds in a sea of whatever chemicals can cross the blood-brain barrier" What humans are is far from settled.
- andai 8y ago
  True, but whatever I am responds poorly to heavy metals.
CalRobert 8y ago
" once you accept that humans are fully physical, embodied minds in a sea of whatever chemicals can cross the blood-brain barrier" I'm not disagreeing, but is this something that everyone reasonable would agree on without any sort of support? "Humans are part of a society that can harm them without effective means of redress." Indeed. I am sad every morning I walk my child to creche and her head (in a pram) is at the same height as the exhaust pipes next to her. Yet, there's nothing to be done, apparently.
- Iv 8y ago
  "I'm not disagreeing, but is this something that everyone reasonable would agree on without any sort of support?" We are lucky then that there is a ton of support to this claim. Some people may argue with the word "fully" but if you replace it by "in big part" I don't think one can disagree with that without throwing a century of medical research out of the window.
  - krageon 8y ago
    There is no consensus about how consciousness arises from the brain specifically, or how it works. We're pretty sure that if the brain breaks, the expression of consciousness will also break (occasionally in predictable ways). Further than that, you can make no definite statements about it and call yourself scientific. It's still mostly a philosophical problem with no clear solutions.
    - CalRobert 8y ago
      "how consciousness arises from the brain specifically" This seems like the most important question in the universe, and one not nearly studied enough. For instance, the idea that consciousness is a fundamental feature of the universe that is simply manifested in brains sounds very woo - but hasn't been falsified. The question of when an animal goes from "unconscious, animate matter" to "thinking self-aware being" seems unclear as well (and is very relevant to medical ethics w.r.t embryo experimentation, etc.) By comparison to another out-there idea, if we're willing to take the Many-Worlds Interpretation seriously (and enough well-informed scientists do) then I'm not sure it's a _completely_ settled matter that we have a good sense that humans are "fully physical, embodied minds". However, lead is bad for brains. I think we know that much.

nabla9 8y ago

If the patient is chronically not well, they will often show symptoms of depression. Diagnosis of exclusion that can't find the cause often ends with depression diagnosis. In this sense depression is a trashcan diagnosis. It's the default end for short decision tree.

AstralStorm 8y ago
Depression is not a diagnosis. The diagnosis is "iatrogenic depression", "substance abuse related depression", "pervasive depressive disorser", "bipolar disorder related depression", "developmental disorder related depression", "adjustment disorder" and only very finally there is the "idiopathic major depressive disorder" and a few gradations thereof, which is the trashcan. And I've probably skipped a few. (E.g. genetic folate metabolism disorder, thyroid related) Treatments are different in each. Lead, mercury and some other heavy metal exposure is one of iatrogenic. They are not commonly tested as they are rare causes and tests are not specific. (As opposed for thyroid panel and folate check which are highly specific.)

brownbat 8y ago

Fair warning, this is a bit of a comment trap, insofar as the post is less about lead per se, and more about a class of decision-making problems involving the allocation of scarce resources and massive uncertainty. But incidentally, public health and governing bodies should definitely work to reduce lead in communities, regardless of the duty of psychiatrists. And maybe some researcher should improve chelation? But there are other things to work on, and that might be simply intractable, so maybe not.

koboll 8y ago
It would be nice if HN had an all-around light moderation policy, with the sole exception that commenters who clearly haven't read the article and are debating with the title be barred from commenting for a certain period of time.
criddell 8y ago
Whenever I see a title that's posing a question, I like to immediately assume the answer is "no". It makes the headline seem pretty ridiculous.
- severine 8y ago
  Betteridge's law of headlines: Betteridge's law of headlines is an adage that states: "Any headline that ends in a question mark can be answered by the word no." It is named after Ian Betteridge, a British technology journalist, although the principle is much older. As with similar "laws", it is intended to be humorous rather than the literal truth.

lostlogin 8y ago

Surprised it hasnt been mentioned yet, but just in case there is a HN reader who hasn’t read the lead article by Drum - it’s good. https://www.motherjones.com/environment/2016/02/lead-exposure-gasoline-crime-increase-children-health/ https://www.motherjones.com/environment/2016/02/lead-exposur...

staz 8y ago
Thanks

amelius 8y ago

Why don't doctors give patients a choice? Some people may wish to pay for more extensive testing.

