Category: Medicine
Could our preoccupation with mental health be part of the problem?
Could our preoccupation with mental health be part of the problem?
In some ways, encouraging people to think and talk more about their mental health is a good thing. There is now less stigma around mental illness, and more people who can benefit from professional help are getting it. But there is also reason to believe that efforts to bring attention to mental health struggles are inadvertently making us more vulnerable to psychological distress.
Start with our expanding conception of mental illness. The more fixated we are on mental health, the more sensitive we become to anything that might qualify as a symptom and the more we use clinical language to describe normal emotional experiences like grief, burnout and loneliness. This broadening of what we think counts as a disorder — known as concept creep — encourages us to pathologize ordinary life and see ourselves as mentally unhealthy.
Here is more from Clay Routledge at the NYT.
The demand for human enhancement technologies
When a new technology promises large private benefits but may impose social costs that markets do not price, demand need not reveal how citizens want it governed. We examine this using a nationally representative U.S. survey experiment (N=5,556) on human enhancement technologies (HET). The experiment randomizes benefit domain, mechanism, heritability, purpose, and risk across vignettes; for each respondent’s assigned vignette, we elicit stated adoption, preferred regulation, and ethical and societal concerns. Overall, about 53% would adopt. Framing the technology as enhancing rather than restorative lowers adoption by about five percentage points, as much as a severe side-effect profile. About 28% would not adopt at any benefit. This refusal is driven overwhelmingly by the enhancing framing rather than by risk, consistent with a non-compensatory constraint for a substantial subgroup. Most who would adopt still favor strict regulation, and most who would never adopt do not wish to forbid others from doing so. Productivity enhancement generates the most ethical concern of any attribute but attracts the least regulation, and respondents favor subsidizing rather than taxing its adoption, consistent with a concern about access rather than safety. Private demand is therefore an unreliable guide to the governance citizens want, and the divergence we document provides a basis for regulators seeking to align the direction of technical change with societal values and priorities.
That is from a new NBER working paper by . And I will repeat this segment: “Productivity enhancement generates the most ethical concern of any attribute…” Do note of course that the last sentence of the authors is completely unwarranted, and is a classic example of underidentified political bias in academic reasoning.
Talk Therapy is Speech
IJ: On Wednesday, the United States District Court for the District of Columbia struck down a D.C. law that barred therapists from other jurisdictions from doing online teletherapy visits with clients in D.C. The decision comes nearly six years after Virginia-based counselor Elizabeth Brokamp teamed up with the Institute for Justice (IJ) to file a lawsuit arguing the law violated the First Amendment.
“This decision is a victory for anyone who speaks for a living,” said IJ Deputy Director of Litigation Robert McNamara. “Elizabeth’s victory here confirms that the First Amendment protects useful speech, including counseling, and that licensing boards can’t censor speech simply because someone doesn’t have their permission to talk.”
Congrats to the IJ! Now, we need to get rid of all the other bans on patients hiring physicians from other states. As I wrote last year:
During the pandemic, many restrictions on telemedicine were lifted, making it far easier for physicians to treat patients across state lines. That window has largely closed. Today, unless a doctor is separately licensed in a patient’s state—or the states have a formal agreement—remote care is often illegal. So if you live in Virginia and want a second opinion from a Mayo Clinic physician in Florida, you may have to fly to Florida, unless that Florida physician happens to hold a Virginia license.
The standard framing says this is a problem of physician licensing. That leads directly to calls for interstate compacts or federalizing medical licensure. Mutual recognition is good. Driver’s licenses are issued by states but are valid in every state. No one complains that Florida’s regime endangers Virginians. But mutual recognition or federal licensing is not the only solution nor the only way to think about this issue.
The real issue isn’t who licenses doctors. It’s that patients are forbidden from choosing a licensed doctor in another state. We can keep state-level licensing, but free the patient. Let any American consult any physician licensed in any state. That’s competitive federalism—no compacts, no federal agency, just patient choice.
