United Health Care

Deciding not to eat sounds to most people the very definition of suicide. It is perhaps no surprise then that a new study concludes that when anorexics choose to take their own lives, they tend to employ some of the most lethal methods available. Yet, in many ways, the new research conducted at the University of Vermont represents a landmark shift in how doctors understand suicidal tendencies in patients suffering from anorexia nervosa.

Anorexia has the highest mortality rate of any psychiatric disorder. But psychologists previously believed that those high rates of death were due to patients' already deteriorated physical state. The hypothesis was that these are people already on the verge of death — they were so malnourished and underweight that even the slightest suicide attempt could easily lead to death.

The new study's authors have shown this assumption is wrong in most cases. Extrapolating from nine case studies of anorexics in Germany and Boston, they concluded that such suicides are not simply a call for help gone wrong, but that anorexics are genuinely determined to die when they attempt to kill themselves. Some of the disturbing means the nine patients profiled used included jumping in front of moving trains, ingesting dangerous household cleaners and setting one's self on fire. These patients also tended to isolate themselves before their suicide attempt, most likely in order to reduce the possibility they would receive life-saving help. "We established that these patients' death had little to do with their low body weight," says lead author Jill Holm-Denoma, a professor of clinical psychology at Vermont and an expert on treating eating disorders. "The methods that they chose could have killed anyone."

Holm-Denoma's work reaffirms, among many others, a 2003 Harvard University study that concluded anorexic women are, by nature of their illness, self-destructive, leading them to have a likelier propensity toward suicide as well as alcohol abuse. That study of about 250 women suffering eating disorders showed the risk of death by suicide among by anorexic women to be as much as 57 times the expected rate of a healthy woman. Research on suicide in 2006 by psychologist Thomas Joiner at Florida State University took those conclusions one step further and suggested anorexics habituate to pain, making them fearless of death, and thus more likely choose a more lethal means to end their lives. Holm-Denoma's research, however, is one of the first studies of the specific methods that suicidal anoxerics use. The gruesome methods they chose as well as how they isolated themselves from rescue, Holm-Denoma says, leaves little doubt that they wished to die.

The new findings, to be published this spring in the Journal of Affective Disorders, come during this year's National Eating Disorder Awareness Week. As many as 10 million women and one million men in the United States suffer from an eating disorder such as anorexia or bulimia, according to the National Eating Disorder Association (NEDA). Females between the ages of 15 and 24 are 12 times more likely to die from anorexia than all other causes of death, the NEDA reports. And suicide is the primary cause of death for anorexics, greater even than starvation. Holm-Denoma stresses her research highlights how seriously treatment providers must take suicide risks amongst those suffering from eating disorders. "The likelihood of whether a patient wants to lethally hurt herself must be assessed right away," Holm-Denoma says, adding, "Addressing psychiatric needs must be paramount."

For the families of anorexics, Holm-Denoma's research only affirms their worst fears. One of the biggest frustrations these families face when their loved one is diagnosed with anorexia is how they can obtain affordable psychiatric help. Insurers rarely pick up the bill. Most health plans argue that eating disorders require mental health treatment not covered by most policies and therefore refuse to pay for long-term care. In the direst cases, health plans will often cover a brief hospitalization to stabilize a patient's weight. But once she begins to gain weight again, she will be sent home. "The biological crisis may have passed," says Barbara Anthony, a Boston-based lawyer and executive director of Health Law Advocates, an organization that aids families. "But hospitals and health plans have done little to provide these patients with the mental health care they desperately need."

Meanwhile, costs related to in-patient treatment for an eating disorder can range from $25,000 to $30,000 a month. Many families are forced to take out second mortgages or deplete savings. Such situations are tragic, Holm-Denoma says. "Anorexia is one of the most serious psychiatric diseases our society faces," she says. "Our work shows even further that more needs to be done to prevent it."

The other day, a nurse at Florida State University in Tallahassee responded to an alarm in a hospital room where a patient named Stan D. Ardman lay gravely ill. Ardman's blood pressure had dropped precipitously, and when the nurse came in, Ardman wheezed and said, "I'm very nauseous and dizzy ... Having trouble breathing."

