Saturday, December 9, 2017

My Free-to-Play Gaming Postmortem

So there was this period of time from mid-September 2015 to mid-October 2017 in which I didn’t write a single blog post. What happened? This post is my attempt to reflect on my hiatus from blogging.

The most convenient answer—and the one most friendly to my ego—is that I had simply gone through some Major Life Changes that got in the way of devoting time to this blog. However, if I dig deeper, I must admit to myself that October 2015 is when I started playing a free Japanese mobile game called Puzzle and Dragons (PAD), and October 2017 was when I started to get tired of playing it; I finally deleted the game from my phone last week.

Left: A random person's monster collection. Right: a monster card in all its glory.
The basic gist of PAD is that you assemble a team based on different “monster cards,” each of which has different properties. You obtain the best cards by spending “magic stones” on a Rare Egg Machine, which pops out a random monster card at a cost of 5 stones. The stones can be earned for free by beating levels in the game or purchased for $0.99 each (or only $59.99 for 85!). With your team, you fight your way through various dungeons, doing damage to the enemies based on how many orbs of the same color you can match in rows or columns of at least 3 on the game’s puzzle board. As with any decently fun game, it felt rewarding to finally beat a difficult level after multiple tries. And the artwork and graphics, hand-drawn by Japanese artists, were top-notch. But in addition to these basic features shared with most games, PAD has many mechanisms that increase its ability to grab ahold of players’ attention, time, and money, and these psychological manipulations are very clear for me to see in retrospect.

Left: Narrowly escaped death from the enemy's attack. Right: My team doing some serious damage to Kali.
The game frequently gives away magic stones and other goodies for free, using reciprocity to make a player feel motivated (or obligated) to keep playing. Also, you get more rewards the more consecutive days you log in, which helps players make the game a daily habit à la Snapstreaks. The most powerful cards, of course, are very rare, so there’s intermittent variable interval reinforcement when you get lucky and land a good card. There are special events every few weeks called “Godfests,” which are the only times players can get certain rare cards, creating some serious FoMO. Once you’ve invested time and energy to assemble a nice collection, there’s a strong tendency towards loss aversion, as no one wants to feel like they’ve wasted all this time for nothing. Since most of PAD’s players are young men, many of the most desirable cards feature scantily-clad female characters, a.k.a. “waifus.” And there’s a community aspect as well, with multiple forums devoted to the game where players share their accomplishments and good Godfest luck, leading to upward comparisons and social reinforcement.

Despite all that, I’m not sure I would say that I was addicted to the game in a clinical sense. I was spending ~30-60 minutes a day playing the game, and maybe another half hour a day reading about it. My personal relationships and work did not suffer, as far as I can tell. Over the course of 2 years, I spent a grand total of $10 on in-app purchases of magic stones. On PAD forums there are reports of “whales” who've spent upwards of thousands of dollars on the game, so I got off relatively easy, at least in a financial sense.

Still, how PAD affected my mind is undeniable. Instead of reading blogs related to psychiatry and mental health, I was reading blogs and watching YouTube channels related to PAD. I stopped even thinking about my blog, and every time I had a spare moment, I would open the PAD app instead of taking in my surroundings or reading a book. In fact, I read far fewer books in 2016 and 2017 compared to any other year in my life since I learned to read, though part of that may be due to reading more on the web. It wasn’t all bad, though. I wasted far less time on Twitter, and I was no longer waking up in the middle of the night with ideas for blog posts. I had a convenient and pleasant distraction from politics. And I’ve spent much less mental energy these last 2 years obsessing about my fantasy football teams than I have in previous years.

So what finally made me stop? A part of it was the fact that PAD’s creators are constantly adding more difficult dungeons, which in turn require ever more powerful (and rare) monster cards to deal with. Playing the game started to feel increasingly like a Sisyphean task. I’d also like to think that a part of me missed blogging and reading books. Recently, I came across the philosophically-oriented Slate Star Codex blog, written by a young psychiatrist, and I thought, “If he can write several 2000 to 5000-word blog posts in a week, then why can’t I be even 3% as productive (i.e. roughly a 1000-word post per month)?”

Lastly, some advice for parents out there: as fun as Super Mario Bros was for us in our youth, it does not remotely compare to the reinforcement mechanisms that today’s microtransaction-driven mobile games employ. I’ve heard multiple stories from parents about their kids stealing their credit cards to spend hundred of dollars on in-app purchases for games like Clash of Clans and Clash Royale. I now believe that parents should not be letting their kids play games like these, which all tend to use similar attention and money-grabbing tactics. As a general rule, this applies to any of the mobile games that you see advertised on TV; how else would those game companies have so much money to spend on prime time ad spots? Recently, regulators in The Netherlands have started investigating whether games that have “loot boxes” (a similar idea to the Rare Egg Machine) are a form of gambling and should be regulated as such. In my mind there is no doubt that these games can work very similarly to gambling, except you can’t actually win any money, so it’s in a way worse than gambling.