Hat tip: Joel Selanikio.
The economic effects of GLP-1s
We estimate the causal impacts of GLP-1 treatment on labor market outcomes using linked Danish administrative data and a matched stacked difference-in-differences design. We compare patients who initiate GLP-1 treatment during the first two years of Semaglutide availability to observably similar patients who initiate four years later. We find that GLP-1 treatment reduces long-term sickness leave by 17.3%. We estimate total fiscal benefits of GLP-1 initiation of approximately 1.3–1.5% of annual labor income per employed individual. We do not detect statistically significant or economically meaningful impacts on income, labor force participation, or employment over four years.
That is from a new NBER working paper by
The Trump Administration’s Threat to Scientific Research
In The Nationalization of American Science I warned that the Trump administration’s rewriting of the seemingly mundane Regulation for Federal Financial Assistance was a tremendous threat to America’s historically successful decentralized system of science funding. Many others are now sounding the alarm.
It’s not surprising that organizations like the AAAS oppose the rule, albeit with unusually strongly worded dissents:
This latest move is a brazen power grab by the Director of the Office of Management and Budget to buck the will of Congress and the American people and will make future discoveries less likely. If this rule becomes final, Americans’ hopes for future cures, national security and economic strength will rely on the scientific sensibilities of the nation’s chief bureaucrat. Alzheimer’s disease will not be cured by a budget analyst from either political party.
But we are now seeing strong pushback from independent thinkers such as:
Grayson Logue writing at The Dispatch:
A sweeping new rule proposed by the Trump administration could remake how that money is awarded and give the president and his political appointees discretion to cancel funding or target recipients for virtually any reason—with little opportunity for recourse.
White House officials argue the new rule is necessary to assert more accountability over federal grantmaking, but observers fear the shift will expand opportunities for politicization, abuse, and even corruption for an administration that has already demonstrated a penchant for using the levers of the federal government to punish partisan enemies and reward ideological allies.
if I was trying to ruin American leadership in scientific research this is pretty much the kind of rule I would write…One of the genuine difficulties with observing the second Trump term is that the assault on state capacity and impartiality has been so multipronged that it is difficult to keep track of everything going on. But these proposed rule changes are monumental and catastrophic.
and Noah Smith:
MAGA’s attack on science is even worse than it looks…despite science’s overwhelming popularity and public trust, Trump and his administration are launching an unprecedented and devastating attack on American science — cutting funding, and forcing science projects to undergo ideological review by government commissars.
It may be that the Trump administration has pushed too far, but my real worry is that we are losing an equilibrium. Science was never completely independent of politics, of course, but even at the worst of times, funding was decentralized and the culture-war material that dominated the headlines was never more than a tiny fraction of the whole. Like an independent judiciary, independent science has been an American virtue. COVID policy, gender policy, and now the Trump administration’s weaponization of these mistakes may have destroyed that equilibrium.
As I wrote in my original post, we are adopting the loser policies of authoritarian nations but those policies are the norm elsewhere for a reason. Centralized control of science is the default because it serves the people in power of whatever party. Decentralization is the fragile exception—a historically unusual achievement that is easier to destroy than rebuild.
Addendum: And here is Andrew Gelman.
Progress against dementia
Mr Stallard has been working for a decade to corroborate this revelation. His findings have, if anything, become even more striking. Last year he and some colleagues published research in the Journal of the American Medical Association showing that, whereas 40 years ago three in every ten Americans aged 85-89 had dementia, by 2024 just one in ten had it (see chart 1). What is more, America is not the only beneficiary of this trend. Between 1988 and 2015 the share of older people being diagnosed with dementia fell by 13% a decade across six countries in North America and Europe, according to a study of almost 50,000 people by Frank Wolters of the Erasmus Medical Centre in Rotterdam, and colleagues.