"O.K.," the nurse responded. "I'm Thomas. I'll be taking care of you." (Thomas is a pseudonym for a nurse in his mid-20s.) Then, in a tone of uncertainty, Thomas said under his breath, "Nauseous and dizzy?"

Ardman moaned, and his heart monitor squalled urgently.

Thomas looked at Ardman's chart, riffled through a book describing prescription drugs, searched a couple of drawers and accidentally dropped something on the floor. Ardman was already receiving a drip of dopamine, a compound that treats low blood pressure. Merely increasing the dosage of dopamine would almost certainly raise Ardman's blood pressure, relieve his nausea and dizziness, and bring him out of crisis.

But Thomas missed that simple solution. Instead, he asked Ardman if he had chest pain. "I'm just nauseous and dizzy," the patient replied. Just then, the monitor made an ominous noise indicating that Ardman's pressure was plummeting further. Thomas vacillated.

"Think out loud," another nurse pleaded to Thomas.

"Uh," Thomas mumbled. "Not sure."

And then he made a fatal mistake. He decided to give Ardman epinephrine, a drug that would certainly raise the patient's blood pressure but that, in combination with the dopamine Ardman had already received, would also spike his heart rate and possibly kill him. Sure enough, after epinephrine was administered, the patient lost consciousness and drifted toward death — although just before he died, the simulation ended.

Stan D. Ardman isn't a real person but a robot simulator ("standard man") used to train medical personnel. Thomas, who is just out of nursing school, was participating in a Florida State study designed to compare the performance of novice nurses like him against that of more experienced ones. The results were surprising. After Thomas left, I watched a nurse with more than 25 years' experience go through the same simulation. At first, when the monitor indicated a drop in blood pressure, Monica (also a pseudonym) coolheadedly began to identify possible treatments. Within seconds she noticed Ardman's dopamine drip, and she knew it was the answer. "She's so fast," said James Whyte IV, an assistant professor at Florida State's School of Nursing who was controlling the robot from a hidden room where we sat watching.

Still, Monica didn't know the robot's weight, which she would need to measure the dopamine increase. She moved to pick up Ardman's chart, which listed his weight, but just then the simulator's blood pressure dropped radically, prompting Monica to make the same error that Thomas had made: she went for epinephrine. After the drug sent Ardman into ventricular tachycardia, Monica was fast enough to shock him with the defibrillator. But this time poor Mr. Ardman died before the experiment ended. The expert had killed Ardman even faster than the novice had.

In making the case that she would be a better President than Barack Obama, Hillary Rodham Clinton never forgets to summon the argument that she has more experience. But as the Florida State simulations show, experience doesn't always help. In fact, three decades of research into expert performance has shown that experience itself — the raw amount of time you spend pursuing any particular activity, from brain surgery to skiing — can actually hinder your ability to deliver reproducibly superior performance.

How can that be? It is widely accepted that mastering most complex human endeavors requires a minimum of 10 years' experience. The 10-year rule was posited as long ago as 1899, when Psychological Review ran a paper saying it takes at least that long to become expert in telegraphy. The modern study of expert performance began in 1973, when American Scientist published an influential article by researchers Herbert Simon and William Chase saying chess enthusiasts had to play for at least 10 years before they could win international tournaments. (Bobby Fischer was an exception; he played for nine years before becoming a grand master at 16.)

The 10-year rule explains, in an obvious and intuitive way, why the novice nurse Thomas failed his simulation: he had completed only two years of training, and he got rattled. "It's funny the things that anxiety can do to people," Whyte, the nursing professor, said, as Thomas ignored the drip. Monica, by contrast, instinctively looked up to see what medications were on the line. But then she made the same error as her inexperienced counterpart. Why?

While 10 years is a necessary minimum to achieve expertise in most fields, it doesn't guarantee success. As Anders Ericsson writes in the introduction to the 901-page Cambridge Handbook of Expertise and Expert Performance (2006), "The number of years of experience in a domain is a poor predictor of attained performance." Ericsson, 60, is a professor at Florida State who moved to the U.S. from his native Sweden in 1976 to study with Simon, co-author of the seminal chess paper. (Simon went on to win a Nobel Prize in economics for his work on decision-making.) Today Ericsson runs Florida State's Human Performance Laboratory, where Thomas and Monica participated in the robot simulations.

