A Q&A with Richard Layard and David Clark, authors of THRIVE

Thrive jacketHow can mental illness—an affliction that affects at least 20 percent of people in developed countries, reduces life expectancy, and wrecks havoc on educational potential—remain chronically under-treated? The answer is simple: mental and physical pain are not viewed equally, and even in a relatively progressive culture, the former remains profoundly stigmatized. As a result, most who suffer from mental health issues suffer in silence, or receive inadequate support. Can this change? Richard Layard and David Clark say it can.

In Thrive, Layard and Clark look at the practical politics of increasing access to mental health care, arguing that the therapies that exist—and work—are available at little to no cost. Recently, both took the time to answer some questions about the book, and the transformative power of mental health care.

What is the message of your book?

Depression and anxiety disorders are the biggest single cause of misery in Western societies. They also cause enormous damage to the economy. But they are curable, in most cases, by modern evidence-based psychological therapy. The shocking thing is that very few of those who need it get any help and fewer still get help based on evidence. In England such help is now becoming available to many of millions who need it. As we show, this help involves no net cost to society. It’s a no-brainer.

What is the scale of the problem?

Surveys of households in rich countries show that around 1 in 6 adults have depression or anxiety disorders severe enough to cause major distress and impair the person’s functioning. Only a quarter of these people are in any form of treatment, most usually medication. This is shocking. For surveys show that mental illness is the biggest single reason why people feel dissatisfied with their lives – accounting for more of the misery in our societies than either poverty or unemployment do.

What is its economic cost?

Mental illness accounts for nearly a half of all absenteeism from work and for nearly a half of all those who do not work because of disability. This imposes huge costs on employers and taxpayers. Mental illness also increases the use of physical healthcare. People with a given physical illness of a given severity use 50% more physical healthcare if they are also mentally ill. This is a huge cost to those who fund healthcare.

Does psychological therapy help?

In the last 40 years considerable progress has been made in developing effective psychological therapies. The most studied therapy is CBT – cognitive behavioural therapy, which is a broad heading for therapies which focus on directly influencing thoughts and behaviours – in order to affect the quality of human experience. In hundreds of randomised controlled trials CBT has been shown to produce recovery rates of over 50% for depression and anxiety disorders. For anxiety, recovery is generally sustained; for depression, the risk of relapse is greatly reduced.

The range of therapies which have been shown to work has been surveyed internationally by the Cochrane Collaboration and in England by the National Institute for Health and Care Excellence (NICE). Besides CBT, NICE also recommend for all depressions Interpersonal Therapy (IPT) and, for mild to moderate depression, Brief Psychodynamic Therapy, Couples Therapy and Counselling. Modern psychological therapies have also been shown to be effective in a wide range of other mental health conditions.

Do these therapies really cost nothing?

Yes. If delivered to a representative group of patients they pay for themselves twice over. First, they pay in reduced invalidity benefits and lost taxes due to invalidity. We know this from a series of controlled trials. Second, they pay for themselves in reduced costs of physical healthcare. Again we know this from controlled trials. It is so partly because the typical cost of an evidence-based course of treatment is only about $2,000.

How can these therapies become more widely available?

Two things are needed. First, there have to be enough people trained to deliver these therapies. This is the responsibility of universities and colleges, including of course supervised on-the-job training. Second, there have to be effective frameworks where trained people can be employed. The evidence is that recovery rates are higher where people are employed in teams where they can get supervision, in-service training, and clear career progression.

Those who fund healthcare have in the USA and UK the legal obligation to provide parity of esteem for mental and physical healthcare, and this requires that they are willing to fund high quality evidence-based therapies that are made easily available and provide the necessary duration of treatment, based on evidence. Insurers never fund half a hip replacement and they should not fund only half a proper course of psychological therapy.

What can be learnt from the English experience?

The English National Health Service has in recent years developed a totally new service to deliver evidence-based psychological therapies. (It’s called Improving Access to Psychological Therapies (IAPT)). This service has, over six years, trained altogether 6,000 therapists and is now treating nearly half a million people a year, with a recovery rate of 46% and rising. The prestigious journal Nature has called it “world-beating”.

How can we prevent mental illness in the first place?