Some smaller studies have also found big declines. Data from the Framingham Heart Study, which has tracked three generations in an American town, show an average drop in new dementia cases of 20% per decade over almost 40 years between the late 1970s and early 2010s. Those who were entering their dotage when Daft Punk’s “Get Lucky” was topping the charts (2013) were 44% less likely to have dementia than those who were doing so when Sting was urging Roxanne to switch off her red light (1978).
Whereas most earlier studies had simply pooled elderly people and then applied a statistical adjustment for age, Mr Stallard looked at narrow bands of ages to compare different cohorts of people over 50 years. By examining the changes between each successive cohort, he calculates that dementia rates have been declining by 2.5-3% for each calendar-year cohort.
Here is more from Jonathan Rosenthal at The Economist. You can think of this as the new instantiation of the Flynn Effect…
Single-payer health care systems are looking worse all the time
That is the theme of my latest Free Press piece, here is one excerpt from it:
Government-run systems often (not always) do a perfectly fine job setting a broken arm or administering a long-standing, well-known medication. They do much less well when it comes to developing, financing, and delivering a new immunological approach to fighting cancer, personalized to your individual genome at a cost of hundreds of thousands of dollars. In our rapidly arriving biomedical future, innovation capacity will matter above all else. And though they may not see it today, the people with the most life ahead of them will reap nearly all of the benefits of a dynamic system, or suffer the consequences of a paralytic one.
Thirty years ago, it was often debated whether the Canadian or British healthcare systems were better than what we have in the U.S. After all, they offered a kind of guaranteed access to health services. The details could differ, but often the healthcare had no upfront price or only a low user fee. In America, in contrast, healthcare was more expensive, there were many millions of uninsured people, and dealing with sometimes rapacious insurers and hospitals could involve significant emotional trauma.
But over time the British and Canadian systems look worse and worse. The queues and rationing have increased, as giving healthcare away for free makes it hard to satisfy demands in a timely manner. In Canada, for instance, the median wait time has risen from 9.3 weeks in the early 1990s to 28.6 weeks today. In the British National Health Service, only 65.3 percent of patients start treatment within 18 weeks.
Worse yet, both of those systems are undercapitalized. In Britain, healthcare is badly understaffed and underfunded. Yet the country already has high taxes, high debt, and slow economic growth, so it is not clear where the new money will come from to recapitalize the system.
And this sentence:
This entire dynamic will be intensified as the pace of medical innovation picks up.
Your life may depend on it.
Will future biomedical advances be low marginal cost?
Most pharmaceuticals involve high upfront costs, to discover and test the drug, and very low marginal costs. Another pill can be printed almost for free.
That cost structure favors health systems, such as that of Britain, that try to pay lower for services. They can end up getting a relatively good deal from price discrimination. After all, they can be served at low marginal cost, at least for those ttreatments.
Now imagine a biomedical future where many more treatments are based on the sequencing of your individual genome, and then the development of specific treatments personalized to you. Obviously it will depend on developments, but very likely those remedies will have relatively high marginal costs.
In that setting the British approach to health care procurement and pricing will work less well. It is the well-capitalized, “overspending” systems, such as the United States, that will have an easier time making the adjustment.
“The rising relative advantage of well-capitalized health care systems” is a neglected trend, because it makes a lot of earlier elite pronouncements about health care economics look a bit off.
GLP-1 drugs and marriage
GLP-1 medications generate large weight loss and may also alter social and economic outcomes. Using the Understanding America Study, I compare women starting GLP-1s for weight loss with matched women who would like to start a GLP-1 but have not. Single women’s marriage/cohabitation rates rise by 29 percentage points and employment among baseline non-employed women rises 27 percentage points after six or more quarters. Existing partnerships do not dissolve, and already-employed women show no upward job mobility. The pattern suggests that part of the female obesity penalty operates at new-match formation rather than only through health or incumbent productivity.
Here is the paper by Rebecca Diamond. And here is a thread on the paper. And not everyone believes the size of these estimates. I do not find them so crazy? Here is Steven’s dialogue with GPT.