Ericsson, a large, gentle man with unkempt salt-and-pepper hair and a button on his jacket missing, has become the world's leading expert on experts, a term he distinguishes from "expert performers" — those individuals, possessing both experience and superior skill, who tend to win Nobel Prizes or international chess competitions or Olympic medals. Ericsson notes that some entire classes of experts — for instance, those who pick stocks for a living — are barely better than novices. (Experienced investors do perform a little ahead of chance, his studies show, but not enough to outweigh transaction costs.)

Experts tend to be good at their particular talent, but when something unpredictable happens — something that changes the rules of the game they usually play — they're little better than the rest of us. Chess grand masters can recall almost entire chessboard layouts from their games (approximately 25 pieces, compared with an average of four for novices), but when chessmen are randomly arranged on a board, those grand masters can recall the placement of only about six pieces. Similarly, experienced actors remember script lines much better than novices do, but they are no better at remembering material other than scripts.

Ericsson's primary finding is that rather than mere experience or even raw talent, it is dedicated, slogging, generally solitary exertion — repeatedly practicing the most difficult physical tasks for an athlete, repeatedly performing new and highly intricate computations for a mathematician — that leads to first-rate performance. And it should never get easier; if it does, you are coasting, not improving. Ericsson calls this exertion "deliberate practice," by which he means the kind of practice we hate, the kind that leads to failure and hair-pulling and fist-pounding. You like the Tuesday New York Times crossword? You have to tackle the Saturday one to be really good.

Take figure-skating. For the 2003 book Expert Performance in Sports, researchers Janice Deakin and Stephen Cobley observed 24 figure skaters as they practiced. Deakin and Cobley asked the skaters to complete diaries about their practice habits. The researchers found that élite skaters spent 68% of their sessions practicing jumps — one of the riskiest and most demanding parts of figure-skating routines. Skaters in a second tier, who were just as experienced in terms of years, spent only 48% of their time on jumps, and they rested more often. As Deakin and her colleagues write in the Cambridge Handbook, "All skaters spent considerably more time practicing jumps that already existed in their repertoire and less time on jumps they were attempting to learn." In other words, we like to practice what we know, stretching out in the warm bath of familiarity rather than stretching our skills. Those who overcome that tendency are the real high performers.

Experience is not only insufficient for expert performance; in some cases, it can hurt. Highly experienced people tend to execute routine tasks almost unconsciously — think of Monica immediately glancing up to see Ardman's dopamine drip — and they retrieve the information they need quickly, rarely pausing to apply rules. Driving is a good example. In a 1991 paper in the journal Ergonomics, a team of researchers found that while new drivers and truly expert drivers (members of Britain's Institute of Advanced Motorists) checked their mirrors often and applied their brakes early, regular drivers with 20 years' experience rarely checked their mirrors and braked much later. Experience in a particular task frees space in your mind for other cognitive pursuits — wondering what's for dinner, answering your cell, singing along with Justin Timberlake — but those things can distract you from the accident you're about to have. Experience can also lead to overconfidence: a study in the journal Accident Analysis & Prevention found that licensed race-car drivers had more on-the-road accidents than controls did.

Which is not to say that, if elected, Clinton or John McCain would drive the country off a cliff — or that Obama, as a comparative novice, would be more cautious and less burdened by his habits. But the study of experience does indicate that the more seasoned candidates wouldn't automatically outperform Obama as President. On the other hand, Ericsson's conclusion that deliberate practice leads to better performance might favor the punctilious, famously diligent Clinton.

The Cambridge Handbook concludes that great performance comes mostly from deliberate practice but also from another activity: regularly obtaining accurate feedback. In a 1997 study published in the journal Medical Decision Making, researchers found that only 4% of interns had known a group of elderly patients for more than a week; by comparison, nearly half the highly experienced attending physicians had known the patients for more than six months. But even with the advantages of years of medical experience and months of knowing the patients, the attending physicians were no more accurate than the interns at predicting the patients' end-of-life preferences, a crucial factor in determining whether a patient has a good death. It was attention to the patients' feelings and values that mattered, not having more knowledge of their diseases. And in the end, determining which of the presidential candidates pays more attention to your concerns requires not adding up their years of experience but a far more complex calculation: deciding what their experiences have led them to truly value.

