
Should Psychiatry Test for Lead More? - smackay
http://slatestarcodex.com/2018/05/23/should-psychiatry-test-for-lead-more/
======
pjc50
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.

~~~
CalRobert
" 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
"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
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.

~~~
sandworm101
Careful. Much of the _consciousness is more than the brain_ argument arrises
from pro-life religious groups. They argue that brain death, or lack of a
physical brain, does not preclude consciousness. This is to support anti-
abortion rules and prevent the removal of life support from the brain dead.
These arguments are a minefield of religious dogma.

~~~
krageon
Maybe where you are, but not where I am from. Here, you are considered a
religious extremist if you do not support abortion (and I think that this is
the reasonable stance, but that is not relevant right now). I'm thus not very
concerned with what secondary agenda you associate this argument, and I will
definitely not be careful of having an uncertain stance just because this is
the case.

------
virmundi
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
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
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
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.

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lostlogin
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-
exposur...](https://www.motherjones.com/environment/2016/02/lead-exposure-
gasoline-crime-increase-children-health/)

~~~
staz
Thanks

------
brownbat
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.

~~~
criddell
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
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.

------
nabla9
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
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.)

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

~~~
dsr_
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
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
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.

------
pasbesoin
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.

------
narrator
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
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.

~~~
kgwgk
It's hard to believe that you've never heard or seen anything that was not
100% about trying to make people better. (pay-for-delay, Valeant,
evergreening, Theranos, citizen's petitions, Shkreli, off-label promotion,
Insys, medicare fraud, Paxil, kickbacks...)

~~~
losvedir
You're right, of course, and those are good counterexamples. In fact, one of
the stocks I helped cover collapsed overnight when fraud was uncovered.

But I see them as outliers who have been largely penalized (jail time, stock
collapse, etc), not as indicative of the industry. The _reason_ there was such
a backlash is because the vast majority of the industry are good people, and
these sorts of behaviors are shocking.

I guess I meant literally everyone I've ever known personally has been like
that. When you look at the news, yeah, you do see scandals. But I maintain
that the idea that the industry would collude to not make cures is wrong. And
similarly with doctors and their treatment of patients, which I've also seen
argued.

~~~
justin66
> But I maintain that the idea that the industry would collude to not make
> cures is wrong.

Why would you need to _collude_ to make a decision like that? Everyone in that
industry makes the same sort of analysis, I imagine. "How many doses of this
will we sell, how much will they cost to make, and how much will we be able to
charge for them?"

If the equation indicates you'll lose money, exactly why _wouldn 't_ you just
move on, assuming you're a for-profit business? You can always lobby for
government or philanthropy or something to pay for the drug, but how many
instances are there of a company just saying _we 're gonna lose at least a
billion on this thing but it will be great and help a lot of people?_

(it's an honest question - maybe you've got an example that will make
everybody a little happier)

------
conistonwater
Link should be: [http://slatestarcodex.com/2018/05/23/should-psychiatry-
test-...](http://slatestarcodex.com/2018/05/23/should-psychiatry-test-for-
lead-more/)

