Vocabulary > Health > Mental health

Mickey Duzyj

Understanding the Anxious Mind

NYT

October 4, 2009
 
By ROBIN MARANTZ HENIG
http://www.nytimes.com/2009/10/04/magazine/04anxiety-t.html

brain

the mentally ill        USA
http://www.nytimes.com/2012/04/07/nyregion/order-on-housing-mentally-ill-adults-in-new-york-city-is-struck-down.html
http://www.nytimes.com/2011/11/05/health/shortage-of-beds-after-irene-shut-a-vermont-mental-hospital.html
http://www.nytimes.com/2011/06/25/opinion/l25mental.html
http://www.nytimes.com/2010/03/02/nyregion/02mental.html
http://www.nytimes.com/2009/09/09/nyregion/09mental.html
http://www.usatoday.com/news/health/2007-05-03-mental-illness_N.htm

cartoons > Cagle > Mentally ill        USA        2013
http://www.cagle.com/news/mentally-ill/#.UQlIemeoR8E

mentally ill woman        2009
http://www.telegraph.co.uk/news/newstopics/politics/lawandorder/
5477085/Mother-unable-to-pay-school-fees-drowned-son-11.html

mentally ill parent
http://women.timesonline.co.uk/tol/life_and_style/women/families/article5123475.ece

mental disorders
http://www.guardian.co.uk/science/2013/may/12/dsm-5-conspiracy-laughable

mental health
http://www.guardian.co.uk/society/mental-health
http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health

mental health system
http://www.nytimes.com/2012/12/27/nyregion/new-yorks-mental-health-system-thrashed-by-services-lost-to-storm.html

mental health laws
http://www.nytimes.com/2013/02/01/us/focus-on-mental-health-laws-to-curb-violence-is-unfair-some-say.html

World Mental Health Day        October 10 2009
http://www.guardianweekly.co.uk/?page=editorial&id=1283&catID=3

Americans with Disabilities Act        USA
http://www.ada.gov/

New TV ad campaign aims to boost mental health        October 2008

England's first mental health promotion TV campaign
to show how lifestyle choices can boost wellbeing.
The advert, run to coincide with World Mental Health Day this Friday,
is borne of a partnership between
the Care Services Improvement Partnership in the east of England,
charity the Mental Health Foundation and ITV Anglia
http://www.guardian.co.uk/society/video/2008/oct/07/mental.health.tv.advertising

mental health of teenagers
http://society.guardian.co.uk/children/story/0,1074,1303181,00.html

mental health of children
http://society.guardian.co.uk/mentalhealth/story/0,8150,1321041,00.html

young people with mental health problems
http://observer.guardian.co.uk/uk_news/story/0,,1826979,00.html
http://observer.guardian.co.uk/leaders/story/0,,1826996,00.html

mental illness
http://www.guardian.co.uk/science/2013/may/12/dsm-5-conspiracy-laughable
http://www.guardian.co.uk/society/2012/jun/18/mental-illness-people-help
http://www.guardian.co.uk/comment/story/0,,1988397,00.html
http://observer.guardian.co.uk/christmasappeal2006/story/0,,1962867,00.html
http://www.usatoday.com/news/health/2006-12-03-mental-ad_x.htm
http://arts.guardian.co.uk/news/story/0,11711,1653761,00.html
http://society.guardian.co.uk/socialcare/story/0,,1569028,00.html
http://observer.guardian.co.uk/readerseditor/story/0,,1283656,00.html
http://society.guardian.co.uk/mentalhealth/story/0,8150,1205153,00.html
http://education.guardian.co.uk/students/health/story/0,,1063595,00.html

Suffering and strength:
Bobby Baker's portraits of living with mental illness        May 2010

Bobby Baker spent 11 years battling mental illness,
an experience she recorded in hundreds of private drawings.
She explains why at long last she's making this remarkable artistic autobiography public
http://www.guardian.co.uk/artanddesign/video/2010/may/12/art-mental-illness

mental patient
http://society.guardian.co.uk/socialcare/news/0,,1948788,00.html

supported-living housing
http://www.guardian.co.uk/commentisfree/2011/apr/26/mental-health-care-supported-living-housing

psychiatric patients' rights
http://www.guardian.co.uk/society/2009/nov/18/mental-health-psychiatric-patients-rights

mental hospital
http://society.guardian.co.uk/health/news/0,8363,1660468,00.html

self-harm
http://education.guardian.co.uk/schools/story/0,5500,1391677,00.html

guns and mental illness

http://www.nytimes.com/2013/01/19/opinion/please-take-away-my-right-to-a-gun.html

http://www.nytimes.com/roomfordebate/2013/01/17/can-mental-health-care-reduce-gun-violence

http://www.nytimes.com/2013/01/16/health/breaking-link-of-violence-and-mental-illness.html

http://www.nytimes.com/2013/01/15/nyregion/new-york-legislators-hope-for-speedy-vote-on-gun-laws.html

http://www.nytimes.com/2012/12/29/opinion/nocera-guns-and-mental-illness.html

mentally disabled people > mistreatment at the Willowbrook State School on Staten Island        1970s

The deplorable conditions at Willowbrook, a state-run institution,
seized the nation’s attention in 1972,
when Geraldo Rivera, then a reporter for WABC-TV in New York,
put a spotlight on them, showing children lying naked on the floor,
their bodies contorted, their feces spread on walls.
His reports were broadcast nationally.
More than 5,400 people lived on the Willowbrook campus,
making it the biggest state-run institution
for mentally disabled people in the United States.
http://www.nytimes.com/2012/10/11/nyregion/barbara-blum-who-rescued-abused-willowbrook-residents-dies-at-82.html

http://www.nytimes.com/2012/10/11/nyregion/barbara-blum-who-rescued-abused-willowbrook-residents-dies-at-82.html

http://www.library.csi.cuny.edu/archives/WillowbrookRG.htm

psychology

psychopathy
http://www.economist.com/science/displayStory.cfm?story_id=4008792 

British Psychological Society
http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health

psychologist
http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health

cognitive psychology > George Armitage Miller        1920-2012
http://www.nytimes.com/2012/08/02/us/george-a-miller-cognitive-psychology-pioneer-dies-at-92.html

community psychology        USA
http://www.nytimes.com/2010/02/08/education/08sarason.html

psychologist        USA
http://www.nytimes.com/2013/01/14/us/
susan-nolen-hoeksema-psychologist-who-studied-depression-in-women-dies-at-53.html
http://www.nytimes.com/2010/02/08/education/08sarason.html

shrink

be in psychotherapy
http://www.nytimes.com/2013/01/20/opinion/sunday/should-therapists-play-cupid.html

talking therapies > cognitive behavior therapy
http://www.nytimes.com/2013/01/14/us/
susan-nolen-hoeksema-psychologist-who-studied-depression-in-women-dies-at-53.html

strange behavior
http://www.nytimes.com/2013/03/28/us/documents-2011-tucson-shooting-case-gabrielle-giffords.html

rumination
the natural instinct to dwell on the sources of problems
rather than their possible solutions
http://www.nytimes.com/2013/01/14/us/
susan-nolen-hoeksema-psychologist-who-studied-depression-in-women-dies-at-53.html

therapy
http://www.guardian.co.uk/society/2013/feb/05/are-no-gods-mental-health

have therapy
http://www.nytimes.com/2013/01/09/health/gaps-seen-in-therapy-for-suicidal-teenagers.html

heal
http://well.blogs.nytimes.com/2012/04/02/a-brief-therapy-helps-heal-trauma-in-children/

psychoanalyst        USA
http://www.nytimes.com/2012/01/17/books/louise-j-kaplan-psychoanalyst-and-author-dies-at-82.html
http://www.nytimes.com/2010/04/27/us/27miller.html

patient-therapist relationship
http://www.nytimes.com/2013/01/20/opinion/sunday/should-therapists-play-cupid.html

inner thoughts and secret desires
http://www.nytimes.com/2013/01/20/opinion/sunday/should-therapists-play-cupid.html

transference / countertransference
http://www.nytimes.com/2013/01/20/opinion/sunday/should-therapists-play-cupid.html

Joyce Brothers (born Joyce Diane Bauer)        USA        1927-2013

former academic psychologist who,
long before Drs. Ruth, Phil and Laura,
was counseling millions over the airwaves

http://www.nytimes.com/2013/05/14/arts/television/dr-joyce-brothers-psychologist-dies-at-85.html

Susan Nolen-Hoeksema / Susan Kay Nolen        1959-2013

psychologist and writer whose work helped explain why
women are twice as prone to depression as men
and why such low moods can be so hard to shake
http://www.nytimes.com/2013/01/14/us/susan-nolen-hoeksema-psychologist-who-studied-depression-in-women-dies-at-53.html

Susan Jane Gildenberg        1938-2012

psychologist who wrote 18 self-help books,
the first of which, “Feel the Fear and Do It Anyway,”
became an international phenomenon
http://www.nytimes.com/2012/11/12/arts/susan-jeffers-psychologist-and-self-help-author-dies-at-74.html

James Griffith Edwards        1928-2012

psychiatrist who helped establish addiction medicine as a science,
formulating definitions of drug and alcohol dependence
that are used worldwide to diagnose and treat substance abuse
http://www.nytimes.com/2012/09/26/health/dr-griffith-edwards-pioneer-in-addiction-medicine-dies-at-83.html

Thomas Szasz        1920-2012

psychiatrist whose 1961 book “The Myth of Mental Illness”
questioned the legitimacy of his field
and provided the intellectual grounding
for generations of critics, patient advocates and antipsychiatry activists,
making enemies of many fellow doctors
http://www.nytimes.com/2012/09/12/health/dr-thomas-szasz-psychiatrist-who-led-movement-against-his-field-dies-at-92.html

Louise Janet Miller        1929-2012

psychoanalyst and author who used
a psychological lens, literary allusion and a feminist sensibility
to soberly define and explain seemingly titillating topics like sexual perversity and fetishes
http://www.nytimes.com/2012/01/17/books/louise-j-kaplan-psychoanalyst-and-author-dies-at-82.html

Hanna Poznanska        1918-2011

British psychoanalyst who helped change child psychology in the United States
by explaining and popularizing the play therapy techniques developed
by her mentor, the seminal psychoanalytic thinker Melanie Klein
http://www.nytimes.com/2011/08/02/health/02segal.html

Eleanor Galenson        1916-2011

psychoanalyst whose research demonstrated
that children are aware of sexual identity in infancy,
even earlier than Freud had propounded
http://www.nytimes.com/2011/01/30/us/30galenson.html

psychiatry        USA
http://opinionator.blogs.nytimes.com/2013/02/06/the-limits-of-psychiatry/
http://www.nytimes.com/2011/04/21/health/21freedman.html
http://www.nytimes.com/2011/03/09/opinion/l09psych.html
http://www.nytimes.com/2011/03/06/health/policy/06doctors.html

Dr. Robert L. Spitzer        USA
considered by some to be the father of modern psychiatry
http://www.nytimes.com/2012/05/19/health/dr-robert-l-spitzer-noted-psychiatrist-apologizes-for-study-on-gay-cure.html

psychiatrist
http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health

psychiatrist        USA
http://www.nytimes.com/2010/05/05/us/05greenspan.html
http://www.nytimes.com/2010/04/19/us/19masterson.html
http://www.nytimes.com/2009/06/23/health/23mind.html

psychiatric disorders > Diagnostic and Statistical Manual of Mental Disorders        DSM        USA
http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health
http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html
http://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html
http://www.nytimes.com/2012/05/09/health/dsm-panel-backs-down-on-diagnoses.html
http://www.nytimes.com/2008/12/18/health/18psych.html

mental disorders        USA
http://www.nytimes.com/2013/03/01/health/study-finds-genetic-risk-factors-shared-by-5-psychiatric-disorders.html

borderline personality disorder        USA
http://health.nytimes.com/health/guides/disease/borderline-personality-disorder/overview.html

personality disorder        USA
http://health.nytimes.com/health/guides/disease/personality-disorders/overview.html
http://www.nytimes.com/2010/04/19/us/19masterson.html

mental disorders on campus        USA
http://www.nytimes.com/roomfordebate/2011/01/12/dealing-with-mental-disorders-on-campus

eating disorders        USA
http://www.nytimes.com/2011/10/14/business/ruling-offers-hope-to-eating-disorder-sufferers.html

eating disorders > Anorexia Nervosa        USA
http://health.nytimes.com/health/guides/disease/anorexia-nervosa/overview.html

eating disorders > Bulimia        USA
http://health.nytimes.com/health/guides/disease/bulimia/overview.html

narcissism        USA
http://www.nytimes.com/2010/04/19/us/19masterson.html

narcissistic personality disorder        USA
http://health.nytimes.com/health/guides/disease/narcissistic-personality-disorder/overview.html

psychosis
http://www.independent.co.uk/life-style/health-and-families/features/living-with-psychosis-im-mad-but-not-bad-2025012.html

hypochondria
http://www.nytimes.com/2013/01/13/opinion/sunday/hypochondria-an-inside-look.html

Attention Deficit Hyperactivity Disorder        A.D.H.D.

http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/overview.html

http://www.nytimes.com/2013/05/01/us/colleges-tackle-illicit-use-of-adhd-pills.html

http://www.nytimes.com/2013/04/03/opinion/diagnosis-human.html

http://www.nytimes.com/2013/03/01/health/study-finds-genetic-risk-factors-shared-by-5-psychiatric-disorders.html

http://www.nytimes.com/2013/02/03/us/concerns-about-adhd-practices-and-amphetamine-addiction.html

http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html

http://www.nytimes.com/roomfordebate/2011/10/12/are-americans-more-prone-to-adhd

http://www.guardian.co.uk/society/attention-deficit-hyperactivity-disorder

http://www.guardian.co.uk/society/2010/sep/30/hyperactive-children-genetic-disorder-study

http://www.guardian.co.uk/lifeandstyle/2010/may/29/adhd-aspergers-children-advice

http://www.nytimes.com/interactive/2008/05/21/health/healthguide/TE_ADHD_CLIPS.html# 

http://media.guardian.co.uk/site/story/0,,1725192,00.html

Attention Deficit Hyperactivity Disorder > medications > Adderall

http://www.nytimes.com/2013/05/01/us/colleges-tackle-illicit-use-of-adhd-pills.html

http://www.nytimes.com/2013/04/03/opinion/diagnosis-human.html

http://www.nytimes.com/2013/02/03/us/concerns-about-adhd-practices-and-amphetamine-addiction.html

Attention Deficit Hyperactivity Disorder > medications > Ritalin

http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/ritalin_drug/index.html

http://www.nytimes.com/2013/04/03/opinion/diagnosis-human.html

Vyvanse, a standard treatment for A.D.H.D.

http://www.nytimes.com/2013/05/01/us/colleges-tackle-illicit-use-of-adhd-pills.html

serotonin

http://www.nytimes.com/2011/09/03/health/03rapport.html

stress
http://society.guardian.co.uk/health/news/0,8363,1061183,00.html

burn-out

burnt-out

trauma
http://well.blogs.nytimes.com/2012/04/02/a-brief-therapy-helps-heal-trauma-in-children/

post-traumatic stress disorder        P.T.S.D.
http://www.nytimes.com/2012/01/11/us/post-traumatic-stress-disorder-may-cause-erratic-driving.html
http://www.guardian.co.uk/traincrash/Story/0,,2120470,00.html

psychotic / the psychotic
http://www.nytimes.com/2012/09/30/us/ending-segregation-of-the-mentally-disabled.html

the manic
http://www.nytimes.com/2012/09/30/us/ending-segregation-of-the-mentally-disabled.html

neurosis

crumbling identity

suffer from blackouts

suffer mood swings

have mental shutdowns

antipsychotics
http://www.nytimes.com/2009/12/12/health/12medicaid.html

psychiatric / psychosis drugs for children
http://www.nytimes.com/2010/09/12/opinion/l12drug.html
http://www.nytimes.com/2010/09/02/business/02kids.html

antidepressant drug / antidepressant
http://topics.nytimes.com/topics/news/health/diseasesconditionsandhealthtopics/antidepressants/index.html
http://www.nytimes.com/2011/07/17/opinion/sunday/l17dialogue.html
http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html
http://www.nytimes.com/2010/01/12/health/12mind.html
http://community.nytimes.com/article/comments/2008/04/15/health/15mind.html
http://www.independent.co.uk/life-style/health-and-wellbeing/
health-news/antidepressant-drugs-udontu-work-ndash-official-study-787264.html
http://www.usatoday.com/news/health/2006-12-13-fda-antidepressants_x.htm
http://www.guardian.co.uk/medicine/story/0,,1773935,00.html
http://society.guardian.co.uk/mentalhealth/story/0,8150,1238132,00.html
http://society.guardian.co.uk/mentalhealth/story/0,8150,1052979,00.html

Seroxat - the world's biggest-selling antidepressant
http://society.guardian.co.uk/mentalhealth/story/0,,913400,00.html

selective serotonin reuptake inhibitors        SSRI / SSRIs

be on SSRI

dementia patients > anti-psychotic medication
http://www.guardian.co.uk/society/2009/nov/12/anti-psychotic-drugs-kill-dementia-patients

side-effect

become suicidal

become aggressive

be terrified of...

panic

panic attack
http://www.guardian.co.uk/society/panic-attacks
http://www.nytimes.com/2012/11/13/sports/golf/charlie-beljans-panic-leads-to-hospital-and-then-pga-title.html
http://www.guardian.co.uk/music/2009/nov/15/ronan-keating-boyzone-gately

potential side-effect

become suicidal

Broadmoor
http://society.guardian.co.uk/mentalhealth/story/0,8150,1103571,00.html

Rosemary Kennedy        USA        1918-2005
http://www.guardian.co.uk/news/2005/jan/11/guardianobituaries.usa

fear

phobia        USA
http://opinionator.blogs.nytimes.com/2012/03/03/things-to-fear-and-loathe/

phobia
http://www.guardian.co.uk/medicine/story/0,11381,1096480,00.html

agoraphobics

agoraphobia

claustrophobia

arachnophobia

obsessive compulsive disorder        OCD
http://www.guardian.co.uk/lifeandstyle/2013/jan/21/mad-fat-diary-rae-earl-childhood-mental-health
http://health.nytimes.com/health/guides/disease/obsessive-compulsive-disorder/overview.html
http://www.nytimes.com/2009/11/27/health/research/27brain.html
http://www.guardian.co.uk/lifeandstyle/obsessive-compulsive-disorder
http://www.guardian.co.uk/lifeandstyle/2009/dec/15/obsessive-complusive-disorder-gamma-knife
http://society.guardian.co.uk/mentalhealth/story/0,8150,1531571,00.html

bipolar disorder
http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health

Bipolar disorder
is a condition in which people go back and forth
between periods of a very good or irritable mood and depression.
The "mood swings" between mania and depression can be very quick.
http://health.nytimes.com/health/guides/disease/bipolar-disorder/overview.html

http://health.nytimes.com/health/guides/disease/bipolar-disorder/overview.html

http://www.nytimes.com/2013/03/01/health/study-finds-genetic-risk-factors-shared-by-5-psychiatric-disorders.html
http://www.guardian.co.uk/society/bipolar-disorder
http://www.nytimes.com/2012/01/18/opinion/my-so-called-bipolar-life.html
http://health.nytimes.com/health/guides/disease/bipolar-disorder/overview.html

bipolar disorder treatment
http://www.guardian.co.uk/film/2011/apr/13/catherine-zeta-jones-bipolar-disorder-treatment

binge eating
http://health.nytimes.com/health/guides/symptoms/binge-eating/overview.html

bulimia
http://health.nytimes.com/health/guides/disease/bulimia/overview.html
http://www.nytimes.com/2010/04/22/fashion/22Melissa.html

schizophrenia
http://www.guardian.co.uk/society/schizophrenia
http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health
http://www.guardian.co.uk/society/2011/feb/05/living-with-schizophrenia-cockburn-intervew
 

The New York Times > Health Guide > Schizophrenia        USA
http://health.nytimes.com/health/guides/disease/schizophrenia/overview.html

http://www.nytimes.com/2013/03/01/health/study-finds-genetic-risk-factors-shared-by-5-psychiatric-disorders.html
http://www.nytimes.com/2012/12/26/opinion/our-failed-approach-to-schizophrenia.html
http://www.nytimes.com/2011/11/26/health/man-uses-his-schizophrenia-to-gather-clues-for-daily-living.html
http://www.nytimes.com/2008/02/24/business/24drug.html

have schizophrenia
http://observer.guardian.co.uk/focus/story/0,,1951739,00.html

live with schizo-affected disorder
http://www.guardianweekly.co.uk/?page=editorial&id=1283&catID=3

have paranoid schizophrenia

 take antipsychotic drugs for schizophrenia

schizophrenia patient

schizophrenic
http://www.nytimes.com/2011/06/17/us/17MENTAL.html
http://www.boston.com/news/local/breaking_news/2011/01/revere_police_i.html
http://www.timesonline.co.uk/tol/news/uk/health/article639470.ece

Eyes wide shut

Sleep is something most of us take for granted,

but for the 3 million Britons who are afflicted with insomnia,

sleeplessness is a serious blight on their lives.

Long-term sufferer Anita Sethi records 24 hours caught between two worlds.

The Guardian        G2        pp. 6-7

27 July 2005
http://www.guardian.co.uk/g2/story/0,,1535398,00.html

memory
http://www.nytimes.com/2011/07/04/nyregion/music-therapy-helps-the-dying.html

painful memories
http://www.guardian.co.uk/science/story/0,,1701033,00.html

sleeplessness
http://well.blogs.nytimes.com/2012/03/12/new-worries-about-sleeping-pills/

insomnia
http://www.nytimes.com/2013/02/08/science/peter-hauri-psychologist-who-focused-on-insomnia-dies-at-79.html
http://www.guardian.co.uk/lifeandstyle/2012/nov/04/how-to-beat-insomnia
http://www.guardian.co.uk/lifeandstyle/2011/jan/30/sleep-problems-new-drugs

insomnia concerns
http://health.nytimes.com/health/guides/specialtopic/insomnia-concerns/overview.html

insomniac
http://www.nytimes.com/2012/03/25/opinion/sunday/the-case-for-sleep-medicine.html

sleeping pills
http://well.blogs.nytimes.com/2012/03/12/new-worries-about-sleeping-pills/

Added 3 March 2010
http://www.shutterisland.com/#/downloads/wallpaper

film > Martin Scorsese > Shutter Island        2009
http://www.shutterisland.com/
http://www.guardian.co.uk/film/filmblog/2010/feb/15/martin-scorsese-shutter-island
http://www.guardian.co.uk/film/2010/feb/11/leonardo-dicaprio-shutter-island

film > Sam Mendes > Revolutionary Road        2008
http://www.guardian.co.uk/film/filmblog/2009/feb/02/revolutionary-road-titanic-kate-winslet

film > Jonathan Demme > Silence of the Lambs        1991
http://film.guardian.co.uk/News_Story/Critic_Review/Guardian_review/0,,530779,00.html

One Flew Over the Cuckoo's Nest        1975
http://movies.nytimes.com/movie/review?res=EE05E7DF1739E76CBC4851DFB767838E669EDE

film > John Cassavetes > A Woman Under the Influence        1974
http://en.wikipedia.org/wiki/A_Woman_Under_the_Influence

film > Ken Loach > Family Life        1971
http://en.wikipedia.org/wiki/Ken_Loach

film > Alfred Hitchcock > Psycho        1960
http://movies.nytimes.com/movie/review?res=EE05E7DF173DE273BC4F52DFB066838B679EDE

film > Alfred Hitchcock > Vertigo        1958
http://movies.nytimes.com/movie/review?res=9905EEDD1031E73BBC4151DFB3668383649EDE
http://www.guardian.co.uk/film/2008/sep/26/poster.vertigo

Lawrence Zeegen is an illustrator, educator and writer.

He has recently published two books —

Digital Illustration: A Master Class in Creative Image-Making (Rotovision)

and The Fundamentals of Illustration (AVA).

He is academic programme leader for communication and media arts

at the University of Brighton. www.zeegen.com

The Guardian        p. 31

7.1.2006

Related
http://www.guardian.co.uk/news/2005/jan/11/guardianobituaries.usa

anxiety

http://www.guardian.co.uk/commentisfree/2013/apr/26/optimism-appealing-pessimism-more-my-thing

http://opinionator.blogs.nytimes.com/2013/04/15/separation-anxiety/

http://opinionator.blogs.nytimes.com/2013/04/01/the-ways-ive-worried/

http://opinionator.blogs.nytimes.com/2013/01/20/you-are-going-to-die/

http://opinionator.blogs.nytimes.com/2012/10/07/brain-scan/

http://health.nytimes.com/health/guides/symptoms/stress-and-anxiety/overview.html

http://opinionator.blogs.nytimes.com/2012/01/14/its-still-the-age-of-anxiety-or-is-it/

people with distressing symptoms of anxiety

anxious

http://well.blogs.nytimes.com/2009/11/18/phys-ed-why-exercise-makes-you-less-anxious/

http://www.nytimes.com/2009/10/04/magazine/04anxiety-t.html

mildly anxious patient

anti-anxiety drug > Xanax

http://opinionator.blogs.nytimes.com/2012/01/14/its-still-the-age-of-anxiety-or-is-it/

http://www.nytimes.com/2011/09/14/us/in-louisville-a-centers-doctors-cut-off-xanax-prescriptions.html

alarm

http://www.guardian.co.uk/commentisfree/2013/apr/26/optimism-appealing-pessimism-more-my-thing

worry

http://opinionator.blogs.nytimes.com/2013/04/01/the-ways-ive-worried/

paranoid
http://www.telegraph.co.uk/news/uknews/crime/7806422/
Cumbria-gunman-Derrick-Bird-watched-violent-film-before-killings.html

in the grip of paranoid delusions
http://www.nytimes.com/2012/12/27/nyregion/new-yorks-mental-health-system-thrashed-by-services-lost-to-storm.html

untreatable mental disorders
http://society.guardian.co.uk/mentalhealth/story/0,8150,1299727,00.html

tranquilliser

tranquilliser prescription

addiction

Prozac / Prozac nation
http://society.guardian.co.uk/health/news/0,8363,1567328,00.html
http://education.guardian.co.uk/schools/story/0,5500,1232550,00.html

Valium and Librium - once popularly known as "mother's little helper"
http://www.guardian.co.uk/medicine/story/0,11381,1145372,00.html

discrimination
http://society.guardian.co.uk/mentalhealth/story/0,8150,1238682,00.html

draft mental health bill
http://society.guardian.co.uk/mentalhealth/story/0,8150,1300340,00.html

National Institute for Mental Health in England        NIMHE
http://www.nimhe.csip.org.uk/

institution        USA
http://www.nytimes.com/2012/09/30/us/ending-segregation-of-the-mentally-disabled.html
http://online.wsj.com/article/SB121218278041833793.html?mod=hpp_us_inside_today

integration        USA
http://www.nytimes.com/2012/09/30/us/moving-mentally-disabled-from-institutions-to-group-homes.html

mad

madness
http://www.guardian.co.uk/commentisfree/video/2011/jan/31/mental-health-psychology
http://www.nytimes.com/2011/01/15/opinion/15herbert.html

Specialists For The Mentally Ill

Undated > 1950s?

Photographer: Hank Walker

Life Images
http://images.google.com/hosted/life/l?imgurl=5c5a2ab6f6a3ce5a

Specialists For The Mentally Ill

Undated > 1950s?

Photographer: Hank Walker

Life Images
http://images.google.com/hosted/life/l?imgurl=0dccab184db3bba9

Mental institution for old people.

Location: US

Date taken: July 1959

Photographer: Grey Villet

Life Images
http://images.google.com/hosted/life/l?imgurl=70c27498987ac8f2

George A. Miller,

a Pioneer in Cognitive Psychology,

Is Dead at 92

August 1, 2012
The New York Times
By PAUL VITELLO

Psychological research was in a kind of rut in 1955 when George A. Miller, a professor at Harvard, delivered a paper titled “The Magical Number Seven, Plus or Minus Two,” which helped set off an explosion of new thinking about thinking and opened a new field of research known as cognitive psychology.

The dominant form of psychological study at the time, behaviorism, had rejected Freud’s theories of “the mind” as too intangible, untestable and vaguely mystical. Its researchers instead studied behavior in laboratories, observing and recording test subjects’ responses to carefully administered stimuli. Mainly, they studied rats.

Dr. Miller, who died on July 22 at his home in Plainsboro, N.J., at the age of 92, revolutionized the world of psychology by showing in his paper that the human mind, though invisible, could also be observed and tested in the lab.

“George Miller, more than anyone else, deserves credit for the existence of the modern science of mind,” the Harvard psychologist and author Steven Pinker said in an interview. “He was certainly among the most influential experimental psychologists of the 20th century.”

Dr. Miller borrowed a testing model from the emerging science of computer programming in the early 1950s to show that humans’ short-term memory, when encountering the unfamiliar, could absorb roughly seven new things at a time.

When asked to repeat a random list of letters, words or numbers, he wrote, people got stuck “somewhere in the neighborhood of seven.”

Some people could recall nine items on the list, some fewer than seven. But regardless of the things being recalled — color-words, food-words, numbers with decimals, numbers without decimals, consonants, vowels — seven was the statistical average for short-term storage. (Long-term memory, which followed another cognitive formula, was virtually unlimited.)

Dr. Miller could not say why it was seven. He speculated that survival might have favored early humans who could retain “a little information about a lot of things” rather than “a lot of information about a small segment of the environment.”

But that, he concluded, was beside the point. He had articulated an idea that was to become a touchstone of cognitive science: that whatever else the brain might be, it was an information processor, with systems that obeyed mathematical rules, that could be studied.

Dr. Miller, who was trained in behaviorism, was among the first of many researchers and theorists to challenge its scientific principles in the 1950s. He and a colleague, Jerome S. Bruner, gave a name to the new research field when they established a psychology lab of their own, the Center for Cognitive Studies, at Harvard in 1960. Just by employing the word “cognitive,” considered taboo among behaviorists, they signaled a break with the old school.

“Using ‘cognitive’ was an act of defiance,” Dr. Miller wrote in 2006. “For someone raised to respect reductionist science, ‘cognitive psychology’ made a definite statement. It meant that I was interested in the mind.”

That new approach to psychological research came to be known as the cognitive revolution.

Dr. Miller’s first and most enduring interest as a scientist was language. His first book, “Language and Communication” (1951), is widely considered a foundational work in psycholinguistics, the study of how people learn, use and invent language. He collaborated with the linguist Noam Chomsky in groundbreaking papers on the mathematics of language and the computational problems involved in interpreting syntax.

He conducted some of the first experiments on how people understand words and sentences, the basis of computer speech-recognition technology. “Plans and the Structure of Behavior” (1960), written with Eugene Galanter and Karl H. Pribram, was an effort to synthesize artificial-intelligence research with psychological research on how humans initiate action — basically, a book about how to build a better robot. Beginning in 1986, he oversaw the development of WordNet, an electronic reference databank intended to help computers understand human language.

Colleagues said he had a role in framing many of his era’s most audacious thoughts about human and artificial thinking; typically, he then moved on to other projects.

“Like most great scientists, he became interested in some phenomenon or other and then simply jumped in to try to illuminate the problem,” said Michael S. Gazzaniga, a leading researcher in cognitive neuroscience at the University of California, Santa Barbara. Dr. Miller helped create the field of cognitive neuroscience in the late 1980s, he said. “He was exceptionally generous.”

George Armitage Miller was born on Feb. 3, 1920, in Charleston, W.Va., the only child of Florence and George Miller, who divorced when he was a child. His father was a steel company executive.

Mr. Miller and his first wife, Katherine, who died in 1996, married while both were undergraduates at the University of Alabama. After graduating with a bachelor’s degree in English and speech, Mr. Miller received his master’s degree and Ph.D. in psychology at Harvard, serving in the Army Signal Corps during World War II in between.

He taught at Harvard beginning in 1955, heading its psychology department from 1964 until 1967, and later taught at Rockefeller University in New York and at the Massachusetts Institute of Technology. He joined the faculty of Princeton in 1979, founded the Cognitive Science Laboratory there and became a professor emeritus in 1990.

His survivors include his wife, Margaret, whom he married in 2008; a son, Donnally; a daughter, Nancy Saunders; and three grandchildren.

Dr. Miller’s paper on the number seven, which he read on April 5, 1955, at a meeting of the Eastern Psychological Association in Philadelphia, opened with a memorable line: “My problem is that I have been persecuted by an integer.”

He went on to make a topical reference to the Communist scare of the McCarthy era: “The persistence with which this number plagues me is far more than a random accident. There is, to quote a famous senator, a design behind it.”

The paper’s ground-shifting implications made it one of the most frequently quoted texts in the canon of modern psychology (and by Dr. Miller’s account, one of the most misquoted). For better or worse, “The Magical Number Seven” came to haunt his scientific career, overshadowing his many other accomplishments.

It resonated more playfully in his golf game. “He made the one and only hole-in-one of his life at the age of 77, on the seventh green” at the Springdale Golf Club in Princeton, his daughter said. “He made it with a seven iron. He loved that.”

    George A. Miller, a Pioneer in Cognitive Psychology, Is Dead at 92, NYT, 1.8.2012,
    http://www.nytimes.com/2012/08/02/us/george-a-miller-cognitive-psychology-pioneer-dies-at-92.html

My So-Called Bipolar Life

January 17, 2012
The New York Times
By JAMIE STIEHM

Washington

OVER the last few weeks, “Homeland,” Showtime’s new psychological thriller, has had quite a rush. Claire Danes, the show’s incandescent star, was nominated for, and then won, the Golden Globe for best actress in a TV drama series; the show also won for best TV drama. Why do I care? Because I know her character all too well.