Popular antidepressants including Prozac and Paxil have little impact on most patients, according to a comprehensive review of newly released data from trials that were conducted before the drugs were approved in the U.S.

Researchers from the U.K., U.S. and Canada analyzed results for fluoxetine (better known by the brand name Prozac), venlafaxine (Effexor), nefazodone (Serzone) and paroxetine (Paxil or Seroxat) — all members of a class of drugs known as selective serotonin reuptake inhibitors (SSRIs). The researchers' paper, published this week in the journal PLoS Medicine, claims that only patients who are diagnosed "at the upper end of the very severely depressed category" get any meaningful benefit from the widely prescribed drugs. For the others, the paper says, antidepressants are barely more effective than a placebo (although patients suffering from depression, like those suffering from chronic pain, generally do see a substantial placebo benefit).

There are plenty of studies about antidepressants. What makes this one so important — the results were front-page news across the U.K. on Tuesday — is that the researchers were able to track down comprehensive unpublished trial results from the drug makers themselves before the drugs were authorized for sale in the U.S., and include them in their review of the literature. The U.S. Food and Drug Administration (FDA) must receive records of all relevant pharmaceutical-company trials, both published and unpublished, before it will approve a drug. Under the Freedom of Information Act, the researchers writing in PLoS Medicine were recently able to obtain those FDA records of industry-sponsored clinical trials. They yield data, they believe, that lets them avoid a bias that often plagues reviews of previous research: the tendency for conclusive positive results to be published, sometimes more than once, and thus over-represented, while mediocre results can be ignored or even swept under the rug.

Drug companies claim the review is still flawed, however. One massive problem: there are many more recent studies than those surveyed in the article, which looked only at pre-approval trials conducted before 1999. Nicholas Francis, a U.K. spokesman for Eli Lilly and Company, which produces Prozac, says that the new study "does not take into account that today more than 12,000 patients have participated in Prozac clinical trials and thousands of scientific papers have referenced Prozac, supporting its use in the treatment of depression." Some 50 million people worldwide have taken Prozac, and in a company statement Lilly said it "is proud of the difference Prozac has made to millions of people living with depression." Similarly, paroxetine producer GlaxoSmithKline warns, "This analysis has only examined a small subset of the total data available ... and this one study should not be used to cause unnecessary alarm and concern for patients." As a spokeswoman for Wyeth, Effexor's maker, points out, these were, after all, the same data the FDA reviewed before approving the drugs for public use.

There are really two issues at the heart of the controversy. One is the difference between "statistical significance" — a measure of whether the drug's effects are reliable, and that patient improvement is not just due to chance — and "clinical significance," whether those effects actually are big enough to make a difference in the life of a patient. The researchers behind this new paper did find that SSRI drugs have a statistically significant impact for most groups of patients: that is, there was some measurable impact on depression compared to the placebo effect. "But a very tiny effect may not have a meaningful difference in a person's life," says Irving Kirsch, lead author on the paper and a professor of psychology at the University of Hull in England. As it happens, only for the most severely depressed patients did that measurable difference meet a U.K. standard for clinical relevance — and that was mostly because the very depressed did not respond as much to placebos. The drug trials showed SSRI patients improved, on average, by 1.8 points on the Hamilton Depression Rating Scale, a common tool to rate symptoms such as low mood, insomnia, and lack of appetite. The U.K. authorities use a drug-placebo difference of three points to determine clinical significance.

The more troubling question concerns what kind of data is appropriate for analyzing a drug's efficacy. The companies are correct in claiming there is far more data available on SSRI drugs now than there was 10 or 20 years ago. But Kirsch maintains that the results he and colleagues reviewed make up "the only data set we have that is not biased." He points out that currently, researchers are not compelled to produce all results to an independent body once the drugs have been approved; but until they are, they must hand over all data. For that reason, while the PLoS Medicine paper data may not be perfect, it may still be among the best we've got.

