It's All in the Spin

Another email from the APA today, oh joy:

CBT More Efficacious Than Other Psychological Interventions for Positive Symptoms of Psychosis.

This was based on the article: Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies, published February 14th on AJP in Advance.

CBT was compared with supportive counseling, social skills training, psycho-education, cognitive remediation and befriending in 48 trials.

Results  Cognitive-behavioral therapy (CBT) was significantly more efficacious than other interventions pooled in reducing positive symptoms (g=0.16). This finding was robust in all sensitivity analyses for risk of bias but lost significance in sensitivity analyses for researcher allegiance, which suffered from low power. Social skills training was significantly more efficacious in reducing negative symptoms (g=0.27). This finding was robust in sensitivity analyses for risk of bias and researcher allegiance. Significant findings for CBT, social skills training, and cognitive remediation for overall symptoms were not robust after sensitivity analyses. CBT was significantly more efficacious when compared directly with befriending for overall symptoms (g=0.42) and supportive counseling for positive symptoms (g=0.23).

The APA seems rather pleased with itself about this result. The email even linked to a news article, CBT Addresses Most-Debilitating Symptoms in Chronic Schizophrenia.

A new cognitive-behavior therapeutic strategy [Recovery Oriented Cognitive Therapy (CT-R)] is helping patients overcome major obstacles to their recovery, especially the negative symptoms...that are considered to be the most intransigent and disabling for patients with schizophrenia. The strategy has been implemented throughout the Philadelphia public mental health system and in Georgia

You'd think they'd at least cross check their own links. CT-R is especially helpful with negative symptoms, but the meta-analysis demonstrated that social skills training was significantly more efficacious than CBT in reducing negative symptoms.

The email caught my eye because I had just finished reading this month's Carlat Report, in which there was an article entitled, "CBT for Schizophrenia: Is Talk Cheap?", which, in turn, references, "Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias," published in the British Journal of Psychiatry.

THIS study looked at 50 trials of CBT for schizophrenia, and found that when raters were blinded to the type of treatment provided, effect size of CBT relative to placebo dropped from 0.62 in unblinded studies, to 0.15 in blinded studies, for overall symptoms. For positive symptoms, the drop was from 0.57 to 0.08. 
Pooled effect sizes were 0.33 for overall symptoms, 0.25 for positive symptoms, and 0.13 for negative symptoms. 
Not sure why they didn't describe the difference between unblinded and blinded studies for negative symptoms. Maybe because the pooled effect size was so low to begin with.

It's kind of like what I wrote about the APA excitement about the meeting in May. Pick some highlight, maybe Alan Alda, talk about how great the meeting will be, and ignore all the annoying little facts that might put a damper on things. 

D is for Dilemma

There's an Obama administration proposal to limit coverage for certain classes of drugs (See NYTimes) in Medicare Part D. Since Part D took effect in 2006, there have been 6 protected medication classes:

Anti-retrovirals
Immunosuppressants when used for organ rejection
Anti-depressants
Anti-psychotics
Anti-convulsant agents
Anti-neoplastics

Protected means a part D plan is required to cover all or substantially all drugs in the class. "Moreover, Part D plans may not impose step therapy or prior authorization requirements for these drugs for beneficiaries who are currently taking the drug: both beneficiaries who are currently enrolled in the plan, as well as beneficiaries taking a protected class drug that are newly enrolled in the plan (source, also the following)."

In 2008, the new Medicare Improvements for Patients and Providers Act (MIPPA) law established 2 criteria for what constitutes a protected class:

1. Where restrictions on that class would have major or life threatening consequences

2. Where there is a significant need for individuals with a disease or disorder treated by the drugs in the class to have access to multiple drugs within that class.

Okay, let's stop here for a minute. I'm thinking that there must be a lot of drug classes that meet these two criteria, so it can't be that simple. Moving on.