Not in every sense, of course. I’m not a blond C.I.A. agent, and I’ve never hunted down or fallen in love with suspected terrorists. But as fans of the show — including, it’s said, President Obama — know, that’s not the only important part of Carrie Mathison, the character played by Ms. Danes. Like me, Carrie has bipolar disorder.

My sister Meredith Stiehm is a writer and consulting producer for the show, and she drew on my experience with the disorder to portray Carrie’s character. Not long ago, I retold the tale of my single manic episode to her, sharpening memories of that day in all its colors.

It was a painful testament to my sister’s skill that scenes that might have been of just passing interest to other viewers pushed me to tears, because in a real way they carried an uncanny emotional resonance.

And yet for all that, I feel the show’s creators, writers and producers, and Ms. Danes, have done us all a public service: perhaps, with the show’s glowing reception, Americans can finally talk openly about bipolar disorder.

Meredith’s interest in my condition is not, of course, limited to her work as a writer. After the manic episode landed me in the Johns Hopkins hospital years ago, Meredith stayed with me at home for a week to help me get back to the regular simplicity of sleeping and waking. One of the first things they tell you about the condition is that sleep really is the “chief nourisher in life’s feast,” as Macbeth put it. I have a mild case, so sleep, and lithium under the care of a doctor, have helped me stay healthy ever since.

My sister knows my back pages well, and while writing the script, she asked me about that spell of several sunny October days. Dormant memories awakened: I was a reporter for The Baltimore Sun, and I was filing stories in the newsroom faster than ever before. It’s strangely fitting that I worked in journalism, which at its best also has its share of frenetic late nights, deadlines and homing in on people. As a reporter at The Sun once said to me, “This is a manic-depressive business.”

Didn’t I know it. A “hypomanic” state, which precedes an episode of mania, is in fact an enhanced, alert, productive mood where one can feel exhilarated and immune to life’s dangers. I seemed to see into people’s hearts when I smiled at them. My speech sped up so much few could understand me.

I ran around Baltimore’s Inner Harbor at high speed, exulting in all my energy. For several days, I woke up at dawn to see the sunrise and take pictures of it. I felt sure something big was going to happen soon in Baltimore and only I could foresee it.

Similarly, a haunted Carrie is convinced that a big terrorist attack is looming large. Her furious focus on her quarry under time pressure leads to sleepless nights and reckless risks, behavior that is both symptom and contributing cause of bipolar illness. Her elevated mood cycles higher and higher, and she falls rapturously in love with the married Marine who she thinks is working for Al Qaeda, played with minute precision by Damian Lewis. Viewers can’t totally dismiss her visions — but then again, she’s not rational. In the hospital ward, she demands a green pen to write everything down, her voice racing faster and faster. Meredith had bottled my mercurial emotions so exactly it hurt.

Bipolar extremes can be truly hard to watch, excruciating even in memory. To see that experience depicted so intensely by Ms. Danes was like peering at a portrait gallery of my own psyche.

As I recovered, I found comfort in company. My colleagues could not have been more gracious. But at the end of the show’s first season (spoiler alert), poor Carrie has lost her job and appears left in a lonely place, about to undergo electroconvulsive therapy.

However, contrary to widespread belief, electroconvulsive therapy is extremely effective. A family friend, Dr. Leon Rosenberg, a geneticist and former dean of Yale Medical School, has the same malady. As a patient overwhelmed by suicidal depression, he made remarkable progress after electroconvulsive therapy. As a doctor, he described his own case in a medical journal and discusses his descent and recovery with students.

Yes, the show cuts close to home at points, but it gets the lead character’s story right. How rare to see a sparkling and spirited representation of what it’s actually like to walk through life with bipolar disorder. So let a thousand conversations bloom. Secrets held up to light and air lose their power in the public square. Spies know it as keepers, and writers know it as tellers.

Jamie Stiehm, a journalist,

is writing a biography of the social reformer Lucretia Mott.

    My So-Called Bipolar Life, NYT, 17.1.2012,
    http://www.nytimes.com/2012/01/18/opinion/my-so-called-bipolar-life.html

It’s Still the ‘Age of Anxiety.’ Or Is It?

January 14, 2012
3:00 pm
The New York Times
Opinionator - A Gathering of Opinion From Around the Web
By DANIEL SMITH

Anxiety: We worry. A gallery of contributors count the ways.

It’s hard to believe that anyone but scholars of modern literature or paid critics have read W.H. Auden’s dramatic poem “The Age of Anxiety” all the way through, even though it won a Pulitzer Prize in 1948, the year after it was published. It is a difficult work — allusive, allegorical, at times surreal. But more to the point, it’s boring. The characters meet, drink, talk and walk around; then they drink, talk and walk around some more. They do this for 138 pages; then they go home.

Auden’s title, though: that people know. From the moment it appeared, the phrase has been used to characterize the consciousness of our era, the awareness of everything perilous about the modern world: the degradation of the environment, nuclear energy, religious fundamentalism, threats to privacy and the family, drugs, pornography, violence, terrorism. Since 1990, it has appeared in the title or subtitle of at least two dozen books on subjects ranging from science to politics to parenting to sex (“Mindblowing Sex in the Real World: Hot Tips for Doing It in the Age of Anxiety”). As a sticker on the bumper of the Western world, “the age of anxiety” has been ubiquitous for more than six decades now.

But is it accurate? As someone who has struggled with chronic anxiety for many years, I have my doubts. For one thing, when you’ve endured anxiety’s insults for long enough — the gnawed fingernails and sweat-drenched underarms, the hyperventilating and crippling panic attacks — calling the 20th century “The Age of Anxiety” starts to sound like calling the 17th century “The Age of the Throbbing Migraine”: so metaphorical as to be meaningless.

From a sufferer’s perspective, anxiety is always and absolutely personal. It is an experience: a coloration in the way one thinks, feels and acts. It is a petty monster able to work such humdrum tricks as paralyzing you over your salad, convincing you that a choice between blue cheese and vinaigrette is as dire as that between life and death. When you are on intimate terms with something so monumentally subjective, it is hard to think in terms of epochs.

And yet it is undeniable that ours is an age in which an enormous and growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated. Last spring, the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax — was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

Earlier eras might have been even more jittery than ours. Fourteenth-century Europe, for example, experienced devastating famines, waves of pillaging mercenaries, peasant revolts, religious turmoil and a plague that wiped out as much as half the population in four years. The evidence suggests that all this resulted in mass convulsions of anxiety, a period of psychic torment in which, as one historian has put it, “the more one knew, the less sense the world made.” Nor did the monolithic presence of the Church necessarily help; it might even have made things worse. A firm belief in God and heaven was near-universal, but so was a firm belief in their opposites: the Devil and hell. And you could never be certain in which direction you were headed.

It’s hard to imagine that we have it even close to as bad as that. Yet there is an aspect of anxiety that we clearly have more of than ever before: self-awareness. The inhabitants of earlier eras might have been wracked by nerves, but none fixated like we do on the condition. Indeed, none even considered anxiety a condition. Anxiety didn’t emerge as a cohesive psychiatric concept until the early 20th century, when Freud highlighted it as “the nodal point at which the most various and important questions converge, a riddle whose solution would be bound to throw a flood of light upon our whole mental existence.”

After that, the number of thinkers and artists who sought to solve this riddle increased exponentially. By 1977, the psychoanalyst Rollo May was noting an explosion in papers, books and studies on the subject. “Anxiety,” he wrote, “has certainly come out of the dimness of the professional office into the bright light of the marketplace.”

None of this is to say that ours is a serene age. Obviously it isn’t. It is to say, however, that we shouldn’t be possessive about our uncertainties, particularly as one of the dominant features of anxiety is its recursiveness. Anxiety begins with a single worry, and the more you concentrate on that worry, the more powerful it gets, and the more you worry. One of the best things you can do is learn to let go: to disempower the worry altogether. If you start to believe that anxiety is a foregone conclusion — if you start to believe the hype about the times we live in — then you risk surrendering the battle before it’s begun.

To receive immediate updates and new posts subscribe to the Anxiety RSS feed.

Daniel Smith is the author of the forthcoming book “Monkey Mind: A Memoir of Anxiety” (Simon & Schuster, July 2012). His work has appeared in The Atlantic, Granta, n+1, New York, The New York Times Magazine and elsewhere. He writes regularly about anxiety at his Web site, The Monkey Mind Chronicles.

This post has been revised to reflect the following correction:

Correction: January 15, 2012

An opinion essay on Jan. 15 about the prevalence of anxiety disorders erroneously attributed a distinction to the anti-anxiety drug alprazolam, or Xanax. It was the only psychiatric medication among the top 15 — not the top 25 — prescription drugs in the United States in 2010. A summary accompanying the article also referred incorrectly to Xanax.
It was prescribed 46.3 million times in the United States in 2010,
as the article correctly noted — not to 46 million people.

    It’s Still the ‘Age of Anxiety.’ Or Is It?, NYT, 14.1.2012,
    http://opinionator.blogs.nytimes.com/2012/01/14/its-still-the-age-of-anxiety-or-is-it/

Finding Purpose After Living With Delusion

November 25, 2011
The New York Times
By BENEDICT CAREY

ATHENS, Ohio — She was gone for good, and no amount of meditation could resolve the grief, even out here in the deep quiet of the woods.

Milt Greek pushed to his feet. It was Mother’s Day 2006, not long after his mother’s funeral, and he headed back home knowing that he needed help. A change in the medication for his schizophrenia, for sure. A change in focus, too; time with his family, to forget himself.

And, oh yes, he had to act on an urge expressed in his psychotic delusions: to save the world.

So after cleaning the yard around his house — a big job, a gift to his wife — in the coming days he sat down and wrote a letter to the editor of the local newspaper, supporting a noise-pollution ordinance.

Small things, maybe, but Mr. Greek has learned to live with his diagnosis in part by understanding and acting on its underlying messages, and along the way has built something exceptional: a full life, complete with a family and a career.

He is one of a small number of successful people with a severe psychiatric diagnosis who have chosen to tell their story publicly. In doing so, they are contributing to a deeper understanding of mental illness — and setting an example that can help others recover.

“I started feeling better, stronger, the next day,” said Mr. Greek, 49, a computer programmer who for years, before receiving medical treatment, had delusions of meeting God and Jesus.

“I have such anxiety if I’m not organizing or doing some good work. I don’t feel right,” he said. “That’s what the psychosis has given me, and I consider it to be a gift.”

Doctors generally consider the delusional beliefs of schizophrenia to be just that — delusional — and any attempt to indulge them to be an exercise in reckless collusion that could make matters worse. There is no point, they say, in trying to explain the psychological significance of someone’s belief that the C.I.A. is spying through the TV; it has no basis, other than psychosis.

Yet people who have had such experiences often disagree, arguing that delusions have their origin not solely in the illness, but also in fears, longings and psychological wounds that, once understood, can help people sustain recovery after they receive treatment.

Now, these psychiatric veterans are coming together in increasing numbers, at meetings and conferences, and they are writing up their own case histories, developing their own theories of psychosis, with the benefit of far more data than they have ever had before: one another’s stories.

“It’s a thrilling time, because people with lived experience are beginning to collaborate in large numbers,” said Gail A. Hornstein, a psychologist at Mount Holyoke College and author of “Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness.” “They are developing their own theories, their own language about what their experiences means from the inside.”

Mr. Greek is one of the most exceptional, having built a successful life and career despite having schizophrenia — and, he says, because of it. He manages the disorder with medication, personal routines, and by minding the messages in his own strange delusions.

“Schizophrenia is the best thing that ever happened to me,” he said. “I know a lot of people with the diagnosis don’t feel that way, but the experience changed me, for the better. I was so arrogant, so narcissistic, so self-involved, and it humbled me. It gave me a purpose, and that purpose has been very much a part of my recovery.”

 

The Village Eccentric

Like many idealistic undergraduates, Mr. Greek arrived at Ohio University in Athens on a mission. Only, like many undergrads, he wasn’t completely sure what it was.

“To discover a psychological code that people should live by, to create world peace,” he said. “Something like that.”

The town was ready to listen, regardless. It was the fall of 1981, and Athens still had one sandal planted in the 1960s; communes thrived in the Appalachian foothills to the north, and big ideas were in the air, at least in the streets and bars near campus, where professors and students gathered.

One stood out. “You can’t imagine how intense he was back then,” said June Holley, a friend and business consultant in Athens. “He had this long, very thick, curly chestnut hair and wild eyes; he looked like a lion. He could be loud, and I think a lot of people just didn’t want to deal with it.”

Local residents gave him the sidewalk, avoided eye contact, and generally accepted him as one variety of village lunatic — in a town with a rich history of them.

He knew the role, at some level. The son of a college math professor and a lawyer, progressives both, Milton Thomas Greek grew up in Roanoke, Ill., and neighboring Benson, about two hours southwest of Chicago. He declared himself an atheist early and often, which in a devout Christian community was one way to stir the air — and the boys who ruled the schoolyard.

“They told me I was damned — damned! — and came after me,” Mr. Greek said. “Now I see that it was just an excuse, like picking on the fat kid for being fat, or the nerd for being a nerd. But at the time I thought it was all about religion.”

He did not discover the secret to world peace and, by senior year, was in a troubled marriage, and began seeing and hearing things others did not. One day he saw a homeless man in the Athens bus station with eyes “like landscapes that went back into the man’s head infinitely far, stretching on for eternity.” God’s eyes; who else?

Later, he was hitchhiking, and a man with long hair and sandals pulled over to offer a ride, his eyes rippling with the same eternal light as the street person’s. Jesus? It had to be (“I’d already met God, so it made sense.”) The man said something about a small town in the woods, and Mr. Greek thought that that town had to be heaven.

His marriage collapsed. His friends stopped calling. He was back at home in Illinois when a doctor finally gave him a diagnosis — schizophrenia — and prescribed medication.

It seemed like a charade, from start to finish. The doctor never asked what he thought his hallucinations meant, or whether the strange thoughts were linked to experiences in his life. He stopped taking the pills.

“I became very suicidal,” he said. “I had no idea what’s happening to me during this entire time. I had been this big atheist, but here I am thinking that the rapture is about to start and that I’m the Antichrist — all this religious imagery.”

 

Why?

The answer was obvious and ultimately liberating, but he had to spend a long time wandering in the woods — literally — to find it.

It was 1984, he had begged his way back into Ohio University for graduate studies in sociology, still lost in his own mind, his thoughts turning darker by the day. He was alienating classmates, professors, friends.

About the only exception was Ms. Holley, a graduate student some 15 years his senior who enjoyed his company, and one day he decided to visit the commune where she lived, with her family and several other families. It took him two days to find it, the first spent wandering the misty woods until dark in a waking, delusional dream, and the second stumbling into a clearing just off Hooper Ridge Road, where Ms. Holley and her friends took him in.

Over the next several months they sat with him, accepted him as a member of the tribe, and encouraged his mission to improve the world at face value. And save his life they probably did, in part by suggesting that he seek help.

It was Ms. Holley who delivered the message. “I trusted her completely, so when she said I was hallucinating — when she used the word ‘hallucination’ — I knew it was true,” Mr. Greek said. “I would have to give the medication another try.”

He was lucky. It worked, blunting the psychosis enough that he was able to complete a programming course and find work, first in Illinois and later back in Athens at Ohio University’s Information Technology department. In time he found something more: During a snowstorm in 1996, Mr. Greek knocked on the door of a neighbor he had seen around Athens, a single mother with two teenage children, carrying a full-time job plus graduate classes, who was at that very moment (he would learn later) praying for something to get her through the winter.

The man at the door did not exactly look like a savior, in his beat-up jeans and unruly hair, his soft eyes and half-smile. But he offered to cook dinner — stir fry — on a day when the fridge was nearly empty.

The two neighbors became friendly, then close, and finally fell for each other. Neither can say exactly when it happened, but she remembers looking out her window one day to see Mr. Greek pull up to his apartment across the street, his old Honda coughing white smoke. He popped the hood and backed away from the car in slow motion, staring at the engine, then turned abruptly toward his apartment — and vanished, falling face-first into some bushes. “I thought, ‘Well, O.K., he’s got something,” she said. “I’m not sure what. Absentmindedness, maybe?”

They married in 2003 (Mr. Greek’s wife, an artist, asked that her name not appear in this article, for her own privacy), and she helped him fit his religious delusions, now controlled by medication, into a coherent personal story that has guided his day-do-day life.

The frightening voices and ominous signs saying that he was damned were no more than embodiments of his very real childhood terror of being cast out, as the schoolyard boys threatened. His search for heaven on earth was in part an attempt to escape that fate, to find a secure place. But it also dramatized a longing to put the world right, a mission that may have started as vain fantasy, but in time became an emotional imperative, a need to commit small acts of kindness, like cooking dinner for a snowed-in neighbor.

 

A Regimen for Coping

“He has this long list of causes that he’s extremely passionate about, and he has strong opinions about almost everything, but he’s also very sensitive to his relations with people and open to other philosophies,” said Melissa Van Meter, who has worked with Mr. Greek at the university and holds very different political views. “It has just impressed me that he could handle so much personally and do so well professionally.”

“When I began to see the delusions in the context of things that were happening in my real life, they finally made some sense,” Mr. Greek said. “And understanding the story of my psychosis helped me see what I needed to stay well.”

Mr. Greek’s regimen combines meditation, work and drug treatment with occasional visits to a therapist and a steady diet of charitable acts. Some of these are meant to improve the community; others are for co-workers and friends, especially those dealing with a psychiatric diagnosis.

To help others experiencing psychotic delusions, he relies on his own theory of what delusions may mean. In an analysis of 20 delusional experiences, all described by sufferers in the first person, Mr. Greek identifies four story lines.

Among them are the rescuer (on a mission to save a particular group); the self-loathing person (lost in a sense of extreme worthlessness); the visionary (on a journey to spiritual realms to bring back truth); and the messianic (out to transform the world through miracles, or contact with deities) — the last of which is his own psychosis story.

Each, in Mr. Greek’s reading, grows out of a specific fear or trauma, whether isolation, abuse or family dysfunction, in the same way his own delusional story symbolized a fear of being a social reject. He is preparing the study for publication in a psychiatric journal and has put much of his thinking into a manual for families dealing with psychosis, called “Schizophrenia: A Blueprint for Recovery.”

Mr. Greek’s analysis of the story lines in psychosis is certainly not the first of its kind, nor the most comprehensive. Psychiatrists, psychologists, therapists and brain scientists have spun out hundreds of ideas about what goes on during a delusion.

But until recently patients themselves — that is, nonprofessionals who have lived with hallucinations and delusions — had little more than their own strange story to study, in any detail. Now they have dozens, and Mr. Greek is one of a small number of such “native” theorists who argue that the content of a delusion should not be ignored but engaged, carefully, once a person has his or her hallucinations under control.

 

Underlying Needs

“By exploring a person’s anomalous beliefs and experiences, we are better able to understand the underlying feeling and needs that give fuel to these experiences,” said Paris Williams, a psychologist who has struggled with psychosis and recently published a doctoral dissertation analyzing the content of six people’s delusions, which has informed Mr. Greek’s work.

For instance, said Dr. Williams, who is working on a book called “Rethinking Madness,” “we can find ways to make them feel safe when they believe they are being persecuted by malevolent forces, or find ways to help them feel empowered when they experience demanding voices.”

One place Mr. Greek feels safe is in a clearing in the woods behind his house, where on a recent afternoon he disappeared wearing a tie-dyed shirt and old jeans with the knees worn completely through. He practices mindfulness meditation here, tuning in to the rhythms of life that usually pass unnoticed.

Back at home, he runs thoughts and perceptions by his wife. “He says things like, ‘Is that a marching band I’m hearing, or am I just hallucinating?’ ” she said. “I’ll say, ‘Uh no, I don’t hear a band, Milt,’ and he’s fine.”

And he visits a therapist when stress levels are running very high. The therapist has given him diagnoses of schizophrenia and “mood disorder, not otherwise specified,” according to his medical records, and she treats him in sessions and with an antipsychotic drug, adjusting the dosage up or down depending on his mood.

Since his mother’s death, Mr. Greek and his wife have taken several more emotional blows, with other close relatives dying. He has been especially stretched, between his work, various community projects, and traveling to speak, often to police groups about how to understand psychotic thinking when dealing with people on the street.

It was too much, and in August he visited his therapist again, and soon after made a deal with his wife. “She and I signed a contract identifying and limiting volunteer work I will do next year,” he said in an e-mail. “I am being coached on how to say no.”

The world is not yet saved from itself, nor for that matter is Athens. But even a messianic rescuer needs a day off, if only to come back stronger the next.

    Finding Purpose After Living With Delusion, NYT, 25.11.2011,
    http://www.nytimes.com/2011/11/26/health/
    man-uses-his-schizophrenia-to-gather-clues-for-daily-living.html

When Your Therapist Is Only a Click Away

September 23, 2011
The New York Times
By JAN HOFFMAN

THE event reminder on Melissa Weinblatt’s iPhone buzzed: 15 minutes till her shrink appointment.

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: “I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!”

And, she added, “I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session.”

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans’ health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.

One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: “Web Therapy,” the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.

“In three years, this will take off like a rocket,” said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. “Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can’t replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed.”

The pragmatic benefits are obvious. “No parking necessary!” touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?

Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day’s drive away. But he was willing to use Skype with long-distance patients. She was game.

Now she prefers these sessions to the old-fashioned kind.

But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?

“There’s that comfort of carrying your doctor around with you like a security blanket,” Ms. Weinblatt acknowledged. “But,” she added, “because he’s more accessible, I feel like I need him less.”

The technology does have its speed bumps. Online treatment upends a basic element of therapeutic connection: eye contact.

Patient and therapist typically look at each other’s faces on a computer screen. But in many setups, the camera is perched atop a monitor. Their gazes are then off-kilter.

“So patients can think you’re not looking them in the eye,” said Lynn Bufka, a staff psychologist with the American Psychological Association. “You need to acknowledge that upfront to the patient, or the provider has to be trained to look at the camera instead of the screen.”

The quirkiness of Internet connections can also be an impediment. “You have to prepare vulnerable people for the possibility that just when they are saying something that’s difficult, the screen can go blank,” said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. “So I always say, ‘I will never disconnect from you online on purpose.’ You make arrangements ahead of time to call each other if that happens.”

Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon. In the Wild Web West, one site sponsored a contest asking readers to post why they would seek therapy; the person with the most popular answer would receive six months of free treatment. When the blogosphere erupted with outrage from patients and professionals alike, the site quickly made the applications private.

Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof?

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? “A lot of patients start therapy and feel worse before they feel better,” noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. “It’s more complex than people imagine. A provider’s Web site may say, ‘I won’t deal with patients who are feeling suicidal.’ But it’s our job to assess patients, not to ask them to self-diagnose.” She practices online therapy, but advocates consumer protections and rigorous training of therapists.

Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression and obsessive-compulsive disorder. Some doctors suggest that Internet addiction or other addictive behaviors could be treated through videoconferencing.

Others disagree. As one doctor said, “If I’m treating an alcoholic, I can’t smell his breath over Skype.”

Cognitive behavioral therapy, which can require homework rather than tunneling into the patient’s past, seems another candidate. Tech-savvy teenagers resistant to office visits might brighten at seeing a therapist through a computer monitor in their bedroom. Home court advantage.

Therapists who have tried online therapy range from evangelizing standard-bearers, planting their stake in the new future, to those who, after a few sessions, have backed away. Elaine Ducharme, a psychologist in Glastonbury, Conn., uses Skype with patients from her former Florida practice, but finds it disconcerting when a patient’s face becomes pixilated. Dr. Ducharme, who is licensed in both states, will not videoconference with a patient she has not met in person. She flies to Florida every three months for office visits with her Skype patients.

“There is definitely something important about bearing witness,” she said. “There is so much that happens in a room that I can’t see on Skype.”

Dr. Heath Canfield, a psychiatrist in Colorado Springs, also uses Skype to continue therapy with some patients from his former West Coast practice. He is licensed in both locations. “If you’re doing therapy, pauses are important and telling, and Skype isn’t fast enough to keep up in real time,” Dr. Canfield said. He wears a headset. “I want patients to know that their sound isn’t going through walls but into my ears. I speak into a microphone so they don’t feel like I’m shouting at the computer. It’s not the same as being there, but it’s better than nothing. And I wouldn’t treat people this way who are severely mentally ill.”

Indeed, the pitfalls of videoconferencing with the severely mentally ill became apparent to Michael Terry, a psychiatric nurse practitioner, when he did psychological evaluations for patients throughout Alaska’s Eastern Aleutian Islands. “Once I was wearing a white jacket and the wall behind me was white,” recalled Dr. Terry, an associate clinical professor at the University of San Diego. “My face looked very dark because of the contrast, and the patient thought he was talking to the devil.”

Another time, lighting caused a halo effect. “An adolescent thought he was talking to the Holy Spirit, that he had God on the line. It fit right into his delusions.”

Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. “It creates this perverse lower version of intimacy,” she said. “Skype doesn’t therapeutically disinhibit patients so that they let down their guard and take emotional risks. I’ve decided not to do it anymore.”

Several studies have concluded that patient satisfaction with face-to-face interaction and online therapy (often preceded by in-person contact) was statistically similar. Lynn, a patient who prefers not to reveal her full identity, had been seeing her therapist for years. Their work deepened into psychoanalysis. Then her psychotherapist retired, moving out of state.

Now, four times a week, Lynn carries her laptop to an analyst’s unoccupied office (her insurance requires that a local provider have some oversight). She logs on to an encrypted program at Breakthrough.com and clicks through until she reads an alert: “Talk now!”

Hundreds of miles away, so does her analyst. Their faces loom, side by side on each other’s monitors. They say hello. Then Lynn puts her laptop on a chair and lies down on the couch. Just the top of her head is visible to her analyst.

Fifty minutes later the session ends. “The screen is asleep so I wake it up and see her face,” Lynn said. “I say goodbye and she says goodbye. Then we lean in to press a button and exit.”

As attenuated as this all may seem, Lynn said, “I’m just grateful we can continue to do this.”

This article has been revised to reflect the following correction:

Correction: September 24, 2011

A caption on a picture in an earlier version of this article

incorrectly described the technology used by Marlene M. Maheu

to communicate remotely with patients.

She uses video conferencing, not Skype.

    When Your Therapist Is Only a Click Away, NYT, 23.9.2011,
    http://www.nytimes.com/2011/09/25/fashion/therapists-are-seeing-patients-online.html

Maurice M. Rapport,

Who Studied Serotonin, Dies at 91

September 2, 2011
The New York Times
By WILLIAM GRIMES

Maurice M. Rapport, a biochemist who helped isolate and name the neurotransmitter serotonin, which plays a role in regulating mood and mental states, and who first described its molecular structure, a development that led to the creation of a wide variety of psychiatric and other drugs, died on Aug. 18 in Durham, N.C. He was 91.

The death was confirmed by his daughter, Erica Rapport Gringle.

In the 1940s Dr. Rapport (pronounced RA-port) was a freshly minted biochemist from the California Institute of Technology when he began working at the Cleveland Clinic Foundation with Irvine H. Page, a leading specialist on high blood pressure and cardiovascular disease.

Scientists had known since the 1860s of a substance in the serum released during clotting that constricts blood vessels by acting on the smooth muscles of the blood-vessel walls. In the 20th century, researchers pinpointed its source in blood platelets, but its identity remained a mystery.

Dr. Rapport, working with Dr. Page and Arda A. Green, isolated the substance and, in a paper published in 1948, gave it a name: serotonin, derived from “serum” and “tonic.”

On his own, Dr. Rapport identified the structure of serotonin as 5-hydroxytryptamine, or 5-HT, as it is called by pharmacologists. His findings, published in 1949, made it possible for commercial laboratories to synthesize serotonin and study its properties as a neurotransmitter.

More than 90,000 scientific papers have been published on 5-HT, and the Serotonin Club, a professional organization, regularly holds conferences to report on research in the field.

Initially, researchers focused on agents to block serotonin, which, by constricting blood vessels, causes blood pressure to rise. After researchers discovered its presence in the brain, and its chemical similarity to LSD, which mimics serotonin in the brain, they began focusing on serotonin’s role in regulating mood and mental functioning.

Further research showed that serotonin also plays a critical role in the central nervous system — where it helps regulate mood, appetite, sex and sleep — and the gut.

This new understanding of the structure and functioning of serotonin led to a changing view of mental disorders as chemical imbalances and opened the way to the development of antidepressants and antipsychotic drugs that act on 5-HT, as well as drugs for treating cardiovascular and gastrointestinal disease.

Maurice Rapoport was born on Sept. 23, 1919, in Atlantic City. His father, a furrier who had emigrated from Russia, left the family when Maurice was a small child. His mother changed the spelling of the family name and Maurice later adopted the middle initial “M,” although it did not stand for anything.

After graduating from DeWitt Clinton High School in the Bronx, he earned a bachelor’s degree in chemistry from City College in 1940 and a doctorate in organic chemistry from Cal Tech in 1946. For his work on serotonin he was awarded a Fulbright Scholarship in 1952 to study with Dr. Daniel Bovet, later a Nobel Prize winner for his work in pharmacology, at the Istituto Superiore di Sanità in Rome.

After doing research in biochemistry at Columbia, immunology at the Sloan-Kettering Institute for Cancer Research and biochemistry at the Albert Einstein College of Medicine, Dr. Rapport joined the staff of the New York Psychiatric Institute, where he created the division of neuroscience by combining the old divisions of chemistry, pharmacology and bacteriology. He also held the post of professor of biochemistry at Columbia’s College of Physicians and Surgeons.

Dr. Rapport retired in 1986 and was a visiting professor in the neurology department of the Albert Einstein College of Medicine until his death.

Dr. Rapport did important research on cancer, cardiovascular disease, connective-tissue disease and demyelinating diseases, a type of nervous-system disorder that includes multiple sclerosis.

One productive area of his research focused on the immunological activity of lipids found in the nervous system, notably cytolipin H, which he isolated from human cancer tissue in 1958. He also identified the lipid galactocerebroside as the substance responsible for producing antigens specific to the brain, a finding that led to a better understanding of the immune system.

Dr. Rapport’s wife, Edith, died in 1988. He lived in Hastings-on-Hudson with his longtime companion, Nancy Reich, who survives him, before failing health made it necessary for him to move in with his daughter, Erica, in Durham, in July. Other survivors are his son, Ezra, of Oakland, Calif.; five grandchildren; and a great-granddaughter.

    Maurice M. Rapport, Who Studied Serotonin, Dies at 91, NYT, 2.9.2011,
    http://www.nytimes.com/2011/09/03/health/03rapport.html

Some With Histories of Mental Illness

Petition to Get Their Gun Rights Back

July 2, 2011
The New York Times
By MICHAEL LUO

PULASKI, Va. — In May 2009, Sam French hit bottom, once again. A relative found him face down in his carport “talking gibberish,” according to court records. He later told medical personnel that he had been conversing with a bear in his backyard and hearing voices. His family figured he had gone off his medication for bipolar disorder, and a judge ordered him involuntarily committed — the fourth time in five years he had been hospitalized by court order.

When Mr. French’s daughter discovered that her father’s commitment meant it was illegal for him to have firearms, she and her husband removed his cache of 15 long guns and three handguns, and kept them after Mr. French was released in January 2010 on a new regime of mood-stabilizing drugs.

Ten months later, he appeared in General District Court — the body that handles small claims and traffic infractions — to ask a judge to restore his gun rights. After a brief hearing, in which Mr. French’s lengthy history of relapses never came up, he walked out with an order reinstating his right to possess firearms.

The next day, Mr. French retrieved his guns.

“The judge didn’t ask me a whole lot,” said Mr. French, now 62. “He just said: ‘How was I doing? Was I taking my medicine like I was supposed to?’ I said, ‘Yes, sir.’ ”

Across the country, states are increasingly allowing people like Mr. French, who lost their firearm rights because of mental illness, to petition to have them restored.

A handful of states have had such restoration laws on their books for some time, but with little notice, more than 20 states have passed similar measures since 2008. This surge can be traced to a law passed by Congress after the 2007 massacre at Virginia Tech that was actually meant to make it harder for people with mental illness to get guns.

As a condition of its support for the measure, the National Rifle Association extracted a concession: the inclusion of a mechanism for restoring firearms rights to those who lost them for mental health reasons.

The intent of these state laws is to enable people to regain the right to buy and possess firearms if it is determined that they are not a threat to public safety. But an examination of restoration procedures across the country, along with dozens of cases, shows that the process for making that determination is governed in many places by vague standards and few specific requirements.

States have mostly entrusted these decisions to judges, who are often ill-equipped to conduct investigations from the bench. Many seemed willing to simply give petitioners the benefit of the doubt. The results often seem haphazard.

At least a few hundred people with histories of mental health issues already get their gun rights back each year. The number promises to grow, since most of the new state laws are just beginning to take effect. And in November, the Department of Veterans Affairs responded to the federal legislation by establishing a rights restoration process for more than 100,000 veterans who have lost their gun privileges after being designated mentally incompetent by the agency.

The issue goes to the heart of the nation’s complicated relationship with guns, testing the delicate balance between the need to safeguard the public and the dictates of what the Supreme Court has proclaimed to be a fundamental constitutional right.

Mike Fleenor, the commonwealth’s attorney here in Pulaski County, whose office opposed restoring Mr. French’s rights, worries that the balance is being thrown off by weak standards.

“I think that reasonable people can disagree about issues of the Second Amendment and gun control and things like that, but I don’t believe that any reasonable person believes that a mentally ill person needs a firearm,” Mr. Fleenor said. “The public has a right to be safe in their community.”

In case after case examined by The New York Times, judges made decisions without important information about an applicant’s mental health.

Larry Lamb, a Vietnam veteran from San Diego who has suffered from depression and post-traumatic stress disorder, lost his gun rights and his cache of weapons in 2006 when he was involuntarily hospitalized after his dog’s death left him suicidal. A psychiatrist who examined Mr. Lamb wrote that he “is extremely paranoid with a full-blown P.T.S.D., believing that he is still at war in the active military and he is a personal bodyguard of the president and many senators.”

