markroseman

Speaking as a daily TaskPaper user, this looks great! I totally get why you're doing the things you're doing with this, implementation-wise, and what you're able to achieve because of it.

Having said that, you know very well what a tough sell it is the more general purpose a tool is, and this is very general purpose. I hope having it out there spurs some ideas around how the novel features of this infrastructure can be the basis for some more concrete and easier to market solutions.

Has anything improved recently for RM2 around secure sync to a LAN? Would like to experiment with one for my psychiatrist wife to replace her paper chart notes, but anything hitting an external cloud service is out of the question for patient information. Sync via cable would be too obtrusive. And I gather handwriting recognition etc. is done via cloud.

Off topic, but one of my CS professors was part of the original Simula group. Had long sinced moved onto more formalized approaches, i.e., denotational semantics. On more than one occasion was heard to say "the only good object is a dead object."

I agree. There's not a chance that it will be enough to change practice at this early stage, but it will be interesting.

On the other hand, there are so many opportunities for experimental design limiting the applicability of results in mental health experiments, that sample size and distribution doesn't even begin to touch on it. Bottom line: getting a meaningful result that is widely applicable is a horrendously complex undertaking.

Simplistic in the extreme, especially given nobody has ever really enumerated all the (many, many) forms of depression in a meaningful way.

Totally agree on your last point. There's little connection between DSM and treatment guidelines (which do exist, separately). And treatment is so fragmented between multiple care providers (with most people accessing a small subset) that many obvious things get lost.

(Caveat: my wife is a psychiatrist. We wrote a book on this: https://mhnav.com/book/)

Have met lots of people who are depressed and don't have a troubled past or present. Your descriptions of etiologies, how medications function and help, etc. are simplistic and ignorant at best. My opinion of your opinion is not high, but luckily that's not a good basis for judgment.

I'd agree in so far as it makes pulling scams (or innocently giving useless advice) far too easy:

"I had depression, and I tried X, and it worked. You've got depression, so you should try X." Extremely unlikely to be helpful, and often can be harmful.

Reading some of the comments is a good reminder that solid and meaningful mental health research is very tough and expensive, just based on the sheer variability, which can't be meaningfully captured by 99.9% of studies. Each needs to be seen as one piece in a much, much larger puzzle.

I wrote up some of the problems with doing/interpreting mental health research here: https://mhnav.com/lies-and-evidence/

Economically, the numbers are on your side (e.g. leading illness for workplace disability)

Applying the (current for any given time) criteria for depression requires a certain amount of training and skill, and the point form list of symptoms that you see as the first section in each diagnosis in the DSM-5 is not standalone. To mention one huge but often-overlooked example, something isn't a mental illness unless it significantly interferes with your life and functioning.

Not to say that people don't incorrectly make diagnoses all the time.

Many of these studies also rely on rating scales (typically HAMD or even PHQ9 for depression) that are a measure of depressive symptoms but don't in themselves have the power to make a diagnosis.

You're probably confusing science as a top-down enterprise rather than a field that works bottom-up (where "bottom" would be grad students). Evidence emerges and builds from below.

Oh please, come on.

There's an entire "field of study" that seems designed to prove that through the age-old mechanism of twisting logic into absurd pretzel knots that don't hold up to scrutiny from any but the most casual observer. It's called antipsychiatry.

If you want to get a taste of how shallow most of it is, check out https://markroseman.com/antipsychiatry/

Immense kudos for the Douglas Coupland reference.

Depends how it's organized, but it could be much better. In Canada, physicians don't need to get approval before they do everything, admin overhead for a physician to bill is a matter of a few minutes a week. Not two full-time staff members just for that.

Is that when you omit infinity from the calculations in the US...?

People seem to think that if you move to single payer that the single payer would behave like any of the existing payers, i.e. you call to fight for approval for everything you do, argue about fees for each item, denying things is routine, blah blah blah.

If you have a single payer system, it doesn't have to work that way. Not even close!

Because all the doctors in countries that have single payer are so horribly done by...?

That also doesn't factor in the indirect benefits to the economy, like all the people who can't start a new business (etc.), being stuck in jobs they don't want because if they left they'd lose their benefits.