The decision to donate a newborn's umbilical-cord blood is, for many expectant mothers, a simple checkmark on a long list of prenatal choices. But for Noel Beninati, one donor's checkmark offered a lifeline. Last May, Beninati received a transplant of stem cells harvested from the blood of an infant's discarded umbilical cord at Boston's Dana Farber Institute, to help him fight a rare blood condition called Myelodysplastic syndrome. After doctors couldn't find a matching bone-marrow donor, the 58-year-old New Yorker says his last hope was cord blood, a solution that would not exist without donors like Kirkpatrick. New parents, Beninati urges, "must understand the importance this decision can mean for the public good."

State legislators agree. More and more have introduced or passed laws to mandate that doctors and hospitals educate expectant parents about the possibility of cord-blood donation. Doctors can now treat some 70 diseases using stem cells harvested from cord blood, and states including Oklahoma, Michigan and Arkansas are considering bills to fund the establishment of additional local public cord-blood banks and collection centers. "Ideally, we want people to see this as a public service akin to blood or organ donation," says Oklahoma state senator Jay Paul Gumm, who has sponsored such legislation. "Something that they automatically think to sign up for."

Despite the claim by the National Marrow Donor Program (NMDP) that more than 10,000 new patients each year could benefit from cord-blood stem-cell transplants, most umbilical cords currently end up as medical waste. Today, a matching donor from the national registry is found only about 25% of the time, and many patients die waiting. So far, doctors have found the most promise in cord blood for conditions such as blood cancers, leukemia, and sickle-cell anemia. But last year, an on-going study at the University of Florida showed cord-blood cells could also be effective at treating type-1 diabetes. Many doctors also believe that these transplants will eventually prove useful in regenerative medicine, helping patients suffering from heart disease, spinal bifida or even traumatic brain injuries.

"The potential is so significant," says Dr. Jennifer Willert, a stem-cell transplant specialist at the Rady Children's Hospital in San Diego. "Not to have families know about the possibility of banking, that's tragic."

Cord blood has several advantages over bone marrow transplants, the procedure to which it is most often compared. The first is that cord blood is collected without risk to the mother or the newborn, whereas a bone marrow donor faces surgery and general anesthesia. Cord-blood transplants also require a less perfect match in unrelated people, opening up a broader spectrum of potential donors, and recipients' bodies are less likely to reject a transplant.

The U.S. currently only has about 70,000 units of cord blood stored at its 20 public cord-blood banks. That's largely because few parents are aware that public donation is even a possibility. Instead, if a mother-to-be has heard of cord-blood banking at all, she's considered private banking, or the storage of her infant's own cord blood, an option costing up to $3,000 plus annual fees. Parents generally see private banking as an insurance policy should their child or a sibling fall ill later in life. Public donation does not guarantee availability to the donor's family should the need later arise. "If you don't save the cells [privately], they can never be fully yours," says Dave Zitlow, a spokesman for San Francisco-based CryoCell, the world's largest cord-blood private bank.

But both the American Academy of Pediatrics and the American Medical Association encourage, in most cases, public donation over private banking. That's because a child has only between one in 1,000 and one in 200,000 chance of needing an infusion of his own cord blood later in life. More public contributions would expand the ethnic diversity in the donor pool, which now predominantly favors Caucasian recipients. What's more, many conditions treated today with cord-blood stem cells are most successful when the donor is not related to the recipient, says Dr. Kent Christopherson, a hematologist at Chicago's Rush University Medical Center. "Odds are you'll never need your own cord blood, but actually your neighbor's," Christopherson says. "So advocating for public donation is in fact a way to help yourself."

A recent NMDP survey showed that 95% of new mothers say had they known about public cord-blood donation, they would have donated. Says Kristi Kirkpatrick, a manager from Pittsburgh who is expecting her second child in March, concurs. "To be able to save a life with something that'd normally go in the trash?" she says. "That's not a difficult decision for anyone to make."