In early 2008, a Superior Court judge in San Diego granted Mr. Lamb’s petition to have his firearms rights restored, after his psychologist testified that he was not dangerous. But the judge, without access to Mr. Lamb’s full medical history, was unaware of a crucial fact: the local Veterans Affairs hospital had placed a “red flag” on Mr. Lamb, barring him from the hospital grounds because he was perceived to be a threat to personnel there.

The spread of these restoration laws is especially striking against the backdrop of the shooting of Representative Gabrielle Giffords of Arizona and others in Tucson early this year by a suspect who has been declared mentally incompetent to stand trial — a case that spotlighted anew the link between mental illness and violence.

Supporters of gun rights and mental health advocates point out that a vast majority of people with mental illness are not violent. At the same time, though, a variety of studies have found that people with serious mental illness are more prone to violence than the general population.

The difficulty of assessing risk emerges in places like Los Angeles, where the Superior Court conducts a relatively thorough review of firearms rights requests. The Times found multiple instances over the last decade in which people who won back their gun rights went on to be charged with or convicted of violent or gun-related crimes, including spousal battery, negligent discharge of a firearm or assault with a firearm.

Then there are the nightmare cases — like that of Ryan Anthony, 35, a former Emmy Award-winning animator at Disney who was involuntarily hospitalized in mid-2001 after losing his job and separating from his wife. Mr. Anthony filed a petition to get back his gun rights in early 2002, telling a court-appointed psychiatrist that he wanted to go skeet shooting.

A few weeks after the court granted his petition, Mr. Anthony bought a Remington 870 12-gauge shotgun, holed up in a Holiday Inn in Burbank, Calif., and committed suicide.

 

An N.R.A. Victory

The galvanizing revelation for gun-control advocates after the Virginia Tech massacre, the worst mass shooting in American history, was that the gunman, Seung-Hui Cho, should never have been able to buy the guns he used in the rampage.

Two years earlier, a special justice declared Mr. Cho “an imminent danger to himself as a result of mental illness” and ordered him to outpatient treatment.

Under federal law, anyone involuntarily committed or adjudicated a “mental defective” is barred from buying or possessing firearms. But the prohibition is often toothless because many states do not share their mental health records with the F.B.I.’s National Instant Criminal Background Check System.

Mr. Cho’s case offered Representative Carolyn McCarthy, Democrat of New York, a chance to advance a stalled bill that she had sponsored several years earlier to improve reporting by states to the F.B.I. database.

Ms. McCarthy’s political career and commitment to gun control was born out of tragedy. In 1993, a deranged gunman opened fire on a commuter train on Long Island, killing six people, including her husband, and gravely injuring her son. After more than a decade working on the issue in Congress, however, she had little to show for it.

Ms. McCarthy said she was wiser after years of setbacks. “I don’t believe in introducing legislation that won’t go anywhere,” she said.

She joined forces with Representative John D. Dingell, a Michigan Democrat and former N.R.A. board member, who acted as a liaison with the gun lobby. The N.R.A. had long been interested in gun-rights restoration. It also wanted to help tens of thousands of veterans who lost their rights after being designated mentally incompetent and unable to handle their finances by the Department of Veterans Affairs.

“We don’t want to treat our soldiers as potential criminals because they’re struggling with the aftermath of dealing with their service,” said Chris Cox, the association’s chief lobbyist.

The gun lobby secured a broad provision in the legislation. The new law made money available to states to help improve their record sharing, but the provision pushed by the N.R.A. made it a prerequisite for states to establish a “relief from disability” program for people with histories of mental health issues to apply for the restoration of gun rights. The Veterans Affairs Department and other federal agencies were required to do the same.

Gun-control groups attacked the provisions. “You make one bad judgment, and you could have another Virginia Tech on your hands,” Kristen Rand, legislative director for the Violence Policy Center, said in an interview.

But the most prominent gun-control organization, the Brady Campaign to Prevent Gun Violence, ultimately supported the bill. “She felt if she didn’t do this, it wasn’t going to proceed,” Paul Helmke, the group’s president, said of Ms. McCarthy. “An imperfect bill is better than no bill.”

Ms. McCarthy said her background as a nurse made her amenable to restoring someone’s rights, “if they could prove they are no longer mentally ill.”

After the bill became law in 2008, the N.R.A. began lobbying state lawmakers to keep requirements for petitioners to a minimum.

In Idaho, for example, a committee of law enforcement and mental health officials proposed requiring courts to make findings by “clear and convincing” evidence and mandating that petitioners have a recent mental health evaluation. But without the N.R.A.’s imprimatur, the legislation went nowhere.

Instead, a Republican state representative, Raúl R. Labrador, who is now a congressman, worked with the N.R.A. to draft a bill, passed last year, that dropped the requirement for a mental health evaluation and lowered the standard of proof to a “preponderance of evidence.”

A few states have set stricter standards. In New York, decisions are made by mental health officials, and applicants must submit a long list of documents, including five years’ worth of medical records and records of psychiatric and substance abuse treatment going back 20 years. State officials can also require applicants to undergo clinical evaluations and risk assessments.

So far, there has been only a trickle of petitions in states with new restoration laws. The statutes are not yet well known, and federal authorities have yet to certify many of the state programs, making them fully operational under federal law.

But the demand will almost certainly grow, given the experience of states with longer-standing restoration statutes. In California, for instance, judges restored gun rights to 180 people in 2010. At the federal level, the Veterans Affairs Department has already received more than 100 applications, of which 12 were processed and one was granted.

As for the original aim of Ms. McCarthy’s legislation, the reporting of mental health records by states to the F.B.I. database remains woeful. The reasons vary, including privacy laws, technological challenges and inattention from state officials.

But one significant hurdle has been that only a handful of states have received the federal money to improve their reporting capabilities. Officials with the Bureau of Justice Statistics indicated that while 22 states applied for grants in 2009 and 2010, only nine have gotten financing. Most of those that did not receive grants were rejected because they did not have certified restoration programs in place.

 

One State’s Experience

Lawmakers in Virginia, the scene of Mr. Cho’s rampage, were among the first to respond to the federal legislation by amending the state’s existing restoration statute to reflect the new law. To restore firearms rights, judges must find that the petitioner “will not likely act in a manner dangerous to public safety” and that “the granting of the relief would not be contrary to the public interest.” There are few specific standards or guidelines beyond that.

In 2010, judges in Virginia considered roughly 40 restoration applications and granted firearms rights under state law to 25 people — 14 who had been involuntarily committed, and 11 who had been the subjects of temporary detention orders and were voluntarily admitted for mental health treatment, according to figures from the Virginia Supreme Court and the State Police. In 2009, the courts restored rights to 21 people.

There is no central repository for cases heard around Virginia, but to get a picture of how the process works in one state, The Times obtained dozens of petitions and judges’ orders, mainly from 2009 and 2010, along with supporting documentation, and interviewed petitioners, lawyers and judges. The hearings were often relatively brief, sometimes perfunctory, and judges had wide latitude in handling the petitions.

Teresa Hall, who had moved to Idaho, said she simply wrote a letter to Hampton General District Court explaining that her commitment several years earlier occurred when she was experiencing marital difficulties. To her shock, she got a judge’s order granting her petition several days later in the mail.

“I was surprised it was that easy,” Ms. Hall said.

Some judges insisted on seeing a doctor’s note, but others did not.

In a typical case, Joshua St. Clair, who served in Iraq with the National Guard, got his gun rights back last year. About six months earlier, Mr. St. Clair, now 22, had heard a rattling at his gate. He said he “kind of blacked out” and the next thing he knew, he was pointing his M-4 assault rifle at his friend’s chest. That led to a temporary detention order, treatment for post-traumatic stress disorder and loss of his firearms rights.

He took a note from his psychiatrist to his restoration hearing, which he said “lasted maybe about five minutes,” but he said the judge did not even ask to see it. The judge asked Mr. St. Clair’s father a few questions and asked Mr. St. Clair himself whether he thought he should have his rights restored. He said, “Of course.”

Often the doctors’ recommendations came from general practitioners, not mental health professionals. The notes tended to be short, often just a few sentences.

In many cases, the hospitalizations occurred just a few months, or even weeks, earlier.

Bobby Bullion, 37, got his gun rights back about four months after he left a note for his wife and son that indicated he was considering suicide — his wife had told him she was divorcing him — and the police found him in his car with two loaded weapons. Mr. Bullion presented the judge with a letter from his psychiatrist endorsing the restoration.

Oran Greenway, 68, had his rights restored in August, just two months after he was involuntarily committed. The judge’s restoration shocked Mr. Greenway’s relatives, who said they had been worried for years about his mental stability. In an interview, he said he started taking Lexapro for depression several years ago. In 2005, he slammed a large branch on a neighbor’s head during an argument, resulting in a conviction for assault and battery.

“Knowing what I know about Oran, I wouldn’t let Oran have a gun,” said Elizabeth Dequino, a cousin who lives up the road.

Even when a court-ordered commitment occurred years ago, the wisdom of restoring certain petitioners’ firearms rights was open to question. David Neal Moon, 63, was involuntarily committed in 1995 after his struggles with schizoaffective bipolar disorder got so bad that he had threatened to commit suicide and was walking in circles around his house with a MAK-90 assault rifle, as if on guard duty, according to medical and court records and an interview with Cynthia Allison, who is now his ex-wife.

A psychiatrist’s report described him threatening to “bash in the face of his wife” and ranting about getting his guns so he could “shoot everybody.” It also mentions a violent hair-pulling episode with his wife.

He had not been committed since, but he had continued to struggle with his illness and was bad about taking his medication, Ms. Allison said.

In an interview, Mr. Moon insisted he took his medication and was not mentally ill. Yet he alluded to his phone being tapped by the State Police and “by maybe the Pentagon.”

His firearms hearing in early 2009 in Amherst General District Court, where Mr. Moon showed up in military camouflage, lasted “about eight minutes,” said Mr. Moon’s lawyer, Gregory Smith, adding that he did not recall presenting any recent medical evaluation.

Just over a month later, another judge granted Ms. Allison a protective order against her husband. The pair had split up, and Mr. Moon had been making veiled threats by phone and telling his children about demons in the walls, according to her court affidavit.

“The judge just sat there and listened to him talk,” Ms. Allison said. “I didn’t even say anything. If you listened to him talk, you could tell he’s as crazy as a bedbug.”

Among those whose applications were denied, many were turned down for technical reasons, like filing in the wrong jurisdiction or failing to show up for a hearing.

In others cases — like one last year in Lynchburg in which the petitioner, Undreas Smith, submitted a letter explaining he had been struggling with recent deaths in his family — the judge ruled against the petitioner because he failed to provide documentation from a mental health provider.

In the case of James Tuckson Jr. of Harrisonburg, who was involuntarily committed in 2006 and applied in October to get back his gun rights, prosecutors said his multiple arrests probably played a significant role in the judge’s decision to deny Mr. Tuckson’s petition.

Presented with The Times’s findings, Richard Bonnie, the chairman of the Virginia Commission on Mental Health Law Reform, which was formed after the Virginia Tech shootings, expressed concerns about the restoration process, particularly the vagueness of the statute. Mr. Bonnie said the panel would begin collecting information on the petitions on a monthly basis to better evaluate how they were being handled.

“There is an ambiguity in the statute that we need to look at,” he said.

 

‘A Hole in the Process’

When Sam French, the man with bipolar disorder whose daughter removed his guns, appeared late last year in Pulaski General District Court, he presented his recent medical records. Progress notes over several months showed that his bipolar disorder and substance abuse were in “remission.”

Nevertheless, Bobby Lilly, an assistant commonwealth’s attorney, opposed the petition, partly because Mr. French’s latest update indicated he had expressed interest in lowering the dosage of his medication. Mr. French’s two most recent hospitalizations had come after he went off his medication.

Mr. Lilly was also worried because it had been less than a year since his release. “We didn’t have a demonstrated track record of being able to comply with whatever the mental health provider’s directives were,” Mr. Lilly said.

In fact, a few months later, in March, a judge at the circuit level — the higher court in Virginia — denied Mr. French’s application for a concealed weapons permit because a five-year wait after a psychiatric commitment is required for such a permit.

But there is no waiting period for the restoration of basic gun rights.

Mr. French’s case fell to Judge Royce Glenwood Lookabill, a genial presence on the bench since 2006. Judge Lookabill said he quizzed Mr. French about whether he had had any other episodes and whether he was taking his prescribed drugs.

“I was satisfied that he wasn’t a danger — again, subject to him taking his medication,” Judge Lookabill said in an interview.

The judge acknowledged, however, that he might have made a different decision had he been aware of Mr. French’s previous commitments, including one that came after he was arrested for public drunkenness and later allegedly assaulted two police officers. (The assault charges were dropped.) No one had checked a state database for his commitment history.

“It’s a hole in the process,” said Mr. Lilly, who added that his office had only limited access to such information.

Judge Lookabill suggested that the process belonged in a higher court and should be made more adversarial. “I would feel a lot more comfortable,” he said, “if there were more safeguards.”

 

An Increased Risk

Most people with mental health issues, of course, will never be violent. But there is widespread consensus among scientists that the increased risk of violence among those with a serious mental illness — schizophrenia, major depression or bipolar disorder — is statistically significant. That risk rises when substance abuse, which is more prevalent among people with mental illness, is also present.

One frequently cited study, led by Jeffrey W. Swanson, an expert on mental health and violence who is now at Duke University, showed that 33 percent of people with a serious mental illness reported past violent behavior, compared with 15 percent of people without a major mental disorder. Violent behavior was defined as including acts ranging from taking part in more than one fistfight as an adult to using a weapon in a fight. The rate for those with substance abuse issues but without a serious mental illness was 55 percent. The highest rate, 64 percent, was exhibited by people with major mental disorders and substance abuse issues.

Other studies have concluded that additional factors significantly increase the risk of violence among people with mental illness, including exposure to violence and being a victim of violence.

But taking these data and applying them to individuals is profoundly difficult.

Scientists have concluded that it is most accurate to augment clinical judgments with an “actuarial” approach, in which variables like psychiatric diagnosis, history of violence and anger control are plugged into a risk assessment model. The models categorize people into higher and lower risk groups. But many clinicians are unfamiliar with the technique. Indeed, none of the doctors who wrote letters on behalf of their patients in cases The Times reviewed appeared to utilize the approach.

Doctors’ declarations clearly influenced judges. But most wrote their letters at the request of their patients, which Randy Otto, a former president of the American Board of Forensic Psychology and an associate professor at the University of South Florida, said can be problematic.

“They’re more subject to pressure from their patients to offer opinions that will help the patients get what they want,” Dr. Otto said.

He said many doctors, particularly those not in the mental health field, are probably not steeped in the most important clues to future violence. Even psychologists and psychiatrists, relying on their clinical judgment alone, are extremely unreliable in predicting violence, studies have shown.

“Unstructured clinical judgments, just judgments of mental health professionals about how risky someone is,” Dr. Otto said, “are probably the least reliable and the least accurate.”

 

Weighing the Threats

The difficulties of predicting violence are particularly striking in Los Angeles County, where the Superior Court has a relatively rigorous process for determining whether to restore gun rights.

In California, anyone placed on a 72-hour or 14-day psychiatric hold and determined to be a danger to themselves or others loses gun rights for five years. But upon discharge, the person can apply to have these prohibitions lifted. Applicants in Los Angeles County are required to provide records from all involuntary hospitalizations, which are checked against a list provided by the State Department of Justice. They must also be examined by a court-appointed psychiatrist, who can call friends or relatives to gather more information.

Under the statute, the burden is on the district attorney to establish that the petitioner “would not be likely to use firearms in a safe and lawful manner.”

Over all, 1,579 petitions have been filed in Los Angeles Superior Court since 2000. More than 1,000 were dismissed, usually because applicants did not furnish the required documentation or failed to show up. Of those who actually got hearings, 381 won their cases.

“Dealing with somebody who suffers from severe mental illness and mixing that with firearms, you really have to cross the t’s and dot the i’s,” said Richard J. Vagnozzi, a deputy district attorney who handles these cases. Mr. Vagnozzi said the process “isn’t perfect, but we do the best we can with the available data and what we’re allowed to do.”

Even with the vigorous checks, there are people like Afshin Poordavoud, who lost his gun rights in June 2000. During a heated argument with his brother, Mr. Poordavoud threatened to shoot himself. His brother called the police, and Mr. Poordavoud was hospitalized briefly, according to court records.

Several months later, Mr. Poordavoud petitioned to have his firearms rights restored and to have the police return his shotgun and 9-millimeter semiautomatic handgun. A court-appointed psychiatrist recommended that the decision be put off for three months and that Mr. Poordavoud get a full psychiatric evaluation and treatment, pointing out that the hospital had found him to be “likely depressed and minimizing his level of depression and suicidal risk.”

Mr. Poordavoud returned to court three months later with a letter from a therapist, indicating he had been undergoing treatment. This time, a different psychiatrist examined him but wrote at the end of his report, “Inconclusive: I have no opinion.” The psychiatrist suggested that the case be referred back to the initial doctor so she could interview Mr. Poordavoud’s therapist and obtain the full file from his hospitalization.

The judge, however, granted Mr. Poordavoud’s restoration request that same day in a pro forma hearing.

In late 2004, Mr. Poordavoud drove up to a house in Chatsworth, Calif., in the middle of the night and began banging on the windows and the doors, shouting for an acquaintance to come out, according to court testimony.

When a man opened the door, Mr. Poordavoud sprayed him and two others with mace, according to court testimony. In the ensuing fight, Mr. Poordavoud slashed at one of them with a pair of brass knuckles fitted with blades.

Mr. Poordavoud retrieved a gun from his car and fired a single shot that missed. In an interview, he said he had only fired in the air in self-defense.

The police eventually charged Mr. Poordavoud with multiple felonies. He pleaded guilty to assault with a deadly weapon and using tear gas not in self-defense, and he was sentenced to about a year in county jail.

“I had an anger problem,” said Mr. Poordavoud, who is no longer allowed to have guns because of his felony record. “I still have an anger problem.”

Violence against others is not the only concern.

Ryan Anthony, the talented but troubled Disney artist who had a history of alcoholism, had talked about suicide for years with relatives. His father, Michael Anthony, said his son once threatened to jump off a highway overpass; another time, he vowed to hang himself from a chandelier in his home. A few months before he filed his petition to restore his firearms rights, he had attempted suicide by swallowing some pills, said his brother Loren.

But Mr. Anthony was able to hide his troubled past when a court-appointed psychiatrist examined him for the restoration hearing in April 2002. He told Dr. Rose Pitt, according to court records, that he had simply been going through a difficult period after he lost his job and split up with his wife. He was normally not a drinker, he said, but began drinking heavily. Since his involuntary hospitalization in mid-2001, he had been sober and attending Alcoholics Anonymous meetings, Dr. Pitt wrote in her report.

“Does not own guns but wants to skeet shoot, and so wants to purchase guns,” Dr. Pitt wrote. “There does not appear to be any contraindication to his being able to get guns.”

His relatives were incredulous. Had they been called, they said, they would have told officials to deny his request.

“I would have said, ‘No, that doesn’t sound right,’ ” Loren Anthony said. “He didn’t like guns.”

Mr. Anthony had been staying with Steven and Sofia Shafit, family friends. They said he had been doing better but was still hurting.

About two weeks after he got his firearms rights restored, he borrowed $300 from Ms. Shafit, saying he wanted to take a girl on a date. Instead, he went out and bought a shotgun — investigators found the receipt by his body — and checked into a room at a Holiday Inn.

On the desk, he left a three-page suicide note, according to a report from the Los Angeles County coroner’s office. At some point, he lay down on the bed, placed the barrel of the shotgun in his mouth and pulled the trigger.

Toby Lyles, Lisa Schwartz and Jack Styczynski contributed research.

    Some With Histories of Mental Illness Petition to Get Their Gun Rights Back, NYT, 2.7.2011,
    http://www.nytimes.com/2011/07/03/us/03guns.html

Alfred Freedman, a Leader in Psychiatry, Dies at 94

April 20, 2011
The New York Times
By WILLIAM GRIMES

Dr. Alfred M. Freedman, a psychiatrist and social reformer who led the American Psychiatric Association in 1973 when, overturning a century-old policy, it declared that homosexuality was not a mental illness, died on Sunday in Manhattan. He was 94.

The cause was complications of surgery to treat a fractured hip, his son Dan said.

In 1972, with pressure mounting from gay rights groups and from an increasing number of psychiatrists to destigmatize homosexuality, Dr. Freedman was elected president of the association, which he later described as a conservative “old boys’ club.” Its 20,000 members were deeply divided about its policy on homosexuality, which its Diagnostic and Statistical Manual of Mental Disorders II classified as a “sexual deviation” in the same class as fetishism, voyeurism, pedophilia and exhibitionism.

Well known as the chairman of the department of psychiatry at New York Medical College and a strong proponent of community-oriented psychiatric and social services, Dr. Freedman was approached by a group of young reformers, the Committee of Concerned Psychiatrists, who persuaded him to run as a petition candidate for the presidency of the psychiatric association.

Dr. Freedman, much to his surprise, won what may have been the first contested election in the organization’s history — by 3 votes out of more than 9,000 cast. Immediately on taking office, he threw his support behind a resolution, drafted by Robert L. Spitzer of Columbia University, to remove homosexuality from the list of mental disorders.

On Dec. 15, 1973, the board of trustees, many of them newly elected younger psychiatrists, voted 13 to 0, with two abstentions, in favor of the resolution, which stated that “by itself, homosexuality does not meet the criteria for being a psychiatric disorder.”

It went on: “We will no longer insist on a label of sickness for individuals who insist that they are well and demonstrate no generalized impairment in social effectiveness.”

The board stopped short of declaring homosexuality “a normal variant of human sexuality,” as the association’s task force on nomenclature had recommended.

The recently formed National Gay Task Force (now the National Gay and Lesbian Task Force) hailed the resolution as “the greatest gay victory,” one that removed “the cornerstone of oppression for one-tenth of our population.” Among other things, the resolution helped reassure gay men and women in need of treatment for mental problems that doctors would not have any authorization to try to change their sexual orientation, or to identify homosexuality as the root cause of their difficulties.

An equally important companion resolution condemned discrimination against gays in such areas as housing and employment. In addition, it called on local, state and federal lawmakers to pass legislation guaranteeing gay citizens the same protections as other Americans, and to repeal all criminal statutes penalizing sex between consenting adults.

The resolution served as a model for professional and religious organizations that took similar positions in the years to come.

“It was a huge victory for a movement that in 1973 was young, small, very underfunded and had not yet had this kind of political validation,” said Sue Hyde, who organizes the annual conference of the National Gay and Lesbian Task Force. “It is the single most important event in the history of what would become the lesbian, gay, bisexual and transgender movement.”

In a 2007 interview Dr. Freedman said, “I felt at the time that that decision was the most important thing we accomplished.”

Alfred Mordecai Freedman was born on Jan. 7, 1917, in Albany. He won scholarships to study at Cornell, where he earned a bachelor’s degree in 1937. He earned a medical degree from the University of Minnesota in 1941 but cut short his internship at Harlem Hospital to enlist in the Army Air Corps.

During World War II he served as a laboratory officer in Miami and chief of laboratories at the Air Corps hospital in Gulfport, Miss. He left the corps with the rank of major.

After doing research on neuropsychology with Harold E. Himwich at Edgewood Arsenal in Maryland, he became interested in the development of human cognition. He underwent training in general and child psychiatry and began a residency at Bellevue Hospital in Manhattan, where he became a senior child psychiatrist.

He was the chief psychiatrist in the pediatrics department at the Downstate College of Medicine of the State University of New York for five years before becoming the first full-time chairman of the department of psychiatry at New York Medical College, then in East Harlem and now in Valhalla, N.Y.

In his 30 years at the college he built the department into an important teaching institution with a large residency program. He greatly expanded the psychiatric services offered at nearby Metropolitan Hospital, which is affiliated with the school and where he was director of psychiatry.

To address social problems in East Harlem, Dr. Freedman created a treatment program for adult drug addicts at the hospital in 1959 and the next year established a similar program for adolescents. These were among the earliest drug addiction programs to be conducted by a medical school and to be based in a general hospital. He also founded a division of social and community psychiatry at the school to serve neighborhood residents.

With Harold I. Kaplan, he edited “Comprehensive Textbook of Psychiatry,” which became adopted as a standard text on its publication in 1967 and is now in its ninth edition.

During his one-year term as president of the American Psychiatric Association, Dr. Freedman made the misuse of psychiatry in the Soviet Union one of the organization’s main issues. He challenged the Soviet government to answer charges that it routinely held political dissidents in psychiatric hospitals, and he led a delegation of American psychiatrists to the Soviet Union to visit mental hospitals and confer with Soviet psychiatrists.

After retiring from New York Medical College, Dr. Freedman turned his attention to the role that psychiatry played in death penalty cases. With his colleague Abraham L. Halpern, he lobbied the American Medical Association to enforce the provision in its code of ethics barring physicians from taking part in executions, and he campaigned against the practice of using psychopharmacologic drugs on psychotic death-row prisoners so that they could be declared competent to be executed.

In addition to his son Dan, of Silver Spring, Md., he is survived by his wife, Marcia; another son, Paul, of Pelham, N.Y.; and three grandchildren.

    Alfred Freedman, a Leader in Psychiatry, Dies at 94, NYT, 20.4.2011,
    http://www.nytimes.com/2011/04/21/health/21freedman.html

Talk Doesn’t Pay,

So Psychiatry Turns to Drug Therapy

March 5, 2011
The New York Times
By GARDINER HARRIS

DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.

“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.”

With thinning hair, a gray beard and rimless glasses, Dr. Levin looks every bit the psychiatrist pictured for decades in New Yorker cartoons. His office, just above Dog Daze Canine Hair Designs in this suburb of Philadelphia, has matching leather chairs, and African masks and a moose head on the wall. But there is no couch or daybed; Dr. Levin has neither the time nor the space for patients to lie down anymore.

On a recent day, a 50-year-old man visited Dr. Levin to get his prescriptions renewed, an encounter that took about 12 minutes.

Two years ago, the man developed rheumatoid arthritis and became severely depressed. His family doctor prescribed an antidepressant, to no effect. He went on medical leave from his job at an insurance company, withdrew to his basement and rarely ventured out.

“I became like a bear hibernating,” he said.

Missing the Intrigue

He looked for a psychiatrist who would provide talk therapy, write prescriptions if needed and accept his insurance. He found none. He settled on Dr. Levin, who persuaded him to get talk therapy from a psychologist and spent months adjusting a mix of medications that now includes different antidepressants and an antipsychotic. The man eventually returned to work and now goes out to movies and friends’ houses.

The man’s recovery has been gratifying for Dr. Levin, but the brevity of his appointments — like those of all of his patients — leaves him unfulfilled.

“I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.”

“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

When he started in psychiatry, Dr. Levin kept his own schedule in a spiral notebook and paid college students to spend four hours a month sending out bills. But in 1985, he started a series of jobs in hospitals and did not return to full-time private practice until 2000, when he and more than a dozen other psychiatrists with whom he had worked were shocked to learn that insurers would no longer pay what they had planned to charge for talk therapy.

“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group. To maintain their incomes, physicians often respond to fee cuts by increasing the volume of services they provide, but psychiatrists rarely earn enough to compensate for their additional training. Most would have been better off financially choosing other medical specialties.

Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house, 14 miles from Dr. Levin’s office. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

“Medication is important,” she said, “but it’s the relationship that gets people better.”

Dr. Levin’s initial efforts to get insurers to reimburse him and persuade his clients to make their co-payments were less than successful. His office assistants were so sympathetic to his tearful patients that they often failed to collect. So in 2004, he begged his wife, Laura Levin — a licensed talk therapist herself, as a social worker — to take over the business end of the practice.

Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment.

As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars. If patients say they cannot make the appointments she scheduled, Ms. Levin changes them.

“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”

She said that she would like to be more giving of herself, particularly to patients who are clearly troubled. But she has disciplined herself to confine her interactions to the business at hand. “The reality is that I’m not the therapist anymore,” she said, words that echoed her husband’s.

Drawing the Line

Ms. Levin, 63, maintains a lengthy waiting list, and many of the requests are heartbreaking. On a January day, a pregnant mother of a 3-year-old called to say that her husband was so depressed he could not rouse himself from bed. Could he have an immediate appointment? Dr. Levin’s first opening was a month away.

“I get a call like that every day, and I find it really distressing,” Ms. Levin said. “But do we work 12 hours every day instead of 11? At some point, you have to make a choice.”

Initial consultations are 45 minutes, while second and later visits are 15. In those first 45 minutes, Dr. Levin takes extensive medical, psychiatric and family histories. He was trained to allow patients to tell their stories in their own unhurried way with few interruptions, but now he asks a rapid-fire series of questions in something akin to a directed interview. Even so, patients sometimes fail to tell him their most important symptoms until the end of the allotted time.

“There was a guy who came in today, a 56-year-old man with a series of business failures who thinks he has A.D.D.,” or attention deficit disorder, Dr. Levin said. “So I go through the whole thing and ask a series of questions about A.D.D., and it’s not until the very end when he says, ‘On Oct. 28, I thought life was so bad, I was thinking about killing myself.’ ”

With that, Dr. Levin began to consider an entirely different diagnosis from the man’s pattern of symptoms: excessive worry, irritability, difficulty falling asleep, muscle tension in his back and shoulders, persistent financial woes, the early death of his father, the disorganization of his mother.

“The thread that runs throughout this guy’s life is anxiety, not A.D.D. — although anxiety can impair concentration,” said Dr. Levin, who prescribed an antidepressant that he hoped would moderate the man’s anxiety. And he pressed the patient to see a therapist, advice patients frequently ignore. The visit took 55 minutes, putting Dr. Levin behind schedule.

In 15-minute consultations, Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications.

“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”

Dr. Levin, wearing no-iron khakis, a button-down blue shirt with no tie, blue blazer and loafers, had a cheery greeting for his morning patients before ushering them into his office. Emerging 15 minutes later after each session, he would walk into Ms. Levin’s adjoining office to pick up the next chart, announce the name of the patient in the waiting room and usher that person into his office.

He paused at noon to spend 15 minutes eating an Asian chicken salad with Ramen noodles. He got halfway through the salad when an urgent call from a patient made him put down his fork, one of about 20 such calls he gets every day.

By afternoon, he had dispensed with the cheery greetings. At 6 p.m., his waiting room empty, Dr. Levin heaved a sigh after emerging from his office with his 39th patient. Then the bell on his entry door tinkled again, and another patient came up the stairs.

“Oh, I thought I was done,” Dr. Levin said, disappointed. Ms. Levin handed him the last patient’s chart.

Quick Decisions

The Levins said they did not know how long they could work 11-hour days. “And if the stock market hadn’t gone down two years ago, we probably wouldn’t be working this hard now,” Ms. Levin said.

Dr. Levin said that the quality of treatment he offers was poorer than when he was younger. For instance, he was trained to adopt an unhurried analytic calm during treatment sessions. “But my office is like a bus station now,” he said. “How can I have an analytic calm?”

And years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit. “You have to have a diagnosis to get paid,” he said with a shrug. “I play the game.”

In interviews, six of Dr. Levin’s patients — their identities, like those of the other patients, are being withheld to protect their privacy — said they liked him despite the brief visits. “I don’t need a half-hour or an hour to talk,” said a stone mason who has panic attacks and depression and is prescribed an antidepressant. “Just give me some medication, and that’s it. I’m O.K.”

Another patient, a licensed therapist who has post-partum depression worsened by several miscarriages, said she sees Dr. Levin every four weeks, which is as often as her insurer will pay for the visits. Dr. Levin has prescribed antidepressants as well as drugs to combat anxiety. She also sees a therapist, “and it’s really, really been helping me, especially with my anxiety,” she said.

She said she likes Dr. Levin and feels that he listens to her.

Dr. Levin expressed some astonishment that his patients admire him as much as they do.

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”

The Levins’s youngest son, Matthew, is now training to be a psychiatrist, and Dr. Donald Levin said he hoped that his son would not feel his ambivalence about their profession since he will not have experienced an era when psychiatrists lavished time on every patient. Before the 1920s, many psychiatrists were stuck in asylums treating confined patients covered in filth, so most of the 20th century was unusually good for the profession.

In a telephone interview from the University of California, Irvine, where he is completing the last of his training to become a child and adolescent psychiatrist, Dr. Matthew Levin said, “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”

    Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy, NYT, 5.3.2011,
    http://www.nytimes.com/2011/03/06/health/policy/06doctors.html

Clearing the Fog in Nursing Homes

February 15, 2011
11:10 am
The New York Times
By PAULA SPAN

The woman, who was in her 90s, had lived for several years at the Ecumen Sunrise nursing home in Two Harbors, Minn., where the staff had grown accustomed to her grimaces and wordless cries. She took a potent cocktail of three psychotropic drugs: Ativan for anxiety and the antipsychotic Risperdal to calm her, plus an antidepressant. In all the time she’d lived at Sunrise, she hadn’t spoken. It wasn’t clear whether she could recognize her children when they came to visit.

Belinda Day Saylor Eva Lanigan, right, director of nursing at the Ecumen nursing home in Two Harbors, Minn., with a resident, Marjorie Labrie, 94.The Two Harbors home happened to be where Ecumen, which operates 16 nonprofit Minnesota nursing homes, was preparing an experiment to see if behavioral rather than pharmacological approaches could help wean residents off antipsychotic medications. They called it the Awakenings program.

“What’s people’s biggest fear? Being a ‘zombie’ in a nursing home,” said Laurel Baxter, the Awakenings project manager.

