Happiness is...

Have you seen Happify? It's an app that has you play games to increase your happiness. It claims to be science-based. For example, I just played, "Negative Knockout". You get 5 negative feelings, and then you destroy them with a slingshot. And you get extra points for destroying them with only two tries, although you get up to 5 tries.

Here's a screenshot:

Look familiar? Of course it does. It's Angry Birds.

Happify claims the benefits of this game are:

Reduce the impact of your negative thoughts
Stop ruminating on your worries
Feel empowered to control your thoughts

I guess it's a fair question. Can Angry Birds improve your life if you rename it, Negative Knockout?

And they even site research, a study done at Ohio State University that took place in Madrid. Students were asked to write down thoughts about their body image. Then half were told to throw out the piece of paper they wrote their thoughts on. The ones who kept their "thoughts" later demonstrated lower body image than the ones who threw them out.

There were two other tasks in the study: one in which the students were asked to write down beliefs about the Mediterranean Diet, and either throw away, leave, or keep their thoughts; another in which the students wrote their thoughts in a word-processing program and then either put them in the recycle bin, or didn't. Both tasks had results similar to the first.

There's another game called, "Uplift", in which you are supposed to tap hot air balloons with positive words, like cozy and jolly, and avoid tapping negative words like judgement and sad.

What can I say? I'm skeptical, at best. That may be because I haven't played enough Happify games-skeptical is one of those negative words.

There are also activities like, "Thx Thx Thx" that asks you to record today's happy moments.

The way it works is that you fill out a little questionnaire that asks things like how often you felt joy in the last week. And then it recommends a track based on your specific needs. And the tracks have the various games and activities. Some of the tracks are Conquer your negative thoughts, Hardwiring happiness, Cope better with stress, Get to know yourself better, Before happiness: Kick-start positive change. Several of these are premium tracks. Also, some of the games and activities within free tracks are premium. And you have a limited time to complete each track.

The tracks are created by experts. For example, the Conquer your negative thoughts track was:

Happify claims to have "combed through the body of positive psychology to build exercises in STAGE, that's savor, thank, aspire, give, empathize, the 5 essential happiness skills you'll develop by using Happify. And of course, you can track your progress.

I don't know anything about positive psychology, but I have noticed an interesting jargon phenomenon among 20 and 30-somethings these days. "Negativity" is to be assiduously avoided. So is being "Judgemental". And one must always aspire to "Productivity".

I don't think productivity is invariably a healthy thing. I also think sometimes one has to exercise judgement about people, and why is it the end of the world if one does? And negativity? I'm not really sure what that means. Is it feeling sad? That's life. Is it letting others know you're sad? That's intimacy. Is it pessimism? That has its role to play.

I'm not comfortable with the idea that negativity has to be conquered, or that happiness is necessarily something to pursue. The implication may be that you're a failure if you're not happy. I guess I've been influenced by Freud's famous therapeutic aim for his hysterical patients, "...Transforming... hysterical misery into common unhappiness."*

*Ihr hysterisches Elend in gemeines Unglück zu verwandeln, SE Vol II, Studies in Hysteria, p. 311. 

RateRx

A little while back, I wrote a post, Virtual Care Physician, about HealthTap, the app that lets you post a medical question and get rapid answers from doctors. The way I checked out Healthtap was by signing up under a false name as a patient, and posting a question about club soda. So now I get occasional email updates from them, and they've come up with an interesting feature called, RateRx, in which, "67,000 top U.S. doctors share their experience and expertise to guide millions toward the best indications."

RateRx is a study that surveyed thousands of US doctors about the clinical utility of medications for specified conditions. Doctors are not permitted to see other doctors' ratings and comments until they've submitted their own, although I'm not sure how they could stop me from viewing ratings as a patient, and then signing on as a doctor and submitting my own ratings. Doctors can also comment on other doctors' comments. The study is ongoing, and contributing doctors can also add ratings for new medications not already on the list.

The way you look up ratings is alphabetically, by condition:

Then you click on the number of treatments or the condition, and you'll get a dropdown list of individual drugs, with ratings and a link to reviews:

The drugs are listed from highest to lowest rated. So it turns out, Prozac is the most highly rated antidepressant, with 4.0 out of 5 stars. The lowest rated is Liothyronine or T3, with 2.2 stars.

