1. 1 Meeting the Future in Managing Chronic Disorders: Individually Tailored Strategies S.A. Murphy Univ. of Michigan In Honor of Clifford C. Clogg

2. 2 In Memory of Cliff Clogg –A statistical scientist: Follow the path of our statistical fathers by addressing important problems. Use this experience to enhance the utility and beauty of mathematical statistics.

3. 3 Outline –Three apparently dissimilar problems –Myopic decision making –Unknown, unobserved causes –Discussion

4. 4 Three Apparently Dissimilar Problems –Artificial Intelligence: Autonomous Helicopter Flight –Management of Chronic Mental Illnesses –Management of a Welfare Program

5. 5 Artificial Intelligence Autonomous Helicopter Flight –Observations: characteristics of the helicopter (position, orientation, velocity, angular velocity, ….), characteristics of the environment (wind speed, wind angle, turbulence….) –Actions/treatments: cyclic pitch (causes forward/backward and sideways acceleration), tilt angle of main rotor blades (direction), tail rotor pitch control (turning) –Rewards: Closeness of helicopter’s flight path to the desired path; avoidance of crashes(!)

6. 6 Andrew Ng’s Helicopter: http://ai.stanford.edu/~ang/

7. 7 The Management of Chronic Mental Illnesses Treating Patients with Opioid Dependence (heroin) –Observations: characteristics of the individual (withdrawal symptoms, craving, attendance at counseling sessions, results of urine tests….), characteristics of the environment (housing, employment.…) –Actions/treatments: methadone dose, amount of weekly group counseling sessions, daily dosing time of methadone, individual counseling sessions, methadone taper –Rewards: minimizing opioid use and maximizing health, minimizing cost

8. 8 http://www.nida.nih.gov/perspectives/vol1no1.html

9. 9 Management of a Welfare Program “Jobs First” Program in Connecticut –Observations: characteristics of the individual (assets, income, age, health, employment), characteristics of the environment (domestic violence, incapacitated family member, # children, living arrangement…) –Actions/treatments: child care, job search skills training, amount of cash benefit, medical assistance, education –Rewards: maximizing employment/independence.

10. 10

11. 11 The Common Thread: Sequential Decision Making Observation, action, observation, action, observation, action,……………………. A strategy tells us how to use the observations to choose the actions. We’d like to develop strategies that maximize the rewards.

12. 12 Role of the Statistician What kinds of data are most useful for developing strategies? What kinds of clinical trials will produce the most useful data? How do we use the data to construct good strategies? (A strategy tells us how to use the observations to choose the actions.)

13. 13 Myopic Decision Making

14. 14 Myopic Decision Making In myopic decision making, decision makers use strategies that seek to maximize immediate rewards. Problems: –Longer term consequences of present actions. –Ignore the range of feasible future actions/treatments (A strategy tells us how to use the observations to choose the actions.)

15. 15 Autonomous Helicopter Flight The helicopter has veered from flight plan. Myopic action: Choose an acceleration and direction that will ASAP bring us back to the flight plan. The result: The myopic action results in the helicopter overshooting the planned flight path and in drastic situations may lead to the helicopter cycling out of control. The mistake: We did not consider the range of actions we can take following the initial action. The ability to slow down is mechanically limited. The message: Use an acceleration that will not quickly return us to the planned flight path but will take into account the ability of the helicopter to slow down and reduce the overshoot.

16. 16 Myopic Decision Making The message: The fields of robotics and artificial intelligence teach us that we should try to construct strategies that are not myopic! –Pay attention to the longer term consequences of present actions. –Do not ignore the range of feasible future actions/treatments (A strategy tells us how to use the observations to choose the actions.)

17. 17 Treatment of Psychosis Myopic action: Choose a medication, say A, that reduces psychosis for as many people as possible. The result: Some patients are not helped and/or experience abnormal movements of the voluntary muscles (TDs). The class of subsequent medications is greatly reduced. The mistake: We should have taken into account the variety of treatments available to those for whom the first treatment is ineffective. The message: Use an initial medication that may not have as large a success rate but that will be less likely to cause TDs.

18. 18 Unknown, Unobserved Causes

19. 19 Artificial Intelligence Scientists who construct strategies that will be used for autonomous helicopter flights can use physical laws: momentum=m*v, W=F*d*cos(θ)……… Scientists know many (most?) of the causes of the observations and know how the observations relate to one another.

20. 20 Conceptual Structure in the Behavioral/Social/Medical Sciences

21. 21 Unknown, Unobserved Causes Scientists who want to use data on individuals to construct treatment strategies must confront the fact that spurious “relationships” occur due to the unknown causes.

22. 22 Unknown, Unobserved Causes

23. 23 Unknown, Unobserved Causes

24. 24 Unknown, Unobserved Causes

25. 25 Unknown, Unobserved Causes The message: Scientists who want to use data on individuals to construct treatment strategies must use statistical methods that ignore spurious “associations” (due to the unknown causes). Scientists in the fields of robotics and artificial intelligence should pay attention to our field!

26. 26 Some Trials

27. 27 ExTENd Ongoing study at U. Pennsylvania (D. Oslin) Goal is to learn how best to help alcohol dependent individuals reduce alcohol consumption.

28. 28

29. 29 STAR*D (www.star-d.org) This trial is over and the data is being analyzed (J. Rush). One goal of the trial is construct good treatment sequences for patients suffering from treatment resistant depression.

30. 30

31. 31 Discussion When thinking how best to manage chronic disorders (poverty, mental illness, other medical conditions) we need to –Allow for longer term effects of the treatments –When comparing treatment options take into account the effect of future treatments –Use data and good statistical methods to develop the strategies.

32. 32 This seminar can be found at: http://www.stat.lsa.umich.edu/~samurphy/seminars/ PSUGeneralLecture10-05.ppt My email address: samurphy@umich.edu