Any visitor can see what she means. Even in quality nursing homes, some residents sit impassively in wheelchairs or nod off in front of televisions, apparently unable to interact with others or to summon much interest in their lives. Nursing home reformers and regulators have long believed that this disengagement results in part from the overuse of psychotropic medication to quell the troublesome behaviors that can accompany dementia — yelling, wandering, aggression, resisting care. For nearly 25 years, federal law has required that psychotropic drugs (which critics call “chemical restraints”) be used only when necessary to ensure the safety of a resident or those around her.


The drugs can cause serious side effects. Since 2008, the Food and Drug Administration has required a so-called black box warnings on their packaging, cautioning that they pose an increased mortality risk for elderly patients. Nevertheless, a national survey reported that in 2004 about a quarter of nursing home residents were receiving antipsychotic drugs. (Among the antipsychotic drugs most commonly used in nursing homes are Risperdal, Seroquel and Zyprexa.)

Though they may be prescribed less frequently following the F.D.A.’s warnings, these drugs are still overused in long-term care, said Dr. Mark Lachs, chief of geriatrics at Weill Cornell Medical College. And once the pills are prescribed, residents keep taking them. “They get perpetualized, like insulin,” he told me, even though the behaviors they’re meant to soothe may wane anyway as dementia progresses.

“If a place is understaffed, if it takes particularly unruly patients, you can see how it happens,” Dr. Lachs added. “Behavioral interventions are far more time-consuming than giving a pill.”

Nevertheless, Ecumen’s Awakenings project emphasizes nondrug responses. “Medications have a place, but that shouldn’t be the first thing you try,” said Eva Lanigan, director of nursing at the Two Harbors facility.

So the home trained its entire staff (housekeepers, cooks, dining room servers, everyone) in a variety of tools to calm and reassure its 55 residents: exercise, activities, music, massage, aromatherapy. It taught people the kind of conversation known as “redirecting” — listening to elders and responding to them without insisting on facts that those with dementia can’t absorb or won’t recall.

“The hands-on, caring part is the most important,” Ms. Lanigan said. “Sometimes, people just want a hug. You sit and hold their hand.”

At the same time, consulting with a geriatric psychiatrist and a pharmacist, the home began gradually reducing the doses of antipsychotics and antidepressants for patients whose families agreed. Among them: the woman with the mysterious cries.

As Dr. Lachs pointed out, behavioral interventions are labor-intensive. Two Harbors hired an additional nurse to oversee those efforts, and Ms. Lanigan was available to answer staff questions around the clock. Ecumen estimates that introducing the program to a 60-bed nursing home cost an additional $75,000 a year for two full-time employees.

The results startled even the believers, however. Every resident on antipsychotics (about 10) was able to stop taking them, and 30 to 50 percent of those taking antidepressants also did well without them. When drugs still seemed necessary, “we tried to reduce them to the lowest dose possible,” Ms. Lanigan said.

Encouraged, Ecumen has introduced the Awakenings program to its 15 other nursing homes, using a $3.8 million, three-year grant from the state of Minnesota. “I believe we may learn that spending a little time now with a resident, preventing the use of psychiatric medications and their side effects, you’ll save time and money in the long run,” said Ms. Baxter, the project manager. “I’m optimistic.”

Of course, you can’t tell how well nondrug approaches work based on one facility’s outcomes. “We know how to reduce behavior problems and mood issues in controlled clinical trials,” said Kimberly Van Haitsma, a senior research scientist at the Polisher Research Institute in Philadelphia. “The actual nuts and bolts of how do you do this and keep it in place — over not weeks or months, but years — is a question the field is struggling with.” Turnover among both staff and residents is high in nursing homes, she pointed out.

But with reduced medications, the woman at the Two Harbors home did seem to awaken. She was able to speak — haltingly and not always understandably, but enough to communicate. And what she let Ms. Lanigan know, after years of being virtually nonverbal, was that she was suffering physical pain, the cause of her crying out.

It took doctors a while to find effective medications for her nerve condition, but they were eventually able to make her more comfortable without further fogging her mind. She stopped taking psychotropic drugs altogether.

None of this can halt dementia; it’s a terminal disease, and it took this resident’s life last year. But in her final months, she smiled and played balloon volleyball with other residents and could say she felt fine or was hungry.

“She engaged more. Her family came to help her eat,” Ms. Lanigan said. “It was a big change.”

Paula Span is the author of “When the Time Comes:

Families With Aging Parents Share Their Struggles and Solutions.”

    Clearing the Fog in Nursing Homes, NYT, 15.2.2011,
    http://newoldage.blogs.nytimes.com/2011/02/15/clearing-the-fog-in-nursing-homes/

Getting Someone to Psychiatric Treatment

Can Be Difficult and Inconclusive

January 18, 2011
The New York Times
By A. G. SULZBERGER and BENEDICT CAREY

TUCSON —What are you supposed to do with someone like Jared L. Loughner?

That question is as difficult to answer today as it was in the years and months and days leading up to the shooting here that left 6 dead and 13 wounded.

Millions of Americans have wondered about a troubled loved one, friend or co-worker, fearing not so much an act of violence, but — far more likely — self-inflicted harm, landing in the streets, in jail or on suicide watch. But those in a position to help often struggle with how to distinguish ominous behavior from the merely odd, the red flags from the red herrings.

In Mr. Loughner’s case there is no evidence that he ever received a formal diagnosis of mental illness, let alone treatment. Yet many psychiatrists say that the warning sings of a descent into psychosis were there for months, and perhaps far longer.

Moving a person who is resistant into treatment is an emotional, sometimes exhausting process that in the end may not lead to real changes in behavior. Mental health resources are scarce in most states, laws make it difficult to commit an adult involuntarily, and even after receiving treatment, patients frequently stop taking their medication or seeing a therapist, believing that they are no longer ill.

The Virginia Tech gunman was committed involuntarily before killing 32 people in a 2007 rampage.

With Mr. Loughner, dozens of people apparently saw warning signs: the classmates who listened as his dogmatic language grew more detached from reality. The police officers who nervously advised that he could not return to college without a medical note stating that he was not dangerous. His father, who chased him into the desert hours before the attack as Mr. Loughner carried a black bag full of ammunition.

“This isn’t an isolated incident,” said Daniel J. Ranieri, president of La Frontera Center, a nonprofit group that provides mental health services. “There are lots of people who are operating on the fringes who I would describe as pretty combustible. And most of them aren’t known to the mental health system.”

Dr. Jack McClellan, an adult and child psychiatrist at the University of Washington, said he advises people who are worried that someone is struggling with a mental disorder to watch for three things — a sudden change in personality, in thought processes, or in daily living. “This is not about whether someone is acting bizarrely; many people, especially young people, experiment with all sorts of strange beliefs and counterculture ideas,” Dr. McLellan said. “We’re talking about a real change. Is this the same person you knew three months ago?”

Those who have watched the mental unraveling of a loved one say that recognizing the signs is only the first step in an emotional, often confusing, process. About half of people with mental illnesses do not receive treatment, experts estimate, in part because many of them do not recognize that they even have an illness.

Pushing such a person into treatment is legally difficult in most states, especially when he or she is an adult — and the attempt itself can shatter the trust between a troubled soul and the one who is most desperate to help. Others, though, later express gratitude.

“If the reason is love, don’t worry if they’ll be mad at you,” said Robbie Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily committed when his increasingly erratic behavior led to a suicide attempt. At the time, he said, he was living in Phoenix with his parents, who he was convinced were trying to kill him. In Arizona it is easier to obtain an involuntary commitment than in many states because anyone can request an evaluation if they observe behavior that suggests a person may present a danger or is severely disabled (often state laws require some evidence of imminent danger to self or others).

But there are also questions about whether the system can accommodate an influx of new patients. Arizona’s mental health system has been badly strained by recent budget cuts that left those without Medicaid stripped of most of their services, including counseling and residential treatment, though eligibility remains for emergency services like involuntary commitment. And the state is trying to change eligibility requirements for Medicaid, which would potentially reduce financing further and leave more with limited services.

Still, people who have been through the experience argue that it is better to act sooner rather than later. “It’s not easy to know when we could or should intervene but I would rather err on the side of safety than not,” said H. Clarke Romans, executive director of the local chapter of the National Alliance on Mental Illness, an advocacy group, who had a son with schizophrenia.

The collective failure to move Mr. Loughner into treatment, either voluntarily or not, will never be fully understood, because those who knew the young man presumably wrestled separately and privately about whether to take action. But the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of Pima County told CNN last Wednesday that Mr. Loughner’s parents were as shocked as everyone else. “It’s been very, very devastating for them,” he said. “They had absolutely no way to predict this kind of behavior.”

Linda Rosenberg, president of the National Council for Community Behavioral Healthcare, said, “The failure here is that we ignored someone for a long time who was clearly in tremendous distress.” Ms. Rosenberg, whose group is a nonprofit agency leading a campaign to teach people how to recognize and respond to signs of mental illness, added, “He wasn’t someone who could ask for help because his thinking was affected, and as a community no one said, let’s stop and make sure he gets help.”

At the University of Arizona, where a nursing student killed three instructors on campus eight years ago before killing himself, feelings of sadness and anger initially mixed with some guilt as the university examined the missed warning signs.

The overhauled process for addressing concerns is now more responsive, even if there are sometimes false alarms, said Melissa M. Vito, vice president for student affairs. “I guess I’d rather explain why I called someone’s parents than why I didn’t do something,” she said.

Many others feel the same way.

Four years ago Susan Junck watched her 18-year-old son return from community college to their Phoenix home one afternoon and, after preparing a snack, repeatedly call the police to accuse his mother of poisoning him. She assumed it was an isolated outburst, maybe connected to his marijuana use. In the coming months, though, her son’s behavior grew more alarming, culminating in an arrest for assaulting his girlfriend, who was at the center of a number of his conspiracy theories.

“I knew something was wrong but I literally just did not understand what,” Ms. Junck, 49, said in a recent interview. “It probably took a year before I realized my son has a mental illness. This isn’t drug related, this isn’t bad behavior, this isn’t teenage stuff. This is a serious mental illness.”

Fearful and desperate, she brought her son to an urgent psychiatric center and — after a five-hour wait — agreed to sign paperwork to have him involuntarily committed as a danger to himself or others. Her son screamed for her help as he was carried off. He was diagnosed with paranoid schizophrenia and remains in a residential treatment facility.

This week Erin Adams Goldman, a suicide prevention specialist with a mental health nonprofit organization in Tucson, is teaching the first local installment of a course that is being promoted around the country called mental health first aid, which instructs participants how to recognize and respond to the signs of mental illness.

A central tenet is that if a person has suspicions about mental illness it is better to open the conversation, either by approaching the individual directly, someone else who knows the person well or by asking for a professional evaluation.

“There is so much fear and mystery around mental illness that people are not even aware of how to recognize it and what to do about it,” Ms. Goldman said. “But we get a feeling when something is not right. And what we teach is to follow your gut and take some action.”


A. G. Sulzberger reported from Tucson,

and Benedict Carey from New York.

    Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive, NYT, 18.1.2011,
    http://www.nytimes.com/2011/01/19/us/19mental.html

Revising Book on Disorders of the Mind

February 10, 2010
The New York Times
By BENEDICT CAREY

Far fewer children would get a diagnosis of bipolar disorder. “Binge eating disorder” and “hypersexuality” might become part of the everyday language. And the way many mental disorders are diagnosed and treated would be sharply revised.

These are a few of the changes proposed on Tuesday by doctors charged with revising psychiatry’s encyclopedia of mental disorders, the guidebook that largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction — and, by extension, when and how patients should be treated.

The eagerly awaited revisions — to be published, if adopted, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, due in 2013 — would be the first in a decade.

For months they have been the subject of intense speculation and lobbying by advocacy groups, and some proposed changes have already been widely discussed — including folding the diagnosis of Asperger’s syndrome into a broader category, autism spectrum disorder.

But others, including a proposed alternative for bipolar disorder in many children, were unveiled on Tuesday. Experts said the recommendations, posted online at DSM5.org for public comment, could bring rapid change in several areas.

“Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled,” said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth.

“And it has huge implications for stigma,” Dr. First continued, “because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”

One significant change would be adding a childhood disorder called temper dysregulation disorder with dysphoria, a recommendation that grew out of recent findings that many wildly aggressive, irritable children who have been given a diagnosis of bipolar disorder do not have it.

The misdiagnosis led many children to be given powerful antipsychotic drugs, which have serious side effects, including metabolic changes.

“The treatment of bipolar disorder is meds first, meds second and meds third,” said Dr. Jack McClellan, a psychiatrist at the University of Washington who is not working on the manual. “Whereas if these kids have a behavior disorder, then behavioral treatment should be considered the primary treatment.”

Some diagnoses of bipolar disorder have been in children as young as 2, and there have been widespread reports that doctors promoting the diagnosis received consulting and speaking fees from the makers of the drugs.

In a conference call on Tuesday, Dr. David Shaffer, a child psychiatrist at Columbia, said he and his colleagues on the panel working on the manual “wanted to come up with a diagnosis that captures the behavioral disturbance and mood upset, and hope the people contemplating a diagnosis of bipolar for these patients would think again.”

Experts gave the American Psychiatric Association, which publishes the manual, predictably mixed reviews. Some were relieved that the task force working on the manual — which includes neurologists and psychologists as well as psychiatrists — had revised the previous version rather than trying to rewrite it.

Others criticized the authors, saying many diagnoses in the manual would still lack a rigorous scientific basis.

The good news, said Edward Shorter, a historian of psychiatry who has been critical of the manual, is that most patients will be spared the confusion of a changed diagnosis. But “the bad news,” he added, “is that the scientific status of the main diseases in previous editions of the D.S.M. — the keystones of the vault of psychiatry — is fragile.”

To more completely characterize all patients, the authors propose using measures of severity, from mild to severe, and ratings of symptoms, like anxiety, that are found as often with personality disorders as with depression.

“In the current version of the manual, people either meet the threshold by having a certain number of symptoms, or they don’t,” said Dr. Darrel A. Regier, the psychiatric association’s research director and, with Dr. David J. Kupfer of the University of Pittsburgh, the co-chairman of the task force. “But often that doesn’t fit reality. Someone with schizophrenia might have symptoms of insomnia, of anxiety; these aren’t the diagnostic criteria for schizophrenia, but they affect the patient’s life, and we’d like to have a standard way of measuring them.”

In a conference call on Tuesday, Dr. Regier, Dr. Kupfer and several other members of the task force outlined their favored revisions. The task force favored making semantic changes that some psychiatrists have long argued for, trading the term “mental retardation” for “intellectual disability,” for instance, and “substance abuse” for “addiction.”

One of the most controversial proposals was to identify “risk syndromes,” that is, a risk of developing a disorder like schizophrenia or dementia. Studies of teenagers identified as at high risk of developing psychosis, for instance, find that 70 percent or more in fact do not come down with the disorder.

“I completely understand the idea of trying to catch something early,” Dr. First said, “but there’s a huge potential that many unusual, semi-deviant, creative kids could fall under this umbrella and carry this label for the rest of their lives.”

Dr. William T. Carpenter, a psychiatrist at the University of Maryland and part of the group proposing the idea, said it needed more testing. “Concerns about stigma and excessive treatment must be there,” he said. “But keep in mind that these are individuals seeking help, who have distress, and the question is, What’s wrong with them?”

The panel proposed adding several disorders with a high likelihood of entering the pop vernacular. One, a new description of sex addiction, is “hypersexuality,” which, in part, is when “a great deal of time is consumed by sexual fantasies and urges; and in planning for and engaging in sexual behavior.”

Another is “binge eating disorder,” defined as at least one binge a week for three months — eating platefuls of food, fast, and to the point of discomfort — accompanied by severe guilt and plunges in mood.

“This is not the normative overeating that we all do, by any means,” said Dr. B. Timothy Walsh, a psychiatrist at Columbia and the New York State Psychiatric Institute who is working on the manual. “It involves much more loss of control, more distress, deeper feelings of guilt and unhappiness.”

    Revising Book on Disorders of the Mind, NYT, 11.2.2010
    http://www.nytimes.com/2010/02/10/health/10psych.html

Poll Reveals Depth and Trauma

of Joblessness in U.S.

December 15, 2009
The New York Times
By MICHAEL LUO and MEGAN THEE-BRENAN

More than half of the nation’s unemployed workers have borrowed money from friends or relatives since losing their jobs. An equal number have cut back on doctor visits or medical treatments because they are out of work.

Almost half have suffered from depression or anxiety. About 4 in 10 parents have noticed behavioral changes in their children that they attribute to their difficulties in finding work.

Joblessness has wreaked financial and emotional havoc on the lives of many of those out of work, according to a New York Times/CBS News poll of unemployed adults, causing major life changes, mental health issues and trouble maintaining even basic necessities.

The results of the poll, which surveyed 708 unemployed adults from Dec. 5 to Dec. 10 and has a margin of sampling error of plus or minus four percentage points, help to lay bare the depth of the trauma experienced by millions across the country who are out of work as the jobless rate hovers at 10 percent and, in particular, as the ranks of the long-term unemployed soar.

Roughly half of the respondents described the recession as a hardship that had caused fundamental changes in their lives. Generally, those who have been out of work longer reported experiencing more acute financial and emotional effects.

“I lost my job in March, and from there on, everything went downhill,” said Vicky Newton, 38, of Mount Pleasant, Mich., a single mother who had been a customer-service representative in an insurance agency.

“After struggling and struggling and not being able to pay my house payments or my other bills, I finally sucked up my pride,” she said in an interview after the poll was conducted. “I got food stamps just to help feed my daughter.”

Over the summer, she abandoned her home in Flint, Mich., after she started receiving foreclosure notices. She now lives 90 minutes away, in a rental house owned by her father.

With unemployment driving foreclosures nationwide, a quarter of those polled said they had either lost their home or been threatened with foreclosure or eviction for not paying their mortgage or rent. About a quarter, like Ms. Newton, have received food stamps. More than half said they had cut back on both luxuries and necessities in their spending. Seven in 10 rated their family’s financial situation as fairly bad or very bad.

But the impact on their lives was not limited to the difficulty in paying bills. Almost half said unemployment had led to more conflicts or arguments with family members and friends; 55 percent have suffered from insomnia.

“Everything gets touched,” said Colleen Klemm, 51, of North Lake, Wis., who lost her job as a manager at a landscaping company last November. “All your relationships are touched by it. You’re never your normal happy-go-lucky person. Your countenance, your self-esteem goes. You think, ‘I’m not employable.’ ”

A quarter of those who experienced anxiety or depression said they had gone to see a mental health professional. Women were significantly more likely than men to acknowledge emotional issues.

Tammy Linville, 29, of Louisville, Ky., said she lost her job as a clerical worker for the Census Bureau a year and a half ago. She began seeing a therapist for depression every week through Medicaid but recently has not been able to go because her car broke down and she cannot afford to fix it.

Her partner works at the Ford plant in the area, but his schedule has been sporadic. They have two small children and at this point, she said, they are “saving quarters for diapers.”

“Every time I think about money, I shut down because there is none,” Ms. Linville said. “I get major panic attacks. I just don’t know what we’re going to do.”

Nearly half of the adults surveyed admitted to feeling embarrassed or ashamed most of the time or sometimes as a result of being out of work. Perhaps unsurprisingly, given the traditional image of men as breadwinners, men were significantly more likely than women to report feeling ashamed most of the time.

There was a pervasive sense from the poll that the American dream had been upended for many. Nearly half of those polled said they felt in danger of falling out of their social class, with those out of work six months or more feeling especially vulnerable. Working-class respondents felt at risk in the greatest numbers.

Nearly half of respondents said they did not have health insurance, with the vast majority citing job loss as a reason, a notable finding given the tug of war in Congress over a health care overhaul. The poll offered a glimpse of the potential ripple effect of having no coverage. More than half characterized the cost of basic medical care as a hardship.

Many in the ranks of the unemployed appear to be rethinking their career and life choices. Just over 40 percent said they had moved or considered moving to another part of the state or country where there were more jobs. More than two-thirds of respondents had considered changing their career or field, and 44 percent of those surveyed had pursued job retraining or other educational opportunities.

Joe Whitlow, 31, of Nashville, worked as a mechanic until a repair shop he was running with a friend finally petered out in August. He had contemplated going back to school before, but the potential loss in income always deterred him. Now he is enrolled at a local community college, planning to study accounting.

“When everything went bad, not that I didn’t have a choice, but it made the choice easier,” Mr. Whitlow said.

The poll also shed light on the formal and informal safety nets that the jobless have relied upon. More than half said they were receiving or had received unemployment benefits. But 61 percent of those receiving benefits said the amount was not enough to cover basic necessities.

Meanwhile, a fifth said they had received food from a nonprofit organization or religious institution. Among those with a working spouse, half said their spouse had taken on additional hours or another job to help make ends meet.

Even those who have stayed employed have not escaped the recession’s bite. According to a New York Times/CBS News nationwide poll conducted at the same time as the poll of unemployed adults, about 3 in 10 people said that in the past year, as a result of bad economic conditions, their pay had been cut.

In terms of casting blame for the high unemployment rate, 26 percent of unemployed adults cited former President George W. Bush; 12 percent pointed the finger at banks; 8 percent highlighted jobs going overseas and the same number blamed politicians. Only 3 percent blamed President Obama.

Those out of work were split, however, on the president’s handling of job creation, with 47 percent expressing approval and 44 percent disapproval.

Unemployed Americans are divided over what the future holds for the job market: 39 percent anticipate improvement, 36 percent expect it will stay the same, and 22 percent say it will get worse.

Marina Stefan and Dalia Sussman contributed reporting.

    Poll Reveals Depth and Trauma of Joblessness in U.S., NYT, 15.12.2009,
    http://www.nytimes.com/2009/12/15/us/15poll.html

Poor Children Likelier to Get Antipsychotics

December 12, 2009
The New York Times
By DUFF WILSON

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?

The questions go beyond the psychological impact on Medicaid children, serious as that may be. Antipsychotic drugs can also have severe physical side effects, causing drastic weight gain and metabolic changes resulting in lifelong physical problems.

On Tuesday, a pediatric advisory committee to the Food and Drug Administration met to discuss the health risks for all children who take antipsychotics. The panel will consider recommending new label warnings for the drugs, which are now used by an estimated 300,000 people under age 18 in this country, counting both Medicaid patients and those with private insurance.

Meanwhile, a group of Medicaid medical directors from 16 states, under a project they call Too Many, Too Much, Too Young, has been experimenting with ways to reduce prescriptions of antipsychotic drugs among Medicaid children.

They plan to publish a report early next year.

The Rutgers-Columbia study will also be published early next year, in the peer-reviewed journal Health Affairs. But the findings have already been posted on the Web, setting off discussion among experts who treat and study troubled young people.

Some experts say they are stunned by the disparity in prescribing patterns. But others say it reinforces previous indications, and their own experience, that children with diagnoses of mental or emotional problems in low-income families are more likely to be given drugs than receive family counseling or psychotherapy.

Part of the reason is insurance reimbursements, as Medicaid often pays much less for counseling and therapy than private insurers do. Part of it may have to do with the challenges that families in poverty may have in consistently attending counseling or therapy sessions, even when such help is available.

“It’s easier for patients, and it’s easier for docs,” said Dr. Derek H. Suite, a psychiatrist in the Bronx whose pediatric cases include children and adolescents covered by Medicaid and who sometimes prescribes antipsychotics. “But the question is, ‘What are you prescribing it for?’ That’s where it gets a little fuzzy.”

Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors have given antipsychotics that the patients do not seem to need. Recently, for example, he met with a 15-year-old girl. She had stopped taking the antipsychotic medication that had been prescribed for her after a single examination, paid for by Medicaid, at a clinic where she received a diagnosis of bipolar disorder.

Why did she stop? Dr. Suite asked. “I can control my moods,” the girl said softly.

After evaluating her, Dr. Suite decided she was right. The girl had arguments with her mother and stepfather and some insomnia. But she was a good student and certainly not bipolar, in Dr. Suite’s opinion.

“Normal teenager,” Dr. Suite said, nodding. “No scrips for you.”

Because there can be long waits to see the psychiatrists accepting Medicaid, it is often a pediatrician or family doctor who prescribes an antipsychotic to a Medicaid patient — whether because the parent wants it or the doctor believes there are few other options.

Some experts even say Medicaid may provide better care for children than many covered by private insurance because the drugs — which can cost $400 a month — are provided free to patients, and families do not have to worry about the co-payments and other insurance restrictions.

“Maybe Medicaid kids are getting better treatment,” said Dr. Gabrielle Carlson, a child psychiatrist and professor at the Stony Brook School of Medicine. “If it helps keep them in school, maybe it’s not so bad.”

In any case, as Congress works on health care legislation that could expand the nation’s Medicaid rolls by 15 million people — a 43 percent increase — the scope of the antipsychotics problem, and the expense, could grow in coming years.

Even though the drugs are typically cheaper than long-term therapy, they are the single biggest drug expenditure for Medicaid, costing the program $7.9 billion in 2006, the most recent year for which the data is available.

The Rutgers-Columbia research, based on millions of Medicaid and private insurance claims, is the most extensive analysis of its type yet on children’s antipsychotic drug use. It examined records for children in seven big states — including New York, Texas and California — selected to be representative of the nation’s Medicaid population, for the years 2001 and 2004.

The data indicated that more than 4 percent of patients ages 6 to 17 in Medicaid fee-for-service programs received antipsychotic drugs, compared with less than 1 percent of privately insured children and adolescents. More recent data through 2007 indicates that the disparity has remained, said Stephen Crystal, a Rutgers professor who led the study. Experts generally agree that some characteristics of the Medicaid population may contribute to psychological problems or psychiatric disorders. They include the stresses of poverty, single-parent homes, poorer schools, lack of access to preventive care and the fact that the Medicaid rolls include many adults who are themselves mentally ill.

As a result, studies have found that children in low-income families may have a higher rate of mental health problems — perhaps two to one — compared with children in better-off families. But that still does not explain the four-to-one disparity in prescribing antipsychotics.

Professor Crystal, who is the director of the Center for Pharmacotherapy at Rutgers, says his team’s data also indicates that poorer children are more likely to receive antipsychotics for less serious conditions than would typically prompt a prescription for a middle-class child.

But Professor Crystal said he did not have clear evidence to form an opinion on whether or not children on Medicaid were being overtreated.

“Medicaid kids are subject to a lot of stresses that lead to behavior issues which can be hard to distinguish from more serious psychiatric conditions,” he said. “It’s very hard to pin down.”

And yet Dr. Mark Olfson, a psychiatry professor at Columbia and a co-author of the study, said at least one thing was clear: “A lot of these kids are not getting other mental health services.”

The F.D.A. has approved antipsychotic drugs for children specifically to treat schizophrenia, autism and bipolar disorder. But they are more frequently prescribed to children for other, less extreme conditions, including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders — especially when the children are covered by Medicaid, the new study shows.

Although doctors may legally prescribe the drugs for these “off label” uses, there have been no long-term studies of their effects when used for such conditions.

The Rutgers-Columbia study found that Medicaid children were more likely than those with private insurance to be given the drugs for off-label uses like A.D.H.D. and conduct disorders. The privately insured children, in turn, were more likely than their Medicaid counterparts to receive the drugs for F.D.A.-approved uses like bipolar disorder.

Even if parents enrolled in Medicaid may be reluctant to put their children on drugs, some come to rely on them as the only thing that helps.

“They say it’s impossible to stop now,” Evelyn Torres, 48, of the Bronx, said of her son’s use of antipsychotics since he received a diagnosis of bipolar disorder at age 3. Seven years later, the boy is now also afflicted with weight and heart problems. But Ms. Torres credits Medicaid for making the boy’s mental and physical conditions manageable. “They’re helping with everything,” she said.

    Poor Children Likelier to Get Antipsychotics, NYT, 12.12.2009,
    http://www.nytimes.com/2009/12/12/health/12medicaid.html

Brain Power

Surgery for Mental Ills Offers Hope and Risk

November 27, 2009
The New York Times
By BENEDICT CAREY

One was a middle-aged man who refused to get into the shower. The other was a teenager who was afraid to get out.

The man, Leonard, a writer living outside Chicago, found himself completely unable to wash himself or brush his teeth. The teenager, Ross, growing up in a suburb of New York, had become so terrified of germs that he would regularly shower for seven hours. Each received a diagnosis of severe obsessive-compulsive disorder, or O.C.D., and for years neither felt comfortable enough to leave the house.

But leave they eventually did, traveling in desperation to a hospital in Rhode Island for an experimental brain operation in which four raisin-sized holes were burned deep in their brains.

Today, two years after surgery, Ross is 21 and in college. “It saved my life,” he said. “I really believe that.”

The same cannot be said for Leonard, 67, who had surgery in 1995. “There was no change at all,” he said. “I still don’t leave the house.”

Both men asked that their last names not be used to protect their privacy.

The great promise of neuroscience at the end of the last century was that it would revolutionize the treatment of psychiatric problems. But the first real application of advanced brain science is not novel at all. It is a precise, sophisticated version of an old and controversial approach: psychosurgery, in which doctors operate directly on the brain.

In the last decade or so, more than 500 people have undergone brain surgery for problems like depression, anxiety, Tourette’s syndrome, even obesity, most as a part of medical studies. The results have been encouraging, and this year, for the first time since frontal lobotomy fell into disrepute in the 1950s, the Food and Drug Administration approved one of the surgical techniques for some cases of O.C.D.

While no more than a few thousand people are impaired enough to meet the strict criteria for the surgery right now, millions more suffering from an array of severe conditions, from depression to obesity, could seek such operations as the techniques become less experimental.

But with that hope comes risk. For all the progress that has been made, some psychiatrists and medical ethicists say, doctors still do not know much about the circuits they are tampering with, and the results are unpredictable: some people improve, others feel little or nothing, and an unlucky few actually get worse. In this country, at least one patient was left unable to feed or care for herself after botched surgery.

Moreover, demand for the operations is so high that it could tempt less experienced surgeons to offer them, without the oversight or support of research institutions.

And if the operations are oversold as a kind of all-purpose cure for emotional problems — which they are not, doctors say — then the great promise could quickly feel like a betrayal.

“We have this idea — it’s almost a fetish — that progress is its own justification, that if something is promising, then how can we not rush to relieve suffering?” said Paul Root Wolpe, a medical ethicist at Emory University.

It was not so long ago, he noted, that doctors considered the frontal lobotomy a major advance — only to learn that the operation left thousands of patients with irreversible brain damage. Many promising medical ideas have run aground, Dr. Wolpe added, “and that’s why we have to move very cautiously.”

Dr. Darin D. Dougherty, director of the division of neurotherapeutics at Massachusetts General Hospital and an associate professor of psychiatry at Harvard, put it more bluntly. Given the history of failed techniques, like frontal lobotomy, he said, “If this effort somehow goes wrong, it’ll shut down this approach for another hundred years.”

 

A Last Resort

Five percent to 15 percent of people given diagnoses of obsessive-compulsive disorder are beyond the reach of any standard treatment. Ross said he was 12 when he noticed that he took longer to wash his hands than most people. Soon he was changing into clean clothes several times a day. Eventually he would barely come out of his room, and when he did, he was careful about what he touched.

“It got so bad, I didn’t want any contact with people,” he said. “I couldn’t hug my own parents.”

Before turning to writing, Leonard was a healthy, successful businessman. Then he was struck, out of nowhere, with a fear of insects and spiders. He overcame the phobias, only to find himself with a strong aversion to bathing. He stopped washing and could not brush his teeth or shave.

“I just looked horrible,” he said. “I had a big, ugly beard. My skin turned black. I was afraid to be seen out in public. I looked like a street person. If you were a policeman, you would have arrested me.”

Both tried antidepressants like Prozac, as well as a variety of other medications. They spent many hours in standard psychotherapy for obsessive-compulsive disorder, gradually becoming exposed to dreaded situations — a moldy shower stall, for instance — and practicing cognitive and relaxation techniques to defuse their anxiety.

To no avail.

“It worked for a while for me, but never lasted,” Ross said. “I mean, I just thought my life was over.”

But there was one more option, their doctors told them, a last resort. At a handful of medical centers here and abroad, including Harvard, the University of Toronto and the Cleveland Clinic, doctors for years have performed a variety of experimental procedures, most for O.C.D. or depression, each guided by high-resolution imaging technology. The companies that make some of the devices have supported the research, and paid some of the doctors to consult on operations.

In one procedure, called a cingulotomy, doctors drill into the skull and thread wires into an area called the anterior cingulate. There they pinpoint and destroy pinches of tissue that lie along a circuit in each hemisphere that connects deeper, emotional centers of the brain to areas of the frontal cortex, where conscious planning is centered.

This circuit appears to be hyperactive in people with severe O.C.D., and imaging studies suggest that the surgery quiets that activity. In another operation, called a capsulotomy, surgeons go deeper, into an area called the internal capsule, and burn out spots in a circuit also thought to be overactive.

An altogether different approach is called deep brain stimulation, or D.B.S., in which surgeons sink wires into the brain but leave them in place. A pacemaker-like device sends a current to the electrodes, apparently interfering with circuits thought to be hyperactive in people with obsessive-compulsive disorder (and also those with severe depression). The current can be turned up, down or off, so deep brain stimulation is adjustable and, to some extent, reversible.

In yet another technique, doctors place the patient in an M.R.I.-like machine that sends beams of radiation into the skull. The beams pass through the brain without causing damage, except at the point where they converge. There they burn out spots of tissue from O.C.D.-related circuits, with similar effects as the other operations. This option, called gamma knife surgery, was the one Leonard and Ross settled on.

The institutions all have strict ethical screening to select candidates. The disorder must be severe and disabling, and all standard treatments exhausted. The informed-consent documents make clear that the operation is experimental and not guaranteed to succeed.

Nor is desperation by itself sufficient to qualify, said Richard Marsland, who oversees the screening process at Butler Hospital in Providence, R.I., which works with surgeons at Rhode Island Hospital, where Leonard and Ross had the operation.