Even if there are kids who can responsibly play these games without spending too much time or money, I would still strongly suspect that these games have an outsized influence on what their players think about—and stop thinking about—even when they’re not playing. And for me, that was ultimately the biggest negative impact.

Tuesday, December 5, 2017

Protests, Then and Now

Lately, I’ve been hearing and reading a lot about how America is the most divided it’s been since the 1960’s. But given all of the social progress made over the course of that tumultuous decade, maybe that’s not such a bad thing. I was not around during the 60’s, but my mental image of that era is filled with vivid images of people protesting: at Selma and the March on Washington, on campuses all over the country, even at the Pentagon.

Which got me thinking, how are today’s mass protestors doing? (My thoughts on the NFL’s anthem protestors—and celebrity protests in general—are somewhat separate and not covered here.)

Last month, I was somewhat taken aback when I read about some anti-fascist rallies:
The explicit goal of the November 4 protests, which have been warped into a number of increasingly bizarre, "antifa"-related conspiracy theories by right-wing media, is to remove Trump and his administration from office. In order to achieve that end, millions of people will have to take to the streets of cities like New York, Austin and San Francisco, demanding that the administration step down, organizers tell Newsweek. It’s something that will not be achieved with the actions of only a few left-wing radicals, they say.
WTF?!? Am I the only one who thinks that holding an antifascist protest in SF is like Martin Luther King and other civil rights leaders marching down the streets of Harlem instead of down Hwy 80 from Selma to Montgomery? If you’re protesting fascism, why in the world are you holding your protests in the most diverse places with the fewest white nationalists and their sympathizers? Why not go to where the Trump voters actually live, like the Deep South or Kansas? If that’s too far for city people to travel, how about taking a bus from Pittsburgh to Johnstown, PA or from Detroit to one of those Michigan counties that went for Trump? Or is that still too inconvenient for people?

Given all this #Resist talk, what are people actually doing to resist our president? During the 50’s and 60’s, the protestors organized very effective sit-ins which not only highlighted the racism and oppression of “separate but equal,” but just as importantly, disrupted lots of segregated businesses. And who can forget the cries of “Hey hey LBJ, how many kids did you kill today?” causing Lyndon B. Johnson to not have a moment’s peace:
The president and his principal spokesmen were finding it harder each week to avoid the chanting protesters, who seemed to be everywhere. For the first time in history, a president was unwelcome in public in most parts of the country, making him a veritable prisoner in the White House, "hunkered down" there, to use one of his favorite expressions.
Fast forward to today, when we have a grossly narcissistic guy who cares most about his image, his money, and his opulent properties, so how is the fight being taken to that guy? Certainly lots of people are being blocked by him on Twitter, but what is most noticeable to me is how much he still gets to enjoy playing golf almost every week. So why aren’t people protesting every single weekend at Mar-a-Lago or Trump National Golf Club? Why aren’t they blocking off traffic, as protestors have done in Oakland and St. Louis? Why aren’t protestors shaming everyone who goes to those Trump properties with shouts of “Hey hey DJT, all your lies won’t set you free!”? Is this asking too much, if indeed this man is as dangerous as we think he is?

Speaking of which, one of the most infuriating things I read this year is this account of what actually happened when anti-Trump protestors came face-to-face with Trump supporters at a Trump rally in Arizona:
Elsewhere in the city, the police had done a masterful job of ensuring that large groups of pro-Trump Americans were separated from groups of anti-Trump Americans. The two groups were usually placed on either side of wide barricaded streets, but on this corner, there were no barricades, no police nearby, and access between the two groups was unobstructed.

Which made it all the more surreal and tragic how genial and almost embarrassed the interactions were. 


The Trump supporters looked up and down at their sudden audience, and, if they could get over their astonishment, smiled and held up their phones to take pictures.

And when the protesters saw just how unarmed and unassuming most of the Trump supporters were, and how free they were of signs, weapons, anything — they were left speechless.

That was a strange thing. There were a hundred or so protesters standing on the high steps, and at any given time a few dozen Trump attendees passing them on the sidewalk, but for much of the time they were in close proximity, and no one said anything.