MIPPA, as it turns out, did not specifically reference the 6 protected drug classes that already existed. So in 2009, CMS announced its intention to review the necessity of the 6 classes, but it allowed that, at least for 2010, those classes would not be messed with. And in 2010, Congress reaffirmed that the 6 classes would remain protected until, basically, somebody figured out that they shouldn't be.

Then, on January 6th of this year, CMS comes along and says, Here's the thing: The 6 protected classes have driven up the costs of Part D. After all, if drug companies know you'll pay for any drug, then you've lost all power to negotiate prices.

We estimate that this change could save the 
Part D program (includes the Part D portion 
of MA–PD plans) approximately $30 million 
in 2016, increasing to $420 million in 2019 
(total of $720* million over this period). 

CMS also claims that there's over-utilization of protected drugs, and that beneficiaries already have adequate protection to ensure they aren't simply switched off their meds. Specifically, "...there are five beneficiary protection provisions in Part D and...only where these patient protections do not adequately protect beneficiaries should the protected class policy apply. [The 5] beneficiary protections [are]: formulary transparency; formulary requirements; reassignment formulary coverage notices; the transition supply policy; and the beneficiary appeals process.

Another editorial break, here. I don't think CMS should be patting itself on the back because they send you a letter and give you some severance meds before they make you switch to something else.

This is the language from the proposal:

Instead of mandating coverage of all 
drug products in a particular class on all 
Part D formularies, we can save costs by 
identifying more efficient formulary 
requirements or other beneficiary 
protections in most cases


So here's the bottom line, all done under the auspices of the affordable care act. There are two criteria:

"First, unrestricted access to all drugs in a category or class of a drug is necessary where a beneficiary initiating access to a drug class would need to receive that access within seven days and, if they did not receive access within seven days, the lack of access would be expected to result in the patient’s death, hospitalization, incapacity, or disability. Second, unrestricted access is necessary where CMS is unable to establish that a formulary that includes less than all drugs in a category or class has sufficient drugs to treat the diseases or conditions treated by those drugs."

There's always going to be some outlier patient who only responds to an expensive medication, so how're they planning to figure that one out?

And here come the exceptions, even for the protected classes:

1. Where there are two or more chemically identical or therapeutically equivalent drugs in a category or class, the requirement to cover all drugs in the category or class would be waived
2. The exceptions policy permits a plan to conduct prior authorization to ensure that a drug is being dispensed for a medically-accepted indication.

1. So if paxil is therapeutically equivalent to zoloft, they don't need to cover wellbutrin?
2. Um...even if the drug is being dispensed for recreational purposes, like you need your adriomycin and haldol for a rave, do they think whoever's dispensing it wouldn't rubber stamp a suitable diagnosis?

Well, The Oscars are coming up, so let's open the envelope and find out which three classes win the "no longer protected" award:

Immunosuppressants when used for organ rejection
Anti-depressants
Anti-psychotics

I'm trying to understand the reasoning whereby not putting a patient on a suitable antipsychotic isn't likely to lead to bad things happening, and where CMS is certain that not all the drugs in these 3 classes are needed, but they are in the other 3.

The implications of this policy change are making my head spin. Why were those six classes chosen to begin with? Does anyone know? That wasn't rhetorical.

And what about the approach? Many more people suffer from hypertension than seizures. And multi-drug regimens for hypertension are not uncommon, with patients sometimes switching meds, depending on effects, or side effects. And doesn't hypertension cause a lot of morbidity? Expensive morbidity? and wouldn't it be cheaper to spend a little more to control blood pressure, than on the consequences of hypertension?

I'm all for trying the cheapest suitable medication on the first go-round, but that doesn't always work. And if doctors are prescribing expensive meds before trying cheaper ones, is it because the expensive meds are better, or because they're on formulary so they're covered, anyway, or because a drug rep stopped by to explain why the off patent meds aren't as good as the shiny new ones?

For now, this is just a proposal, and comments will be accepted until 5pm on March 7th, at http://www.regulations.gov.