“We get hundreds of requests a year and do only one or two,” Mr. Marsland said. “And some of the people we turn down are in bad shape. Still, we stick to the criteria.”

For those who have successfully recovered from surgery, this intensive screening seems excessive. “I know why it’s done, but this is an operation that could make the difference between life and death for so many people,” said Gerry Radano, whose book “Contaminated: My Journey Out of Obsessive-Compulsive Disorder” (Bar-le-Duc Books, 2007), recounts her own suffering and long recovery from surgery. She also has a Web site, freeofocd.com, where people from around the world consult with her.

But for the doctors running the programs, this screening is crucial. “If patients are poorly selected or not followed well, there’ll be an increasing number of bad outcomes, and the promise of this field will wither away,” said Dr. Ben Greenberg, the psychiatrist in charge of the program at Butler.

Dr. Greenberg said about 60 percent of patients who underwent either gamma knife surgery or deep brain stimulation showed significant improvement, and the rest showed little or no improvement. For this article, he agreed to put a reporter in touch with one — Leonard — who did not have a good experience.

 

The Danger of Optimism

The true measure of an operation, medical ethicists say, is its overall effect on a person’s life, not only on specific symptoms.

In the early days of psychosurgery, after World War II, doctors published scores of papers detailing how lobotomy relieved symptoms of mental distress. In 1949, the Portuguese neurologist Egas Moniz won the Nobel Prize in medicine for inventing the procedure.

But careful follow-up painted a darker picture: of people who lost motivation, who developed the helpless indifference dramatized by the post-op rebel McMurphy in Ken Kesey’s novel “One Flew Over the Cuckoo’s Nest,” played by Jack Nicholson in the 1975 movie.

The newer operations pinpoint targets on specific, precisely mapped circuits, whereas the frontal lobotomy amounted to a crude slash into the brain behind the eyes, blindly mangling whatever connections and circuits were in the way. Still, there remain large gaps in doctors’ understanding of the circuits they are operating on.

In a paper published last year, researchers at the Karolinska Institute in Sweden reported that half the people who had the most commonly offered operations for obsessive-compulsive disorder showed symptoms of apathy and poor self-control for years afterward, despite scoring lower on a measure of O.C.D. severity.

“An inherent problem in most research is that innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid,” Dr. Christian Ruck, the lead author of the paper, wrote in an e-mail message. The institute’s doctors, who burned out significantly more tissue than other centers did, no longer perform the operations, partly, Dr. Ruck said, as a result of his findings.

In the United States, at least one patient has suffered disabling brain damage from an operation for O.C.D. The case led to a $7.5 million judgment in 2002 against the Ohio hospital that performed the procedure. (It is no longer offered there.)

Most outcomes, whether favorable or not, have had less remarkable immediate results. The brain can take months or even years to fully adjust after the operations. The revelations about the people treated at Karolinska “underscore the importance of face-to-face assessments of adverse symptoms,” Dr. Ruck and his co-authors concluded.

 

The Long Way Back

Ross said he felt no difference for months after surgery, until the day his brother asked him to play a video game in the basement, and down the stairs he went.

“I just felt like doing it,” he said. “I would never have gone down there before.”

He said the procedure seemed to give the psychotherapy sessions a chance to work, and last summer he felt comfortable enough to stop them. He now spends his days studying, going to class, playing the odd video game to relax. He has told friends about the operation, he said, “and they’re O.K. with it — they know the story.”

Leonard is still struggling, for reasons no one understands. He keeps odd hours, working through most nights and sleeping much of the day. He is not unhappy, he said, but he has the same aversion to washing and still lives like a hermit.

“I still don’t know why I’m like this, and I would still try anything that could help,” he said. “But at this point, obviously, I’m skeptical of the efficacy of surgery, at least for me.”

Ms. Radano, who wrote the book about her recovery, said the most important thing about the surgery was that it gave people a chance. “That’s all people in this situation want, and I know because I was there,” she said while getting into her car on a recent afternoon.

On the passenger seat was a container of decontaminating hand wipes. She pointed and laughed. “See? You’re never completely out.”

    Surgery for Mental Ills Offers Hope and Risk, NYT, 27.11.2009,
    http://www.nytimes.com/2009/11/27/health/research/27brain.html

Vets’ Mental Health Diagnoses Rising

July 17, 2009
The New York Times
By JAMES DAO

A new study has found that more than one-third of Iraq and Afghanistan war veterans who enrolled in the veterans health system after 2001 received a diagnosis of a mental health problem, most often post-traumatic stress disorder or depression.

The study by researchers at the San Francisco Department of Veterans Affairs Medical Center and the University of California, San Francisco, also found that the number of veterans found to have mental health problems rose steadily the longer they were out of the service.

The study, released Thursday, was based on the department health records of 289,328 veterans involved in the two wars who used the veterans health system for the first time from April 1, 2002, to April 1, 2008.

The researchers found that 37 percent of those people received mental health diagnoses. Of those, the diagnosis for 22 percent was post-traumatic stress disorder, or PTSD, for 17 percent it was depression and for 7 percent it was alcohol abuse. One-third of the people with mental health diagnoses had three or more problems, the study found.

The increase in diagnoses accelerated after the invasion of Iraq in 2003, the researchers found. Among the group of veterans who enrolled in veterans health services during the first three months of 2004, 14.6 percent received mental health diagnoses after one year. But after four years, the number had nearly doubled, to 27.5 percent.

The study’s principal author, Dr. Karen H. Seal, attributed the rising number of diagnoses to several factors: repeat deployments; the perilous and confusing nature of war in Iraq and Afghanistan, where there are no defined front lines; growing public awareness of PTSD; unsteady public support for the wars; and reduced troop morale.

Dr. Seal said the study also underscored that it can take years for PTSD to develop. “The longer we can work with a veteran in the system, the more likely there will be more diagnoses over time,” said Dr. Seal, who is co-director of the mental health clinic for Iraq and Afghanistan veterans at the San Francisco veterans medical center.

The new report joins a growing body of research showing that the prolonged conflicts, where many troops experience long and repeat deployments, are taking an accumulating psychological toll.

A telephone survey by the RAND Corporation last year of 1,965 people who had been deployed to Iraq or Afghanistan found that 14 percent screened positive for PTSD and 14 percent for major depression. Those rates are considerably higher than for the general public.

“The study provides more insight as to just how stressed our force and families are after years of war and multiple deployments,” said René A. Campos, deputy director of government relations for the Military Officers Association of America. “Our troops and families need more time at home — more dwell time, fewer and less frequent deployments.”

The study was posted Thursday on the Web site of The American Journal of Public Health.

Dr. Seal cautioned that, unlike the RAND study, the results from her research could not be extrapolated to the roughly 1.6 million veterans who have served in Iraq or Afghanistan because about 60 percent of them were not receiving health care through the veterans system.

But she noted that the number of Iraq and Afghanistan war veterans receiving care through the veterans system was at a historic high, 40 percent, potentially making the study’s results more universal.

The study also found that veterans older than 40 with the National Guard or the Reserves were more likely to develop PTSD and substance abuse disorders than those under 25. A possible reason, Dr. Seal said, is that older reservists go to war from established civilian lives, with families and full-time jobs, making combat trauma potentially more difficult to absorb.

“It’s the disparity between their lives at home, which they are settled in, and suddenly, without much training, being dropped into this situation,” she said.

In contrast, the study found that among active-duty troops, veterans under 25 were more likely to develop PTSD and substance abuse problems than those over 40, possibly because those younger troops were more likely to have been involved in front-line combat, Dr. Seal said.

    Vets’ Mental Health Diagnoses Rising, NYT, 17.7.2009,
    http://www.nytimes.com/2009/07/17/health/views/17vets.html

Dr. Darrel A. Regier

is co-chairman of a panel compiling the latest

Diagnostic and Statistical Manual of Mental Disorders

Brendan Smialowski for The New York Times

Psychiatrists Revising the Book of Human Troubles

NYT

18 December 2008
http://www.nytimes.com/2008/12/18/health/18psych.html
 

Psychiatrists Revising the Book of Human Troubles

December 18, 2008
The New York Times
By BENEDICT CAREY

The book is at least three years away from publication, but it is already stirring bitter debates over a new set of possible psychiatric disorders.

Is compulsive shopping a mental problem? Do children who continually recoil from sights and sounds suffer from sensory problems — or just need extra attention? Should a fetish be considered a mental disorder, as many now are?

Panels of psychiatrists are hashing out just such questions, and their answers — to be published in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — will have consequences for insurance reimbursement, research and individuals’ psychological identity for years to come.

The process has become such a contentious social and scientific exercise that for the first time the book’s publisher, the American Psychiatric Association, has required its contributors to sign a nondisclosure agreement.

The debate is particularly intense because the manual is both a medical guidebook and a cultural institution. It helps doctors make a diagnosis and provides insurance companies with diagnostic codes without which the insurers will not reimburse patients’ claims for treatment.

The manual — known by its initials and edition number, DSM-V — often organizes symptoms under an evocative name. Labels like obsessive-compulsive disorder have connotations in the wider culture and for an individual’s self-perception.

“This is not cardiology or nephrology, where the basic diseases are well known,” said Edward Shorter, a leading historian of psychiatry whose latest book, “Before Prozac,” is critical of the manual. “In psychiatry no one knows the causes of anything, so classification can be driven by all sorts of factors” — political, social and financial.

“What you have in the end,” Mr. Shorter said, “is this process of sorting the deck of symptoms into syndromes, and the outcome all depends on how the cards fall.”

Psychiatrists involved in preparing the new manual contend that it is too early to say for sure which cards will be added and which dropped.

The current edition of the manual, which was published in 2000, describes 283 disorders — about triple the number in the first edition, published in 1952.

The scientists updating the manual have been meeting in small groups focusing on categories like mood disorders and substance abuse — poring over the latest scientific studies to clarify what qualifies as a disorder and what might distinguish one disorder from another. They have much more work to do, members say, before providing recommendations to a 28-member panel that will gather in closed meetings to make the final editorial changes.

Experts say that some of the most crucial debates are likely to include gender identity, diagnoses of illness involving children, and addictions like shopping and eating.

“Many of these are going to involve huge fights, I expect,” said Dr. Michael First, a professor of psychiatry at Columbia who edited the fourth edition of the manual but is not involved in the fifth.

One example, Dr. First said, is binge eating, now in the manual’s appendix as a tentative category.

“A lot of people want that included in the manual,” Dr. First said, “and there’s some research out there, some evidence that drugs are helpful. But binge eating is also a normal behavior, and you run the risk of labeling up to 30 percent of people with a disorder they don’t really have.”

The debate over gender identity, characterized in the manual as “strong and persistent cross-gender identification,” is already burning hot among transgender people. Soon after the psychiatric association named the group of researchers working on sexual and gender identity, advocates circulated online petitions objecting to two members whose work they considered demeaning.

Transgender people are themselves divided about their place in the manual. Some transgender men and women want nothing to do with psychiatry and demand that the diagnosis be dropped. Others prefer that it remain, in some form, because a doctor’s written diagnosis is needed to obtain insurance coverage for treatment or surgery.

“The language needs to be reformed, at a minimum,” said Mara Keisling, executive director of the National Center for Transgender Equity. “Right now, the manual implies that you cannot be a happy transgender person, that you have to be a social wreck.”

Dr. Jack Drescher, a New York psychoanalyst and member of the sexual disorders work group, said that, in some ways, the gender identity debate echoed efforts to remove homosexuality from the manual in the 1970s.

After protests by gay activists provoked a scientific review, the “homosexuality” diagnosis was dropped in 1973. It was replaced by “sexual orientation disturbance” and then “ego-dystonic homosexuality” before being dropped in 1987.

“You had, in my opinion, what was a social issue, not a medical one; and, in some sense, psychiatry evolved through interaction with the wider culture,” Dr. Drescher said.

The American Psychiatric Association says the contributors’ nondisclosure agreement is meant to allow the revisions to begin without distraction and to prevent authors from making deals to write casebooks or engage in other projects based on the deliberations without working through the association.

In a phone interview, Dr. Darrel A. Regier, the psychiatric association’s research director, who with Dr. David Kupfer of the University of Pittsburgh is co-chairman of the task force, said that experts working on the manual had presented much of their work in scientific conferences.

“But you need to synthesize what you’re doing and make it coherent before having that discussion,” Dr. Regier said. “Nobody wants to put a rough draft or raw data up on the Web.”

Some critics, however, say the secrecy is inappropriate.

“When I first heard about this agreement, I just went bonkers,” said Dr. Robert Spitzer, a psychiatry professor at Columbia and the architect of the third edition of the manual. “Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.”

Scientists who accepted the invitation to work on the new manual — a prestigious assignment — agreed to limit their income from drug makers and other sources to $10,000 a year for the duration of the job. “That’s more conservative” than the rules at many agencies and universities, Dr. Regier said.

This being the diagnostic manual, where virtually every sentence is likely to be scrutinized, critics have said that the policy is not strict enough. They have long suspected that pharmaceutical money subtly influences authors’ decisions.

Industry influence was questioned after a surge in diagnoses of bipolar disorder in young children. Once thought to affect only adults and adolescents, the disorder in children was recently promoted by psychiatrists on drug makers’ payrolls.

The team working on childhood disorders is expected to debate the merits of adding pediatric bipolar as a distinct diagnosis, experts say. It is also expected to discuss whether Asperger’s syndrome, a developmental disorder, should be merged with high-functioning autism. The two are virtually identical, but bear different social connotations.

The same team is likely to make a recommendation on so-called sensory processing disorder, a vague label for a poorly understood but disabling childhood behavior. Parent groups and some researchers want recognition in the manual in order to help raise money for research and obtain insurance coverage of expensive treatments.

“I know that some are pushing very hard to get that in,” Dr. First said, “and they believe they have been warmly received. But you just never know for sure, of course, until the thing is published.”

In all, it is a combination of suspense, mystery and prepublication controversy that many publishers would die for. The psychiatric association knows it has a corner on the market and a blockbuster series. The last two editions sold more than 830,000 copies each.

    Psychiatrists Revising the Book of Human Troubles, NYT, 18.12.2008,
    http://www.nytimes.com/2008/12/18/health/18psych.html


 

William Duke

A Crisis of Confidence for Masters of the Universe

NYT

16 December 2008
 http://www.nytimes.com/2008/12/16/health/views/16mind.html

Mind

A Crisis of Confidence for Masters of the Universe

December 16, 2008
The New York Times
By RICHARD A. FRIEDMAN, M.D.

Meltdown. Collapse. Depression. Panic. The words would seem to apply equally to the global financial crisis and the effect of that crisis on the human psyche.

Of course, it is too soon to gauge the true psychiatric consequences of the economic debacle; it will be some time before epidemiologists can tell us for certain whether depression and suicide are on the rise. But there’s no question that the crisis is leaving its mark on individuals, especially men.

One patient, a hedge fund analyst, came to me recently in a state of great anxiety. “It’s bad, but it might get a lot worse,” I recall him saying. The anxiety was expected and appropriate: he had lost a great deal of his (and others’) assets, and like the rest of us he had no idea where the bottom was. I would have been worried if he hadn’t been anxious.

Over the course of several weeks, with the help of some anti-anxiety medication, his panic subsided as he realized that he would most likely survive economically.

But then something else emerged. He came in one day looking subdued and plopped down in the chair. “I’m over the anxiety, but now I feel like a loser.” This from a supremely self-confident guy who was viewed by his colleagues as an unstoppable optimist.

He was not clinically depressed: his sleep, appetite, sex drive and ability to enjoy himself outside of work were unchanged. This was different.

The problem was that his sense of success and accomplishment was intimately tied to his financial status; he did not know how to feel competent or good about himself without this external measure of his value.

He wasn’t the only one. Over the last few months, I have seen a group of patients, all men, who experienced a near collapse in their self-esteem, though none of them were clinically depressed.

Another patient summed it up: “I used to be a master-of-the-universe kind of guy, but this cut me down to size.”

I have plenty of female patients who work in finance at high levels, but none of them has had this kind of psychological reaction. I can’t pretend this is a scientific survey, but I wonder if men are more likely than women to respond this way. At the risk of trading in gender stereotypes, do men rely disproportionately more on their work for their self-esteem than women do? Or are they just more vulnerable to the inevitable narcissistic injury that comes with performing poorly or losing one’s job?

A different patient was puzzled not by his anxiety about the market, but by his total lack of self-confidence. He had always had an easy intuitive feel for finance. But in the wake of the market collapse, he seriously questioned his knowledge and skill.

Each of these patients experienced a sudden loss of the sense of mastery in the face of the financial meltdown and could not gauge their success or failure without the only benchmark they knew: a financial profit.

The challenge of maintaining one’s self-esteem without recognition or reward is daunting. Chances are that if you are impervious to self-doubt and go on feeling good about yourself in the face of failure, you have either won the temperamental sweepstakes or you have a real problem tolerating bad news.

Of course, the relationship between self-esteem and achievement can be circular. Some argue that that the best way to build self-esteem is to tell people at every turn how nice, smart and talented they are.

That is probably a bad idea if you think that self-esteem and recognition should be the result of accomplishment; you feel good about yourself, in part, because you have done something well. On the other hand, it is hard to imagine people taking the first step without first having some basic notion of self-confidence.

On Wall Street, though, a rising tide lifts many boats and vice versa, which means that there are many people who succeed — or fail — through no merit or fault of their own.

This observation might ease a sense of personal responsibility for the economic crisis, but it was of little comfort to my patients. I think this is because for many of them, the previously expanding market gave them a sense of power along with something as strong as a drug: thrill.

The human brain is acutely attuned to rewards like money, sex and drugs. It turns out that the way a reward is delivered has an enormous impact on its strength. Unpredictable rewards produce much larger signals in the brain’s reward circuit than anticipated ones. Your reaction to situations that are either better or worse than expected is generally stronger to those you can predict.

In a sense, the stock market is like a vast gambling casino where the reward can be spectacular, but always unpredictable. For many, the lure of investing is the thrill of uncertain reward. Now that thrill is gone, replaced by anxiety and fear.

My patients lost more than money in the market. Beyond the rush and excitement, they lost their sense of competence and success. At least temporarily: I have no doubt that, like the economy, they will recover. But it’s a reminder of just how fragile our self-confidence can be.

Richard A. Friedman is a professor of psychiatry

at Weill Cornell Medical College.

    A Crisis of Confidence for Masters of the Universe, NYT, 16.12.2008,
    http://www.nytimes.com/2008/12/16/health/views/16mind.html

Mind

Standing in Someone Else’s Shoes, Almost for Real
 

December 2, 2008
The New York Times
By BENEDICT CAREY

From the outside, psychotherapy can look like an exercise in self-absorption. In fact, though, therapists often work to pull people out of themselves: to see their behavior from the perspective of a loved one, for example, or to observe their own thinking habits from a neutral distance.

Marriage counselors have couples role-play, each one taking the other spouse’s part. Psychologists have rapists and other criminals describe their crime from the point of view of the victim. Like novelists or moviemakers, their purpose is to transport people, mentally, into the mind of another.

Now, neuroscientists have shown that they can make this experience physical, creating a “body swapping” illusion that could have a profound effect on a range of therapeutic techniques. At the annual meeting of the Society for Neuroscience last month, Swedish researchers presented evidence that the brain, when tricked by optical and sensory illusions, can quickly adopt any other human form, no matter how different, as its own.

“You can see the possibilities, putting a male in a female body, young in old, white in black and vice versa,” said Dr. Henrik Ehrsson of the Karolinska Institute in Stockholm, who with his colleague Valeria Petkova described the work to other scientists at the meeting. Their full study is to appear online this week in the journal PLoS One. .

The technique is simple. A subject stands or sits opposite the scientist, as if engaged in an interview.. Both are wearing headsets, with special goggles, the scientist’s containing small film cameras. The goggles are rigged so the subject sees what the scientist sees: to the right and left are the scientist’s arms, and below is the scientist’s body.

To add a physical element, the researchers have each person squeeze the other’s hand, as if in a handshake. Now the subject can see and “feel” the new body. In a matter of seconds, the illusion is complete. In a series of studies, using mannequins and stroking both bodies’ bellies simultaneously, the Karolinska researchers have found that men and women say they not only feel they have taken on the new body, but also unconsciously cringe when it is poked or threatened.

In previous work, neuroscientists have induced various kinds of out-of-body experiences using similar techniques. The brain is so easily tricked, they say, precisely because it has spent a lifetime in its own body. It builds models of the world instantaneously, based on lived experience and using split-second assumptions — namely, that the eyes are attached to the skull.

Therapists say the body-swapping effect is so odd that it could be risky for anyone in real mental distress. People suffering from the delusions of schizophrenia or the grandiose mania of bipolar disorder are not likely to benefit from more disorientation, no matter the intent.

But those who seek help for relationship problems, in particular, often begin to moderate their behavior only after they have worked to see the encounters in their daily life from others’ point of view.

“This is especially true for adolescents, who are so self-involved, and also for people who come in with anger problems and are more interested in changing everyone else in their life than themselves,” said Kristene Doyle, director of clinical services at the Albert Ellis Institute in New York.

One important goal of therapy in such cases, Dr. Doyle said, is to get people to generate alternative explanations for others’ behavior — before they themselves react.

The evidence that inhabiting another’s perspective can change behavior comes in part from virtual-reality experiments. In these studies, researchers create avatars that mimic a person’s every movement. After watching their “reflection” in a virtual mirror, people mentally inhabit this avatar at some level, regardless of its sex, race or appearance. In several studies, for instance, researchers have shown that white people who spend time interacting virtually as black avatars become less anxious about racial differences.

Jeremy Bailenson, director of the Virtual Human Interaction Lab at Stanford University, and his colleague Nick Yee call this the Proteus effect, after the Greek god who can embody many different self-representations.

In one experiment, the Stanford team found that people inhabiting physically attractive avatars were far more socially intimate in virtual interactions than those who had less appealing ones. The effect was subconscious: the study participants were not aware that they were especially good-looking, or that in virtual conversations they moved three feet closer to virtual conversation partners and revealed more about themselves than others did. This confidence lingered even after the experiment was over, when the virtual lookers picked more attractive partners as matches for a date.

Similar studies have found that people agree to contribute more to retirement accounts when they are virtually “age-morphed” to look older; and that they will exercise more after inhabiting an avatar that works out and loses weight.

Adding a physical body-swapping element, as the Swedish team did, is likely to amplify such changes. “It has video quality, it looks and feels more realistic than what we can do in virtual environments, so is likely to be much more persuasive,” Dr. Bailenson said in a telephone interview.

Perhaps too persuasive for some purposes. “It may be like the difference between a good book, where you can project yourself into a character by filling in with your imagination, and a movie, where the specific actor gets in the way of identifying strongly,” he went on.

And above and beyond any therapeutic purposes, the sensation is downright strange. In the experiments, said Dr. Ehrsson, the Swedish researcher, “even the feeling from the squeezing hand is felt in the scientist’s hand and not in your own; this is perhaps the strangest aspect of the experience.”

    Standing in Someone Else’s Shoes, Almost for Real, NYT, 2.12.2008,
    http://www.nytimes.com/2008/12/02/health/02mind.html

Use of Antipsychotics in Children Is Criticized

November 19, 2008
The New York Times
By GARDINER HARRIS

WASHINGTON — Powerful antipsychotic medicines are being used far too cavalierly in children, and federal drug regulators must do more to warn doctors of their substantial risks, a panel of federal drug experts said Tuesday.

More than 389,000 children and teenagers were treated last year with Risperdal, one of five popular medicines known as atypical antipsychotics. Of those patients, 240,000 were 12 or younger, according to data presented to the committee. In many cases, the drug was prescribed to treat attention deficit disorders.

But Risperdal is not approved for attention deficit problems, and its risks — which include substantial weight gain, metabolic disorders and muscular tics that can be permanent — are too profound to justify its use in treating such disorders, panel members said.

“This committee is frustrated,” said Dr. Leon Dure, a pediatric neurologist from the University of Alabama School of Medicine who was on the panel. “And we need to find a way to accommodate this concern of ours.”

The meeting on Tuesday was scheduled to be a routine review of the pediatric safety of Risperdal and Zyprexa, popular antipsychotic medicines made, respectively, by Johnson & Johnson and Eli Lilly & Company. Food and Drug Administration officials proposed that the committee endorse the agency’s routine monitoring of the safety of the medicines in children and support its previous efforts to highlight the drugs’ risks.

But committee members unanimously rejected the agency’s proposals, saying that far more needed to be done to discourage the medicines’ growing use in children, particularly to treat conditions for which the medicines have not been approved.

“The data show there is a substantial amount of prescribing for attention deficit disorder, and I wonder if we have given enough weight to the adverse-event profile of the drug in light of this,” Dr. Daniel Notterman, a senior health policy analyst at Princeton University and a panel member, said when speaking about Risperdal.

Drug agency officials responded that they had already placed strongly worded warnings on the drugs’ labels.

“I’m a little puzzled about the statement that the label is inadequate,” said Dr. Thomas Laughren, director of the agency’s division of psychiatry products. “I’m anxious to hear what more we can do in the labeling.”

Kara Russell, a spokeswoman for Johnson & Johnson, said, “Adverse drug reactions associated with Risperdal use in approved indications are accurately reflected in the label.”

But panelists said the current warnings were not enough.

While panel members spoke at length about Risperdal, they said their concerns applied to the other medicines in its class, including Zyprexa, Seroquel, Abilify and Geodon.

The committee’s concerns are part of a growing chorus of complaints about the increasing use of antipsychotic medicines in children and teenagers. Prescription rates for the drugs have increased more than fivefold for children in the past decade and a half, and doctors now use the drugs to settle outbursts and aggression in children with a wide variety of diagnoses, even though children are especially susceptible to their side effects.

A consortium of state Medicaid directors is evaluating the use of the drugs in children on state Medicaid rolls to ensure that they are being properly prescribed.

The growing use of the medicines has been driven partly by the sudden popularity of the diagnosis of pediatric bipolar disorder.

The leading advocate for the bipolar diagnosis is Dr. Joseph Biederman, a child psychiatrist at Harvard University whose work is under a cloud after a Congressional investigation revealed that he had failed to report to his university at least $1.4 million in outside income from the makers of antipsychotic medicines.

In the past year, Risperdal prescriptions to patients 17 and younger increased 10 percent, while prescriptions among adults declined 5 percent. Most of the pediatric prescriptions were written by psychiatrists.

From 1993 through the first three months of 2008, 1,207 children given Risperdal suffered serious problems, including 31 who died. Among the deaths was a 9-year-old with attention deficit problems who suffered a fatal stroke 12 days after starting therapy with Risperdal.

At least 11 of the deaths were children whose treatment with Risperdal was unapproved by the F.D.A. Once the agency approves a medicine for a particular condition, doctors are free to prescribe it for other problems.

Panel members said they had for years been concerned about the effects of Risperdal and similar medicines, but F.D.A. officials said no studies had been done to test the drugs’ long-term safety.

Dr. Dure said he was concerned that doctors often failed to recognize the movement disorders, including tardive dyskinesia and dystonia, that can result from using these medicines.

“I have a bias that extra-pyramidal side effects are being under-recognized with these agents,” Dr. Dure said.

Dr. Laughren of the F.D.A. said the agency could do little to fix the problem. Instead, he said, medical specialty societies must do a better job educating doctors about the drugs’ side effects.

    Use of Antipsychotics in Children Is Criticized, NYT, 19.11.2008,
    http://www.nytimes.com/2008/11/19/health/policy/19fda.html

Bailout Provides More Mental Health Coverage

October 6, 2008
The New York Times
By ROBERT PEAR

WASHINGTON — More than one-third of all Americans will soon receive better insurance coverage for mental health treatments because of a new law that, for the first time, requires equal coverage of mental and physical illnesses.

The requirement, included in the economic bailout bill that President Bush signed on Friday, is the result of 12 years of passionate advocacy by friends and relatives of people with mental illness and addiction disorders. They described the new law as a milestone in the quest for civil rights, an effort to end insurance discrimination and to reduce the stigma of mental illness.

Most employers and group health plans provide less coverage for mental health care than for the treatment of physical conditions like cancer, heart disease or broken bones. They will need to adjust their benefits to comply with the new law, which requires equivalence, or parity, in the coverage.

For decades, insurers have set higher co-payments and deductibles and stricter limits on treatment for addiction and mental illnesses.

By wiping away such restrictions, doctors said, the new law will make it easier for people to obtain treatment for a wide range of conditions, including depression, autism, schizophrenia, eating disorders and alcohol and drug abuse.

Frank B. McArdle, a health policy expert at Hewitt Associates, a benefits consulting firm, said the law would force sweeping changes in the workplace.

“A large majority of health plans currently have limits on hospital inpatient days and outpatient visits for mental health treatments, but not for other treatments,” Mr. McArdle said. “They will have to change their plan design.”

Federal officials said the law would improve coverage for 113 million people, including 82 million in employer-sponsored plans that are not subject to state regulation. The effective date, for most health plans, will be Jan. 1, 2010.

The Congressional Budget Office estimates that the new requirement will increase premiums by an average of about two-tenths of 1 percent. Businesses with 50 or fewer employees are exempt.

The goal of mental health parity once seemed politically unrealistic but gained widespread support for several reasons:

¶Researchers have found biological causes and effective treatments for numerous mental illnesses.

¶A number of companies now specialize in managing mental health benefits, making the costs to insurers and employers more affordable. The law allows these companies to continue managing benefits.

¶Employers have found that productivity tends to increase after workers are treated for mental illnesses and drug or alcohol dependence. Such treatments can reduce the number of lost work days.

¶The stigma of mental illness may have faded as people see members of the armed forces returning from Iraq and Afghanistan with serious mental problems.

¶Parity has proved workable when tried at the state level and in the health insurance program for federal employees, including members of Congress.

Dr. Steven E. Hyman, a former director of the National Institute of Mental Health, said it was impossible to justify insurance discrimination when an overwhelming body of scientific evidence showed that “mental illnesses represent real diseases of the brain.”

“Genetic mutations and unlucky combinations of normal genes contribute to the risk of autism and schizophrenia,” Dr. Hyman said. “There is also strong evidence that people with schizophrenia have thinning of the gray matter in parts of the brain that permit us to control our thoughts and behavior.”

The drive for mental health parity was led by Senator Pete V. Domenici, Republican of New Mexico, who has a daughter with schizophrenia, and Senator Paul Wellstone, the Minnesota Democrat who was killed in a plane crash in 2002. Mr. Wellstone had a brother with severe mental illness.

Prominent members of both parties, including Betty Ford, Rosalynn Carter and Tipper Gore, pleaded with Congress to pass the legislation.

Representatives Patrick J. Kennedy, Democrat of Rhode Island, and Jim Ramstad, Republican of Minnesota, led the fight in the House. Mr. Kennedy has been treated for depression and, by his own account, became “the public face of alcoholism and addiction” after a car crash on Capitol Hill in 2006. Mr. Ramstad traces his zeal to the day in 1981 when he woke up in a jail cell in South Dakota after an alcoholic blackout.

The Senate passed a mental health parity bill in September 2007. The House passed a different version in March of this year.

A breakthrough occurred when sponsors of the House bill agreed to drop a provision that required insurers to cover treatment for any condition listed in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.

Employers objected to such a requirement, saying it would have severely limited their discretion over what benefits to provide. Among the conditions in the manual, critics noted, are caffeine intoxication and sleep disorders resulting from jet lag.

Doctors often complain that insurers, especially managed care companies, interfere in their treatment decisions. But doctors and mental health advocates cited the work of such companies in arguing that mental health parity would be affordable, because the benefits could be managed.

Pamela B. Greenberg, president of the Association for Behavioral Health and Wellness, a trade group, said providers of mental health care typically drafted a treatment plan for each person. In complex cases, she said, a case manager or care coordinator monitors the patient’s progress.

A managed care company can refuse to pay for care, on the grounds that it is not medically necessary or “clinically appropriate.” But under the new law, insurers must disclose their criteria for determining medical necessity, as well as the reason for denying any particular claim for mental health services.

Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, an advocacy group, said, “Under the new law, we will probably see more aggressive management of mental health benefits because insurers can no longer impose arbitrary limits.”

The law will also encourage insurers to integrate coverage for mental health care with medical and surgical benefits. Under the law, insurers cannot have separate cost-sharing requirements or treatment limits that apply only to mental illness and addiction disorders.

The law comes just three months after Congress eliminated discriminatory co-payments in Medicare, the program for people who are 65 and older or disabled.

Medicare beneficiaries pay 20 percent of the government-approved amount for most doctors’ services but 50 percent for outpatient mental health services. The co-payment for mental health care will be gradually reduced to 20 percent over six years.

The mental health parity law was forged in a highly unusual consensus-building process. For years, mental health advocates had been lobbying on the issue.

Insurers and employers, which had resisted earlier versions of the legislation, came to the table in 2004 at the request of Mr. Domenici and Senators Edward M. Kennedy, Democrat of Massachusetts, and Michael B. Enzi, Republican of Wyoming.

Each side had, in effect, a veto over the language of any bill. Insurers and employers, seeing broad bipartisan support for the goal in both houses of Congress, decided to work with mental health advocates. Each side gained the other’s trust.

“It was an incredible process,” said E. Neil Trautwein, a vice president of the National Retail Federation, a trade group. “We built the bill piece by piece from the ground up. It’s a good harbinger for future efforts on health care reform.”

    Bailout Provides More Mental Health Coverage, NYT, 6.10.2008,
    http://www.nytimes.com/2008/10/06/washington/06mental.html

Op-Ed Columnist

The Luxurious Growth

July 15, 2008
The New York Times
By DAVID BROOKS

We all know the story of Dr. Frankenstein, the scientist so caught up in his own research that he arrogantly tried to create new life and a new man. Today, if you look at people who study how genetics shape human behavior, you find a collection of anti-Frankensteins. As the research moves along, the scientists grow more modest about what we are close to knowing and achieving.