Something was happening there, in that close confrontation between the two groups. There was recognition. There was the uncomfortable knowledge that they were in many ways very similar people. The rally attendees were not frothing at the mouth and were not spouting racial epithets. They were moms, dads, teenagers, and families who for whatever reason have an exceedingly high tolerance for wretched behavior and the absence of moral leadership from their chief executive.

Thus the protesters were flummoxed. It seemed cruel and strange to yell “Nazi” to a pair of grandparents in yellow polo shirts, or at a trio of Eagle Scouts, and so given the chance to say something directly to Trump supporters passing by them, mere inches away, much of the time they said nothing.
How about “Shame, shame, shame!” or “Your emperor has no clothes!” or “We want a president, not a wannabe dictator!” Am I just being unrealistic? Are my expectations too high? I think that on some level, this lack of basic effectiveness at protesting is one reason why the man is still in office.

Has our consumerist culture (see my last blog post on this), smartphones, and the internet made everyone so complacent that they don’t know how to break out of their own little bubbles to stage an effective protest anymore? Do we really think that some hashtags, clever signs, and funny hats are enough?

Wednesday, November 8, 2017

How Making Consumers Happy Got Us Here

If you’ve never seen Malcolm Gladwell’s 2004 TED Talk: “Choice, happiness and spaghetti sauce,” please take a moment to check it out:

In the talk, Gladwell focuses on the work of “someone who, I think, has done as much to make Americans happy, as perhaps anyone over the last 20 years, a man who is a great personal hero of mine, someone by the name of Howard Moskowitz, who is most famous for reinventing spaghetti sauce.”

Gladwell goes on to describe Moskowitz’s key insight in coming up with chunky pasta sauce for Prego, which is that there is no single sauce that is perfect for everyone, but there is a perfect sauce for each individual consumer. As the saying goes: “The customer is always right.” Thus, the explosion from just Prego vs Ragu to different varies of Prego and Ragu to the cornucopia of choices we have for pasta sauce today.

But as the sauce went, so went everything else. We no longer have to suffer through the primitive days of ABC’s Wide World of Sports or just one cable sports channel. There’s ESPN 2 (and 3 and Classic), FS1, NBCSN, CBSSN, even channels devoted to motorsports or golf. Long gone are the days of everyone tuning in to Walter Cronkite for the day's news. Instead, everyone can find the talking head who agrees most with their personal views and never have to be inconvenienced by a dissenting view.

Online, we no longer have to be exposed to the same reality or set of facts. Facebook, YouTube, Google News, et al. make it so we don’t even have to go out of our way to search out those with similar views; these behemoths feed us stuff based on all the data they have gathered from tracking our online behavior. Of course, they’re doing this to make us happy, but what price are we paying for this sort of happiness?

Which brings us, inevitably, to the present political situation. I think it’s obvious that our current president would not be in office if not for this drive to feed consumers only what they want to see, hear, and experience. Much has been made about how the Russians took advantage of people’s news feeds to try to drive Americans further apart. However, even without foreign interference, I believe that modern America’s brand of consumerism is damaging to all Americans, young and old, left and right. It tells the consumer, “only you and what you want matters.” This kind of implicit message inevitably leads to inflated egos all around, self-selection into smaller and smaller interest groups, and less of a willingness to see things from another perspective. Not surprisingly, frustration, anger, and inability to compromise are the result when people who are used to shaping their own reality are confronted by realities determined by others with different beliefs, such as when a black president gets elected or a controversial speaker gets invited to speak at a college campus.

Is fixing our system (which I believe involves fixing our culture) even possible at this point? Once the Pandora’s Box of unlimited choice for the consumer has been opened, is there any going back to the spirit of “ask not what your country can do for you—ask what you can do for your country”? In my less hopeful moments, I think that it would take some sort of unimaginable catastrophe—like the Great Depression bringing an end to the Roaring 20’s—to drive people to put sufficient effort into overcoming the centrifugal forces that are splitting us apart. Yet, as Tom Hanks said, “If you’re concerned about what’s going on today, read history and figure out what to do because it’s all right there.” I'm not sure if he was thinking about a specific historical era, but what came to my mind was what happened during the Renaissance Papacy, when the Popes became so focused on worldly riches, pleasure, and power that they lost their religious legitimacy, leading directly to the Protestant Reformation.

