Epistemic Spot Check: Full Catastrophe Living (Jon Kabat-Zinn)

Full Catastrophe Living is a little weird, because between the first edition and the second a lot of science came out testing the thesis.  For this blog post, I’m reviewing the new, scienced-up edition of FCL.  However I have ordered the older edition of the book (thanks, Patreon supporters and half.com) and have dreams of reviewing that separately, with an eye towards identifying what could have predicted the experimental outcome.  E.g. if the experimental outcome is positive, was there something special about the model that we could recognize in other self-help books before rigorous science comes in?

I originally planned on fact checking two chapters, the scientific introduction and one of the explanatory chapters.  Doing the intro was exhausting and demonstrated a consistent pattern of “basically correct, from a small sample size, finding exaggerated”, so I skipped the second chapter of fact checking. I also skipped the latter two thirds of the book.

Overview

You’ve probably heard about mindfulness, but just in case: mindfulness is a meditation practice that involves being present and not holding on to thoughts, originally created within Buddhism.  Mindfulness Based Stress Reduction is a specific class created by the author of this book, Jon Kabat-Zinn.  The class has since spread across the country; he cites 720 programs in the introduction.   Full Catastrophe Living contains both a playbook for teaching the class to yourself, the science of why it works (I’m guessing this is new?), a section on stress, and followup information on how to integrate meditation into your life.

Introduction

Claim: Humans are happier when they focus on what they are doing than when they let their mind wander, which is 50% of the time.

Accurately cited, large effect size, possible confounding effects. (PDF).  The slope of the regression between mind wandering and mind not-wandering was 8.79 out of a 100 point scale, and the difference between unpleasant mind wandering and any mind not-wandering task was ~30 points.  Pleasant mind wandering was exactly as pleasant as focusing on the task at hand.  Focusing accounting for 17.7% of the between-person variation in happiness, compared to 3.2% from choice of task.

Some caveats:

  • People’s minds are more likely to wander when they’re doing something unpleasant, and when they are having trouble coping with that unpleasantness.   The study could be identifying a symptom rather than a cause.
  • The study population was extremely unrepresentative, consisting of people who chose to download an iPhone app.

Claim: Loss of telomeres is associated with stress and aging; meditation lengthens telomeres by reducing stress (location 404).

Research slightly more theoretical than is represented, but theoretical case is strong. (Source). First, let’s talk about telomeres.  Telomeres are caps on the ends of all of your chromosomes.  Because of the way DNA is copied, they will shorten a bit on every division.  There’s a special enzyme to re-lengthen them (telomerase), but leading thought right now is that stress inhibits it.  Short telomeres are associated with the diseases of aging (heart issues, type two diabetes) independent of chronological age.  This is hard to study because telomere length is a function of your entire life, not the last week, but is pretty established science at this point.

Mindfulness reduces stress, so it’s not implausible that it could lengthen telomeres and thus reduce aging.  The authors also present some evidence that negative mood reduces the activity of telomerase.  This is a very strong theoretical case, but is not quite proven.

Claim: Happiness research Dan Gilbert claims meditation is one of the keys to happiness, up there with sleep and exercise (location 461).

Confirmed that Gilbert is a happiness researcher and said the quote cited, although I can’t find where he personally researched this.

Claim: “Researchers at Massachusetts General Hospital and Harvard University have shown, using fMRI brain scanning technology, that eight weeks of MBSR training leads to thickening of a number of different regions of the brain associated with learning and memory, emotion regulation, the sense of self, and perspective taking. They also found that the amygdala, a region deep in the brain that is responsible for appraising and reacting to perceived threats, was thinner after MBSR, and that the degree of thinning was related to the degree of improvement on a perceived stress scale.” (location 502)

Accurate citation, but: small sample size (16/26), and for the first study the effect size was quite small (1%) for regions of a priori interest, and the second had quite wide error bands (source 1) (source 2).  However the book does refer to these findings as preliminary.