dsr_ 8y ago
Two important details: 1. Doctors don't appear to even think about lead poisoning unless you give them big fat clues like "My job is scraping lead paint off a bridge." What they don't think about, they don't ask about, just like everyone else. 2. The patients presenting with psychiatric symptoms that could be caused by lead poisoning are much more likely to be near the poverty line than a random sampling of people with stress and depression. Insurance companies are not likely to pay for lead blood tests unless they see a good reason to do so, and poor people are much less likely to have insurance in the first place.
- amelius 8y ago
  True. But the article speaks of more than just lead poisoning. > And when you’ve answered that, what about copper? Omega-3/omega-6 ratio? Vitamin D levels? Cortisol? Magnesium balance? The methylation cycle? Cortisol? Mitochondrial function? Inflammation? Covert viral infections? Covert autoimmune disorders? Paraneoplastic syndromes? Allergies? Light exposure? Circadian rhythm? Selenium? Lithium levels in your local water supply? Insulin resistance? Gut microbiome? PANDAS? FODMAPs? Structural brain abnormalities? And that’s not even getting into the psychosocial stuff! I want my doctor to tell me what tests have what probability of being positive, and the cost, so I can make an informed decision.
  - AstralStorm 8y ago
    Half of the things do not require tests at all. E.g. light exposure and circadian rhythm are answered in a questionnaire. (And sleep quality - clue to sleep apnea.) Likewise allergies and their medication or major gut diseases. Water sample is less useful as many people use enough bottled water and diffuse sources (out of home) to make test at any one location pointless. Leave it to epidemiology. Just ask if the person is taking lithium. Insulin resistance is done with the standard metabolic and blood panel. These are best done as screening regularly. (But nobody wants to pay for that.) Since you will be checking thyroid why not extend. Gut microbiome is speculative. We do not even have tests. Brain abnormalities? Either it is in history (major surgeries, seizures) or we don't even know what they are. Vitamins and microelements are also speculative.

narrator 8y ago

Heavy metal poisoning is a cause of mental illness that is reversible and does not require the patient to take drugs for the rest of their lives. We like selling drugs to people for the rest of their lives in this country.

losvedir 8y ago
I despise this sentiment. It's one of those tired cliches like "if you're not the customer you're the product", which at first pass seems like some cute insight, but is actually awful at predicting anything about reality. This disagrees with literally everything I have ever heard or seen in the healthcare industry, whether that's from doctors (family), drug development (friends), or healthcare-focused finance (career). Everyone I've ever known or worked with in healthcare has always been 100% about trying to make people better. Yes, even in finance, where I evaluated biotech stocks to make recommendations to buy or sell. The better the the drug worked, the more excited everyone was about it. It's so hard to make a drug, that some sort of evil "let's help them but not cure them" approach isn't even possible, not that anyone I know would even want that. Yes, there was that Goldman Sachs report floating around a couple months ago about the difficulties to businesses when finding cures, but even that report's takeaway was about the need for finding companies that continue to innovate and come up with new therapies.
- narrator 8y ago
  Except chelation uses old, cheap out of patent drugs that only have to be taken for a limited time. American industry doesn't like cheap, old drugs.
  - AstralStorm 8y ago
    Chelation is ineffective at repairing damage done by chronic heavy metal intake. It is mostly useful for acute toxicity. (And potentially cleaning up cholesterol arterial plaque, that is being investigated.) It has major side effects. Even in trial like 15% drop out rates were reported due to side effects. The main treatment if actual exposure is known and chronic is to... stop the exposure.

virmundi 8y ago

Cops should do the same test. There was an NPR story a while back about a school, mostly black, that did poorly on a standardized test. The school officials declared the test racist. The science teacher couldn’t find that from the test. He wondered about lead. Low and behold the school was full of lead poisoned children. They started treatment and the scores improved by the end of the year ( the also abated the houses with grant money). We know lead causes aggression issues. We know poor communities have higher incidence of lead in their homes. How many criminals could be prevented, or reformed with lead treatment?

tyu100 8y ago
The article was about why testing for lead in depression is probably not a good idea or at least not a better idea than a million other things.
- virmundi 8y ago
  I know. Lead testing is a soap box for me. Palatka has a high crime rate. I would love to know how much of it might be solved with cops testing.
  - bblough 8y ago
    If you're in Palatka, then I'm not far from you. If you want to meet up for coffee or a meal or something, my contact info is in my profile.
- jerf 8y ago
  The article was about the lack of utility of testing for it in individual psychiatric cases. When you have a correlated problem like an entire school underperforming for no apparent reason (that is, even by the standards of a poor school, it is exceptionally poor), the math changes a lot. You have a rational reason to suspect some sort of correlated cause.
crankylinuxuser 8y ago
I'd go further.. When a chemical that you were dosed with, and willingly did not and would never take, is determined that it made you do erratic and/or dangerous behavior, should the courts find you at fault? It's different when you willingly take a drug (eg: meth) and you end up hurting or killing someone on it. You chose to take the drugs which lead to violence. I know of nobody who willingly doses Pb.

pasbesoin 8y ago

Yes. They should also look at environmental toxins. "Sick" houses, etc. And physiological problems. Anecdotally, I've seen a lot of mental health treatment that went after symptoms while ignoring root causes. P.S. Over time, physically induced problems can lead to outright mental problems. PTSD, for example. Also, IANAD.