From the Wikipedia entry:
The popes of this period used the papal military not only to enrich themselves and their families, but also to enforce and expand upon the longstanding territorial and property claims of the papacy as an institution. […] With ambitious expenditures on war and construction projects, popes turned to new sources of revenue from the sale of indulgences and of bureaucratic and ecclesiastical offices. […] The popes of this period became absolute monarchs, but unlike their European peers, they were not hereditary, so they could only promote their family interests through nepotism.
That period of the papacy lasted roughly a century before the Reformation forced Catholicism to reform itself. Yes, there were bloody religious wars as a result of the split in Western Christianity, and peace between Catholics and Protestants took centuries to achieve in some places. And some pundits argue that the Reformation created as many horrors as it addressed. But the overall (admittedly simple) lesson I get from this history is that there are many potential Martin Luthers out there, waiting to change the world, even if inadvertently. I just hope we don’t have to wait a hundred years for that to happen.

Sunday, October 15, 2017

About That Jean Twenge Smartphone Article

Note: As you may notice, this is my first blog post in over 2 years. This blog isn’t dead, it was just resting! I’m thinking about writing a post about why I haven’t blogged in so long; maybe it'll even be done less than 2 years from now.

For the past 3 months, my most frequently-visited blog post has been my critique of Jean Twenge’s claims of a “narcissism epidemic” from 2013. Google tells me that it’s one of the top results in searches for “jean twenge criticism.” So in this post, I would like to share my views on her latest work.

I read her article for The Atlantic, “Have Smartphones Destroyed a Generation?” (an excerpt from her new book iGen), the day that it came out, because as a psychiatrist who works with adolescents, it’s clear to me that smartphones have been changing their lives in ways profound and subtle. I actually like many aspects of the article, including her sympathetic portrayal of the complexity that smartphones have brought into teenagers’ already complex lives. Also, I think she presents the data well, and the data sources that she uses are nationally representative surveys that have been around a long time and are well-respected. I think she makes a rather convincing case that many teens today are living their social lives online rather than hanging out with their friends in person.

However, I do have some criticisms of Twenge’s far-reaching claims about the effects of smartphones, but first, that ridiculous title:

Thankfully, it seems the author agrees:

One criticism that others have voiced is that Twenge seems to draw conclusions based primarily on the correlation between the rise in smartphone use and increases in mental health issues in teens over the same span. While she acknowledges that many of the trends she highlights, such as adolescents taking longer to take on adult responsibilities, predate the introduction of smartphones, she sees the rising use of smartphones as some sort of inflection point. But there are so many other trends going on in our culture, including parents becoming more over-protective, rising political/racial/economic divides, etc., to pin the blame on smartphones seems overly facile. Heck, if I were being cheeky, I would point out that the sale of yoga pants has drastically increased since 2011, corresponding to increases in teen depression:

Source: Business Insider

But just because they correlate does not mean that one has anything to do with the other.

Thus, my biggest criticism stems from Twenge’s seeming certainty about the decisive role of smartphones coupled with a seeming lack of curiosity about examining deeper causes for why these trends are happening. In a recent NY Times Magazine article about increasing rates of anxiety in teens, Twenge had this to say:
“The use of social media and smartphones look culpable for the increase in teen mental-health issues,” [Twenge] told me. “It’s enough for an arrest — and as we get more data, it might be enough for a conviction.”
I’m sorry, but I think the situation is closer to her finding evidence of a crime, and possibly even a weapon, but she is nowhere near identifying—much less convicting—a suspect.

I find it vexing that Twenge seems to view each generation as a distinct and determinative entity, rather than some arbitrary line drawn by demographers, as she shows in this tweet:
That is just preposterous. She writes as though each generation somehow pops into existence with its own innate characteristics, rather than being influenced by—and reacting to—the generations that have come before. However, one of the few things I know for sure is the huge extent to which young people are influenced by their elders. For example, this recent article (also in The Atlantic, lol) highlighted just how much even 1-year-old infants learn from observing the actions of the adults around them. And what are kids observing these days?

In my own practice, I often hear from kids and teens who say that their parents are on their laptops checking work email or on their phones checking Facebook all the time. These kids are bored and lonely, so as soon as they have access to a smart device, what do they do? Twenge’s work makes it easy for parents to blame the devices and not think about how their own actions may be influencing their children. While that may protect parents’ egos and sell more books, it’s a very incomplete and misleading picture, to say the least.

I have not yet read Twenge’s new book, but I was hoping that it would take a deeper look at the culture as a whole, especially the critical role that parents can play in changing the situation. However, one look at the book’s table of contents reveals that only the last 26 pages are devoted to a chapter on “Understanding—and Saving—iGen”. This scathing review from NY Mag further breaks down the book and the motivations of the author. The reviewer takes the view that Twenge is less a scholar who investigates all aspects of a complex issue than she is someone positioning herself as a guru for marketers looking to understand the latest generation of teens.