Claim: “They also show that functions vital to our well-being and quality of life, such as perspective taking, attention regulation, learning and memory, emotion regulation, and threat appraisal, can be positively influenced by training in MBSR.” (location 508).

Misleading.  These are really broad claims and no specific study is cited.  However, source 2 above has the following quote: “The results suggest that participation in MBSR is associated with changes in gray matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking.”  This is a very carefully phrased statement indicating that mindfulness is in the right ballpark for affecting these things, but is not the same as demonstrating actual change.

Claim: “Researchers at the University of Toronto, also using fMRI, found that people who had completed an MBSR program showed increases in neuronal activity in a brain network associated with embodied present-moment experience, and decreases in another brain network associated with the self as experienced across time. […]  This study also showed that MBSR could unlink these two forms of self-referencing, which usually function in tandem.” (location 508).

Accurate citation, small sample size (36) that they made particularly hard to find (source).  I can’t decipher the true size of the effect.

Claim: Relative to another health class, MSBR participants had smaller blisters in response to a lab procedure, indicating lower inflammation (location 529).

True, but only because the other class *raised* inflammation (source). Also leaves out the fact that both groups had the same cortisol levels and self-reported stress.  So this looks less like MBSR helped, and more like the control program was actively counterproductive.

For the record, this is where I got frustrated.

Claim: “people who were meditating while receiving ultraviolet light therapy for their psoriasis healed at four times the rate of those receiving the light treatment by itself without meditating.” (location 534)

Accurate citation (of his own work), small sample size (pdf).

Claim: “we found that the electrical activity in certain areas of the brain known to be involved in the expression of emotions (within the prefrontal cerebral cortex) shifted in the MBSR participants in a direction (right-sided to left-sided) that suggested that the meditators were handling emotions such as anxiety and frustration more effectively. […]

This study also found that when the people in the study in both groups were given a flu vaccine at the end of the eight weeks of training, the MBSR group mounted a significantly stronger antibody response in their immune system”

Accurate citation (of his own work), slightly misleading, small sample size.  Once again, he’s strongly implying a behavioral effect when the only evidence is that MSBR touches an area of the brain. On the other hand, the original paper gets into why they make that assumption, so either it’s correct or we just learned something cool about the brain.

Claim: MSBR reduced loneliness and a particular inflammatory protein among the elderly (location 551).

Not statistically significant. (source)  More specifically; the loneliness finding was significant but uninteresting, since the treatment was “8 weeks with a regular social activity” and the control was “not.”  The inflammation finding had p = .075.  There’s nothing magic about p < .05 and I don’t want to worship it, but it’s not a strong result.

I also researched MBSR in general, and found it to have a surprisingly large effect on depression and anxiety.

The Model

To the extent Full Catastrophe Living has a model, it’s been integrated so fully into the cultural zeitgeist that I have a hard time articulating it. It could be summarized as “do these practices and some amount of good things from this list will happen to you.” Which kills my hypothesis that having a good model is necessary to getting good results.

 

You Might Like This Book If…

I don’t know. I found it a slog and only read the first third, but the empirical evidence is very much on mindfulness’s side and I don’t know what better thing to suggest.

 

 

 

Thanks to the internet for making it possible for me to do these kinds of investigations.

Thanks to Patreon supporters for giving me money.

 

 

The Parable of Ignac Semmelweiss

When I was a kid, my dad told me the parable of the first physician to realize you should maybe mothers would not suffer quite so many horrifying deaths if doctors washed their hands between autopsies and childbirth. Unfortunately this doctor was an asshole, so everyone ignored him. He eventually went crazy from the stress of knowing so many women were being killed by their doctors, and died in a mental hospital. And that is why we don’t dismiss ideas just because they come from crazy assholes, no matter how much we want to.

I really like this story, and tell it to myself sometimes when I want to dismiss someone for being crazy and/or an asshole. Recently I got curious how true it actually was, so I pulled a couple of books on the topic, of which I finished one, The Doctor’s Plague by Sherwin B. Nuland.