Two Roads to Fast Clinical Trials, and the US Takes Neither
The HHS (FDA, NIH, ARPA-H and related agencies) is moving to speed clinical trials in what they are calling Operation TrialBlazer (kudos on the pun). The motivator, of course, is China:
China has made biotechnology a strategic national priority, systematically expanding its clinical research infrastructure with government backing, streamlined regulatory pathways, and sustained investment. In 2021, China’s global share of Phase 1 trials surpassed the United States’ share for the first time, a milestone that would have seemed unlikely just a decade earlier. And in 2024, China surpassed the United States in the total number of clinical trials registered, with over 7,100 registered, representing 39% of global trials…. For certain cutting edge modalities, including cell and gene therapy, radioligand therapy, and stem cell therapy, China uses investigator-initiated trials to provide additional flexibility, though with some tradeoffs around oversight and quality control. This means that drugs can move into human testing if a researcher has an interest and funding. In the U.S., comparable trials might wait years to start.
I am also pleased to see that they mention Australia, another advanced democracy, as a leader in clinical trial regulation:
Australia’s Clinical Trial Notification System allows trials to begin in fewer than 70 days after a final protocol is submitted, with regulatory approval granted in as little as 21 to 28 days and sites activated within 6 to 12 weeks.
Keep those comparisons in mind. Operation TrialBlazer proposes some good reforms such as CMC clarification. CMC is Chemistry, Manufacturing, and Controls–and it deals with the basics of manufacturing a drug. The FDA, however, is very risk averse and companies know that so they have often gone overboard in CMC: for example, proving stability of a formula at 6+ months when the trial is to last only a few weeks or documenting their full commercial manufacturing process before they even know if the drug works and knowing full-well that the process will be changed many times before a drug actually gets to market. In short, a lot of cost for very little benefit. The FDA is now clarifying that this kind of thing is not necessary. Good, that is low-hanging fruit. There are other good ideas as well.
But note what they are not proposing. Despite using China and Australia as exemplars they are not going down either path. Where China is fastest is in cell therapy, gene therapy, radioligand, and stem cell work and in these areas, China lets trials proceed on an investigator-initiated basis: as the TrialBlazer document puts it, a drug can move into humans “if a researcher has an interest and funding.” China then combines this open (or lax) front end (for these products) with an all-of-government industrial policy to accelerate winners.
The US is declining to go down that path. Ok, not my call, but I get it. But they are also declining to follow Australia. In Australia there is also no government prospective regulatory evaluation of most early-phase clinical trials. Under the Clinical Trial Notification (CTN) scheme, the sponsor submits their protocol package to a Human Research Ethics Committee (HRECs)–Australia’s IRBs–and once the ethics committee approves, the sponsor notifies the regulator, the Therapeutic Goods Administration (TGA), and pays a fee. The TGA does not read and clear the package before the trial starts. The roughly 21-to-28-day “approval” and sub-70-day start figures in the document are fast precisely because the regulatory step is not an evaluation. The government regulator stays out of the front end for most clinical trials, although in direct contrast with China it does step in for the highest risk biologicals. China has decided, high-risk, high-reward.
Australia does certify the certifiers, the HRECs. Europe uses a similar system for medical device approval. It’s a system proposed by former medical officer at the FDA Henry Miller and one I have long supported for the US. China is more laissez-faire.
The US architecture in contrast rests on the “gold standard” FDA reviews and the “FDA will retain full regulatory authority and decision-making.” In short, all of the TrialBlazer reforms are about making the gatekeeper faster, cheaper to prepare for, and less uncertain. None of it is about getting rid of the gatekeeper.