Prozac seems to be the only SSRI on the list, which also includes, in descending number of stars:

Effexor                      3.9
Wellbutrin                3.9
Remeron                   3.3
Imipramine               3.0
Desipramine             3.0
Nortriptyline             3.0
Tranylcypromine      2.9
Isocarboxazid           2.8
Phenelzine                2.8
Protriptyline             2.8
Trazadone                 2.7
Trimipramine           2.6
Amoxapine               2.5
Maprotiline              2.5
Chlordiazepoxide     2.2
   & Amitriptyline
Liothyronine            2.2


One nice feature is that when you click on the reviews, you can see each doctor who submitted a rating, and link to his or her profile. Not everyone comments. For instance, in the case of Prozac, there were three comments up at the top, and none below. These are the comments, and all three commenters are psychiatrists:

Actually, I counted, and 23 of the 47 raters of Prozac are psychiatrists. A bunch of the others are neurologists. Then there are a few family medicine docs, as well as some internists. A couple of OB/Gyns, a pediatrician, a couple nephrologists, 1 pharmacologist, 3 clinical psychologists, and 1 labeled, "American Board of Phlebology". Personally, I'm not comfortable having people who can't prescribe or don't see patients comment on how patients respond to medications.

The drug that was most frequently rated, 103 to be exact, was desipramine. The comments were mainly about side effects. One comment I thought was useful was, "If the side effects can be tolerated, it can work. Usually, the prescribed dose is too low."

Most of the comments about Phenelzine were about dietary concerns, with some good general descriptions:

Phenelzine or Nardil is an antidepressant in the group called MAO Inhibitors. These older medications have the highest response rate, which is about 80%. They also require dietary restrictions to prevent a high blood pressire reaction to foods containing tyramine (cheese, processed meat, red wine, soy and some others). Other side effects: insomnia, dizziness.

and

Useful for atypical depression. People with atypical depression tend to feel better during enjoyable activities, have increased appetite and sleep a couple hours more each day than when not depressed, have a feeling that their arms & legs are heavy, & have an ongoing fear of rejection. Problem with this med: dangerous interactions with MULTIPLE other meds and SEVERAL foods.

So here's my assessment:

It's not a bad idea to have a large survey of doctor ratings and comments. The comments are probably more useful than the ratings, and can be very informative for patients.

It would be helpful to have more statistics listed, like how many of the raters of cardiac medications are cardiologists. I mean, it's not like I know nothing about cardiology, but I wouldn't presume to comment on how well those meds work in the clinical setting, because that's not what I do. By the way, the American Board of Phlebologist also put in his two cents about Amlodipine/HCTZ/Valsartan. I suspect he pops up in most ratings, and gets his name out there that way.

The main drawback is that the setup can be misleading. It seems like a gross oversight to have ratings for lots of MAOI's and Tricyclics, but only one SSRI. I think that would confuse a patient who is looking for advice about commonly prescribed antidepressants. I don't know if RateRx just expects doctors to add the most commonly prescribed meds, but it seems to me the people running the survey should encourage ratings of those drugs. It's not like it's hard to get prescribing information. Drug companies certainly know which meds are most popular.

So check out RateRx, and let me know what you think.

App Review: NbNomenclature

A while back, I wrote a post called, What's In A Name?, about a proposed 5-Axis drug nomenclature system. The idea was that our current system of describing psychoactive medication involves terms like "Antidepressant" and "Antipsychotic", even though antidepressants are sometimes prescribed for anxiety, and antipsychotics for depression, and this is confusing, especially to patients.

Instead, the new system has a different way of describing drug class, along with mechanism of action,  indications uses, and relevant side effects, as well as neurobiology.

I had some concerns about how this system would be used, and by whom. There was talk of a future merge with DSM, whatever that would mean. It was created by people with strong ties to industry. The claim is that it would be a collaborative model, and I wondered what the charge for that collaboration would be. And I also wondered if reporting off-label uses as part of the drug description would influence future drug indication.

This was over a year ago.

More recently, Clinical Psychiatry News reported the launch of the drug terminology overhaul. The launch was accompanied by the release of a paperback book, as well as a new app, NbNomenclature, available for free download on iTunes App store and google play.  See also Nigella's comments on The Practical Psychosomaticist.

Not sure why Nigella had difficulty downloading it. Maybe because she was using an ipad. I put it on my iphone, and it does work. I haven't attempted an ipad yet.

So  I thought I'd share some of my thoughts. The home screen looks like this:

If I type in say, nortriptyline, I get this (the screen shot is missing the neurobiology section, down at the bottom, but I'll get to that):

It gives the official indication as Major Depressive Disorder, under the check mark (or tick, if you're British), but the + sign gives you the conditions it's used for.

Common and serious side effects under the - sign, that's useful.

What it doesn't give you is what you do get on something like Epocrates, dosing:

(Yes, I get crappy signal. Thanks, Verizon)

This lack of further information is strange in light of what I read in the app's stated mission:

"This proposed nomenclature aims to reflect the current pharmacological knowledge base and cannot necessarily represent the ultimate scientific truth...we feel that it's better to present a cutting-edge scientific interpretation than to wait for the definitive conclusion. We need to treat our patients now, and we cannot postpone treatment until all the facts are known.