First we must of course treat it as soon as it appears. This is often in childhood, where the same evidence-based treatments for depression and anxiety disorders apply as in adulthood. For children’s behaviour problems, parent training and family therapy are recommended.

But we must also reduce the overall prevalence of mental illness. This requires major changes throughout society. First, more support and education for parents. Second, schools which give more priority to the well-being of children. Third, employers who treat their workers with appreciation and encouragement and not as income-maximising machines. Fourth, more positively-oriented media. And finally, a new citizens’ culture giving more priority to compassion, both as an emotion and as a spring for action.

Richard Layard is one of the world’s leading labor economists and a member of the House of Lords.  David M. Clark is professor of psychology at the University of Oxford. Layard and Clark were the main drivers behind the UK’s Improving Access to Psychological Therapies program.

Read chapter one here.

Martin Gardner Celebration At Princeton

Martin GardnerMartin Gardner, an acclaimed popular mathematics and science writer and author of Undiluted Hocus-Pocus: The Autobiography of Martin Gardner, would have had his 99th birthday this month. In honor of this special occasion, the mathematical community is putting together a number of events celebrating this Gardner.

At Princeton University on October 25th from 6:30 – 8:30 PM in the Friend Center, Room 101, there is a free public lecture by Tadashi Tokieda on toy Models. He will share with you some unique toys he has made and collected, and show you the mathematics and physics behind them. Following the lecture, a panel of people who knew Martin Gardner well will share their favorite stories about him. You will have time to ask questions and talk with the presenters and share your memories as well.

Mark Setteducati (President, Gathering 4 Gardner) Panel Moderator
James Gardner (University of Oklahoma, Martin Gardner’s son)
John Conway (Emeritus Professor of Mathematics, Princeton University)
Colm Mulcahy (Spelman College and Author of Mathematical Card Magic: Fifty-Two New Effects)

There are many Celebration of Mind events taking place around the world. Check out the map (http://celebrationofmind.org/) and you can find event close to you.

Come and celebrate the joy of math!

Toward a public health approach — a new proposal for our response to Alzheimer’s Disease from medical anthropologist Margaret Lock

This video from the Alzheimer’s Association gives a sense of the magnitude of the Alzheimer’s Disease epidemic. We will soon publish The Alzheimer Conundrum by Margaret Lock that argues that the quest for a “silver bullet” cure or vaccine, while admirable is unlikely to be successful. To supplement these efforts, she makes the case for diverting some funds and time to developing a comprehensive public health approach that will improve the quality of life for Alzheimer’s patients and their caretakers and also lower costs that are estimated to be $203 billion dollars in 2013 and will balloon to $1.1 trillion by 2050.

Sample chapter 1 of The Alzheimer Conundrum and leave us your thoughts in the comments below.

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“Pandemics: Are We All Doomed?” – The Princeton in Europe lecture 2013

Sunetra Gupta, Professor of Theoretical Epidemiology at the University of Oxford, joined us for the third annual Princeton in Europe lecture, held in London on 17th April 2013.  In the midst of measles outbreaks in Wales, and the new H7N9 strain of bird flu in China, Professor Gupta takes us on a tour through the history of virulent worldwide diseases and considers the potential risks that future pandemics could pose to our global population.

To find out more about PUP Europe and the European Advisory Board, visit our website: http://press.princeton.edu/europe/. The 2014 lecture will be delivered on 8th April 2014 by Sir Diarmaid MacCulloch, Professor of the History of the Church at the University of Oxford. His topic will be: “What if Arianism had won?”

@Google Presents Michael Nielsen: Reinventing Discovery

If you can’t join us today at the Princeton Public Library for Michael Nielsen’s TEDx talk, I hope you enjoy this great talk for Authors@Google.

If you would like details on the PPL event tonight, click here: http://tedxsalonopensourcing.eventbrite.com/

You can also read a free excerpt from Michael’s new book Reinventing Discovery: The New Era of Networked Science here: http://press.princeton.edu/chapters/s9517.pdf

Could a video game yield a breakthrough cure for AIDS?

Alan Boyle at Cosmic Log reports on the latest example of a growing trend in open science or collaborative science. It may seem unbelievable, but he writes, “Video-game players have solved a molecular puzzle that stumped scientists for years, and those scientists say the accomplishment could point the way to crowdsourced cures for AIDS and other diseases.”