First: the story as told by my dad is way more accurate than a story half remembered 25 years later has any right to be. The doctor in question is Ignac Semmelweis. Like most such discoverers, Semmelweis’s genius was not an entirely unique idea, other people had noticed autopsies and childbed fever seemed to go together, but he was the one to invent handwashing. He got a little more support than my dad mentioned, but managed to alienate them by, as I was told, being an asshole. He refused to write up his results because he had already proven them to his satisfaction. He wrote angry letters attacking the most prominent doctors in Europe. He did not play well with the other children. And he did indeed die in a mental hospital. The only thing my dad got wrong was the cause of the insanity: it was probably Alzheimer’s, not frustrated genius.

But there was another part of the story I knew but hadn’t considered; the autopsies that were contaminating doctors were being done in pursuit of curing childbed fever. The infection was spread by examinations meant to teach students. The very things doctors were doing to cure women were hurting them. Over the medium term, everyone would have been better of if they’d stopped trying. I find this terrifying.

 

Open Opportunities in Longevity

My hobby at the Foresight Institute Vision Weekend was asking people involved in longevity research what their talent gaps were. Here are the answers:

  1. “Do whatever you’re most interested in”
  2. A groundbreaking creative work that brings immortality into the mainstream.
  3. Translating the research into something that laymen can get excited about.
    1. Did I mention I write for geroscience.com ? Relive the days when I explained basic medical science a lot.
  4. There is no talent gap, they just need money.
  5. Communications, both connecting scientists to each other and spreading their research, and increasing the knowledge of smart laymen.
  6. Young people.  And then communication.
  7. Money.

 

I just published three documents supporting by big Mental Health Shallow Review, published at the effective altruism forums.  Check it out here.

Thanks to Peter Hurford for funding this research. If you would like to hire me for a research project, please reach out at elizabeth – at – this – domain .

Cost Effectiveness of Mindfulness Based Stress Reduction

The Problem

The WHO estimates that depression and anxiety together account for 75,000,000 DALYs annually, making up ~5% of total DALYs. In “Measuring the Impact of Mental Illness on Quality of Life”, I argue that there is good reason to think that the system used to generate these estimates severely underestimates the impact of mental illness, and thus the true damage may be much higher. To try to get an estimate on the harms of mental health and the benefits of alieviating mental health problems, I did a preliminary cost-effectiveness analysis of Mindfulness Based Stress Reduction (MBSR).

The Intervention

MBSR is an eight week class that uses a combination of mindfulness, body awareness, and yoga to improve quality of life and perhaps physical health for a variety of conditions.

MBSR was created by Jon Kabat-Zinn at the University of Massachusetts in the 1970s, but has spread widely since then. The exact extent of this spread is hard to measure because no official registration is required to teach mindfulness and many classes and books claim to be mindfulness inspired. For the purpose of this evaluation I looked only at things that were officially MBSR or adhered very closely to the description.

Cost of MBSR

Herman, et al. (2017) estimated the marginal cost of an MBSR class participant at $150. The first three hits on google (run in an incognito browser but suspiciously near the location from which I ran the search) for MBSR listed a cost of $395-$595, $275-$425, and $350. The difference between the top of the range and the marginal cost indicates that the high end of that range probably covers all of the costs involved with MBSR (space rental and instructor time for eight weeks of classes plus one eight hour retreat) and then some, so I will use $600 as the ceiling on costs and $150 as the floor.

MBSR has an unusually high time ongoing cost (one hour per day). To model this, I included a range of DALYs as a cost, ranging from 0 (indicating no cost) to 1/24 (as if the participant were dead for that hour). It is unclear how the one hour duration was chosen and I could not find any studies on the comparative impact of different lengths of meditation; it’s quite plausible one could get the same results in less time. For the purpose of this document I used the official program, because it was the most consistently studied.