Why Does this Bother Me?

I got an email today about the annual meeting of the APA, which is in NYC this year. I suppose I could attend, even though I terminated my membership in the APA a while ago. This was in the email:

APA 2014: Changing the Practice and Perception of Psychiatry

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. This column was written by Dr. Lieberman and Philip Muskin, M.D., chair of the APA Scientific Program Committee. Please send your comments to pnupdate@psych.org.

Annually, thousands of mental health professionals descend on a major American city to participate in a three-ring circus of pedagogic activities that comprise the annual meeting of the American Psychiatric Association. This event is an academic smorgasbord of all information relevant to psychiatric medicine and mental health care. It provides one-stop shopping for clinicians who wish to avail themselves of the latest scientific developments and all the education needed to practice their craft. The annual meeting is the highlight of the year for U.S. psychiatry.

APA’s 167th Annual Meeting will take place May 3 to 7 in New York City and will be the epicenter for those who wish to learn of emerging knowledge and connect to leaders in the field of psychiatry. New York is a perfect place to host this year’s meeting, given the extraordinary and historic events of the past year, including the launch of DSM-5, the release of the final rule for the Mental Health Parity and Addiction Equity Act, further implementation of the Affordable Care Act, and the emotionally wrenching discussion of mental illness and violence in the media.

The theme of the 2014 annual meeting is aptly titled “Changing the Practice and Perception of Psychiatry,” reflecting the historic transformation in how our profession will be practiced, as well as perceived by our medical colleagues and the public at large. The Scientific Program Committee, chaired by Phil Muskin with Co-Chair Cam Carter, has produced an amazing program with a who’s who of luminaries scheduled to speak. The Opening Session will feature a “Dialogue on Science and the Media” that I will moderate between Nobel Laureate Eric Kandel and the acclaimed actor Alan Alda. The Convocation Lecture will be delivered by a major political figure who is leading major legislative initiatives in mental illness. Look for more information in a future issue. 

I happen to be a huge Alan Alda fan, and that alone is a draw. But my skin is just crawling, and I'm not sure why. 

Here's a link to the full text of above. Many of the sessions are organized into tracks, such as forensics, child/adolescent, ethics. There's a mentoring track for residents. and a track dedicated to military health care.

There's also an integrated care track:

The Integrated Care Track features interactive sessions applicable to every psychiatric physician in this current culture of health care reform and comprehensive patient-centered service. By participating in workshops led by experts like Lori Raney, M.D., you will learn practical skills to prepare for leadership roles of the psychiatrist within a collaborative care team. The CPT coding workshop, chaired by Ronald Burd, M.D., is another educational opportunity relevant to all due to changes in health care financing and reimbursement that occurred at the start of 2014.

"Leadership roles of the psychiatrist within a collaborative care team." This is a definite formicatory sentence. I wanna reply, "You mean, as opposed to psychiatric roles of the psychiatrist within a collaborative care team," because in a collaborative care model, the psychiatrist doesn't see patients, just supervises those who do, and signs off on the charts of these unexamined patients. And as Socrates said, "The unexamined patient is not worth treating." Or something like that. (I was gonna write, "not worth living", but that sounded way harsh.)

I think what bothers me about the meeting is everything that's left unsaid. There's all this, "Yay! DSM-5! Here's how to use it!" Rather than, "DSM-5, let's talk about the controversy". 

And there's, "Yay! RDoc! NIMH!!" as though we're already at an advanced stage of knowing how the brain produces psychiatric illness. 

"Yay! Psychopharm!" as though there are no questions about efficacy and safety, even with Paxil study 329 glaring in everyone's face. 

I also hate the phrase, "Patient Centered Care". 

As opposed to what? Kumquat-Centered Care?

And I'm irritated by the notion that the APA meeting presents, "all information relevant to psychiatric medicine and mental health care." Do they really think there's no valid perspective on psychiatry outside that of the APA?