However, before Call of Duty fans use this as an excuse to log even more hours in front of the tv, the video game in question isn’t a shoot ’em up, XBOX 360 kind of game, rather it is a game called Foldit in which players

manipulate virtual molecular structures that look like multicolored, curled-up Tinkertoy sets. The virtual molecules follow the same chemical rules that are obeyed by real molecules. When someone playing the game comes up with a more elegant structure that reflects a lower energy state for the molecule, his or her score goes up. If the structure requires more energy to maintain, or if it doesn’t reflect real-life chemistry, then the score is lower.

Researchers posted the monkey virus puzzle to Foldit as “kind of a last-ditch effort,” according to Firas Khatib, the lead author of a paper reporting these findings in Nature Structural & Molecular Biology. Not only did Foldit gamers solve the puzzle, they did so in record time — 10 days.

This feat is the latest real-world example of the power of Open Science — a new form of collaborative science that draws on “scientists” both professional and citizen and harnesses the power of the internet to collaborate over great distances. Science has traditionally rewarded solo endeavors, but increasing numbers of researchers are turning to these novel research methods.

Boyle describes the Foldit success as “a giant leap for citizen science — a burgeoning field that enlists Internet users to look for alien planets, decipher ancient texts and do other scientific tasks that sheer computer power can’t accomplish as easily.” Think you have what it takes to play Foldit and perhaps contribute to the next big medical breakthrough? You can join in the fun here: http://fold.it/

So, why does this matter to Princeton University Press? In November, we will publish the timely book Reinventing Discovery by Michael Nielsen. In the book, Nielsen, a leading proponent of Open Science, describes how the internet and crowd-sourcing are contributing to collaborative science and plots the way forward. He even has a section of the book devoted to the development of Foldit and why it is so successful. He describes concrete methods to encourage collaboration even in fields that have traditionally eschewed these forms of collaboration. If you would like to sample this book, a free excerpt is now available on our web site here: http://press.princeton.edu/chapters/s9517.pdf (PDF)

PGS Exclusive: A Parasitologist’s Weight-Loss Clinic by Eugene Kaplan

Want to lose weight? Are parasites the solution? Parasitologist and expert Eugene Kaplan looks at recent reported trends of using parasites to lose weight and discovers that all is not as it seems.

Recently it has been reported that the government of Hong Kong has had to resort to an edict against a recently popular mechanism for weight loss: swallow the parasitic roundworm, Ascaris lumbricoides, to eat some of the food you ingest and deprive you of the calories. In other words, you eat the Whopper, fries and coke and seek absolution for your sins, not in the confession box from your priest, but in the similarly dark inner recesses of your gut from a worm.

First, I am puzzled by the technique. Do you eat the eight to twelve inch adult worms in a bowl of slowly writhing noodles or do you eat the eggs in feces-contaminated bok choy? Either way, this is a serious gastronomical challenge. Not to mention, that if you opt for the eggs, they will hatch and the juveniles will migrate through your lungs before ending up in your gut.

And to further complicate things, here’s a tip. Make sure these are the human-infecting version of the worm, else the alien larva, let’s say from a similar species in a dog or cat, will get confused in its wanderings and could end up in your eye or brain.

And as if these potential complications weren’t enough, here’s the real rub: unless you swallow enough of these living noodles to clog up your intestine, they will not eat enough to deprive you of the calories that make you overweight. I can attest to this. I had an eight inch female in my intestines and didn’t feel a thing nor lose an ounce of weight. Ascaris has a relatively slow metabolism. It’s not like you have a being like the one in Alien inside you. This is just a pencil thick, eight inch weight-loss device, hardly enough to transform your body on its own.

While the use of Ascaris to lose weight may sound like the stuff of science fiction, it actually is part of a long history of parasitic weight loss. At the 1938 World’s Fair, one could buy a weight-loss pill that brazenly stated it contained “tapeworms”. This was legitimate. The pill contained the scolices (anterior end) of the human beef tapeworm which would produce a bevy of foot long ribbon-like tapeworms hanging in your upper intestine, bathed in your intestinal juices. No eating a bowl of living noodles – users just had to take a pill like any other weight-loss pill – and it was touted as a safe method of weight loss.