It wasn’t long ago that headlines were blaring about the discovery of an aggression gene, a happiness gene or a depression gene. The implication was obvious: We’re beginning to understand the wellsprings of human behavior, and it won’t be long before we can begin to intervene to enhance or transform human life.

Few talk that way now. There seems to be a general feeling, as a Hastings Center working group put it, that “behavioral genetics will never explain as much of human behavior as was once promised.”

Studies designed to link specific genes to behavior have failed to find anything larger than very small associations. It’s now clear that one gene almost never leads to one trait. Instead, a specific trait may be the result of the interplay of hundreds of different genes interacting with an infinitude of environmental factors.

First, there is the complexity of the genetic process. As Jim J. Manzi pointed out in a recent essay in National Review, if a trait like aggressiveness is influenced by just 100 genes, and each of those genes can be turned on or off, then there are a trillion trillion possible combinations of these gene states.

Second, because genes respond to environmental signals, there’s the complexity of the world around. Prof. Eric Turkheimer of the University of Virginia, conducted research showing that growing up in an impoverished environment harms I.Q. He was asked what specific interventions would help children realize their potential. But, he noted, that he had no good reply. Poverty as a whole has this important impact on people, but when you try to dissect poverty and find out which specific elements have the biggest impact, you find that no single factor really explains very much. It’s possible to detect the total outcome of a general situation. It’s harder to draw a linear relationship showing cause and effect.

Third, there is the fuzziness of the words we use to describe ourselves. We talk about depression, anxiety and happiness, but it’s not clear how the words that we use to describe what we feel correspond to biological processes. It could be that we use one word, depression, to describe many different things, or perhaps depression is merely a symptom of deeper processes that we’re not aware of. In the current issue of Nature, there is an essay about the arguments between geneticists and neuroscientists as they try to figure out exactly what it is that they are talking about.

The bottom line is this: For a time, it seemed as if we were about to use the bright beam of science to illuminate the murky world of human action. Instead, as Turkheimer writes in his chapter in the book, “Wrestling With Behavioral Genetics,” science finds itself enmeshed with social science and the humanities in what researchers call the Gloomy Prospect, the ineffable mystery of why people do what they do.

The prospect may be gloomy for those who seek to understand human behavior, but the flip side is the reminder that each of us is a Luxurious Growth. Our lives are not determined by uniform processes. Instead, human behavior is complex, nonlinear and unpredictable. The Brave New World is far away. Novels and history can still produce insights into human behavior that science can’t match.

Just as important is the implication for politics. Starting in the late 19th century, eugenicists used primitive ideas about genetics to try to re-engineer the human race. In the 20th century, communists used primitive ideas about “scientific materialism” to try to re-engineer a New Soviet Man.

Today, we have access to our own genetic recipe. But we seem not to be falling into the arrogant temptation — to try to re-engineer society on the basis of what we think we know. Saying farewell to the sort of horrible social engineering projects that dominated the 20th century is a major example of human progress.

We can strive to eliminate that multivariate thing we call poverty. We can take people out of environments that (somehow) produce bad outcomes and try to immerse them into environments that (somehow) produce better ones. But we’re not close to understanding how A leads to B, and probably never will be.

This age of tremendous scientific achievement has underlined an ancient philosophic truth — that there are severe limits to what we know and can know; that the best political actions are incremental, respectful toward accumulated practice and more attuned to particular circumstances than universal laws.
 

Bob Herbert is off today.

    The Luxurious Growth, NYT, 15.7.2008,
    http://www.nytimes.com/2008/07/15/opinion/15brooks.html?ref=opinion

This Land

Through Decades of Change, a Core Crew Remains

June 30, 2008
The New York Times
By DAN BARRY

Danbury, Conn.

Lately, in the maintenance garage at the Danbury rest stop just off Interstate 84, the topic of conversation can shift suddenly from grass-cutting and litter pickup to death. What happens afterward? Where do we go? When I die, will you remember me?

Is there coffee in heaven?

The conversation among the four workers might return just as abruptly to what needs to be mowed next, or it might simply surrender to silence, like a lawn mower out of gas. After a while they will wriggle their hands back into their work gloves and return to prettifying the grounds for people who barely notice them, who are just passing through.

Then, when midafternoon arrives, the men will climb back into a state-owned van. Bob, 57, who wants to be known simply as Bob, sits in the way back, his Special Olympics cap worn at an almost jaunty angle. Bobby McKay, 62, sits in the middle row, staring out the window, his travel-worthy coffee mug cradled like a puppy in his hands. Tony Daversa, 59, sits in the front passenger seat, chattering about everything he sees, including a passing cemetery.

“There’s the body,” he says one afternoon.

“Will you shut up,” his friend Bob jokes from the back.

“There’s the body,” Tony says again, in sing-song.

At the wheel is Dave Lavery, 51, their driver, supervisor, counselor, friend. On the way to work he always stops the van at the South Britain Country Store so they can buy coffee, and on the way home he stops there again because refills are free. He gently reminds Bob not to curse. He encourages Bobby to talk. He listens to Tony’s questions about mortality, prompted by recent deaths in Tony’s small, removed world.

Soon a collegelike campus comes into view, signaling that Dave has safely returned them once again to the Southbury Training School, a 1,600-acre residence for people with mental retardation. Bob, Bobby and Tony have lived here since before man landed on the moon, since before J.F.K. was shot, for as long as they remember.

The van drops the men off in front of their home buildings. Bobby, who had a paper route before he was placed here as a teenager, back when his hair was dark, plops onto the couch, exhausted but still eager to go to a minor-league baseball game in a few hours. Bob, whose parents placed him here when he was 8, leans before his stereo system and pushes buttons until it emits the feel-the-fire wailing of Kenny Rogers.

“Listen to this,” Bob says, playing air drums. “Listen.”

Tony, who bounced around foster homes before coming here as a young teenager, stops briefly in his bedroom, then hustles out to a second job picking up trash in another building. His lined face conveys the then and the now of his life: the wide eyes of full engagement with his world today, offset by a telltale mangled ear.

Decades ago someone stomped on his ear while he was sleeping; stomp might be too gentle a word, given that his ear now looks like a small conch.

“I don’t know who did it,” he says, big eyes looking away.

These men were here at the Southbury Training School — opened in 1941 as a “school for mental defectives” — in the early 1960s, when it was the best that government had to offer: a place where even the well-to-do sent their mentally impaired and troubled boys and girls, a place of many swing sets.

They were here in the mid-1980s, when conditions became so substandard, even dangerous, that the school, then with a population of more than 1,100, was placed under federal oversight and stopped accepting admissions.

They were here through the 1990s, as the school struggled to improve its care, as some residents moved off campus, often to group homes, and other residents, mostly older ones, died. And they were here in 2006, when the school was released from the supervision of a court monitor, although a consent decree with the federal government remains.

The swing sets are gone, but these men are here still, a part of a declining, aging population that has dropped below 500. They live in settings similar to group homes, have one-on-one contact with social workers, work out in the gym, keep bank accounts, plan for day trips and shopping trips. And every weekday morning they climb into that van and head off for work at a rest stop welcoming people to Connecticut.

Twenty years ago, the state Department of Transportation hired a crew from the training school to maintain the rest area’s grounds. Dave was put in charge, and among those he selected for the initial crew was Bobby, who some staff members thought should not leave school grounds. Bobby has proved them wrong; he and his crew mates continue to work hard to keep the rest area clean, and they take evident pride in their yellow D.O.T. vests.

“It says to the world: I made it,” Dave explains.

Another workday dawns. Dave drives the van through the school’s verdant campus, collecting his crew. He has known these men for decades. A couple of them spend Thanksgiving with his family every year.

As always, the van stops at the country store for coffee. The men sit mostly in silence on the 25-mile ride to the rest stop, save for the occasional slurp from a travel mug. And soon after they arrive at the maintenance garage and open its doors, Tony puts on a pot of coffee.

Over the years, a lot of coffee has been drunk in the van and at the garage, because coffee has special meaning. It goes back to when an extra cup of coffee could be a privilege, or maybe a way for a staff member to say thank you, good job, I can depend on you. A hint of independence now flavors their coffee.

And over the years, the crew’s makeup has changed; people have come and gone. Two years ago, there were five: Dave, Bob, Bobby, Tony and a birdlike man named Robert, who did not speak but would communicate with gestures. Dave would look in his rearview mirror and see Robert moving fist over fist. Coffee, he was saying.

But Robert, who used to set out napkins for his workmates when they ate lunch in the maintenance garage, died last summer. Then Danny, another training school resident, died. Then others died, including Bob’s father and a beloved staff member at the school named Gina.

Tony in particular began struggling with mortality. As a result, the garage’s refrigerator is adorned with a haphazardly taped collage of death notices and memorial announcements — for Robert and Danny and Gina and Bob’s dad. There is also a circled advertisement for the Naugatuck funeral home that Tony says will take care of him when he dies and goes to heaven — where, he has been assured, there will be coffee.

“But God don’t want me yet,” he says.

The men finish their coffee. Bobby sits. Tony has a cigarette. Bob lights up a pipe. Among them, a combined 140 years at the Southbury Training School.

After a while, Dave says it’s time to get back to work. The men stand up and walk out of the dim garage.

    Through Decades of Change, a Core Crew Remains, NYT, 30.6.2008,
    http://www.nytimes.com/2008/06/30/us/30land.html

What Happened to Ricky

In the '50s,

disabled children often disappeared into state institutions.

Now, one family seeks its lost son.

May 31, 2008; Page A1
The Wall Street Journal
By CLARE ANSBERRY

PORTLAND, Ore. -- Tom and Betty West committed their mentally disabled son to a state institution. His name was Richard, and he was three years old. It was 1959. The massive complex was remote and family ties not encouraged. The state eventually moved Richard to a different facility without informing the Wests of the location. Four decades passed without a family member laying eyes on Richard.

As they entered their 80s, the Wests thought increasingly about Richard, the fifth of their eight children. How was he? Where did he live? Mr. West wanted to make sure that, following his death, some of his pension flowed to Richard.

State officials rejected Mr. West's request for information, calling Richard's whereabouts private. The Wests hired an attorney who ran into the same roadblocks. "At that point, I thought there is nothing more I could do," says Mr. West, a retired dam builder who is 87.

The Wests belong to a generation of parents who decades ago relinquished their disabled children, usually at the urging of physicians or other authorities. From the 1930s into the 1960s, tens of thousands of these children entered state facilities, which offered services that local communities lacked. Many never saw their families again.

"Fifty years ago, families were often advised to place their child in an institution, and basically told that, for the good of the child and family, to forget that the person existed," says Charlie Lakin, project director of the Research and Training Center on Community Living at the University of Minnesota.

Back in the '60s, an Oregon family put their mentally disabled child in a public institution, and he eventually became a ward of the state. Recently, the family tracked him to a small group home and hope to retie lost bonds. (May 31)
Half a century later, that old policy is still haunting families across America. Middle-aged siblings want to find their absent younger brother or sister before it is too late. Aging parents wish they knew what became of their child. Cousins and nieces wonder about relatives known only by name and family lore.

Yet even as greater acceptance and inclusion greet today's mentally disabled children, many of yesterday's remain lost. Privacy laws can prevent families from finding their loved ones. In some cases, facilities have closed, scattering residents into group homes and apartments without family notification. About 40% of residents of large state institutions have no family contact, surveys have shown.

Efforts to help restore lost connections are surfacing. In 2005, Oregon passed legislation and adopted a procedure to make it easier for relatives to track down people who were institutionalized. A dozen other states are studying its approach.

Last summer, Arc, a national advocacy group for the developmentally disabled, created a registry where people can list who they are trying to find. About 290 families have registered, from nearly every state. But a match can be made only if both sides register. Of the 86 disabled adults who have registered, none have been matched to registered families. Among those searching is a 50-year-old woman who learned only in adulthood about the existence of her developmentally disabled twin sister, says Arc.

'Brother Was in Fairview'

One evening in 2005, a television news channel in Portland interviewed a man named Jeff Daly about the discovery of his developmentally disabled sister, Molly, who had been living at Oregon's Fairview home.

Watching TV that night was Jeff West, the youngest sibling of Richard West. Born after Richard left their family home, Jeff West had never met his brother. But he knew all about him, including the name of the first institution Richard had entered. Turning to his wife as they watched that interview, Jeff West said: "My brother was in Fairview."

At the time she became pregnant with their fifth child in 1955, Betty and Tom West lived in a three-bedroom house in The Dalles, Ore. The pregnancy went smoothly, but the delivery didn't. Richard was blue at birth and immediately put on oxygen, then sent home with assurances that he was fine.

He rarely cried. But as months passed, he didn't roll over or crawl. He showed little emotion or recognition. If Mrs. West walked out of the room, he didn't protest. His older brothers played around him. "He seemed like he was in his own little world," recalls his older brother Steve.

Mrs. West read to him and repeated basic words, hoping he would catch on. Once, she thought he said "Mama," but he never said it again. When she started giving him solid food, he choked. At age two, he weighed 17 pounds. "I knew there was something wrong, but I couldn't pinpoint it," she says.

At monthly checkups, she relayed her concerns to her doctor, who said Richard was fine. As months passed without progress, she insisted something was wrong. Tired of her questions, the doctor told her not to come back, she says.

Second Opinion

Mrs. West found a new physician who examined Richard and concluded he was severely mentally retarded. The physician explained that Richard might learn to walk but would never talk. He would always have the mentality of a three-year-old and need 24-hour care. "It was a relief knowing it wasn't my imagination" or fault, says Mrs. West.

Soon pregnant again, Mrs. West became overwhelmed at the thought of caring for a newborn and a mentally disabled toddler, along with four older kids. The community offered no programs to help Richard. Having come from North Dakota, the Wests had no family nearby. "I didn't know what to do," says Mrs. West.

She asked her doctor. Gently, he told Mrs. West it would be better for Richard and everyone else if he was institutionalized. "You have to think of the other kids," she remembers the physician telling her.

She was numb. It went against everything the young couple believed. They had built a close family. They had come from close families.

In the end, they felt they had no other option. After Richard received an official diagnosis of "idiot" and "marked mental retardation," the Wests reluctantly agreed to send him 130 miles away to Oregon Fairview Home near Salem. A sprawling complex of dormitories and agricultural operations, Fairview was crowded with a wave of baby boomers with developmental disabilities. At mealtime, nurses lined children in high chairs against the wall, feeding the younger ones and taping forks into the hands of older children to encourage use of utensils.

Black-and-White Film

An old black-and-white film called "In Our Care" describes Fairview, showing a porch crowded with children clapping and rolling a ball. "This child spends most of her time tearing paper into shreds," the narrator says.

The day Richard left for Fairview, Mrs. West packed his clothes and dressed him in his best outfit -- a white blazer with a crest on the pocket and dark shorts. She and her husband told the other children Richard was going to a place where he could get special care. "We kind of knew he had a problem that our mother just couldn't take care of," says the oldest, Tom Jr., who was 11 at the time.

At the front office, an administrator recommended that Mr. and Mrs. West kiss Richard goodbye and leave quickly. "It was a terribly difficult day," says Betty West.

To visit Richard, the Wests had to make appointments. They tried to see him at least once in the summer, bringing along the other children. Richard didn't seem to recognize them but held their hands as they played Ring around the Rosie. His younger sister Barbara West remembers the smell of antiseptic and wondering why her older brother slept in a crib when she didn't.

One afternoon, when Richard was about 8 years old, his parents were walking hand-in-hand with him down the sidewalk. An older woman approached and held her hands out. Richard wriggled free and ran into the woman's outstretched arms. He hugged her, showing affection he had never shown his family. Betty remembers crying and telling her husband it was time to let go.

'Let Him Be'

"He has someone who loves him here. She makes him happy. We need to let him be," she recalls saying.

They continued to send him clothing but never went back to visit.

"He didn't know us," says Mrs. West.

"That was the only thing that made it bearable," says her husband.

In the West home, Richard became a powerful memory. The youngest child, Jeff, saw various photographs of the brother he'd never met -- Richard on the floor with his older brothers, Richard at the pool with their mother, Richard dressed up the day he went to Fairview. His parents had told Jeff why Richard didn't live at home. "They never shied away from talking about him," says Jeff.

No Forwarding Address

None of the children pressed their parents to find out how Richard was doing, although privately they wondered. "Anytime the family was together at Christmas or Thanksgiving, I would think how we used to play around him on the floor," says his older brother Bob.

In the 1980s, the state informed the Wests that Richard was being moved a couple hundred miles east to another state facility. A few years later, the Wests received a letter saying Richard was being placed in a smaller residence. The letter didn't say where. The Wests felt they lacked standing to ask because their son was a ward of the state.

He had, in fact, been transferred to a group home in Baker City, about 300 miles away. There, workers wondered about Richard's family. "Do they know he exists? Do they care?" says caregiver Tracy Hylton. "Many families don't want to have contact, and when there isn't any contact, we have to assume that is the case."

The turning point came the evening that Jeff West saw the television interview with Mr. Daly, the Oregon man who had found his long-lost mentally disabled sister. Suddenly, Jeff West was struck with the desire to find Richard.

Other siblings, however, were apprehensive. "Do you really want to do that?" brother Larry remembers saying. "Are you going to bring up things that are hurtful?"

Debby Peery, the second-youngest, wondered what their responsibility might be and how others would react.

"I was a little nervous about what the caretakers would think of us suddenly showing up after 40 years," she says. "But I was also excited."

All worried about their parents. "I didn't know how much guilt they carried," says Jeff West. At that point, Jeff didn't know his parents had recently and unsuccessfully tried to find Richard so that he could receive Mr. West's pension.

When asked about tracking down his disabled son, the elderly Mr. West responded, "Go for it."

40 Years Later

A flurry of phone calls followed. Jeff West talked to Mr. Daly, who gave him phone numbers of agencies with group homes. One was in Baker City. Jeff West provided his parents' Social Security numbers and Richard's date of birth to verify he was family. The woman at the group home said Richard was there.

Weeks later, the family met with Richard for the first time in 40 years. His caregivers, Ms. Hylton and Carrie Baird, drove Richard to the home of a sibling. They worried whether the West family would take Richard away from his group home, where he was comfortable and loved. "It would have been hard for us if he left," says Ms. Hylton.

Likewise, Mr. and Mrs. West felt anxious, not knowing whether Richard would want to see them or be angry. "I didn't know how he would take to us," says Mr. West.

Richard walked in, holding a Sponge Bob Square pants book with buttons that played songs. His parents sat on one couch. He sat on another, next to Ms. Hylton and Ms. Baird, holding their hands. He looked around the room, his face registering no apparent emotion. Mrs. West held back the urge to hold him. "I would have loved to given him a hug," she says. "But they said don't touch him because he won't like it."

Dates at McDonald's

Over lunch and through the afternoon, the Wests listened to Ms. Hylton and Ms. Baird describe how Richard loves music, does his own laundry, washes dishes, mows the lawn and sets the table. He has a job refilling ink cartridges. And a girlfriend: On dates to McDonalds they eat apple pie. Always known to his family as Ricky, he now preferred to be called Richard.

The Wests told stories about Richard's younger years and their struggles to help him. Richard grew restless and pressed a button on his book that is his signal to leave. He walked outside and got in the van.

Mr. and Mrs. West thanked Ms. Hylton and Ms. Baird for taking good care of Richard. The Wests say it eased their minds to see Richard healthy and seemingly content.

A few months after visiting Richard, Jeff West received Richard's signed permission to look at his records at Oregon's Department of Human Services office. Going through them helped the family piece together the unknown part of Richard's life. Some was reassuring. Some wasn't.

At Fairview, Richard learned things his parents never thought possible. By 12, he could dress, feed himself, catch a ball, fold pajamas and fish. He had friends and foster grandparents who took him out for ice cream. At 16, Richard taught himself to whistle. He loved Volkswagens and was sometimes found sitting in one in the Fairview parking lot.

Then there were glimpses of what they envisioned institutional life would be like. Over the years, Richard would run away and get in trouble for hitting. He was often put on Thorazine to sedate him.

Like Oliver Twist

Most troubling were the annual photographs of him behind a board saying, "Richard Alan West, Case 5727." In the photos, his face is thin and expressionless. The images reminded his parents of orphans begging for gruel in Oliver Twist. "That doesn't look like a very nice life," says Mr. West.

The records also contained references to the times that the Wests visited Richard. The documents said Richard had become visibly upset and withdrawn following their departure -- suggesting that he had known them better than they had realized. "These were things we didn't know," says Mr. West.

Now, Richard receives regular calls, letters, McDonald's gift certificates and visits from his family. Last summer, the family drove four cars to Richard's home. This summer, the Wests are hoping to have Richard home for a family reunion.

Mrs. West sends Richard towels and sweatshirts embroidered with his name. When getting dressed in the morning, Richard selects the same shirts repeatedly -- the ones his mother sent. "He knows it came from his family, and it means something," says Ms. Hylton.

    What Happened to Ricky?, WSJ, 31.5.2008,
    http://online.wsj.com/article/SB121218278041833793.html?mod=hpp_us_inside_today

Insure Me, Please

The Murky Politics of Mind-Body

March 30, 2008
The New York Times
By SARAH KERSHAW

From Plato and Aristotle to Descartes, the great thinkers have for millennia argued over what is known in philosophy as the “mind-body problem,” the relationship between spirit and flesh. Dualism tends to win the day: The mind and the body, while linked, are separate. They exist independently, perhaps mingling but not merging.

The debate lives on these days in less abstract form in the United States: How much of a difference should it make to health care — and health insurance — if a condition is physical or mental?

Decades of culture change and recent scientific studies have blurred the line between these types of disorders. Now a critical moment has been reached in a 15-year debate in statehouses and in Congress over whether treatment for problems like depression, addiction and schizophrenia should get the same coverage by insurance companies as, say, diabetes, heart disease and cancer.

This month, the House passed a bill that would require insurance companies to provide mental health insurance parity. It was the first time it has approved a proposal so substantial.

The bill would ban insurance companies from setting lower limits on treatment for mental health problems than on treatment for physical problems, including doctor visits and hospital stays. It would also disallow higher co-payments. The insurance industry is up in arms, as are others who envision sharply higher premiums and a free-for-all over claims for coverage of things like jet lag and caffeine addiction.

Parity raises all sorts of tricky questions. Is an ailment a legitimate disease if you can’t test for it? A culture tells the doctor the patient has strep throat. But if a patient says, ‘‘Doctor, I feel hopeless,’’ is that enough to justify a diagnosis of depression and health benefits to pay for treatment? How many therapy sessions are enough? If mental illness never ends, which is typically the case, how do you set a standard for coverage equal to that for physical ailments, many of which do end?

The United States has a long history of separating the treatment of mental and physical illnesses, dating back to the days when the severely mentally ill were put in poorhouses, jails and, later, public asylums. That ended after the deinstitutionalization movement of the 1960s, but mental health experts and advocates say that the delivery of services is still far from equal, because emotional illness is still not considered to be on a par with medical illness.

Countries like Canada and the United Kingdom, with national health care systems that don’t limit access to any services, have long ago moved toward merging these two branches of health care, and the Scandinavian countries are known for treating mental illnesses as medical diseases, according to researchers who have studied the various systems.

In the United States over the last five years, research studies examining the link between physical brain abnormalities and disorders like severe depression and schizophrenia have begun to make a strong case that the disorders are not scary tales of minds gone mad but manifestations of actual, and often fatal, problems in brain circuitry. These disorders affect behavior and mood, and they look different from Parkinson’s disease or multiple sclerosis in brain imaging. Still, a growing number of studies — and many more are under way — are making the biological connection, redefining the concept of mental illness as brain illness.

“Insurance companies balk at this, but there are striking similarities between mental and physical diseases,” said George Graham, the A.C. Reid professor of philosophy at Wake Forest University. “There is suffering, there is a lacking of skills, a quality of life tragically reduced, the need for help. You have to develop a conception of mental health that focuses on the similarities, respects the differences but does not allow the differences to produce radically disparate and inequitable forms of treatment.”

While squarely in the minority, some still question the legitimacy of calling any mental ailment a disease. A louder chorus argues that addiction is a behavioral and social problem, even a choice, but not a disease, as many mental health professionals and the founders and millions of followers of Alcoholics Anonymous maintain.

Critics of parity say that anything that would not turn up in an autopsy, as in depression or agoraphobia, cannot be equated with physical illness, either in the pages of a medical text or on an insurance claim. These critics also say that because the mental abnormality research is so new, it should still be considered theory rather than an established basis for equal payment and treatment. “Schizophrenia and depression refer to behavior, not to cellular abnormalities,” said Jeffrey A. Schaler, a psychologist and an assistant professor of justice, law and society at American University in Washington. “So what constitutes medicine? Is it what anybody says is medicine? Is it acupuncture? Is it homeopathy?”

Nevertheless, as federal parity legislation has wobbled along over the years, 42 states have adopted their own versions of parity, offering a patchwork of standards for insurance companies on coverage for addiction and mental illnesses. A federal law would extend insurance parity to tens of millions more Americans who are not covered under the laws and set one broad standard for the nation. As the states have experimented with parity, however, many providers have complained that insurance companies have often found it easy to deny benefits by ruling that claims are not “medically necessary,” a potentially tough standard when it comes to ailments of the mind.

Meanwhile, attitudes about mental illnesses and addiction have changed significantly in the decades since advocates for the mentally ill — and for parity — first tried to include broad coverage of mental illnesses in the nation’s insurance plans. Pop culture has normalized and even glamorized rehab and even suicide attempts, chipping away slowly at social stigmas and lending strength to the idea that the sufferer of a mental illness or addiction may be a victim, rather than a perpetrator. Still, a cancer patient generally remains a far more sympathetic figure than a cocaine addict or a schizophrenic.

But scientific advances may go a long way to help the parity cause. The biological and neurological connection lends strength to the notion that mental illnesses are as real and as urgent as physical illnesses and that there may, at long last, even be a cure in this lifetime, or the next.

And if you can cure something, you can treat it and there is a finite quality to that treatment — and its cost. So you may, if you are an insurance company, be a lot more willing to pay for it.

“The more research that is done, the more the science convinces us that there is simply no reason to separate mental disorders from any other medical disorder,” said Thomas R. Insel, director of the National Institute of Mental Health, which has conducted a series of studies on the connection between depression and brain circuitry and on Thursday released an important study showing a connection between genetics and the ability to predict the risk for schizophrenia.

Last fall, the Senate passed its own parity bill with substantial differences from the House bill, which had been co-sponsored by Representative Patrick J. Kennedy, Democrat of Rhode Island. Mr. Kennedy has admitted to struggling with addiction and depression.

Supporters and opponents both expect the negotiations over how to reconcile the two bills to be protracted; President Bush, who has voiced support for the more limited coverage called for in the Senate bill, has said he would not support the House version, which estimates a cost to the government of $3.8 billion over the next decade through coverage from federally funded insurance. The bill also includes ways to offset the cost.

The precise impact of the House bill on private health insurance premiums was difficult to calculate, insurance industry experts said, but they said that increases to group plans would be likely, with some of the costs passed on to employees. Neither bill applies to employers with 50 or fewer employees or to the individual insurance market.

Despite such warnings that premiums might increase, however, it is unclear by how much. Such extensive parity requirements have never been tested on a federal level, and one question is how many people might take advantage of new benefits even if they were available.

The uncertainty is plain when experts try to estimate the effect. The Congressional Budget Office estimated that the Senate bill, with its minimalist approach, would increase health-plan costs by four-tenths of one percent. However, a report released last month by the Council for Affordable Health Insurance, an insurance industry group, estimated that state-based parity formulas were likely to increase rates by about 5 to 10 percent, on average. And a 2006 study in The New England Journal of Medicine, examining the costs associated with a parity program put into place by President Bill Clinton for all federal employees, found that it actually didn’t increase the use or the cost of mental health services. And that plan, it said, was similar to the one proposed in the more generous House bill.

The House bill would require insurance companies that offer mental health benefits to cover treatment for the hundreds of diagnoses included in the Diagnostic and Statistical Manual of Mental Disorders, from paranoid schizophrenia to stuttering to insomnia to chronic melancholy, or dysthymia.

The Bush administration and other opponents say the list of disorders is far too broad. That leads from parity to another, parallel morass in the fields of psychiatry and pharmacology. Both fields are accused of over-diagnosis and of seizing on fashionable diagnoses — bipolar disorder or post-traumatic stress disorder, for example — for financial gain or through highly subjective assessments.

“It’s the phone-book approach of possible conditions,” said Karen Ignagni, president of America’s Health Insurance Plans, an industry group representing insurance companies that cover 200 million Americans. “And this comes at a time when advocates have made a very persuasive case about the importance of covering behavioral health.”

But in the halls of Congress, at least, the mind-body problem is far from resolved, particularly when it is uncertain who the next president will be.

    The Murky Politics of Mind-Body, NYT, 30.3.2008,
    http://www.nytimes.com/2008/03/30/weekinreview/30kers.html

Daring to Think Differently About Schizophrenia

February 24, 2008
The New York Times
By ALEX BERENSON

NORTH WALES, Pa. — SCIENTISTS who develop drugs are familiar with disappointment — brilliant theories that don’t pan out or promising compounds derailed by unexpected side effects. They are accustomed to small steps and wrong turns, to failure after failure — until, in a moment, with hard work, brainpower and a lot of luck, all those little failures turn into one big success.

For Darryle D. Schoepp, that moment came one evening in October 2006, while he was seated at his desk in Indianapolis.

At the time, he was overseeing early-stage neuroscience research at Eli Lilly & Company and colleagues had just given him the results from a human trial of a new schizophrenia drug that worked differently than all other treatments. From the start, their work had been a long shot. Schizophrenia is notoriously difficult to treat, and Lilly’s drug — known only as LY2140023 — relied on a promising but unproved theory about how to combat the disorder.

When Dr. Schoepp saw the results, he leapt up in excitement. The drug had reduced schizophrenic symptoms, validating the efforts of hundreds of scientists, inside and outside of Lilly, who had labored together for almost two decades trying to unravel the disorder’s biological underpinnings.

The trial results were a major breakthrough in neuroscience, says Dr. Thomas R. Insel, director of the National Institute of Mental Health. For 50 years, all medicines for the disease had worked the same way — until Dr. Schoepp and other scientists took a different path.

“This drug really looks like it’s quite a different animal,” Dr. Insel says. “This is actually pretty innovative.”

Dr. Schoepp and other scientists had focused their attention on the way that glutamate, a powerful neurotransmitter, tied together the brain’s most complex circuits. Every other schizophrenia drug now on the market aims at a different neurotransmitter, dopamine.

The Lilly results have fueled a wave of pharmaceutical industry research into glutamate. Companies are searching for new treatments, not just for schizophrenia, but also for depression and Alzheimer’s disease and other unseen demons of the brain that torment tens of millions of people worldwide.

Driving the industry’s interest is the huge market for drugs for brain and psychiatric diseases. Worldwide sales total almost $50 billion annually, even though existing medicines have moderate efficacy and have side effects that range from reduced libido to diabetes.

The glutamate researchers warn that their quest for new treatments for schizophrenia is far from complete. The results of the Lilly trial covered only 196 patients and must be validated by much larger trials, the last of which may not be finished until at least 2011. Other glutamate drugs are even further away from approval. And even if the drugs win that approval, they may be viewed skeptically by doctors who have been disappointed by side effects in other drugs that were once been hailed as breakthroughs.

Still, for Dr. Schoepp, the drug’s progress so far is cause for celebration — and relief.

“I don’t think people appreciate how much money, time and good technical research goes into what we do,” he says. “Sometimes, people think the idea is the thing. I think the idea can be the easy part.”

LILLY continues to develop LY2140023 and has begun a trial of 870 patients that is scheduled to be completed in January 2009. But Dr. Schoepp is no longer involved in its development. He left Lilly in April to become senior vice president and head of neuroscience research at Merck, where he oversees a division of 300 researchers and support staff members.

Dr. Schoepp’s new base is a modest office on the top floor of a four-story Merck building here in North Wales, north of Philadelphia. He has a view of the building’s big front lawn and a busy two-lane road called the Sumneytown Pike. The huge Merck research complex called West Point, where 4,000 scientists and support staff members work, is less than a mile to the north.

For Dr. Schoepp, 52, the Merck job is the latest stop in a research career that began at Osco Drug’s store No. 807 in downtown Bismarck, N.D. He grew up in Bismarck in a working-class family; at 16, he started working at the Osco, which has since closed. He quickly decided to become a scientist.

“I just found it fascinating,” he says. “I was hungry for science.” While reading a magazine for pharmacists, he noticed an ad for a free pamphlet published by Merck called “Pharmacists in Industry.” He wrote away for the pamphlet, which convinced him that he could have a career developing medicines.

He applied to North Dakota State University, where he focused on psychopharmacology, a discipline that studies the way chemicals affect the brain. “I was really interested in psychiatric disorders,” he says. “I fell in love with dopamine.”

His love affair was so consuming that his wife joked that “dopamine” would be his daughter’s first word.

Although scientists sometimes decide to study a disease because of problems it has caused among family members, Dr. Schoepp says his fascination with mental illness has been purely academic. “My family has more heart disease than anything else,” he says.

After graduating from North Dakota State, he received a scholarship to a doctoral program in pharmacology and toxicology at West Virginia University. He graduated in 1982. Nearly five years later, he joined Lilly, which was about to introduce Prozac, the first modern antidepressant — a drug that changed both psychiatry and the public perception of depression and mental illness.

Prozac became a blockbuster almost instantly after Lilly introduced it in 1987, making the company one of the most visible players in Big Pharma and giving it room to invest in long-shot scientific research. Ray Fuller, a Lilly scientist who was a co-discoverer of Prozac, encouraged Dr. Schoepp to focus his attention on glutamate.

Glutamate is a pivotal transmitter in the brain, the crucial link in circuits involved in memory, learning and perception. Too much glutamate leads to seizures and the death of brain cells. Excessive glutamate release is also one of the main reasons that people have brain damage after strokes. Too little glutamate can cause psychosis, coma and death.