In conclusion, while there certainly is a mental health crisis going on in today’s teens (and adults!) and pinning the blame on smartphones is understandable, I believe it will take far more than getting rid of everyone’s favorite devices to make our culture healthier for future generations.

Wednesday, September 16, 2015

The Paroxetine Study 329 Re-Write

I've not really written about GlaxoSmithKline's infamous paroxetine (Paxil) Study 329, except to briefly allude to it in a previous post. This is probably because I felt others had covered it so extensively already, especially over at the 1boringoldman blog. Another anonymous child psychiatrist has an entire website summarizing the study, and there's even a detailed wikipedia page. So go to those sites if you haven't heard of this study before. However, I wanted to write this post to share my thoughts about the re-analysis of the study's data by an independent, mostly-international team, which was accepted for publication in the BMJ.

First off, I want to be clear that I don't think the new publication's results will be news for anyone in the profession who has been paying attention. In my years of practice (which admittedly are not many), I've never seen a young patient prescribed paroxetine by a child psychiatrist. While studying for a board exam the other day, I saw this (source):

If it's been covered in a textbook published in 2010, you can be sure it's pretty common knowledge by now. In this regard, the profession has been self-correcting. However, it seems that despite acknowledging the risks of paroxetine, the profession has turned a blind eye toward the actions of the psychiatrists who had helped popularize its use in kids in the first place. None of the well-known academics whose names are attached to the study have offered to retract the paper, and as far as I know, none have suffered professionally. In fact, one of them, Karen Dineen Wagner, was just elected president of the American Academy of Child and Adolescent Psychiatry (AACAP).

There have been efforts to address this issue within AACAP, most notably by 2 regional child psychiatry organizations, including the Northern California Regional Organization of Child and Adolescent Psychiatry (NCROCAP). Dr. Mickey Nardo, the brains behind and one of the authors of the Study 329 re-write, informed the AACAP Ethics Committee about the study's faults, and they initially seemed receptive.* However, those efforts went nowhere. At a recent AACAP annual meeting, I was chatting with an older child psychiatrist, who is a "Distinguished Fellow" of the organization and has been involved in AACAP affairs for decades. Somehow, the topic of NCROCAP came up. When I commented that they seemed to be an activist bunch, he replied, "Yes, probably too much so, which is not good for the group process."

Well, now we see the outcomes of this "group process." By prioritizing group harmony over doing the right thing, AACAP has invited outside intervention. This BMJ editorial accompanying the new publication, by Peter Doshi, is one of the most damning things I've ever read about institutional intransigence.* It'll be interesting to see how the organization reacts.

UPDATE: As I was finishing this blog post, I got the following email (New York Times article published around 6:30pm EST, email was sent around 6:34pm*):
Dear Members,

This week, The BMJ published a study, “Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence,” which reanalyzes data from a clinical trial performed in the late 1990s and published in JAACAP in 2001. The conclusions of this article contradict those of the original study. Please know that the Academy has been fully aware of the pending publication of this article by The BMJ.

Research provides the foundation for child and adolescent psychiatry’s knowledge base. The Academy encourages rigorous scientific design and methodology and supports the highest ethical and professional standards. We also believe it is essential that research be conducted within a strong framework of transparency and disclosure. As an organization, AACAP has been a leader in advocating for the positive changes that have taken place in the last decade in the relationship between the pharmaceutical industry and academic and professional associations.

As the leading national professional medical association dedicated to promoting the healthy development of children, adolescents, and families, through advocacy, education, and research, our response to The BMJ publication is as follows:
  • AACAP has the utmost respect for the The BMJ and we thank them for their continued efforts to further scientific knowledge and understanding.
  • AACAP supports transparency in clinical trial reporting and welcomes the RIAT initiative, which enables publicly available primary data to be reanalyzed and published as new, potentially revised reports.
  • JAACAP is a forum for scientific reporting and scholarly discussion. The scientific process builds on itself over time through a cycle of new research, analysis, and ongoing dialog. This process stimulates debate and moves the field forward toward a better understanding of critical issues.
  • As with most medical journals, JAACAP operates with full editorial independence. AACAP does not influence or direct decisions regarding specific publications. Furthermore, the statements and opinions expressed in JAACAP articles are those of the authors, and not necessarily those of AACAP, the editors, or the publisher. Inquiries about the articles and study in question should be addressed to their respective authors.
Moving forward, we will continue to monitor any developments and keep the membership informed of relevant information as it becomes available. Please direct any questions to the Communications Department via email at

Thank you for your continued support!

Paramjit T. Joshi, MD
President, AACAP
Like I said, this is gonna be interesting.

These sentences were added/edited after original publication for completeness.