The catch – there is no evidence that such an infection can cause you to lose weight – common superstition notwithstanding. Unless you are in terrible physical shape – in which case you would probably be emaciated and not in need of this weight-loss program –a heavy tapeworm infection would not cause you to lose weight, but it might cause death.
A more logical idea is to purchase leeches from a leech farm (there is one in my neighborhood; I can get you the phone number). Leeches are used to suck fluids from lymph-swollen sites where an appendage was just reattached surgically and swelling threatens to burst the sutures. If you use enough leeches, say you arrange them so that they sprout from your arm like branches from a tree, they could remove enough blood to shift your weight scale to the left..

I can go on, like swallowing the cysts of the one-celled animals, Giardia or Entamoeba histolytica. The severe diarrhea would deprive you of excess water and food and leave you emaciated in a week – ads for this method could promise “rapid weight loss.” But the aforementioned techniques seem to be adequate.

And so we arrive at the end of this weight-loss clinic. While parasites might seem like a sure-fire, quick solution, perhaps it might be better to simply forego the Whopper next time.

Eugene H. Kaplan is the Donald E. Axinn Endowed Distinguished Professor of Ecology and Conservation (emeritus) at Hofstra University. His many books include What’s Eating You: People and Parasites and Sensuous Seas: Tales of a Marine Biologist. He is about to embark on a trip to Israel, perhaps stuffed pigeon will be on the menu again.

Like this article? Read Gene’s other blog posts here: Go Ahead, Try the Guinea Pig and here Climate Change is Bringing an Invasion of Parasites.

Princeton Global Science, Issue 3

You will notice we have slightly changed the way we are producing Princeton Global Science. The first two issues were published all at once on the 1st and 15th of the month, but for the past two weeks, we have posted articles as they were ready. So today, I am posting more or less a table of contents to highlight these contributions.

Paul Nahin contributes a video log about his publishing relationship with with Princeton University Press and his writing process — it turns out he writes a page a day, no matter what. Paul has written eight books for PUP and he describes the behind-the-scenes wrangling that goes into writing his books and the cover designs for three of them.

We also have a dialogue with Paul Thagard, author of The Brain and the Meaning of Life, in which he describes how a book that was originally conceived as an assessment of current research in neuroscience shifted to tackle one of the largest philosophical questions — what is the meaning of life?

Our natural history guides are a large part of our publishing program and with two new guides publishing in October, it makes sense that our Princeton Field Guide series is highlighted this issue. Science Group Publisher Robert Kirk describes the history of this popular series and we have features on the most recent additions The Princeton Field Guide to Dinosaurs by Gregory S. Paul and Parrots of the World by Joseph M. Forshaw with illustrations by Frank Knight.

Click here to view the daily dinosaur feature which draws on information and images from The Princeton Field Guide to Dinosaurs and click here for a sneak peek of the page layout and gorgeous illustrations from Parrots of the World.

As always, we also include a classic text from Princeton University Press history. This issue’s selection from A Century of Books is Finite Dimensional Vector Spaces by Paul R. Halmos.

PGS Exclusive: How the FDA Shapes Modern Science, including Cancer Therapeutics by Daniel Carpenter

Science is often portrayed as an independent activity, a calling that involves the isolation of the ivory tower and the lab. Yet in ways that we scarcely recognize, almost every facet of modern medical science is deeply shaped by the government, and in particular by the U.S. Food and Drug Administration (FDA). The very structure, procedure, methods and concepts of modern medical science – as well as the way that billions of dollars are spent – are deeply shaped by the FDA, in ways illuminated by a new Princeton book, Reputation and Power: Organizational Image and Pharmaceutical Regulation at the FDA, written by Harvard professor Daniel Carpenter. Here, Carpenter reflects on how the FDA shapes modern science, specifically focusing on cancer therapeutics.