“The main thoroughfare of communication in the brain is glutamate,” says Dr. John Krystal, a psychiatry professor at Yale and a research scientist with the VA Connecticut Health Care System.

Along with Bita Moghaddam, a neuroscientist who was at Yale and is now at the University of Pittsburgh, Dr. Krystal has been responsible for some of the fundamental research into how glutamate works in the brain and how it may be implicated in schizophrenia.

Schizophrenia affects about 2.5 million Americans, about 1 percent of the adult population, and it usually develops in the late teens or early to mid-20s. It is believed to result from a mix of causes, including genetic and environmental triggers that cause the brain to develop abnormally.

The first schizophrenia medicines were developed accidentally about a half-century ago, when Henri Laborit, a French military surgeon, noticed that an antinausea drug called chlorpromazine helped to control hallucinations in psychotic patients. Chlorpromazine, sold under the brand name Thorazine, blocks the brain’s dopamine receptors. That led the way in the 1960s for drug companies to introduce other medicines that worked the same way.

The medicines, called antipsychotics, gave many patients relief from the worst of their hallucinations and delusions. But they also can cause shaking, stiffness and facial tics, and did not help the cognitive problems or the so-called negative symptoms like social withdrawal associated with schizophrenia.

In the 1980s, drug companies looked for new ways to treat the disease with fewer side effects. By the mid-1990s, they had introduced several new schizophrenia medicines, including Zyprexa, from Lilly, and Risperdal, from Johnson & Johnson. At the time, the new medicines were hailed as a major advance — and the companies marketed them that way to doctors and patients.

In fact, the new medicines, called second-generation antipsychotics, had much in common with the older drugs. Both worked mainly by blocking dopamine and had little effect on negative or cognitive symptoms. The newer medicines caused fewer movement disorders, but had side effects of their own, including huge weight gain for many patients. Many doctors now complain that the companies oversold the second-generation compounds and that new treatments are badly needed.

“People say that there are drugs to treat schizophrenia,” says Dr. Carol A. Tamminga, professor of psychiatry at the University of Texas Southwestern, in Dallas. “In fact, the treatment for schizophrenia is at best partial and inadequate. You have a cadre of cognitively impaired people who can’t fit in.”

WHILE most of the industry focused on second-generation medicines during the 1980s and 1990s, a handful of academic and industry researchers found intriguing hints that glutamate might provide an alternative treatment pathway.

Psychiatrists and neuroscientists have wondered about a possible connection between glutamate and schizophrenia since the early ’80s, when they first learned that phencyclidine, the street drug commonly called PCP, blocks the release of glutamate.

People who use PCP often have the hallucinations, delusions, cognitive problems and emotional flatness that are characteristic of schizophrenia. Psychiatrists noted PCP’s side effects as early as the late 1950s. But they lacked the tools to determine how PCP affected the brain until 1979, when they found that it blocked a glutamate receptor, called the NMDA receptor, that is at the center of the transmission of nerve impulses in the brain.

The PCP finding led a few scientists to begin researching glutamate’s role in psychosis and other brain disorders. By the early 1990s, they discovered that besides triggering the primary glutamate receptors — NMDA and AMPA — glutamate also triggered several other receptors.

They called these newly found receptors “metabotropic,” because the receptors modified the amount of glutamate that cells released rather than simply turning circuits on or off. Because glutamate is so central to the brain’s activity, directly blocking or triggering the NMDA and AMPA receptors can be very dangerous. The metabotropic receptors appeared to be better targets for drug treatment.

“Rather than acting as an all-or-nothing signal, they fine-tune that signal and modulate that signal,” said P. Jeffrey Conn, director of a Vanderbilt University drug research program. “It’s really an attempt to be very subtle in the way that you regulate the system.”

During the 1990s, molecular biologists discovered genes for eight metabotropic glutamate receptors, which were located at different places inside nerve cells and had different structures. The finding allowed for the possibility that drug companies could create chemicals to turn them on and off selectively, rather than hitting all of them at once.

For Dr. Schoepp and others, finding the receptors was only the first part of the struggle. They also had to find chemicals that would either block or trigger the receptors selectively. At the same time, the chemicals had to be relatively easy to formulate and capable of crossing the blood-brain barrier, which protects the brain from being easily penetrated by outside agents.

The work was arduous, but the Lilly scientists made slow progress. In 1999, Dr. Schoepp and two other scientists published a 46-page research paper that detailed scores of different chemicals that produced reactions at the glutamate sites.

At about the same time, scientists at Yale, led by Dr. Moghaddam, were demonstrating that activating metabotropic glutamate receptors in rats could reverse the effects of PCP — a seminal finding, providing the first proof that altering the path of glutamate transmission in the brain might help relieve the symptoms of psychosis.

Although the finding in rats was promising, developing animal models for schizophrenia and other brain diseases is extremely difficult, said Paul Greengard, professor of molecular and cellular neuroscience at Rockefeller University.

Even when compared with diseases like cancer, brain disorders are notoriously complex. Scientists have only a limited understanding of the chemistry of consciousness, or of how problems in the brain’s electrical circuitry affect the ability to form memories, learn or think.

“We do not know with any of these neuropsychiatric disorders what the ultimate basis is,” Dr. Greengard says. “Let’s say you could find that too much of protein X was involved in schizophrenia. Would you then know what schizophrenia is? You would not.”

Nonetheless, the findings in rats were promising. Those studies, as well as Dr. Krystal’s tests in 2001 of volunteers given ketamine, a drug that has effects similar to PCP, hinted that the glutamate drugs might help to treat the cognitive and negative symptoms of schizophrenia. Drugs currently on the market do little to treat those symptoms.

Even before the findings at Yale, Lilly had put its first metabotropic glutamate receptor compound into human testing. Researchers initially tested the drug on patients with panic disorder, and it showed some positive results. But Lilly stopped human testing of the drug in 2001 when long-term testing in animals showed that it caused seizures.

Even so, Lilly decided that it had enough evidence to justify tests of another chemical compound, LY404039, that affected the same receptors.

“They had to take a risk on letting these drugs be tested on models or for disorders that were justified purely on pretty basic science,” Dr. Krystal says. “There is nothing with these drugs that is straightforward or makes developing them a basic path.”


When it tried to test LY404039 in humans, the company ran into yet another hurdle. The human body didn’t easily absorb it. So Lilly created a drug that the body could absorb, LY2140023, which is metabolized into LY404039 in the body.

Bingo. LY2140023 was the drug that got Dr. Schoepp jumping out of his office chair in 2006, nearly three years after the first trials in humans began. In the Lilly test, the drug was slightly less effective over all than Zyprexa, which is considered the most effective among the widely used schizophrenia treatments.

But LY2140023 also appeared to have fewer side effects than Zyprexa, which can cause severe weight gain and diabetes. The new drug also appeared to improve cognition, something that existing treatments don’t do, said Dr. Insel of the National Institute of Mental Health.

IF Lilly’s new round of tests confirms the drug’s efficacy by early next year, the company is likely to move ahead to an even larger clinical trial, involving thousands of patients, that could lead to federal approval for the compound. Still, approval is at least three to four years away, and other big drug makers are already scrambling to compete with Lilly.

In January, Pfizer agreed to pay Taisho Pharmaceutical, a Japanese company, $22 million for the rights to develop Taisho’s glutamate drug for schizophrenia. Taisho will receive more payments if the drug moves forward in development.

Since it hired Dr. Schoepp, Merck has also been moving aggressively. It has struck two deals since December to work with Addex Pharmaceuticals, a Swiss company, to develop glutamate drugs for schizophrenia, Parkinson’s and other diseases. Merck has paid Addex $25 million so far, with more payments to come if the drugs move forward.

Another glutamate drug, meanwhile, has been shown in preclinical studies to reverse mental retardation in adult rats, a finding that previously appeared impossible, Dr. Insel said.

Dr. Steven M. Paul, the president of Lilly Research Laboratories, says Lilly expects competition in glutamate research to intensify. “We’d like to believe we have a head start here, and hopefully a good head start,” he says. “But this area will heat up here; this will be an area where there will be a lot of investment.”

For Dr. Schoepp, the sudden interest in glutamate is exciting, and he acknowledges that he eagerly awaits the results of the large Lilly trial early next year. And what if the drug fails in that trial, after all the work that he and scientists around the world have put in?

“I would probably go out and have a beer,” he says. “You have to define failure. If you collect information and it tells you what you need to know, you’re not a failure.”

    Daring to Think Differently About Schizophrenia, NYT, 24.2.2008,
    http://www.nytimes.com/2008/02/24/business/24drug.html

Midlife Suicide Rises, Puzzling Researchers

February 19, 2008
The New York Times
By PATRICIA COHEN

Shannon Neal can instantly tell you the best night of her life: Tuesday, Dec. 23, 2003, the Hinsdale Academy debutante ball. Her father, Steven Neal, a 54-year-old political columnist for The Chicago Sun-Times, was in his tux, white gloves and tie. “My dad walked me down and took a little bow,” she said, and then the two of them goofed it up on the dance floor as they laughed and laughed.

A few weeks later, Mr. Neal parked his car in his garage, turned on the motor and waited until carbon monoxide filled the enclosed space and took his breath, and his life, away.

Later, his wife, Susan, would recall that he had just finished a new book, his seventh, and that “it took a lot out of him.” His medication was also taking a toll, putting him in the hospital overnight with worries about his heart.

Still, those who knew him were blindsided. “If I had just 30 seconds with him now,” Ms. Neal said of her father, “I would want all these answers.”

Mr. Neal is part of an unusually large increase in suicides among middle-aged Americans in recent years. Just why thousands of men and women have crossed the line between enduring life’s burdens and surrendering to them is a painful question for their loved ones. But for officials, it is a surprising and baffling public health mystery.

A new five-year analysis of the nation’s death rates recently released by the federal Centers for Disease Control and Prevention found that the suicide rate among 45-to-54-year-olds increased nearly 20 percent from 1999 to 2004, the latest year studied, far outpacing changes in nearly every other age group. (All figures are adjusted for population.)


For women 45 to 54, the rate leapt 31 percent. “That is certainly a break from trends of the past,” said Ann Haas, the research director of the American Foundation for Suicide Prevention.

By contrast, the suicide rate for 15-to-19-year-olds increased less than 2 percent during that five-year period — and decreased among people 65 and older.

The question is why. What happened in 1999 that caused the suicide rate to suddenly rise primarily for those in midlife? For health experts, it is like discovering the wreckage of a plane crash without finding the black box that recorded flight data just before the aircraft went down.

Experts say that the poignancy of a young death and higher suicide rates among the very old in the past have drawn the vast majority of news attention and prevention resources. For example, $82 million was devoted to youth suicide prevention programs in 2004, after the 21-year-old son of Senator Gordon H. Smith, Republican of Oregon, killed himself. Suicide in middle age, by comparison, is often seen as coming at the end of a long downhill slide, a problem of alcoholics and addicts, society’s losers.

“There’s a social-bias issue here,” said Dr. Eric C. Caine, co-director at the Center for the Study of Prevention of Suicide at the University of Rochester Medical Center, explaining why suicide in the middle years of life had not been extensively studied before.

There is a “national support system for those under 19, and those 65 and older,” Dr. Caine added, but not for people in between, even though “the bulk of the burden from suicide is in the middle years of life.”

Of the more than 32,000 people who committed suicide in 2004, 14,607 were 40 to 64 years old (6,906 of those were 45 to 54); 5,198 were over 65; 2,434 were under 21 years old.

Complicating any analysis is the nature of suicide itself. It cannot be diagnosed through a simple X-ray or blood test. Official statistics include the method of suicide — a gun, for instance, or a drug overdose — but they do not say whether the victim was an addict or a first-time drug user. And although an unusual event might cause the suicide rate to spike, like in Thailand after Asia’s economic collapse in 1997, suicide much more frequently punctuates a long series of troubles — mental illness, substance abuse, unemployment, failed romances.

Without a “psychological autopsy” into someone’s mental health, Dr. Caine said, “we’re kind of in the dark.”

The lack of concrete research has given rise to all kinds of theories, including a sudden drop in the use of hormone-replacement therapy by menopausal women after health warnings in 2002, higher rates of depression among baby boomers or a simple statistical fluke.

At the moment, the prime suspect is the skyrocketing use — and abuse — of prescription drugs. During the same five-year period included in the study, there was a staggering increase in the total number of drug overdoses, both intentional and accidental, like the one that recently killed the 28-year-old actor Heath Ledger. Illicit drugs also increase risky behaviors, C.D.C. officials point out, noting that users’ rates of suicide can be 15 to 25 times as great as the general population.

Jeffrey Smith, a vigorous fisherman and hunter, began ordering prescription drugs like Ambien and Viagra over the Internet when he was in his late 40s and the prospect of growing older began to gnaw at him, said his daughter, Michelle Ray Smith, who appears on the television soap “Guiding Light.” Five days before his 50th birthday, he sat in his S.U.V. in Bloomfield Hills, Mich., letting carbon monoxide fill his car.

Linda Cronin was 43 and working in a gym when she gulped down a lethal dose of prescription drugs in her Denver apartment in 2006, after battling eating disorders and depression for years.

Looking at the puzzling 28.8 percent rise in the suicide rate among women ages 50 to 54, Andrew C. Leon, a professor of biostatistics in psychiatry at Cornell, suggested that a drop in the use of hormone replacement therapy after 2002 might be implicated. It may be that without the therapy, more women fell into depression, Dr. Leon said, but he cautioned this was just speculation.

Despite the sharp rise in suicide among middle-aged women, the total number who died is still relatively small: 834 in the 50-to-54-year-old category in 2004. Over all, four of five people who commit suicide are men. (For men 45 to 54, the five-year rate increase was 15.6 percent.)

Veterans are another vulnerable group. Some surveys show they account for one in five suicides, said Dr. Ira Katz, who oversees mental health programs at the Department of Veterans Affairs. That is why the agency joined the national toll-free suicide hot line last August.

In the last five years, Dr. Katz said, the agency has noticed that the highest suicide rates have been among middle-aged men and women. Those most affected are not returning from Iraq or Afghanistan, he said, but those who served in Vietnam or right after, when the draft ended and the all-volunteer force began. “The current generation of older people seems to be at lesser risk for depression throughout their lifetimes” than the middle-aged, he said.

That observation seems to match what Myrna M. Weissman, the chief of the department in Clinical-Genetic Epidemiology at New York State Psychiatric Institute, concluded was a susceptibility to depression among the affluent and healthy baby boom generation two decades ago, in a 1989 study published in The Journal of the American Medical Association. One possible reason she offered was the growing pressures of modern life, like the changing shape of families and more frequent moves away from friends and relatives that have frayed social support networks.

More recently, reports of a study that spanned 80 countries found that around the world, middle-aged people were unhappier than those in any other age group, but that conclusion has been challenged by other research, which found that among Americans, middle age is the happiest time of life.

Indeed, statistics can sometimes be as confusing as they are enlightening. Shifts in how deaths are tallied make it difficult to compare rates before and after 1999, C.D.C. officials said. Epidemiologists also emphasize that at least another five years of data on suicide are needed before any firm conclusions can be reached about a trend.

The confusion over the evidence reflects the confusion and mystery at the heart of suicide itself.

Ms. Cronin explained in a note that she had struggled with an inexplicable gloom that would leave her cowering tearfully in a closet as early as age 9. After attempting suicide before, she had checked into a residential treatment program not long before she died, but after a month, her insurance ran out. Her parents had offered to continue the payments, but her sister, Kelly Gifford, said Ms. Cronin did not want to burden them.

Ms. Gifford added, “I think she just got sick of trying to get better.”

    Midlife Suicide Rises, Puzzling Researchers, NYT, 19.2.2008,
    http://www.nytimes.com/2008/02/19/us/19suicide.html

Vicious Killing Where Troubled Seek a Listener

February 14, 2008
The New York Times
By AL BAKER

It was just after 8 p.m. in a suite of mental health offices at East 79th Street and York Avenue. One doctor was seeing patients; another was working in her study.

It is a common scene in the offices of countless Manhattan therapists after dark: The lights stay on as paperwork is done and patients are treated into the evening.

Then a middle-aged man in a black cap and sneakers came in from the freezing rain, toting two pieces of black luggage. He said he was there to see a psychiatrist named Kent D. Shinbach. But Dr. Shinbach had another patient, a woman, waiting for him, so the man sat on a couch and made small talk. Then he disappeared into the office of the other doctor, Kathryn Faughey, the police said.

And there — in what investigators described as a furious swirl of violence on Tuesday night — the man stabbed Dr. Faughey in the head, face and chest. Hearing her screams, Dr. Shinbach rushed in and saw her lying still and bleeding on the tan carpet by the foot of her desk.

The attacker turned on him, stabbing him in the face, head and hands, the police said. Dr. Faughey, 56, was declared dead at the scene; Dr. Shinbach, who is in his 70s, survived, but was left in critical condition.

A day later, the police said they did not know the motive for the frenzied attack nor the identity of the killer, though investigators are pursuing the possibility that he was a patient at the offices, where five health care professionals work, or that he was a relative of a patient there or was somehow involved with one.

But even before a motive had been determined, psychiatrists, psychologists and social workers who work in Manhattan — a place long linked in the public imagination with the stereotypical image of an urbanite on a couch discussing his worries — reacted with alarm. Several said the violence in the office at 435 East 79th Street reminded them of the dangers inherent in a career spent helping people, particularly those in emotional pain.

Dr. Faughey grew up in Sunnyside, Queens, and lived across the street from her office. Her husband of 25 years, Walter Adam, said he became worried about 8:30 p.m. because his wife was late. He looked out the window of their 17th-floor apartment and noticed that the light was still on in her office. He called and got no answer. Then he saw police cars on the block.

“I thought it was an automobile accident,” he said. “Finally I said, ‘I better go over and see what’s going on.’ ”

He heard the news from a police officer: His wife had been killed.

“She’s taken very good care of me,” Mr. Adam said. “She’s looked after me. She’s a good and decent woman. Never harmed anyone.”

Police Commissioner Raymond W. Kelly said that after stabbing both doctors, the attacker pinned Dr. Shinbach against the wall with a spindled chair, took $90 from his wallet and fled to the building’s neatly painted basement and out a service exit. He left his two suitcases behind in the basement, where the police found a smear of blood on the door. The woman who had been waiting to see Dr. Shinbach had gone into his office at one point and was unharmed.

During the attack on Dr. Shinbach, which lasted about 10 minutes, the attacker told him, “She’s dead,” the police said, adding that other comments he made did not shed light on his actions.

Mr. Kelly said a key part of the investigation was to determine whether the killer “was a patient of any of the health care professionals in that suite of offices.”

Three knives were later found: one at Dr. Faughey’s left foot; another, a 9-inch blade that was bent in the attack, underneath her desk; and a meat cleaver, also bent and with a broken handle, lying in front of a wall of books. Blood was splashed on the walls and floor. “It was obvious a fierce struggle had taken place,” said Paul J. Browne, the Police Department’s chief spokesman.

Investigators found that the larger suitcase, which had wheels and a handle, held women’s slippers and a blouse, as well as disposable diapers for adults. Inside the smaller bag were eight knives — mostly kitchen knives — three lengths of rope and rolls of duct tape.

Dr. Faughey received a doctorate in clinical psychology from the Ferkauf Graduate School of Psychology at Yeshiva University in 1981. She had been practicing cognitive behavior psychotherapy on the Upper East Side for more than 20 years, according to her Web site.

“My approach is focused and solution-oriented,” according to a quotation on the site. “My sessions move quickly. I am interactive, and I give feedback.”

Mr. Adam said his wife achieved tremendous results for her patients. “The way she turned around people’s lives, saved people’s lives,” he said.

“She was always a person who was reading and studying,” said Kevin Faughey, Dr. Faughey’s oldest brother and one of her six siblings. “She always had goals in her life that she wanted to do something for humanity, in some way, shape or form to help.”

Dr. Shinbach has admitted patients to Beth Israel Medical Center and Gracie Square Hospital, said Dr. Michael Serby, an associate chairman of Beth Israel. “Clearly he’s a brave individual and a hero.”

Dr. Frederick J. Long, a Manhattan psychiatrist who has known Dr. Shinbach for 14 years, described him as dedicated and caring. “He is the best mentor I’ve ever had,” Dr. Long said, adding that Dr. Shinbach was among the first psychiatrists to take an interest in elderly patients.

Another colleague said Dr. Shinbach’s relationship with Dr. Faughey was limited to the shared office space; they did not see each other’s patients.

The attacker’s entrance and departure were captured by security cameras. He arrived at the first-floor offices just after 8 p.m. He left at 8:59 p.m. through the basement door, on which investigators found blood. Investigators said the attacker might have cut his hand. It is common in such furious attacks, when blood can make the weapons slick. The police said DNA tests would be conducted to determine whose the blood was, but it was unclear how long the tests would take.

In the videotape, the man’s arrival is seen as a doorman holds a glass door open for him; he briskly walks in, stating that he was there to see Dr. Shinbach. Pulling his bags, he then goes up a short set of steps from the lobby to the professional offices.

The videotape of the man leaving shows him from behind, as he rounds a corner in the basement and disappears out the exit, onto 79th Street between First and York Avenues. The police are checking security videos from businesses in the area to see if they can pick up images of him.

At a news conference, Mr. Kelly held up a sketch of the suspect that was based on descriptions provided by witnesses who saw the man before the attack.

Dr. Shinbach, who was interviewed by detectives after undergoing surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, did not recognize his attacker.

Mr. Kelly described the killer as a man in his 40s, about 5-foot-9, with brownish or blond hair. He was wearing a three-quarter-length green coat and sneakers. A baseball cap believed to be the killer’s was found in Dr. Faughey’s office, the police said.

After the attack, Dr. Shinbach yelled for help from Dr. Faughey’s office window. The building’s doorman had left just left on a break and heard his cries.

Later, the doorman, Frank Batista, said he was almost certain he could identify the attacker — “99.9 percent.”

Reporting was contributed by John Eligon, Dmitry Kiper,

Robin Stein, Stacey Stowe, Andrew Tangel and Carolyn Wilder.

    Vicious Killing Where Troubled Seek a Listener, NYT, 14.2.2008,
    http://www.nytimes.com/2008/02/14/nyregion/14slay.html

Working in Mental Health,

the Prospect of Violence Is a Part of the Job

February 14, 2008
The New York Times
By JAMES BARRON

Therapists — psychiatrists, psychotherapists, psychiatric social workers and other mental health professionals — are as much part of the New York landscape as hot dog vendors. And they have discovered, sometimes the hard way, that delving deeply into people’s feelings can be dangerous.

As police detectives searched on Wednesday for a man who killed a psychologist with a meat cleaver and other knives — and seriously injured another therapist, who heard their struggle from his nearby office and went to help — therapists said they had learned to develop their own physical and psychological defenses against violence.

But they conceded that a shrewd and determined attacker who appears normal could fool them.

“You do this work long enough, and you pretty much see everything, even in Manhattan,” said Dr. Robert H. Reiner, the executive director of Behavioral Associates, a private outpatient psychotherapy institute on the Upper East Side.

The identity of the attacker in Tuesday’s killing was not known, and the police said it was not clear if he was a patient or a patient’s relative, or if he had some other connection to the victims.

Still, therapists said they recognized the inherent risk in treating some types of patients. Dr. Reiner said most of the patients he saw, in six to eight “intake interviews” a day, had anxiety disorders that carried a low risk of violence. But every so often, he realizes that a patient has a severe psychosis.

“Often as not, it’s someone who’s walking around like you and me, and the psychosis is well disguised, and I realize they could be dangerous,” Dr. Reiner said. “And I look at the window and I think, ‘How quick can I get out?’ Every psychotherapist in an urban area knows this feeling.”

Just how much violence is directed at therapists is an open question. Of a dozen therapists in private practice in New York City who were interviewed on Wednesday, only one said he had ever seen violence in his office, and he was not the target: A father and son came to blows, he said.

But when Christina E. Newhill, an associate professor at the University of Pittsburgh, surveyed 1,129 therapeutic workers nationwide in 2003, 58 percent said they had had to deal with violence, though only 24 percent of those said they had actually been attacked. Twenty-five percent of those who had to deal with violence said clients had damaged or destroyed property, while half said the episodes did not go beyond threats.

Gary Arthur, a professor emeritus at Georgia State University, surveyed all 6,400 licensed therapists in Georgia in 2001. Of the 1,132 who responded, 14 had been shot at, 6 attacked with a knife, 209 pushed or shoved, 112 slapped and 87 hit by objects thrown at them. None of the therapists who said they had been shot at were struck by the bullets, he said.

“The results were scary,” he said in an interview. “Our profession remains very high on the list for risk of danger.”

Twice in his years as a psychologist, Dr. Alan Hilfer, now the chief psychologist at Maimonides Medical Center in Brooklyn, has had to deal with violent patients: once when a father and son got into a knock-down-drag-out brawl in his consultation room, and once when a teenager threw a paperweight at the therapist in the next office.

Dr. Hilfer said therapists were not taught precautions — like where to position oneself during a consultation — during training.

He recalled being asked, early in his career, to interview a man seeking treatment. “I allowed him to come between me and the door” in the consultation room, Dr. Hilfer said. “He became agitated and threatening, and I couldn’t get out of the room.”

In some group practices or in hospitals, he said, therapists leave the door open during a first encounter with a patient. They also alert a colleague, who listens for sounds of a disturbance.

Dr. Newhill teaches a class that tells prospective therapists how to do risk assessments and handle patients who turn violent. In a telephone interview, she said she started the class because of a murder in California in 1989. A therapist at a mental health clinic in Santa Monica was stabbed 31 times in her office by a patient, a street person who Dr. Newhill said was delusional.

“Violence is an interaction between the person and their environment,” she said, adding that the best predictor of future violence is a recent history of violence. She tells her students to work out, in advance, a plan that includes a way to signal for help. Some therapists install silent alarms. Others work out a phrase that lets a colleague know help is needed: “Please cancel my appointment for 3 o’clock” could mean “Call 911,” for example.

Dr. Reiner, of Behavioral Associates, said patients who turn violent had often “scoped things out in advance.” He said they would figure out whether a therapist worked alone or in an office with secretaries, other therapists or even video surveillance cameras.

But therapists who work by themselves, as many do in Manhattan, cannot turn to a colleague or a subordinate for assistance when a session degenerates.

“There is no warning system” for solo practitioners, Dr. Hilfer said. “We can try to use our clinical awareness and our knowledge of the patient, and if we are concerned about a patient, we will send them for a consult with someone. But in terms of protection, there’s none. It underscores the vulnerability that many of us understand.”

John Eligon and Anthony Ramirez contributed reporting.

    Working in Mental Health, the Prospect of Violence Is a Part of the Job, NYT, 14.2.2008,
    http://www.nytimes.com/2008/02/14/nyregion/14pysch.html

Man Sought in Psychologist’s Stabbing

February 13, 2008
The New York Times
By AL BAKER

Armed with a suitcase full of knives, an unidentified middle-aged man unleashed a rampage of violence inside the offices of an Upper East Side psychiatry practice on Tuesday night, fatally stabbing and slashing a well-known psychologist before wounding her colleague when he tried to come to her aid, officials said on Wednesday.

The assailant had not been identified as of Wednesday afternoon, the police said, though investigators were pursuing a theory that he was either a patient at the suite of offices, at 440 East 79th Street, or that he had some kind of ties to the establishment or the services it provided.

Originally, the assailant had arrived at the offices, about five seconds after 8 p.m. on Tuesday, asking to visit Dr. Kent T. Shinbach, 70, a psychiatrist there, the police said.

But at some point he disappeared inside the office of another counselor there, Kathryn Faughey, 56, the police said.

There, he unleashed a barrage of violence, fatally stabbing Dr. Faughey. At some point, when Dr. Shinbach heard the attack and went to the office of his colleague, the assailant turned on him and Dr. Shinbach was seriously injured, officials said.

The scene was marked by blood and upended furniture, the police and neighbors said.

“We could see in the office where the blinds had been ripped off and were hanging at a strange angle and the entire office was in disarray,” said Alexandra Pike, 20, a student who could see into the office where the attack occurred from the window of her apartment across the street. “Papers were strewn around and there was overturned furniture. And it was clear there was some kind of scuffle.”

It is unclear what the man’s motive was, and Police Commissioner Raymond W. Kelly released a sketch of the suspect after a news conference at 1 Police Plaza on Wednesday, saying detectives were seeking him. The sketch was based on descriptions provided to detectives of those who saw the man in the moments before the attack — including the surviving victim — but who could not identify him by name.

“Obviously there is a forensic evidence aspect to this case,” Mr. Kelly said. “We’re getting information from the doctor and other medical professionals in the suite to determine if they have any information to add as the investigation goes forward.”

He added: “We’re fully engaged on several fronts.”

Mr. Kelly described the assailant as a man in his 40’s, about 5 feet 9 inches, with brownish or blond hair. He was wearing a three-quarter length green coat, with sneakers and a baseball cap, said Mr. Kelly, as he held up the sketch before a bank of television cameras.

The first sign of the man’s entrance at the building was captured on videotape —as he walked in the front door about five seconds after 8 p.m., passed by a doorman and went into the counselors’ suite of offices, the police said. He was inside for about an hour: A videotape showed him leaving through a basement door about 8:54 p.m., the police said, and it showed a view of him from his back.

Blood was found on the door — a panic door that locks on its own when it shuts — indicating the assailant might have been wounded.

Before he fled, the assailant left two suitcases in the basement. Inside one was assorted women’s clothing — some shoes, a top, as well as diapers for adults. He other had about eight knives, the police said. Upstairs in the room of Ms. Faughey, investigators found three other weapons, including two knives and a cleaver with a broken handle, the police said.

A female patient was in the lobby of the counselors’ suite when the assailant showed up, the police said. She apparently left before the attack on Dr. Faughey became known, but detectives tracked her down and interviewed her, the police said. Dr. Shinbach was also interviewed after undergoing surgery at New York Hospital/Weill Cornell Medical Center.

    Man Sought in Psychologist’s Stabbing, NYT, 13.2.2008,
    http://www.nytimes.com/2008/02/13/nyregion/13doc.html

Orphanages Stunt Mental Growth, a Study Finds

December 21, 2007
The New York Times
By BENEDICT CAREY

Psychologists have long believed that growing up in an institution like an orphanage stunts children’s mental development but have never had direct evidence to back it up.

Now they do, from an extraordinary years-long experiment in Romania that compared the effects of foster care with those of institutional child-rearing.

The study, being published on Friday in the journal Science, found that toddlers placed in foster families developed significantly higher I.Q.’s by age 4, on average, than peers who spent those years in an orphanage.

The difference was large — eight points — and the study found that the earlier children joined a foster family, the better they did. Children who moved from institutional care to families after age 2 made few gains on average, though the experience varied from child to child. Both groups, however, had significantly lower I.Q.’s than a comparison group of children raised by their biological families.

Some developmental psychologists had sharply criticized the study and its sponsor, the MacArthur Foundation, for researching a question whose answer seemed obvious. But previous attempts to compare institutional and foster care suffered from serious flaws, mainly because no one knew whether children who landed in orphanages were different in unknown ways from those in foster care. Experts said the new study should put to rest any doubts about the harmful effects of institutionalization — and might help speed up adoptions from countries that still allow them.

“Most of us take it as almost intuitive that being in a family is better for humans than being in an orphanage,” said Seth Pollak, a psychologist at the University of Wisconsin, who was not involved in the research. “But other governments don’t like to be told how to handle policy issues based on intuition.

“What makes this study important,” he went on, “is that it gives objective data to say that if you’re going to allow international adoptions, then it’s a good idea to speed things up and get kids into families quickly.”

In recent years many countries, including Romania, have banned or sharply restricted American families from adopting local children. In other countries, adoption procedures can drag on for many months. In 2006, the latest year for which numbers are available, Americans adopted 20,679 children from abroad, more than half of them from China, Guatemala and Russia.

The authors of the new paper, led by Dr. Charles H. Zeanah Jr. of Tulane and Charles A. Nelson III of Harvard and Children’s Hospital in Boston, approached Romanian officials in the late 1990s about conducting the study. The country had been working to improve conditions at its orphanages, which became infamous in the early 1990s as Dickensian warehouses for abandoned children.

After gaining clearance from the government, the researchers began to track 136 children who had been abandoned at birth. They administered developmental tests to the children, and then randomly assigned them to continue at one of Bucharest’s six large orphanages, or join an adoptive family. The foster families were carefully screened and provided “very high-quality care,” Dr. Nelson said.

On I.Q. tests taken at 54 months, the foster children scored an average of 81, compared to 73 among the children who continued in an institution. The children who moved into foster care at the youngest ages tended to show the most improvement, the researchers found.

The comparison group of youngsters who grew up in their biological families had an average I.Q. of 109 at the same age, found the researchers, who announced their preliminary findings as soon in Romania as they were known.

“Institutions and environments vary enormously across the world and within countries,” Dr. Nelson said, “but I think these findings generalize to many situations, from kids in institutions to those in abusive households and even bad foster care arrangements.”

In setting up the study, the researchers directly addressed the ethical issue of assigning children to institutional care, which was suspected to be harmful. “If a government is to consider alternatives to institutional care for abandoned children, it must know how the alternative compares to the standard care it provides. In Romania, this meant comparing the standard of care to anew and alternative form of care,” they wrote.

Any number of factors common to institutions could work to delay or blunt intellectual development, experts say: the regimentation, the indifference to individual differences in children’s habits and needs; and most of all, the limited access to caregivers, who in some institutions can be responsible for more than 20 children at a time.

“The evidence seems to say,” said Dr. Pollak, of Wisconsin, “that for humans, we need a lot of responsive care giving, an adult who recognizes our distinct cry, knows when we’re hungry or in pain, and gives us the opportunity to crawl around and handle different things, safely, when we’re ready.”