There were a couple of strange things about the Virgin Atlantic Boeing 747 that taxied out along one of London Heathrow's two main runways and took off into the bright sky late Sunday morning. First, there were only five people on board, while more than 100 watched intently from a nearby hangar. Second, the plane was the first commercial jet ever to fly on biofuel: a fuel produced from plant matter instead of petroleum or other fossil fuels. "This is the first stage on a journey towards renewable fuel," Virgin founder Richard Branson told reporters in the hangar shortly before take-off, his voice drowned out every now and then by the roar of overhead planes. "It's the equivalent of those exciting first few steps of a baby."

As it happens, Virgin's eco-plane ran only one engine on the experimental fuel; the other three burned standard jet fuel. And the biofuel-powered engine was using a blend of conventional jet fuel and biofuel: 80/20 in favor of the regular stuff. In total, then, just 5% of the 49,000-lb (22,000 kg) fuel load consisted of the novelty: a special mix of coconut oil and oil from the Brazilian babassu plant, prepared by Seattle-based Imperium Renewables over the last 18 months and tested by General Electric Aviation in Ohio.

Even as environmental groups roundly pooh-poohed the flight as a publicity stunt, Virgin and its partners stressed that percentages weren't the point. The event was, the businesses claim, meant merely as a demonstration. "What we're proving today is that biofuel can be used for a plane," Branson told reporters. "Two years ago, people said it was absolutely impossible." Among the fears: that biofuel would freeze before a plane reached cruising altitude, or that it would require massive and costly changes to the aircraft or fueling systems to work at all. Those prognosticators were proved wrong. The fuel Virgin used Sunday required no equipment modifications at all; the plane flew to 25,000 feet (7,600 m) without incident; and the environmental benefits seem clear, at least once the fuel is loaded onto the plane. Internal company testing suggests the biofuel, when burned, releases just half the emissions of conventional jet fuel.

Still, there are no plans to make commercial air fleets run on coconuts. In fact, biofuel producers in general have had a tough couple of years. As food prices soar worldwide, people are growing ever more worried that biofuel production can drive up the prices of staple foods. Tens of thousands of Mexicans marched in January 2006, for example, to protest the rising price of corn, used in the U.S. to make ethanol. Virgin and partners claim that their airplane fuel is, as Branson says, "completely environmentally and socially sustainable." It's not made from staple-food crops or from crops that required deforestation. But even coconuts and babassu have their problems: the oil yield is just not that high. If a 747 could run on coconut oil alone, it would still take more than a dozen acres of crop to fill one plane.

Down the line, say Branson and Imperium Renewables CEO John Plaza, biofuel producers are more interested in jatropha, a thorny plant that grows well on non-agricultural land in Latin America and Africa. They're also interested in farming algae, which Branson calls "the jet fuel of the future." Development of those feedstocks does look promising, but commercial mass production is still years off. And getting regulatory approval for the new jet fuel could take several years as well. So if biofuel ever takes off in aviation, it will likely be a decade before it has any noticeable impact on industry emissions.

Is it worth the effort? Some critics — like Greenpeace activists who breached Heathrow security Monday to protest the airport's proposed third runway — argue it makes more sense simply to fly less. Others argue there are bigger, more realistic environmental gains to be made by building more efficient airplanes. Boeing's 787 Dreamliner, once it's finally shipped out to its buyers, is expected to burn 20% less fuel than similar-sized planes — and that plane will be in commercial use in just a few months. As priorities go in aviation sustainability, "Right now [biofuel] will be very low," Virgin Atlantic CEO Steve Ridgway tells TIME. But with fears that the days of oil are numbered, it only makes sense that a business would try to diversify its raw materials in the long term. And cutting overall industry emissions will be no easy task if demand for flights continues to grow. "We cannot be Luddites and turn the clock back," Ridgway says.

Just before 12:30 at Heathrow, Virgin Atlantic's 747 touched down in Amsterdam, finishing off the event without a hiccup — which is more than could be said for Branson himself. For kicks, the mogul had drunk a sample of his firm's coconut oil and babassu oil jet-fuel blend. "My God that was horrible," he told reporters afterward. "I've been burping ever since." Now that, without a doubt, is a publicity stunt.

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