Addendum: Full disclosure, I did some consulting with ARPA-H on related work. See also my previous post on the a radical deregulatory approach, Montana’s SB535 and a Potential Biotech Renaissance in America
Elderly Health and Longevity in the US
Rising elderly life expectancy is a well-known source of fiscal pressure on Social Security and Medicare – but how have declining mortality and morbidity affected the two programs’ relative finances? Using nearly three decades of Medicare Current Beneficiary Survey data (1992-2019), we estimate that these demographic changes raised expected lifetime Social Security spending by over twice as much as expected lifetime Medicare spending: 14% compared to 6%. The slower growth of elderly lifetime health care spending than annuity spending reflects two features of how longevity has increased: the additional 2.4 years of remaining life expectancy were entirely healthy – free of physical or cognitive limitations – while the expected amount of time spent with severe health limitations fell by about 30%, reducing expected lifetime nursing-home and home-health use. We then write down a stylized life-cycle model of a risk-averse retiree facing stochastic mortality and health to illuminate the key forces that affect the optimal allocation of a fixed amount of public funds across Medicare and Social Security.
That is from a new NBER working paper by Liran Einav and Amy Finkelstein. In general I wish to switch resources from Medicare to Social Security, or at least give individuals the option to do so. You can use dollars to buy health care, but it is not always so easy to make the transformation in the opposite direction.
The Shingles Vaccine Reduces Dementia
In 2023 in Can the Shingles Vaccine Prevent Dementia? I wrote:
A new paper provides good evidence that the shingles vaccine can prevent dementia, which strongly suggests that some forms of dementia are caused by the varicella zoster virus (VZV), the virus that on initial infection causes chickenpox.
We now have three more studies–from America, Australia and Canada–that find similar results using large numbers and credible research designs. Thus, I think we can up this to the Shingles vaccine reduces dementia.
Eric Topol summarizes the new evidence and writes:
If you are 50+ and have not gotten Shingrix vaccinated, you may want to consider that. You get protection vs Shingles (which can be dreadful), slowing of your biological aging (by methylation and RNA metrics), and ~20% reduction of dementia, predominantly related to Alzheimer’s disease. All of this benefit is magnified in women compared with men, but 3 of the studies showed some reduction of dementia in men. As a tradeoff, men appear to derive more cardiovascular benefit, but that evidence is not as compelling as protection from dementia from natural experiments.
Montana’s SB535 and a Potential Biotech Renaissance in America
In 2024, China’s NMPA approved 83 new drugs, the FDA approved 50. China’s share of new commercial clinical trials jumped from 8% globally in 2013 to 30% in 2024, just behind the US at 35%. Last year, China-based Jiangsu Hengrui Pharmaceuticals overtook AstraZeneca as the top clinical trial sponsor in the world.
What’s remarkable is how China is winning: deregulation and capitalism. It’s faster and easier to set up a clinical trial in China than in the United States. China is even experimenting with the peer approval model I’ve long advocated. The Medical Tourism Pilot Zone on Hainan island lets medical institutions import and use any pharmaceutical or device approved in the EU, US, or Japan — no separate Chinese approval needed. China is using our own regulatory judgments to get treatments to its patients faster than we do.
The core problem is that our clinical trial and drug approval system is slow and expensive. Getting a new drug to market in the US takes billions of dollars and a decade or more of clinical trials — and all of that before a company earns a single dollar. The consequence is drug lag and drug loss and also learning loss. Innovation is a dynamic process. You must build to build better.
It’s not over for the United States, however. Montana’s SB535, signed into law in May 2025, is the most important regulatory innovation in drug approval in my lifetime. The law authorizes investigational drugs and therapies that have cleared Phase I trials to be prescribed and sold — bypassing the traditional FDA approval pathway. It makes Montana the first state to license experimental treatment centers, “one stop shops” for otherwise hard-to-access care.
This is a very big deal.
SB535 makes Montana the only state in the nation where firms can move more quickly from a successful Phase I trial into limited commercialization. This positions Montana as a highly attractive location for biopharma, biotherapeutics, and other life sciences companies that want to accelerate time-to-market while continuing the federal FDA approval process.