Cost Effectiveness Analysis of MBSR

Both depression and anxiety are measured with a variety of clinical surveys. To estimate impact, I assumed that the top score on each survey caused a DALY loss equal to severe depression/anxiety, as estimated by the World Health Organization, and that a drop of N percentage points led to a drop of disability weight * N. For example, a drop of 8 points on an 80 point scale of anxiety (disability weight of severe anxiety: 0.523) causes a gain of .0523 DALYs.

For a survey of papers showing potential impact, see this spreadsheet. The estimates range from 2% to 11%, clustered around 7%.

I have created a Guesstimate model to estimate the impact of MBSR. Results were quite promising. On a randomly selected guesstimate run, the average cost was $290/DALY, with a range from $43/DALY to $930/DALY. This is close to but better than Strong Mind’s $650/DALY and overlaps with estimates of antimalarial treatment ($8.15-$150/DALY). Note that the MBSR estimate may understate the impact due to systemic biases in how DALYs are calculated. However it may also overstate the impact, as medical studies tend to overstate intervention impacts for a variety of reasons.

The model makes no attempt to account for co-morbid disorders. Individuals with depression and anxiety would likely see higher benefits, since the same hour of meditation would impact both.

This model makes the rather optimistic assumption the benefits persist for life. This assumes that the participant would have been counterfactually depressed forever without treatment.  In reality the average depressive episode lasts six months, and of people who have suffered at least one episode, the average lifetime number of episodes is four. If we assume the participant gets two years of benefit out of treatment the cost becomes $1200 to $14,000/DALY, with an average of $5200/DALY.

Caveats

All of the effectiveness studies cited were done on developed world citizens with only mild to moderate mental illnesses. Most were middle aged, and access to MBSR implies a minimum SES bar. It is possible that more severe depression is not amenable to MBSR, or that it is amenable and shows a larger absolute change because there is farther to improve.

I could find no studies on MBSR in the developing world, although since mindfulness meditation was originally created before there was such a thing as the developed world, there is a higher than typical chance that its usefulness will survive cultural translation.

All of the studies referenced had small sample sizes. They all show a consistent effect, but it’s possible publication bias is keeping negative studies out of view.

Official MBSR has an unusually high time cost compared to medication and therapy. The costs are high both upfront (eight weeks of classes and an all day retreat) and ongoing (one hour of meditation/day). Some patients may be able to get the benefits of MBSR with less time; others may not be able to practice at all due to the time demands.

 

For more on this see my shallow review of mental health .

Measuring the Impact of Mental Illness on Quality of Life

Introduction

I am currently evaluating multiple interventions aimed at mental illness. In order to compare these to each other and interventions in other areas, it is important to make an estimate of severity of the problem and of the impact of interventions. Several standard systems for evaluating health interventions exist, each of which has strengths and weaknesses. How accurate/useful are these systems for mental illness?

Death Rate

Mental illness has a death toll (primarily from suicide and overdoses) that can be compared to deaths from physical ailments. Death has the advantage of being a binary state subject to very little measurement error or differing definitions across culture. However it is an imperfect proxy for suffering inflicted by mental illness. Depending on culture one country may have a higher depression rate but lower suicide rate. A country with better medical services may have a worse drug problem but fewer deaths from overdoses. Cause of death is subject to manipulation. Mortality is also a very poor measure of anxiety, since anxiety is almost never the immediate cause of death (although it may shorten lifespan).

Disability Adjusted Life Years

Disability adjusted life years (DALYs) are an attempt to use a single number to express the health of a population. The calculation method can vary from study to study; for purposes of this post I will be referring only to the methods used in the Global Burden of Disease 2010 (hereafter GBD 2010) study.