Yes, in a properly functioning universal healthcare system, wait times for specialists can be longer for things that are less urgent. First priority is those with the most medical need, not whoever steps up to pay to play.

Lower administrative costs? In the US, doctors need at least one or two full-time admin staff to negotiate with a variety of insurance providers, argue for approval of every line item, etc. Here in Canada, I spend about 5-10 minutes per week dealing with all aspects of billing for my wife's medical practice.

Healthcare is under stress everywhere, but those of you in the USA who don't understand how fundamentally broken your system is need to give your heads a shake. It's precisely because of how it's treated like a business first, thinking that competition is the solution to the problem, and applying other business principles is the way to improvement that things are the way they are. Read medical forums like KevinMD and you hear constantly about highly trained physicians ready to abandon the profession because they're treated like automatons, high suicide rates, and the best way to find a side hustle because their jobs suck so badly. Your country is being held back by the ludicrous way healthcare is structured, citizens shackled to employers, with the worst results for money spent anywhere in the civilized world. Citizens are so brainwashed they're unwilling to acknowledge the ideological morass that created and sustains this all. People who remain so frightened when people say the word 'socialism' that they double down on stupidity. Or refuse to look outside your borders because you're self-evidently the greatest country on earth. Pitiful.

Wow, where to start...

1. The whole 'chemical imbalance' thing is a gross over-simplification that might help as an introductory mental model but breaks down quickly.

2. The right thing to be measuring is symptoms, not the mythical chemical imbalance. Studies do measure changes in symptoms, typically using various rating scales, e.g. HAM-D. Measuring this way has its issues and challenges, but is being done.

3. Yes, there is an element of experimentation to find the right medication, which is hardly unique to psychiatric medications.

4. Yes, some medications are hard to quit without doing so slowly. Too many doctors don't help their patients with this.

5. Antidepressants are surprisingly effective, at least compared with many other medications. A good metric for effectiveness is the "number needed to treat" (NNT). It basically means how many people do you have to give a treatment to before you get a positive response that you otherwise wouldn't. With antidepressants, it's generally low single digits, for many around 4. Only helping 1 in 4 doesn't sound great. But check out theNNT.com for some comparisons. Aspirin to prevent heart attacks (NNT of 50-200 for people with previous heart disease, NNT 2000+ for those without previous heart disease). Antihypertensives (NNT ~100). See what's considered successful in other areas of medicine...

Some other reinvented wheel that makes one thing 10x easier but takes five years to build up an infrastructure from scratch for everything else that real programs need (an infrastructure that was already present in whatever the new thing replaced). Let a bit more time pass to forget a few other things, rinse and repeat. In other words, no net productivity gains, just churn.

Varies by jurisdiction, but there are a lot of places, including many areas in the USA, where this is very much an issue, affecting licensing and credentialing. Would it survive a court challenge? Probably not, but I don't know a lot of doctors who would take the risk of reputation, career prospects, lost income, etc. to find out.

Your "one size fits all" approach to depression is greatly at odds with the great diversity of presentations that exist. There are absolutely roles for biological solutions like antidepressants to play for many people.

Best to think of them as a possible way of accelerating a course of psychotherapy.

Depression and anxiety can result in a rather wide range of cognitive symptoms. For many people, that's what eventually convinces them to seriously pursue treatment. Yes, there are risks that side effects of SSRI's can affect cognition, but there are many alternatives. Ultimately you're trying to optimize your wellness, whatever that may look like.

Compliance with medication regimes and followup care can affect outcomes in cardiology, as in other areas. Understanding a patient's psychiatric illness, psychosocial functioning, and other factors can help predict treatment compliance. That in turn may influence the treatment regime the cardiologist recommends.

Medications that are prone to abuse, ones that may be more complex to take, ones that can be dangerous if someone takes too many... all are things the cardiologist should be aware of which takes some basic psychiatric knowledge.

There are few in cardiology, but many physical health meds can definitely create psychiatric side effects. How do you differentiate those from an existing psychiatric illness?

There's a large body of literature that recognizes the links between cardiac care and mental health, resulting in poorer outcomes, increased system utilization and costs, etc. Saying "this is my area, that's yours" exacerbates this problem.