Montana’s regulatory system creates the possibility of a self-funding clinical pipeline: companies using early commercial revenues to finance the path to full FDA approval. You get treatments to patients faster, and you keep companies alive long enough to prove their treatments work. Experimental treatments are not for everyone–these treatments are cash based–no Medicaid or Medicare and probably no private insurance either–but after conventional treatments have failed experimental treatments should be available for some patients, both for their benefit and for ours.
Montana is not alone. Florida now allows non-FDA approved stem cell therapies:
A new law in Florida, CS/CS/SB 1768, allows physicians to market and administer stem cell therapies that have not been approved by the U.S. Food and Drug Administration (FDA) for orthopedic conditions, wound care and pain management.
These experiments in regulatory federalism are vital and not just for patients but also for geopolitical competition. I am thrilled China is pursuing medical innovation (I predicted and applauded this in my TED talk) but I also don’t want to see America falling behind.
The Trump administration has been supportive. I would like to see HHS and the FDA working with companies operating under state right-to-try frameworks — sharing data, clarifying federal-state boundaries favorably, and treating these experiments as the biotech competitiveness infrastructure they are.
The FDA approval process has long been treated as the only legitimate path to market. The cost of that orthodoxy is measured in companies that never reached viability, innovations that never got off the ground, and patients who died when they didn’t have to. I have spent thirty years trying to get people to see the invisible graveyard. That’s hard. Most remain blind. But China’s bursting pipeline of new drugs is visible — could this be a Sputnik moment for biotech?
An American biotech renaissance — driven by AI, federalism, and regulatory innovation — is possible. The path forward is to double down on what makes America great: the laboratories of democracy are working, and in Montana and Florida, so are the labs.
General-purpose large language models outperform specialized clinical AI tools on medical benchmarks
This result does not surprise me at all. Here is part of the abstract:
Frontier LLMs outperformed clinical AI tools in all three evaluations. Clinical AI tools performed comparably to auto-enabled Google Search AI Overview on the RCQ. These findings highlight the need for independent, real-world evaluation of AI tools before they enter clinical settings.
From Krithik Viswanath, et.al. As a side note, this (and the more general version of the point) is one big reason why some fairly large number of Emergent Ventures proposals are rejected rather quickly.
Here Comes the Sun(screen)
I have been banging on about FDA delay in approving new sunscreens since 2013. Well it has finally happened. Twenty six years after being approved by the European Union and thirteen years after then-FDA Commissioner Margaret A. Hamburg told lawmakers that sorting out the sunscreen issue was “one of the highest priorities” the FDA has approved a new sunscreeen ingredient.
The US has been slow because it regulates sunscreens under the the more expensive, time consuming and rigorous drug standard rather than the less expensive cosmetic standard. Does this mean that our sunscreens are safer? No.
In fact, American sunscreens may be less safe.
Sunscreens protect by blocking ultraviolet rays from penetrating the skin. Ultraviolet B (UVB) rays, with their shorter wavelength, primarily affect the outer skin layer and are the main cause of sunburn. In contrast, ultraviolet A (UVA) rays have a longer wavelength, penetrate more deeply into the skin and contribute to wrinkling, aging and the development of melanoma, the deadliest form of skin cancer. In many ways, UVA rays are more dangerous than UVB rays because they are more insidious. UVB rays hit when the sun is bright, and because they burn they come with a natural warning. UVA rays, though, can pass through clouds and cause skin cancer without generating obvious skin damage.
The problem is that American sunscreens work better against UVB rays than against the more dangerous UVA rays. That is, they’re better at preventing sunburn than skin cancer. In fact, many U.S. sunscreens would fail European standards for UVA protection. Precisely because European sunscreens can draw on more ingredients, they can protect better against UVA rays. Thus, instead of being safer, U.S. sunscreens may be riskier.
European sunscreens are also more pleasant to apply, and because they work better with makeup they are probably used more often as part of a skin care regimen, which may reduce the prevalence of skin cancer. Once again, the United States’ slower and seemingly more risk-averse approach actually increases risk.
The lesson, for those who are listening, is general.