    Orphanages Stunt Mental Growth, a Study Finds, NYT, 21.12.2007,
    http://www.nytimes.com/2007/12/21/health/21cnd-foster.html

For Children,

a Scary World Out There (in There, Too)

November 12, 2007
The New York Times
By TINA KELLEY

Fears of crawling insects, the dark and all types of vegetables are common among young children, as any child-rearing expert will attest.

And increasingly over the past few years, parents have seen their children contend with another fear: automatic flush toilets.

Kristen Kligerman discovered this on a visit to Newark Liberty International Airport. In the ladies’ room, her daughter Magda, then 4, leapt off the toilet and refused to get back on after it suddenly flushed.

“She was just terrified,” recalled Ms. Kligerman, an architect in Manhattan. “I had to explain that it was a machine, and it flushed the toilet.”

Automatic toilets, their infrared eyes flashing, have proliferated in restaurants, airports, museums, department stores and office buildings. The American Museum of Natural History has them. So does Bloomingdale’s.

Unlike their antiquated, manually operated predecessors, the toilets can flush at the slightest movement, and emit a high-pitched whine that, to some ears, sounds like a cat being strangled.

Even some adults confess that the machines make them nervous. But to many toddlers, they are the stuff of nightmares.

“One feature of things in the world that make kids anxious is unpredictability, and things that are new or novel,” said Philip Kendall, director of the Child and Adolescent Anxiety Disorders Clinic at Temple University. “A novel experience for kids can be when that machine flushes automatically. They didn’t touch anything. It can be a bit shocking. Most people get over it, but kids are a little less prepared to do that.”

So many children are afraid of the toilets that parents have begun trading strategies for outsmarting the electric eyes. One company has developed a portable device to block the sensors, and a Web site (www.mouseplanet.com/potties) lists all of the manual toilets at Disneyland.

Robyn Whitlock of Naperville, Ill., said that her twin boys, now 5 ½, could rattle off every McDonald’s in a 20-mile radius that had automatic toilets. She said she would drive three miles out of her way to find an old-fashioned device.

“If it was an emergency, I’d cover his ears,” she said of her son Andrew.

For Jenny Tate, her 4-year-old daughter Eve’s terror meant stopping at three different highway rest stops on a trip to Virginia during the summer. At the first stop, the automatic toilet set off hysteria.

“Her eyes got really big, and she leapt off and hung on to me,” said Ms. Tate, of Maplewood, N.J. “I went back to put her on the seat and she was clinging to me, and wouldn’t let me put her on it.”

Two rest stops later, it became clear that all the toilets were the same, and the situation became urgent. “I ended up having to hold her down, crying and struggling with me the whole time,” said Ms. Tate, who added that Eve’s fears have since abated.

Jerilyn Ross, president of the Anxiety Disorders Association of America, said that a fear of automatic toilets did not, in itself, meet the criteria for a psychiatric diagnosis.

“Anxiety in and of itself is normal and healthy,” she said, “but when anxiety is excessive, irrational, and if it interferes with one’s daily life, then it may be an anxiety disorder, which is something that may need to be treated.”

She added, “If it persists beyond normal developmental stages and interferes with a child’s life, so they won’t go into the bathroom or go to school because they’re afraid of needing the bathroom and hearing the toilet flush, then it’s more than normal anxiety.”

She said that children usually outgrow their fears in six months to a year.

Meanwhile, the ease with which the toilets inspire terror has not escaped the eyes of entrepreneurs.

Jeffrey Kay, a marketing consultant in Mount Kisco, N.Y., said he decided to find a way to deal with automatic flushes in 2002, after his daughter, Courtney, then 3 or 4, was surprised by one and started losing ground in potty training.

He developed the Flush-Stopper, a reusable piece of plastic with putty on the back that can be placed on the toilet’s electric eye, blocking the sensor. The device comes with a resealable bag, for sanitary storage. Mr. Kay estimated that he had sold more than 110,000 of the devices, which cost $2.99.

Automatic toilets, he said, are built to work for adults, not for children, who wiggle around a lot.

“Sometimes they spit back at you, so I could understand why kids get scared,” he said. “I think toilets are intimidating enough without them attacking you.”

Susan Kennedy, director of marketing for Sloan Valve, a manufacturer of automatic bathroom fixtures in Franklin Park, Ill., said that automatic toilets were invented to increase hygiene in public bathrooms. They save water, she noted, and cut down on the need for cleaning.

Parents, Ms. Kennedy said, should be grateful for the existence of the automatic flush. “It’s going to keep their kids from getting sick, not touching handles of the flush valve,” she said.

Asked about the noise that the devices sometimes emitted, Ms. Kennedy conceded, “Yes, it’s a different sound, and you don’t have control over it, but you don’t really need to.”

Elizabeth Pantley, author of “The No-Cry Potty Training Solution,” advised parents not to overreact to the toilets or to their children’s concerns. She suggested that parents take children who are starting potty training to a plumbing fixture store to show them what is underneath, behind and around a toilet, and what happens when a toilet flushes.

For children who panic about automatic flushing, she said, “You can say, ‘Ooh, look what happened, it flushed without you.’ That really helps a lot.”

Other parents carry Post-it notes to cover the sensors; some get online help before taking long trips.

Having survived Magda’s airport bathroom incident, Ms. Kligerman tried to educate her about the toilets, to assuage her fear. She pointed out the way the light on the toilets flashed before the flush, like a countdown. It did not help much, she said.

Little children, she noted, like to take their time.

“They sit there and sing their little song,” she said. “To be hurried by the countdown clock is not something that is pleasant.”

    For Children, a Scary World Out There (in There, Too), NYT, 12.11.2007,
    http://www.nytimes.com/2007/11/12/nyregion/12flush.html

Panic Attack Symptoms

October 1, 2007
By THE ASSOCIATED PRESS
Filed at 4:22 p.m. ET
The New York Times

A study of more than 3,000 older women found a panic attack may signal future risk of heart attack or stroke. Symptoms of a panic attack include:

--Palpitations, pounding heart, or accelerated heart rate

--Sweating

--Trembling or shaking

--Sensations of shortness of breath or smothering

--Feeling of choking

--Chest pain or discomfort

--Nausea or abdominal distress

--Feeling dizzy, unsteady, lightheaded, or faint

--Feelings of ''unreality'' or being detached from oneself

--Fear of losing control or going crazy

--Fear of dying

--Numbness or tingling sensations

--Chills or hot flushes

------

Source: Diagnostic and Statistical Manual of Mental Disorders.

 

(This version CORRECTS lead to reflect

that study focused on possible risk, not symptoms.))

    Panic Attack Symptoms, NYT, 1.10.2007,
    http://www.nytimes.com/aponline/us/AP-Panic-Attacks-Glance.html

Panic Attacks May Hike Heart Attack Risk

October 1, 2007
By THE ASSOCIATED PRESS
Filed at 4:13 p.m. ET
The New York Times

CHICAGO (AP) -- The rapid pulse and shortness of breath of a panic attack can feel like a heart attack, and it may signal heart trouble down the road, a study of more than 3,000 older women suggests.

Women who reported at least one full-blown panic attack during a six-month period were three times more likely to have a heart attack or stroke over the next five years than women who didn't report a panic attack.

The researchers took into account other risk factors such as smoking, high blood pressure, inactivity and depression and still found that panic attacks raised risk.

The findings add panic attacks to a list of mental health issues -- depression, fear, hostility and anxiety -- already linked in previous research to heart problems, said study co-author Dr. Jordan Smoller of Boston's Massachusetts General Hospital.

''Postmenopausal women who are experiencing panic attacks may be a subgroup with elevated risk,'' Smoller said. ''Monitoring them and reducing their cardiovascular risk may be important.''

The study, published in Monday's Archives of General Psychiatry, wasn't designed to explain the link, Smoller said. He speculated that a panic attack may trigger heart rhythm problems or that stress hormones released during an attack may harm the heart.

The findings don't surprise Susie Rissler, 51, of Terre Haute, Ind. A panic attack sufferer since childhood, she's also has had three mini-strokes.

''You feel like the whole world is caving in,'' Rissler said of her panic attacks, which can include a racing heartbeat and chest pains. ''I've had shaking, sweating, curling up in a ball totally afraid to even look around. Panic attacks can really destroy a person in a lot of different ways.''

Some of the reported panic symptoms may have been heart problems in disguise, Smoller said. Symptoms such as racing heart, chest pain or shortness of breath, experienced as a panic attack, may have been caused by an undiagnosed heart problem.

''One study doesn't settle a question,'' he cautioned. ''The number of events seen in this sample is still relatively small.'' Forty-one of the 3,243 women in the analysis had a heart attack or death from a heart problem. An additional 40 had strokes.

The study, which enrolled women from 1997-2000 and followed them for five years, was funded by the drug company Glaxo Wellcome, which is now GlaxoSmithKline PLC. The company makes Paxil, an anti-anxiety drug. Some of the study's co-authors reported financial ties to that company and others.

The research relied on the women's memories, rather than doctors' diagnoses, which could be considered a weakness of the study, said Dr. JoAnn Manson of Harvard's Brigham and Women's Hospital. But Manson, who wasn't involved in the study, said it's likely the findings point to a real connection between panic and heart problems.

''It does tie together very well with what we know about the biology and physiology of the stress hormones,'' Manson said. ''I think it does suggest that this is something to discuss with your doctor'' for women prone to panic attacks.

Previous research has found that panic attacks are more common in women than in men. The researchers found that 330 of the women, ages 51 to 83 years at the start of the study, reported a full-blown panic attack during the previous six months. Of those, about 4 percent, went on to have a heart attack or stroke. That compares with 2 percent of the women who reported no panic attacks but who had heart attacks or strokes.

Once the researchers adjusted for other health factors, they found the heart and stroke risk three times greater among women who had panic attacks.

A full-blown attack was defined as a sudden attack of fear, anxiety or discomfort accompanied by at least four of 12 symptoms, such as shortness of breath.

Laura Kubzansky of the Harvard School of Public Health, who wasn't involved in the new study but does similar research, said stress hormones may cause immediate heart damage or wear-and-tear over time. During panic, ''the body is flooded with hormones that in the short run help the body cope with an emergency, but in the long run take a toll,'' she said.

While treating panic with medication may help some people with the psychological distress, there's no evidence yet that medication alone reduces heart risk, Kubzansky said.

''We still don't know how best to address this or how reversible these effects are,'' Kubzansky said.

------

On the Net:

Archives of General Psychiatry: http://archpsyc.ama-assn.org/

    Panic Attacks May Hike Heart Attack Risk, NYT, 1.10.2007,
    http://www.nytimes.com/aponline/us/AP-Panic-Attacks-Heart.html

Bipolar Soars as Diagnosis for the Young

September 4, 2007
The New York Times
By BENEDICT CAREY

The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers report today in the most comprehensive study of the controversial diagnosis.

Experts say the number has almost certainly risen further since 2003.

Many experts theorize that the jump reflects that doctors are more aggressively applying the diagnosis to children, and not that the incidence of the disorder has increased.

But the magnitude of the increase surprises many psychiatrists. They say it is likely to intensify the debate over the validity of the diagnosis, which has shaken child psychiatry.

Bipolar disorder is characterized by extreme mood swings. Until relatively recently, it was thought to emerge almost exclusively in adulthood. But in the 1990s, psychiatrists began looking more closely for symptoms in younger patients.

Some experts say greater awareness, reflected in the increasing diagnoses, is letting youngsters with the disorder obtain the treatment they need.

Other experts say bipolar disorder is overdiagnosed. The term, the critics say, has become a catchall applied to almost any explosive, aggressive child.

After children are classified, the experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side effects like rapid weight gain.

In the study, researchers from New York, Maryland and Madrid analyzed a National Center for Health Statistics survey of office visits that focused on doctors in private or group practices. The researchers calculated the number of visits in which doctors recorded diagnoses of bipolar disorder and found that they increased, from 20,000 in 1994 to 800,000 in 2003, about 1 percent of the population under age 20.

The spread of the diagnosis is a boon to drug makers, some psychiatrists point out, because treatments typically include medications that can be three to five times more expensive than those for other disorders like depression or anxiety.

“I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar disorder, but the tremendous controversy reflects the fact that we haven’t matured enough,” said Dr. John March, chief of child and adolescent psychiatry at the Duke University School of Medicine, who was not involved in the research.

“From a developmental point of view,” Dr. March said, “we simply don’t know how accurately we can diagnose bipolar disorder or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness. The label may or may not reflect reality.”

Most children who qualify for the diagnosis do not proceed to develop the classic features of adult bipolar disorder like mania, researchers have found. They are far more likely to become depressed.

Dr. Mani Pavuluri, director of the pediatric mood disorders program at the University of Illinois, Chicago, said the label was often better than any of the other diagnoses often given to difficult children.

“These are kids that have rage, anger, bubbling emotions that are just intolerable for them,” Dr. Pavuluri said, “and it is good that this is finally being recognized as part of a single disorder.”

The senior author of the study, Dr. Mark Olfson of the New York State Psychiatric Institute at the Columbia University Medical Center, said, “I have been studying trends in mental health services for some time, and this finding really stands out as one of the most striking increases in this short a time.”

The increase makes bipolar disorder more common among children than clinical depression, the authors said. Psychiatrists made almost 90 percent of the diagnoses, and two-thirds of the young patients were boys, said the study, published in the September issue of The Archives of General Psychiatry.

About half the patients were identified as having other mental difficulties, mostly attention deficit disorder.

The children’s treatments almost always included medication. About half received antipsychotic drugs like Risperdal from Janssen or Seroquel from Astrazeneca, both developed to treat schizophrenia.

A third were prescribed so-called mood stabilizers, most often the epilepsy drug Depakote. Antidepressants and stimulants were also common.

Most children took a combination of two or more drugs, and 4 in 10 received psychotherapy.

The regimens were similar to those of a group of adults with bipolar diagnoses, the study found.

“You get the sense looking at the data that doctors are generalizing from the adult literature and applying the same principles to children,” Dr. Olfson said.

The increased children’s diagnoses reflect several factors, experts say. Symptoms appear earlier in life than previously thought, in teenagers and young children who later develop the full-scale disorder, recent studies suggest.

The label also gives doctors and desperate parents a quick way to try to manage children’s rages and outbursts in an era when long-term psychotherapy and hospital care are less accessible, they say.

In addition, drug makers and company-sponsored psychiatrists have been encouraging doctors to look for the disorder since several drugs were approved to treat it in adults.

Last month, the Food and Drug Administration approved one of the medications, Risperdal, to treat bipolar in children. Experts say they expect that move will increase the use of Risperdal and similar drugs for young people.

“We are just inundated with stuff from drug companies, publications, throwaways, that tell us six ways from Sunday that, Oh my God, we’re missing bipolar,” said Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at the Stony Brook University School of Medicine on Long Island. “And if you’re a parent with a difficult child, you go online, and there’s a Web site for bipolar, and you think: ‘Thank God, I’ve found a diagnosis. I’ve found a home.’ ”

Some parents whose children have received the diagnosis say that, with time, the label led to effective treatment.

“It’s been a godsend for us,” said Kelly Simons of Montrose, Colo., whose son Brit, 15, was prone to angry outbursts until given a combination of lithium, a mood stabilizer, and Risperdal, which was often given to children “off label,” several years ago. He now takes just lithium and is an honor roll student.

Other parents say their children have suffered side effects of drugs for bipolar disorder.

Ashley Ocampo, 40, of Tallahassee, Fla., whose 8-year-old son is being treated for bipolar, said that he had tried several antipsychotic drugs and mood stabilizers and that he had improved.

“He has gained weight,” Ms. Ocampo said, “to the point where we were struggling find clothes for him. He’s had tremors and still has some fine motor problems that he’s getting therapy for. But he’s a fabulous kid. And I think, I hope, that we’re close to finding the right combination of medications to help him.”

    Bipolar Soars as Diagnosis for the Young, NYT, 4.9.2007,
    http://www.nytimes.com/2007/09/04/health/04psych.html

New Schizophrenia Drug Shows Promise in Trials

September 3, 2007
The New York Times
By ALEX BERENSON

In a clinical trial of about 200 patients, an experimental drug from Eli Lilly reduced schizophrenia symptoms without the serious side effects of current treatments, according to a paper published yesterday in the journal Nature.

The drug must still be evaluated on many more patients to test for the possibility of side effects that have not yet emerged, and it is at least three to four years from completing regulatory review.

But schizophrenia researchers said the trial’s results were surprising and impressive, especially since the drug works in a different way from existing antipsychotic medicines, all of which have serious side effects, including substantial weight gain and tremors.

Lilly will begin a larger clinical trial for the drug this month. If that trial confirms the results seen so far, the new drug could mark a breakthrough in the treatment of schizophrenia — and open the way to a broad new class of treatments for the disease. Schizophrenia, a devastating mental illness that affects 1 percent of adults, or about 2.5 million in the United States, usually begins in the late teens or 20s and is marked by psychotic delusions as well as social withdrawal and cognitive impairment.

“This is potentially one giant step forward for patients,” said Dr. Jeffrey Lieberman, chairman of the psychiatry department at Columbia and the lead investigator on a federally sponsored clinical trial of schizophrenia medicines. “This drug may turn out to be not just a comparably good antipsychotic agent, but a better antipsychotic agent.”

Dr. Lieberman has not been involved with the development of the medicine and does not receive any payments or consulting fees from Lilly.

The new drug also has the potential to be a blockbuster for Lilly. Medicines for schizophrenia and bipolar disorder are the fourth-best selling class of medicines in the United States, with sales of $12 billion in the United States and $18 billion worldwide last year.

The troubled history of Zyprexa, another antipsychotic medicine from Lilly, will lead regulators and psychiatrists to scrutinize the new medicine closely for hidden dangers, Dr. Lieberman said. When it introduced Zyprexa in 1996, Lilly hailed it as a breakthrough with fewer side effects than older drugs. But Zyprexa causes severe weight gain, and the American Diabetes Association has linked it to diabetes. Internal Lilly documents show that the company played down Zyprexa’s side effects, worrying they would hurt sales.

Despite that history, psychiatrists will be eager to see whether the new Lilly medicine works, since the existing drugs are of limited help for many patients. Existing schizophrenia medicines, whether older drugs such as Thorazine or newer medicines like Zyprexa, all work by blocking the brain’s dopamine receptors.

But the new Lilly drug does not directly affect dopamine. Instead, it modulates brain activity through a different set of receptors. As a result, it has the potential to be the first truly novel treatment for schizophrenia since Thorazine was introduced 1954, Dr. Lieberman and other researchers said.

Lilly’s new drug — which does not have a name yet and is referred to as LY2140023 — emerged from almost two decades of research by Dr. Darryle D. Schoepp, a toxicologist and pharmacologist who joined Lilly in 1988.

For decades, psychiatrists have known that users of PCP, a street drug sometimes called angel dust, have symptoms nearly identical to those of people with schizophrenia. By the 1980s, scientists had discovered that PCP blocked brain receptors that are triggered by an amino acid called glutamate. This led some companies and scientists to study ways to stimulate glutamate receptors as a treatment for schizophrenia.

But the brain has many different kinds of glutamate receptors, and figuring out how to stimulate or block them in medically beneficial ways has proved complicated. Instead of focusing on the receptors blocked by PCP, Dr. Schoepp concentrated on modulating the action of glutamate receptors in the brain’s prefrontal cortex, an area responsible for personality and learning.

“This is a system that is so fundamental to the function of your brain that it is quite powerful,” said Dr. Schoepp.

But because drugs that blocked dopamine had been the only successful schizophrenia treatments, many researchers viewed the glutamate pathway as unlikely to produce useful medicines, said Dr. P. Jeffrey Conn, director of the Vanderbilt University drug discovery program and an expert on glutamate research.

Dr. Schoepp deserved praise for persuading Lilly to invest in a field that appeared to be a long shot, Dr. Conn said, adding, “He locked in very early.”

As a result, Lilly appears to have a multiyear lead over its competitors in glutamate drugs, Dr. Conn said. Dr. Schoepp left Lilly in March to become the head of neuroscience research for Merck. Dr. Schoepp and Dr. Steven Paul, the president of Lilly Research Laboratories, both said that his departure would not hurt the development of Lilly’s new medicine

Dr. Joseph T. Coyle, a professor of psychiatry and neuroscience at Harvard Medical School, said the Lilly trial validated the theory that modulating glutamate receptors might control the symptoms of schizophrenia. Even if this drug fails in later trials, companies and scientists are likely to pursue glutamate research more aggressively, he said.

“When you see a company that comes up with something that’s completely different, completely out of the box, that attracts attention,” Dr. Coyle said.

Existing drugs are reasonably good at treating the hallucinations and delusions of schizophrenia. But they are far less effective at treating the so-called negative symptoms of the disease — the lack of motivation and emotion that leave many patients unable to work or have normal social relationships. The side effects of existing medicines, which affect nearly all patients, are also severe. Older drugs like Thorazine often cause tics and movement disorders, while newer medicines typically have fewer effects on movement but can cause weight gain and other metabolic changes.

In the clinical trial whose results were reported yesterday, LY2140023 had none of those side effects and appeared to work about as well as Zyprexa at reducing symptoms. In the trial, which was conducted in Russia from August 2005 to June 2006, patients were given the experimental drug, Zyprexa or a placebo. About 100 patients received the experimental medicine.

For the drug to be approved, Lilly will need to replicate the results in larger trials. This month, Lilly will begin a trial with 870 patients to determine the most effective dose of the drug. That trial is expected to be complete in January 2009, and if it is successful Lilly will probably start a large Phase III trial that could cover at least 2,000 patients.

“We have to confirm safety and efficacy with multiple studies,” Dr. Paul of Lilly said. He said he did not want to offer a prediction of when Lilly might ask the Food and Drug Administration for approval. But he said Lilly intended to develop the drug aggressively.

“We are very actively working on this target and related targets because we believe that this mechanism is now validated,” he said.

    New Schizophrenia Drug Shows Promise in Trials, NYT, 3.9.2007,
    http://www.nytimes.com/2007/09/03/business/03drug.html

Albert Ellis, 93, Influential Psychotherapist, Dies

July 25, 2007
The New York Times
By MICHAEL T. KAUFMAN

Albert Ellis, whose innovative straight-talk approach to psychotherapy made him one of the most influential and provocative figures in modern psychology, died yesterday at his home above the institute he founded in Manhattan. He was 93.

The cause, after extended illness, was kidney and heart failure, said a friend and spokeswoman, Gayle Rosellini.

Dr. Ellis (he had a doctorate but not a medical degree) called his approach rational emotive behavior therapy, or R.E.B.T. Developed in the 1950s, it challenged the deliberate, slow-moving methodology of Sigmund Freud, the prevailing psychotherapeutic treatment at the time.

Where the Freudians maintained that a painstaking exploration of childhood experience was critical to understanding neurosis and curing it, Dr. Ellis believed in short-term therapy that called on patients to focus on what was happening in their lives at the moment and to take immediate action to change their behavior. “Neurosis,” he said, was “just a high-class word for whining.”

“The trouble with most therapy is that it helps you to feel better,” he said in a 2004 article in The New York Times. “But you don’t get better. You have to back it up with action, action, action.”

If his ideas broke with conventions, so did his manner of imparting them. Irreverent, charismatic, he was called the Lenny Bruce of psychotherapy. In popular Friday evening seminars that ran for decades, he counseled, prodded, provoked and entertained groups of 100 or more students, psychologists and others looking for answers, often lacing his comments with obscenities for effect.

His basic message was that all people are born with a talent “for crooked thinking,” or distortions of perception that sabotage their innate desire for happiness. But he recognized that people also had the capacity to change themselves. The role of therapists, Dr. Ellis argued, is to intervene directly, using strategies and homework exercises to help patients first learn to accept themselves as they are (unconditional self-acceptance, he called it) and then to retrain themselves to avoid destructive emotions — to “establish new ways of being and behaving,” as he put it.

His methods, along with those of Dr. Aaron T. Beck, a psychiatrist who was working independently, provided the basis for what is known as cognitive behavior therapy. A form of talk therapy, it has been shown to be at least as effective as drugs for many people in treating anxiety, depression, obsessive-compulsive disorder and other conditions.

His admirers credited Dr. Ellis with adapting the “talking cure,” the dominant therapy in extended Freudian sessions, to a pragmatic, stop-complaining-and-get-on-with-your-life form of guidance later popularized by television personalities like Dr. Phil.

Dr. Ellis had such an impact that in a 1982 survey, clinical psychologists ranked him ahead of Freud when asked to name the figure who had exerted the greatest influence on their field. (They placed him second behind Carl Rogers, the founder of humanistic psychology.) His reputation grew even more in the next two decades.

In 1955, however, when Dr. Ellis introduced his approach, most of the psychological and psychiatric establishment scorned it. His critics said he misunderstood the nature and force of emotions. Classical Freudians also took offense at Dr. Ellis’s critical observations about psychoanalysis and its founder. Dr. Ellis contended that Freud “really knew very little about sex” and that his view of the Oedipus complex, as suggesting a universal law of human disturbance, was “foolish.”

A sexual liberationist, Dr. Ellis collaborated with Dr. Alfred C. Kinsey in his taboo-breaking research on sexual behavior, and his writings about sex drew complaints from members of the American Psychological Association.

As a base for his work he established the Institute for Rational Living, now the Albert Ellis Institute, in a townhouse on East 65th Street in Manhattan. He lived there on the top floor.

The article in The Times described Dr. Ellis at 90, hard of hearing and recovering from abdominal surgery, coming downstairs one day in the spring of 2004 to lead one of his Friday sessions, just as he had for 30 years.

“Do you know why your family is trying to control you?” he asked a volunteer who had joined him in front of the audience. “Because they are out of their minds!” he said, inserting an unprintable adjective.

Another participant recalled the murder of her sister years ago by a drug dealer. “Why can’t you understand that some people are crazy and violent and do all kinds of terrible things?” Dr. Ellis declared. “Until you accept it, you’re going to be angry, angry, angry.”

Some critics complained that his seminars were more stand-up comedy than serious lecture. Still, despite his iconoclasm, or perhaps because of it, rational emotive behavior therapy became one of the most popular systems of psychotherapy in the 1970s and ’80s. In 1985, the American Psychological Association presented Dr. Ellis with its award for “distinguished professional contributions.”

Dr. Ellis was the author or co-author of more than 75 books, many of them best sellers. Among them were “A Guide to Successful Marriage,” “Overcoming Procrastination,” “How to Live With a Neurotic,” “The Art of Erotic Seduction,” “Sex Without Guilt,” “A Guide to Rational Living,” and “How to Stubbornly Refuse to Make Yourself Miserable About Anything — Yes, Anything.”

He often went back to his own life experiences to help explain his positive frame of thinking. Albert Ellis was born on Sept. 27, 1913, in Pittsburgh, the oldest of three children. As a child, he wrote, he had a kidney disorder that turned him from sports to books. His parents moved to the Bronx and separated when he was 11. He once wrote that he had limited but amiable contacts with his father, a traveling salesman, and that his mother, an amateur actress, was not interested in domestic life.

He maintained that the experience had left no scars. “I took my father’s absence and my mother’s neglect in stride,” he wrote, “and even felt good about being allowed so much autonomy and independence.”

He did well in school, skipped grades, won writing contests and, he said, was pleased with his accomplishments.

But at 19 he was painfully shy and eager to change his behavior. In one exercise he staked out a bench in a park near his home, determined to talk to every woman who sat there alone. In one month, he said, he approached 130 women.

“Thirty walked away immediately,” he said in the Times article. “I talked with the other 100, for the first time in my life, no matter how anxious I was. Nobody vomited and ran away. Nobody called the cops.”

Though he got only one date as a result, his shyness disappeared, he said. He similarly overcame a fear of speaking in public by making himself do just that, over and over. He became an accomplished public speaker.

Dr. Ellis studied accounting at City College during the Depression and took up some entrepreneurial schemes after graduating. In one, he paired used men’s jackets and pants of similar colors and sold them as suits. He wrote fiction but found no publishers. He had read a good deal about sex and set up a bureau in which he counseled couples.

His first marriage, to Karyl Corper, an actress, in 1938, ended in annulment. His second, in 1956, to Rhoda Winter, a dancer, ended in divorce. For 37 years, from 1966 to 2003, he lived with a companion, Janet L. Wolfe, a psychologist who had been executive director of the institute. More recently he married Debbie Joffe-Ellis, a psychologist and former assistant, who survives him.

After receiving a doctorate in clinical psychology from Columbia in 1947, Dr. Ellis spent several years undergoing classical psychoanalysis while using its techniques in his job at a state mental hygiene clinic in New Jersey. He quit in 1950 to begin a private practice specializing in sex and marriage therapy and soon started drifting from Freudian orthodoxy, finding it, he said, a waste of time.

He turned to Greek, Roman and modern philosophers and considered his own experience. Out of this came rational emotive behavioral therapy, which he decided would focus not on excavating childhood but on confronting the irrational thoughts that lead to self-destructive feelings and behavior. He founded his Manhattan institute in 1959.

“I was hated by practically all psychologists and psychiatrists,” he recalled. They thought his approach was “superficial and stupid,” he said, and “they resented that I said therapy doesn’t have to take years.”

In 2005, Dr. Ellis sued the institute after it removed him from its board and canceled his Friday seminars. He and his supporters claimed that the institute had fallen into the hands of psychologists who were moving it away from his revolutionary therapy techniques.

The board said it had acted out of economic necessity, asserting that payouts to Dr. Ellis for medical and other expenses were jeopardizing the institute’s tax-exempt status. Dr. Ellis was by then hard of hearing and required daily nursing care. Some board members said they were uncomfortable with his confrontational style and eccentricities and saw him as a liability.

In January 2006, a State Supreme Court judge ruled that the board had been wrong in ousting Dr. Ellis without proper notice and reinstated him. But his friend Ms. Rosellini said Dr. Ellis’s relations with the board had remained strained afterward.

Despite his failing health, Dr. Ellis maintained a demanding schedule late into his life.

“I’ll retire when I’m dead,” he said at 90. “While I’m alive, I want to keep doing what I want to do. See people. Give workshops. Write and preach the gospel according to St. Albert.”

    Albert Ellis, 93, Influential Psychotherapist, Dies, NYT, 25.7.2007,
    http://www.nytimes.com/2007/07/25/nyregion/25ellis.html

Obituary

Rosemary Kennedy

The family's dark secret
until her brother, President Kennedy, acknowledged her

Tuesday 11 January 2005
00.03 GMT
The Guardian
Sue Woodman
This article was first published on guardian.co.uk at 00.03 GMT
on Tuesday 11 January 2005.
It was last updated at 00.03 GMT on Tuesday 11 January 2005.

From early in childhood, it was evident that Rosemary Kennedy, who has died aged 86, had developmental problems. Rosemary - Rose or Rosie to her family - was sister to John F Kennedy, and the third of nine children of the privileged, wealthy Boston family of Joseph and Rose Kennedy.

Rosemary was lobotomised at the age of 23, and spent her adult life in institutional care. Her plight led her younger sister, Eunice Kennedy Shriver, to champion mental health projects, and to found the Special Olympics in 1968 to celebrate the prowess of mentally disabled athletes.

Rosemary had been slow to walk and talk, and had neither the academic nor the athletic skills of her siblings. An IQ test showed mental retardation. But her ambitious father, Joe, kept her condition secret, not just from the public, but from friends and distant family as well. He believed the truth could harm his sons' political aspirations and tarnish his family's shining aura.

The Kennedys had Rosemary schooled at home by governesses and nuns, and allowed her to attend balls and parties if accompanied by her brothers. Diaries from 1936 and 1938 describe the tea parties, dress fittings and social visits that were part of Rosemary's life, as well as her visit to the White House in the era of President Franklin D Roosevelt.

When Rosemary's mood swings and temper became hard to control, the family moved her to a convent. She began to sneak out at night, and the family feared she might come to harm - or get pregnant. Her father was desperate for a solution. It was recommended to him in 1941 that Rosemary have a prefrontal lobotomy, which involved cutting fibres in the brain, an operation intended to calm severely mentally ill patients. This procedure had been performed on perhaps 350-500 people by then, all but one of them older and sicker than Rosemary.

The lobotomy did not help. In fact, it caused Rosemary to regress into a childlike state in which she sat for hours staring at the walls. Her rage stayed unabated. She was then sent to an institution where her father never visited her. And whenever her mother came, Rosemary refused to acknowledge her.

Rosemary was not referred to again in public until 1960, when her brother John became president. A statement from the National Association for Retarded Children revealed that he had "a mentally retarded sister who is in an institution in Wisconsin".

Rosemary lived at the St Coletta School for Exceptional Children in Jefferson, Wisconsin, from 1949 until her death. Her home was a house on the school grounds, which had been specially built for her and two nurses.

Rosemary's most devoted champion was Eunice, who took over her care after their mother's stroke in 1983. Eunice visited Rosemary regularly and brought her home for visits.

Eunice persuaded her father to use the resources of the Joseph P Kennedy Foundation to support causes for the mentally ill. Over the decades, the Kennedy family have funded research and built several facilities. Eunice travelled widely to promote the cause, even conferring with President de Gaulle, who had a retarded child.

A Kennedy family statement, announcing Rosemary's death, called her "a lifelong jewel to every member of our family... From her earliest years, her mental retardation was a continuing inspiration to each of us and a powerful source of our family's commitment to do all we can to help all persons with disabilities live full and productive lives."

Eunice, 83, and Rosemary's other sisters Patricia, 80, and Jean, 76, were with her at her death, as was her surviving brother, Senator Edward Kennedy, 72.

· Rosemary Kennedy, born September 13 1918; died January 7 2005

    Rosemary Kennedy, G, 11.1.2005,
    http://www.guardian.co.uk/news/2005/jan/11/guardianobituaries.usa

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War > Veterans

Negative feelings

Death > Suicide

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