Journalists report daily on the latest results from a “Phase II” trial or a “Phase III” experiment. Yet where do these terms come from? When did we demand that medical experiments be partitioned into phases? For better or worse, these phases created the modern clinical trial industry, and they are the legacy of the FDA. Whenever scientists begin work on a drug or medical device, they must submit an experimental “protocol” that specifies what will happen not just in the next experiment, but the one after that, and the one after that. The very concepts and statistical measures used in these experiments must be approved by the FDA before any of the tests can begin. The entire world – ranging from European drug regulators and the World Health Organization to agencies and researchers in China, India, Israel and Latin America – now relies upon this phased system of experiment. But until now, no one has recognized it for what it is: the creation of an American government agency.

In terms of developing new treatments, cancer therapeutics has arguably been one of the success stories of modern medical science. Drugs like cisplatin and paclitaxel have become reliable weapons in the oncologist’s arsenal, and they have been infused into the veins of tens of millions of human beings. Yet the very terms of modern oncology – what counts as a success when treating cancer, such as tumor progression and viral load – have been shaped by what the FDA accepts as “surrogate endpoints” for a clinical trial. When the FDA decided that tumor regression counts as evidence of treatment efficacy for cancer patients, drug companies, scientists and statisticians around the world responded by tailoring their experiments, measures and statistical methods to the standard of tumor regression. The very shape of oncology was changed.

Historian of science Steven Shapin has described scientists as “struggling for credibility and authority,” and the FDA is also moved and constrained by a similar politics of legitimacy and trust. The agency’s vast power is enabled, but also limited by, its reputation. And because science and medicine rarely speak with one voice – cardiologists disagree with endocrinologists on the proper course of diabetes treatment, statisticians dissent from physicians on whether an experiment is informative or rigorous – the politics of pharmaceutical regulation depends upon a delicate equipoise among constituencies and audiences. The conflict between oncologists and FDA officials changed both the course of cancer treatment as well as the operations of regulators.

Does the FDA’s influence upon science help or hinder medical progress? This is a complicated question to which pundits and politicians have given simplistic answers. Yet talk to a scientist in the medical or biotechnology field, and they will tell you that theirs is a heavily regulated life. Any experiment with humans or animals needs to have a protocol designed in advance of the tests, needs approval by an organizational board or two (including a separate committee if human subjects are involved), is subject to inspection by federal agencies at any time, and must spell out the sequence of tests and methods used. And if the experiment involves a drug or device (and now, a tobacco product) the experiment needs assent of the U.S. Food and Drug Administration (FDA).

New historical and statistical evidence shows us that FDA decisions can scare off drug development by inducing companies and scientists to abandon their therapeutic projects. The politics of reputation can work to ameliorate or exacerbate these constraints. Some politicians, companies and disease sufferers press the agency for more rapid approval? of new therapies, while consumer advocates, other politicians and many medical professionals press the agency toward more stringent requirements upon drugs and drug experiments. In other ways, by standardizing terms and expectations, FDA regulations make scientific progress more possible. When statistical tests and physiologic measures are standardized; when scientists speak to one another with a common vocabulary that has been honed by these standards; when expectations and scientific discourse are focused upon a common protocol for a sequence of experiments – when these things happen, the basic terms of inquiry are stabilized so that effort and thought can be devoted to testing hypotheses and developing treatments. In many cases, regulation permits science to progress.

New Princeton Global Science tomorrow

Check in tomorrow for Q&As with authors Deborah M. Gordon and Tom Boellstorff. Deborah tells us what her study of ants reveals about collective behavior, while Tom describes the difficulties he encountered in conducting ethnographic research in Second Life.

Also in this edition of PGS will be exclusive articles from Dan Carpenter, author of Reputation and Power: Organizational Image and Pharmaceutical Regulation at the FDA and Eugene Kaplan, author of What’s Eating You? People and Parasites.

Princeton Global Science launches September 1st

Next week we will launch Princeton Global Science on this blog. Hope you will join us on September 1st for original content from from our science editors and authors. More to come!

“Your book made me retch. And itch. Why are you so keen on parasites?” the Toronto Star gets under Eugene Kaplan’s skin

Nancy White of the Toronto Star interviews What’s Eating You? author Eugene Kaplan about his fascination with parasites. He reveals what he thinks are the worst parasites a human can get, talks about bedbugs and the impact of global warming on parasite infestations, and lastly tells the tale of a woman who was pregnant with …

(wait for it)


Read the complete Q&A here.