I glanced at the program, and I was pleased to find a reasonable emphasis on psychotherapy, especially of the psychodynamic variety, and Kernberg and Fonagy will be there. And Kandel is always a welcome presence.

I'm not sure why I find the whole thing so icky, or why I expect anything to be different. I just remember being at the meeting in NYC 10 years ago, and the most impressive thing was all the pharmaceutical presentation areas. Maybe there won't be as many this year. And maybe they're trying to keep them out of the program. 

I found this paragraph on page 7:

Sunshine Act

Some of APA’s non-CME accredited events and some refreshments at APA events are sponsored by pharmaceutical or medical device companies. Participation in these events/ food offerings may be reportable under the Physician Payment in the Sunshine Act.

Just this one little blurb. Like, hey, that's not a herd of elephants we all see traipsing about the Javits Center.

I feel like there's some big issue being sidestepped. That the influence of industry is so integral that no one even bothers to talk about the conflicts of interest. I know there's a lot of excess hype about David Kupfer's ownership of Psychiatric Assessments, Inc., which provides assessment instruments to be used in conjunction with DSM-5 (Link), but it's as if the meeting just goes along its merry way, completely oblivious to Voldemort's shriveled, twisted soul lying under a bench.

As though psychiatry isn't a mess. 

It really bothers me.

A Valentine's Day Tail

Mel Blanc

In his autobiography, That's not all Folks, Mel Blanc, who did the voice characterization for most of the Warner Bros. cartoon characters, most famously, Bugs Bunny, relates an amusing anecdote.
On January 24th, 1961, he was in a bad car accident. The surgeon told his family, "Mel has numerous internal injuries, compound fractures of both legs, a fractured arm, and a severe concussion. But we're most concerned about the pressure building around the brain."
His prognosis was not good.
He did pull through, but remained unconscious. Then on Valentine's Day, he spoke for the first time. "Noticing the image of Bugs Bunny on the wall-mounted television, [his doctor] thought to ask, 'How are you feeling today, Bugs Bunny?'"
Blanc replied, "Eh, just fine, Doc. How're you?"

I'm fascinated by the word, Doc. What I mean by that is I find it interesting to consider who calls who, "Doc".
For example, say I had a patient who was a Classics professor, maybe a scholar of Aeschylus (I'm completely making this up, BTW). It would be weird if he called me, "Doc", right?
But say my patient was an old-style cab driver, born and raised in Brooklyn. It wouldn't be so weird if he called me, "Doc".

What about people who are not my patients?

I first started to think about this a number of years ago, when I happened to get to my therapist's office before she did, one day. I waited in the lobby until she arrived, and as she came into the building, I heard the doorman say, "Hey, Doc!" I thought it sounded friendly and natural, and I simultaneously realized I would never call her, "Doc".
Then I started paying attention to it in the hospital. The nurses generally used the address, "Doctor".  It was the rest of the staff, janitorial, security, who, I discovered, use, "Doc". I think it's a way of being both respectful and collegial at the same time. After all, I have a lot more education and professional training than a typical security guard, but we still work in the same place. And let's face it, I couldn't do my job if the staff didn't do their jobs. It's as though "Doctor" would be too formal, would put too much distance between us, and my name would be too informal or disrespectful (plus they might not know my name), but "Doc" means we're equals, colleagues, but also not.
And of course, there's the medical tradition of being called, "Dr Jones" by your attending, on rounds, even when you're still a medical student. Or of calling your fellow residents, "Doctor so-and-so". I think this is done half as a sarcastic joke, and half to acknowledge, with some pride, that these are your colleagues, and you have a shared experience of all the rigors of medical school and residency. And more to the point, a shared identity, with some semblance of a shared perspective.
Because really, the Bugs Bunny story is about identity. Mel Blanc was obviously not Bugs Bunny. but he spent so many years creating Bugs Bunny, bringing him to life, as only he could, that the character became part of his identity, in the same way that being a doctor is part, but not all, of mine.
I mentioned recently that I wrote an article for the January issue of The Carlat Report entitled, An Ethical Perspective on the Affordable Care Act. I think I also mentioned that writing it was demoralizing, as I learned about all the problems involved in the ACA. But if I had to sum up the concern, I'd say it's that going forward, doctors may not be doctors anymore.
If you work in coordinated care and never get to see patients, if you are held to demonstrating "quality care" by using checklists rather than interviewing skills, if you are limited in your decisions about what kind and how much therapy a patient needs by insurance requirements, if you spend more time filling out forms than working with patients, then what has become of all the time, effort and money you put into becoming a doctor with some expertise in your field?
If you can be replaced by a nurse who had two days of training in depression management and behavioral strategies, or a piece of paper with checkboxes, or a bottle of pills, what will it mean to be a doctor? And who will I be then?