Aggregated DALYs for a population are calculated by multiplying the [disability prevalence] x [disability weight] x [years until remission or death]. Some surveys (but not all) include further discounts for age, assuming that a year lived as a 70 year old is less valuable than a year lived as a 25 year old. This is known as age-weighting. Disability weight is calculated by asking individuals to compare two scenarios and rate which person seems “healthier.” GBD 2010 surveyed approximately 14,000 individuals from five countries (Bangladesh, Indonesia, Peru, the United Republic of Tanzania and the United States of America) and offered a web based survey as well, which was eventually taken by approximately 16,000 people. Previous versions of the GBD exclusively used the evaluations of health care practitioners.

Because they are only are a measure of health, DALYs are not a good measure of suffering. For example, a loved one dying is an obvious cause of suffering via grief, but has no impact on the DALY metric of the survivors. DALYs also deliberately exclude the availability of mitigations: vision impairment has the same DALY cost regardless of the availability of corrective lenses (Voight & King, 2010). These choices make DALYs highly legible and comparable, at the cost of excluding many things one might care about. Additionally, “Healthy” is a highly ambiguous term, which many cultures consider to refer only to physical health. This suggests that if one cares about suffering, or includes mental health in their definition of health, DALYs are likely to severely underrate the impact of mental illness.
Quality Adjusted Life Years

QALYs are explicitly designed to evaluate quality of life, not just health. Instead of choosing which of two individuals is healthier, survey participants may choose which situation they would rather live in (e.g., five years of blindness or four years of deafness), what risk of death they would accept in order to cure an ailment (e.g. 10% risk of death for surgery to restore function to your leg), or “how bad does this sound to you on a scale of 1-100?”

QALYs are noticeably better than DALYs for measuring the impact of mental illness, in that everyone agrees mental illnesses lower quality of life. However there is still concern that they underestimate the impact because people are bad at imagining themselves in different situations, and bad at imagining mental illness in particular. Dolan (2008) argues that any rating based on trade-offs is inherently weak, because humans are so bad at remembering the past and anticipating the future. He favors using ratings of subjective well being from people currently suffering from a condition. Brazier, et al. (2008) cites data that the general public rates mental health issues as less important than physical health, less so than those who suffer from mental illness (Brazier (2008), which if true would lead to an underestimate of the cost of mental illness. Meanwhile De Wit, Busschbach, and De Charro (2000) argue that people underestimate their ability to adapt to situations, and thus all QALY cost estimates are overestimates. Michael Plant argues that this applies only to physical ailments, and that this leads people to underestimate the severity of mental illness relative to physical illness.

Issues Comparing DALYs/QALYs for Mental Illness with Other Illnesses

The cost-effectiveness estimates for malaria nets are based solely on the averted physical suffering. In order to truly compare malaria QALYs with depression QALYs, we must take into consideration the mental health toll of malaria. This turns out to be a very complicated question that can’t be answered without getting into moral ontology, which is beyond the scope of this document.

For a very, very crude idea of the effect on bednets on suffering, see this guesstimate model, which lets you estimate the mental illness cost of malaria from mourning and mental-health related side effects. Ultimately the DALY/$ (guesstimated in the range of 10^-3 and 10 ^-5) are insignificant next to the DALY/$ gain from deaths averted (in the range of 10^-1).

Financial Cost

Illness (mental or physical) can exact an enormous physical toll on sufferers, in both cost of treatment and lost productivity. Productivity loss is more difficult to measure than death and thus not as precise a metric, but it is significantly more objective and comparable across ailments than DALYs or QALYs. For more information on the productivity costs of mental illness, see this post.

A second issue is that using productivity loss as a metric will bias interventions towards people with higher potential incomes, which is the opposite of most people’s instincts.

Conclusions

None of these measurements met my goals of being easy to measure and capturing the entire impact of mental illness. This is not surprising, since even the impacts of physical ailments are hard to measure. The only clear conclusion is that QALYs are better than DALYs for any purpose I can think of. Of the options available, death and financial cost are the most objective, easiest to measure, and easiest to compare to other ailments, but lose a lot of data around suffering. QALYs capture that data, but are still of questionable suitability for comparing to other ailments.