Therefore this nomenclature is based on:

1. The need to treat now.

2. Updated neuroscience insights.

3. The judgement of the members of the task force." (italics mine)


With all this emphasis on the need to treat NOW, it would be nice to know how to dose the patient sitting in front of me, and what dosing forms are available for writing a prescription.

Maybe the Nb people didn't think that was important since we'll all be using electronic prescribing software that will tell us dosing options and forms. But for me, it keeps the app from being really useful, except perhaps to medical students who don't prescribe anything and don't need to know dosages. (Don't freak. I do remember most dosage forms, but there are some meds I don't prescribe very often, and I look those up just to be sure. Also, when titrating or tapering, sometimes you need weird, in-between dosage strengths.)


One nice feature is that if you're looking at a drug, and you swipe left, you get a similar drug. One left swipe from nortriptyline takes me to amoxapine.

Curious about this feature, I looked up Strattera, which it lists as a norepinephrine reuptake inhibitor (NE-RI in the app's abbreviation system). One left swipe takes me to desipramine, another NE-RI, then to lofepramine, maprotiline, and reboxetine, all indicated for Major Depression, unlike Strattera. So the new classification system is based strictly on mode of action.

Again, my question-who is going to use this? If I'm looking up Strattera, then presumably I want a medication for ADHD. If I'm looking for an alternative, I don't want to end up with an antidepressant. As an experienced clinician, I already know what other ADHD meds are out there. For an inexperienced clinician, this could cause a lot of problems. Or maybe the idea is for doctors to experiment based on mode of action.

Okay, so I couldn't find another ADHD med by swiping. I went back to the home page, clicked on "approved indication", and looked up ADHD. I got two hits: amphetamine and lisdexamfetamine. Aren't they missing a few? It turns out, they have several categories of ADHD. The one I checked was just ADHD. ADHD in children in Canada gives me guanfacine, ADHD in children >6y in the US gives me clonidine, and ADHD in children >6y and adults gives me methylphenidate and atomoxetine, right back where I started. Those are all the ADHDs they had.

In contrast, looking up ADHD in Epocrates gives me a list of 31 drugs, from Adderall to Zenzedi. Kinda easier to find alternatives.

As for the neurobiology section, nortriptyline looks like this:

Those highlighted phrases don't link to anything. Maybe they will down the line.

Bottom line: I can't think why this would be useful to anyone who already prescribes medications. And I'm not sure what the long term implications of a system like this are.

If an app rating consists of "A", "AP", and "APP", from worst to best, I rate it a "A".