Happy Valentine's Day!

Starting to Think about Medical Necessity

I thought it was all over when I cracked the CPT code. I felt liked I had accessed the secrets of the universe, and there was nothing more to do but sit back and let my patients enjoy their reimbursement.

But times change, tides roll in and out, and insurance companies find new ways to be, well, they're not even A-holes. They're B-holes.

It's no longer sufficient to document  1-3 presenting problems, 6 exam elements, and 1 ROS,  code a 99213, and call it a day.

This is from Magellan Health, their Medical Necessity Criteria Guidelines 2014. Incidentally, how do you think Ferdinand Magellan, the original, would feel about having a health insurance company named after him?

There seem to be 2 categories to qualify for outpatient psychiatric care: Severity of Need, and Intensity and Quality of Service.

Severity of Need requires criteria A,B,C,D, E to be met, so you can see where this is headed.

A-DSM-5 diagnosis, or evaluation for one.
It doesn't say anything about ICD-9 or 10.

B-Presenting impairment consistent with the DSM-5 diagnosis.

C. (This is a quote)

One of the following:
1) the patient has symptomatic distress and demonstrates impaired functioning due to
psychiatric symptoms and/or behavior in at least one of the three spheres of functioning
(occupational, scholastic, or social), that are the direct result of a DSM-5 diagnosis. This is
evidenced by specific clinical description of the symptom(s) and specific measurable
behavioral impairment(s) in occupational, academic or social areas. or
2) the patient has a persistent illness described in DSM-5 with a history of repeated admissions
to 24-hour treatment programs for which maintenance treatment is required to maintain
community tenure, or
3) there is clinical evidence that a limited number of additional treatment sessions are required
to support termination of therapy, although the patient no longer has at least mild
symptomatic distress or impairment in functioning. The factors considered in making a
determination about the continued medical necessity of treatment in this termination phase
are the frequency and severity of previous relapse, level of current stressors, and other
relevant clinical indicators. Additionally, the treatment plan should include clear goals
needing to be achieved and methods to achieve them in order to support successful
termination (such as increasing time between appointments, use of community resources,
and supporting personal success).

So, measurable impairment, or repeated admissions to 24-hour programs (what about longer?), or needs a specific number of additional sessions to terminate.

D. The patient does not require a higher level of care.
Magellan specifies at the beginning of the document that the least restrictive care is always the most desirable.  

E. The patient appears to be motivated and capable of developing skills to manage symptoms or make behavioral change. 

What if they're not? And how can you tell? 

That's just "Severity of Need". Intensity and Quality of Service has criteria A through L, which take up two whole pages. You can check them out, yourself-they're on pages 103-104 of the document. But they include things like: 

*documentation (extensive) of symptoms 

*medically necessary and appropriate treatment plan (How do you establish a medically necessary plan to determine medical necessity?) 

*9 required components of the treatment plan

*patient is motivated

*patient is adherent

*patient is showing progress

*no duplication of services 

And a couple of my favorites:

*Treatment is effective as evidenced by improvement in SF-BH, CHI, and/or other valid outcome measures. 

 

*Visits for this treatment modality are recommended to be no greater than one session per week, except for: (i) acute crisis stabilization, or (ii) situations where the treating provider demonstrates more than one visit per week is medically necessary. 

*As the patient exhibits sustained improvement or stabilization of a persistent illness, frequency of visits should be decreased over time (e.g., once every two weeks or once per month) to reinforce and encourage self-efficacy, autonomy, and reliance on community and natural supports. 

Okay. Clearly these guidelines were developed by people who have not gone anywhere near a patient in a very long time or have never treated a patient, period. This is the kind of thing you'd come up with if you had to figure out how to make money from a field you know nothing about.

And this is just Magellan.

What about Anthem?

Well, Anthem, the most recent update I could find, anyway, from October 2013, lets you use DSM-IV or ICD diagnoses. And they refer to "Severity of Illness (SI)", rather than need.

All of the following must be present:

1. Specific symptoms or disturbances of mood and/or behavior are present, with functional impairment, which are consistent with the DSM/ICD diagnosis listed, and these disturbances/symptoms are likely to improve with treatment; AND
2. The Covered Individual demonstrates motivation for treatment and is capable of benefiting from the treatment approach planned.

Then they talk about "Intensity of Service (IS)":

All of the following must be present:

1. Treatment goals target resolution of specific symptoms or stabilization of mood and/or behavior consistent with the DSM/ICD diagnoses listed and also target specific domains of functional impairment; AND
2. Medication is being used for conditions where indicated, and if not, documentation of the reason and treatment interventions addressing the omission of this treatment; AND
3. If substance abuse/dependence is a diagnosis or indicated to be present, a substance use evaluation has been performed when appropriate and treatment is being provided; AND
4. Community/natural supports and resources are identified and utilized or skills to develop community/natural supports is  a treatment goal, including school/work interventions, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities; AND
5. Coordination of care with other clinicians providing care to the Covered Individual or family members, including psychiatrist/therapist and primary care physician (PCP) is documented; AND
6. For children/adolescents, family participation in treatment or family therapy is documented unless contraindicated with documentation of the reason; AND
7. Treatment is not duplicative of services being provided by another clinician for the same reasons/diagnoses;AND
8. Provider must be properly licensed to provide the treatment requested

And then there's the issue of frequency, if treatment is being provided more than once a week:

Frequency Criteria: for treatment that occurs more frequently than once per week (excluding Medication Management) must have all of the following (1 - 3) to qualify:

1. Either the Covered Individual has been discharged from an inpatient, residential or partial hospitalization program (PHP) service and more frequent outpatient (OP) treatment is required as a transition for the purposes of stabilization while returning to the community or the Covered Individual is in crisis as evidenced by suicidal ideation or high risk behavior that is manageable on an OP basis, or an unexpected increase in symptoms and/or behaviors or worsening in mood where the treatment goals are focused on stabilization of the crisis;AND
2. The symptoms/behaviors or mood that represent the crisis can be stabilized with more frequent treatment as evidenced by urgent psychiatric contact and medication changes if indicated and reports of progress with resolving the crisis; AND
3. The condition has not stabilized to the point where less frequent treatment which targets less critical symptoms/behaviors is equally appropriate.

In other words, the only reason to meet more than once a week is if there's an acute crisis just shy of requiring hospitalization.

I'm getting a little too irked to write anymore, so I'm gonna stop for now, but please do check out the documents, and let me know if you have any idea how to integrate this into regular notekeeping, and how to tailor the content to a specific patient's insurance requirements.

Smile and Smile

Watching my dog has got me thinking a lot about the genetic underpinnings of behavior. She's a rescue, so I don't know what her lineage is, but she seems to be some mix of terrier and herding dog. The herding behavior is fascinating. When we have people over, she's fine as long as everyone is sitting around the table, which she views as a kind of pen. When someone gets up, she starts barking and nipping at their heels to get them back in the "pen". In the dog park, when dogs start chasing each other, instead of joining directly in the pack of running dogs, she goes at them in an arc that cuts off the lead dog. And the other day, I had her off-leash in a large, empty field. She loves to run, and she took off, but almost immediately she started running in circles with increasingly smaller radii.