Virtual Care Physician

I got the following email: Become a HealthTap+ Prime Virtual Care Doctor HealthTap+ and HealthTap+ Medical Group, PC. have partnered to create a healthier, happier world—one person at a time. As a Prime Doctor with HealthTap+ Medical Group, you have freedom to shape your own lifestyle. Boost your income and practice medicine remotely from wherever you wish (at home, in your office, even a vacation home) using your own equipment to provide Virtual Consults via video, audio, and text using HealthTap+ Prime, the next-generation platform for delivering care online and onto mobile devices. You’ll have the ability to provide quality services that keep patients coming back, attract exceptional peers in the medical profession, and help create the future of healthcare by demonstrating what’s possible when people have immediate access to trusted doctors. We are looking for Board Certified physicians (MD and DO) who possess the skills or knowledge of a primary care physician. As a Prime Doctor you will receive the following benefits: Boost your income (earn up to $180/hr) Care for patients anytime and anywhere most convenient for you Work free of administrative hassles, overhead, or additional costs Join an elite group of thought leaders to revolutionize personal health Take a minute to sign up here: https://www.healthtap.com/?Prime Shifts are selected on a first-come, first-served basis! This is an independent contractor position with HealthTap+ Medical Group, PC for Virtual Consults via HealthTap+ Prime. I googled "healthtap prime", and one link took me to a review on Reidbord's Reflections, Steven Reidbord's blog. The original HealthTap model seems to be a double social network, where anyone with the app, or on their site, can ask a medical question, and get an answer, from a doctor, for free, pretty quickly. So there's the network of "askers", and the network of doctors.  As Dr. Reidbord notes, it would work better as a knowledge-base model, rather than a social network. But there are fun features like "Tap Tips", which seem to be unsolicited pearls. You can look things up by topic, and you can set up a feed. For doctors, there's something called the "virtual practice", which allows you to advertise yourself, schedule appointments, and offer an individualized app to your patients. And there are little perks and awards, "Best doctor in Hoboken" based on some rating system. Also for doctors, there are all kinds of disclaimers like, "see your doctor if..." I clicked the link to Dr Reidbord's page on HealthTap, to see what kinds of questions came up. Some simple things, like, "Is ECT effective for depression?" There seems to be a one word answer, "Very", followed by a brief explanation: Electroconvulsive therapy (ECT) has one of the highest success rates of any treatment for depression. But because it involves anesthesia and other risks, it is reserved for severe conditions that do not respond to less intensive treatments. There are a lot of "maybe" kinds of questions: "Does risperidone work right away?", "Any tips for anxiety?", "Best antidepressant?". Some specific questions, "Can I take beta-blockers and paxil?", and some I wouldn't know what to do with, "Why can't I sleep at night?".  Dr. Reidbord's answers are impressive. First of all, they're limited to 400 characters. He manages to know when to answer directly, when to say, Maybe, when to say, You might want to see your doctor, and when to say, See your doctor. I don't think I'd be able to navigate those shoals. (If you're reading this, Dr. Reidbord, kudos). I decided to try HealthTap from the patient's perspective, so I signed up for an account under a false name and date of birth, and an email I rarely use. The UI of the app is pretty good. I glanced through some questions, and many were along the lines of, "How can I lose 40 pounds in 1 year?" The answers were decent-eat healthily, drink water, get sleep, exercise-but many grandmothers could give you the same answer, and I got the impression that most of it was common sense. There were some reviews from users who are grateful for having access to doctors, rather than someone crazy online. But for a lot of the questions, I didn't think it would be that misleading or confusing to google.  I decided to post a question. One question I saw was about sodas, whether they're unhealthy, including sugar free and club soda. One answer mentioned tooth decay. I drink a lot of club soda, so I started to wonder, is it adversely affecting my teeth. Now, I'm sure I could have looked this up myself. But I asked, "Is club soda bad for me?" I got two answers within a couple minutes, both of which said club soda was fine, as long as it's not in excess. And one answer mentioned teeth. I "thanked" one of the responders-I supposed it's like "liking". I was pleased that my question was vague and didn't include what I really wanted to know, but I still got the answer I was looking for. (By the way, does anyone know the difference between seltzer and club soda?) Then I decided to try a difficult question, "What is the proof that DSM-5 diagnosis criteria are accurate." I got one answer, 43 minutes later: "History. These codes are compiled by the symptoms of millions of patients. The diagnostic codes are created around a constellation of symptoms by doing it this way the risk of mis diagnosis is lessened. A patient is not diagnosed by one symptom but a series of them adding up to a diagnostic criteria" You can decide if that answers my question. The responder is an Aesthetic Medicine doctor "known for" (one of the app features) acne, botox, laser tattoo removal, thermage, body contouring, being knowledgeable,... I should mention that the club soda question was answered by a Pain Medicine doctor, and a Clinical Psychologist, who was the one who wrote about teeth.  There also seems to be a way to get faster answers from doctors for $0.99. I haven't tried that yet. I checked out the link in the email to sign up to be a Virtual Care Physician. There was a video with words like "delighted". Everyone had some sort of laptop, ipad or mobile device, and was happily tapping away. One doctor was demonstrating to her patient, on a Skype-like system, something about neck pain. At least, that's what it looked like. Apparently, malpractice insurance is included with the virtual care position.  Is this the future of medicine? The talking heads on the video seemed very pleased that patients could have 24/7 access to doctors, without visiting an ER.  I read an article in New York Magazine, a few weeks ago, about the future of health insurance. It described a new insurance, available now in NYC, called, Oscar. It's a techy, startup operation, with subway ads like, "Finally, health insurance that won't make your head explode. And if it does, you're covered." The techy part seems to include health profiles for users, and the ability to get medical care quickly and easily: He gave an example: A few weeks earlier, he’d felt some rawness in his throat that he was worried might be strep. Using his Oscar iPhone app, he put in a request with his doctor, who phoned him back in 15 minutes. The doctor, Kushner recalled, “asked me to stand in front of a mirror and look at the back of my throat. Did I have white spots on the back of my throat? I did. He said, ‘I’m going to prescribe you Amoxicillin.’ ” (Oscar has stressed that the call feature is not intended for ongoing care nor major ­medical conditions. “We’re not going to treat diabetes by phone,” Nazemi told me.) So the virtual phenomenon is not exclusive to HealthTap.  I was pretty surprised that I was being contacted for a primary care job. Technically, I'm qualified, but I wouldn't recommend myself for primary care. I was also surprised that they're restricting the initial virtual push to primary care. Psychotherapy seems much better suited.  I'm gonna break it down now. And I'm gonna include both the patient's and the doctor's perspectives. Pros: 24/7 access immediate response to questions answers from actual doctors good UI tools for doctors to get new patients and make access easier for current patients way for doctors to make some extra money challenge of writing succinct answers social network atmosphere and tropes Cons: no physical exams doctors viewed as experts outside their primary fields over-prescribing of antibiotics medicine practiced in a way that could be construed as irresponsible, and at the very least has unforeseeable consequences.