She doesn't live on a sheep farm in New Zealand, with lots of older, wiser dogs to teach her how to herd. She just herds, even when there are no herd animals around, which implies she's "wired" for these behaviors, whatever that means. I'm accustomed to thinking of DNA as dictating things like eye color and predisposition to certain diseases. I even read somewhere that whether or not you like cilantro is genetically determined. But complex behaviors like herding?

When she was around 4 months old, I noticed that she, as well as other dogs, not only mark territory, but after they've urinated on a spot to mark it, they hold up their chests and heads, and make these feet-wiping movements. The posture makes them look proud. But that's probably backwards. It's more likely that I associate pride with that posture. That I've assigned a meaning, or a name, to a particular behavior that exists regardless of what I call it or think of it.

This is the frame of mind I brought to reading, Turning the Frown Upside Down: Using Botulinum Toxin to Treat Depression. The premise for the study is the Facial Feedback Hypothesis, which states that, "...facial movement can influence emotional experience. For example, an individual who is forced to smile during a social event will actually come to find the event more of an enjoyable experience."

The article is just a little blurb, but there's some interesting research on this. In Cosmetic use of botulinum toxin-A affects processing of emotional language, Havas, et al, had patients, all women, I believe, read happy, sad, and angry sentences before and after being injected with botox in the corrugator supercilii muscle, for frown lines. They found that botox significantly slowed the reading of sad and angry sentences, while not affecting the time for reading the happy sentences. There are plenty of problems with this study, but the idea that you would feel less sad or angry if you were unable to frown, is fascinating.

So, frown less, feel better. How about, smile more feel better?

In Inhibiting and facilitating conditions of the human smile: A nonobtrusive test of the facial feedback hypothesis, Strack et al tried to control for the fact that in previous studies of facial feedback, subjects were able to easily discern what was being tested. What Strack et al did differently was tell the subjects that the purpose of the study was to determine the difficulty people who can't use their arms or hands have with tasks, such as writing. They had one group hold pens with their lips, resulting in a frown. A second group held pens in their teeth, resulting in a smile. And the control group held pens in their non-dominant hands. All groups had to fill a questionnaire, and rate the difficulty involved. The last task was to rate the funniness of a cartoon. As expected, the teeth group found it much funnier than the lip group.

The ideas underlying the facial feedback hypothesis are not new.

Darwin writes:
The free expression by outward signs of an emotion intensifies it. On the other hand, the repression, as far as this is possible, of all outward signs softens our emotions... Even the simulation of an emotion tends to arouse it in our minds. 
(The Expression of the Emotions in Man and Animals)


In What is an Emotion?, William James (1884) writes:

Our natural way of thinking about these standard emotions is that the mental perception of some fact excites the mental affection called the emotion, and that this latter state of mind gives rise to the bodily expression. My thesis on the contrary is that the bodily changes follow directly the PERCEPTION of the exciting fact, and that our feeling of the same changes as they occur IS the emotion....we feel sorry because we cry, angry because we strike, afraid because we tremble, and not that we cry, strike, or tremble, because we are sorry, angry, or fearful, as the case may be...

That the heart-beats and the rhythm of breathing play a leading part in all emotions whatsoever, is a matter too notorious for proof. And what is really equally prominent, but less likely to be admitted until special attention is drawn to the fact, is the continuous co-operation of the voluntary muscles in our emotional states....In depression the flexors tend to prevail

in elation or belligerent excitement the extensors take the lead.

Maybe Shakespeare was wrong. Maybe you can't, "Smile and smile and be a villain." Unless, that is, you enjoy being a villain.