Noteworthy News Articles on Mental Health Topics, November 15-22, 2000

Comforting Lessons In Arranging Life's Details
David Leavitt, New York Times- 11/6/2000

The other night I saw a television program about Asperger's syndrome, a disorder characterized by, among other things, the inability to read human emotions and a compensatory passion for objects and rituals. One of the little boys profiled on the program was obsessed with washers and dryers, another with trains, a third with game shows. I do not have Asperger's syndrome. Even so, as I watched these boys--especially the one who spent so much of his time building cardboard miniatures of Speed Queen dryers--I found myself thrown back to the early days of my own childhood, when I developed a fascination with telephones. This began about the time that my parents replaced the rotary phones in our house with new push-button models. After that, I would find myself taking careful note, whenever I visited a new friend, of just how many phones his parents owned, what color they were, which style. Soon I had established a private ideal of how phones ought to be arranged, any digression from which--a Princess phone, say, in a kitchen--caused me real distress. Kitchens, according to my thinking, were supposed to have wall-mounted Slimlines. Princess phones belonged in bedrooms.
    Another Asperger-like obsession from those days was with Playboy magazine, which I obliged my mother to buy me each month, less to satisfy some nascent erotic curiosity than because I so appreciated the reliability of the magazine's monthly features: the hidden bunny on the cover, the Vargas girl, the centerfold. In December I would lay out all 12 of that year's centerfolds on the family-room floor, then calculate how many of the playmates had been photographed from head to knee, how many from head to toe. The point of inconsistency--the fact that not every centerfold was photographed the same way--bothered me, especially when the two types of centerfolds could not be divided into six and six; for I had imposed upon the magazine the mandate never to stray from its precise geometry and therefore grew anxious at even the most minor detour.
    It went on like that. Telephones and Playboy soon gave way to board games, soap operas, subways. When I was nine, on a visit to London, I rode the Underground all the way to Stanmore, not because there was anything to do in Stanmore but because it was the terminus of the Bakerloo (now the Jubilee) line, and I wanted to see what the end of the line looked like. (Later, this enthusiasm for the Underground led to a novel, "While England Sleeps.") Subway maps, which I collected in all the cities we visited and studied in earnest (memorizing the names of the stations, the number of interchanges, the points at which the trains came aboveground), provided a source of comfort during my adolescence, an escape route when stress or shyness overwhelmed me. Even as late as college, at moments of bewilderment I would resort to the old ritual of drawing imaginary subway systems, delineating with colored pens the different lines and taking care that in my world (as opposed to the real one) no two stations ever had the same name. Yet in retrospect I see that by making the transition from merely looking at maps to inventing them, I had crossed a crucial threshold. "Men make use of their illnesses," Aldous Huxley once wrote, "at least as much as they are made use of by them."
    It was record albums that really showed me the way out. At first, when I started collecting them, I took less interest in their contents than in the principle according to which the songs on each one were arranged. Again, I imposed an arbitrary set of rules. I didn't like it if there were more songs on one side than the other; the songs had to be at least three minutes long, with a title that appeared in neither the first nor the last line. (If the title appeared in both the first and last lines, I would remove the offending album from my shelf.)
    Then one afternoon my mother brought home from the library Grace Paley's "Enormous Changes at the Last Minute." I took immediate notice. This was the first short story collection I had ever seen, and skimming through it, what struck me instantly was its similarity to a record album. Here, too, short works were being gathered under a single title that at once accentuated their individuality and implied a common ground. And like the list of songs on the back of a record, the table of contents provided the book with its backbone: in Paley's case, the first three titles--""Wants," "Debts," "Distance"--sounded like a poem. Although it would be while before I actually read Paley's stories, and even longer before their off-kilter poetry and generous humor ignited in me the will to write my own, nonetheless the discovery of a new system to interrogate led me the next day to the library, where I found more story collections. And of course, within a matter of weeks, I wasn't only studying the tables of contents. I was reading them.
    What got me excited, I see now, was the recognition that the imagination could impose upon ordinary life the very coherence that ordinary life so often fails to sustain. After all, no one could claim that the characters in Paley's stories led tidy lives. Yet the stories, the very shaping of the paragraphs, had an ordering effect on them; though the world might be messy, the sentences were lean, cohesive, beautiful. So I gave up seeking an elusive perfection in record albums and telephones, and started inventing.
    This doesn't mean, of course, that even at 39 there aren't days when I long to retreat from my work and look at telephone catalogs instead. That creativity lies just on the other side of madness is a commonplace, though popularly the madness with which art is associated is of the delusional variety, marked by visions and demons. Yet what of that more common writer's madness that calls to mind a windup robot that hits the wall and keeps walking. In "Middlemarch," George Eliot limned the futility of vast totalizing projects, and in Mr. Casaubon, with his emotional illiteracy and blinkered devotion to an impossible "Key to All Mythologies." She created one of literature's first cases of Asperger's syndrome. Of course, all that distinguishes Eliot, who wrote many novels, from Mr. Casaubon, who never finished his "Key," is the saving grace of the imagination.

Experts Explore Deep Sleep and the Making of Memories
Sandra Blakeslee, New York Times- 11/15/2000

NEW ORLEANS--By isolating slabs of tissue from the brains of sleeping cats and inspecting millions of cells at a time, scientists have discovered what they think my be a key element in the brain's machinery for making long-term memories. It seems that during an extremely quiet phase of sleep, when researchers thought that nothing much was happening in the brain, groups of cells involved in the formation of new memories signal one another. The signals, discovered only a few years ago, appear to allow cells in many parts of the brain to form lasting links. Then, when a few of the cells are stimulated during waking hours, the links are activated and an entire memory is recalled. The finding, described by a number of scientists at the Society for Neuroscience meeting in New Orleans in early November, is part of continuing research on the role of sleep in consolidating memories. The research results are being published in the December issue of Cerebral Cortex.
    While many steps in this process have been worked out, it was not known how individual cells actually linked up to form memory networks that could last a lifetime. The research also bears on one of the deepest mysteries of biology: why do all animals sleep? One idea is that sleep is critical for the maintenance and storage of long-term memories. Indeed, for some time many neuroscientists have theorized that a phase of sleep, rapid eye movement or REM sleep, is when memories are stored. Though the new work calls that theory into question, it too suggests that people and animals sleep, at least in part, so they can remember, said Dr. Terrence J. Sejnowski, a neuroscientist at the Salk Institute in San Diego. "Why do almost all of us need eight hours of downtime each night?" he asked. "Our sensory systems are down, our muscles are paralyzed and we are very vulnerable. Evolution must have a purpose in mind."
    During the day, he said, many bits of information enter short-term memory, but most of it is unimportant and can easily be discarded. But other information is important, Dr. Sejnowski said. So the brain needs to meld it with older memories, storing the new information as it updates older information. The brain accomplishes this task by entering a series of different chemical and electrical states during the day and night, said Dr. Alexander Borbely, a researcher at the University of Zurich who studies sleep in people. When people are awake, he said, their brains produce a wide variety of fast electrical activity as many neurotransmitters--chemicals that help carry information--are released. Cells that are involved in paying close attention to an event are especially stimulated. This heightened level of activity seems to tag them for special attention during sleep.
    As people fall asleep, their brains enter a different state, Dr. Borbely said. Neurotransmitters that help keep them awake are reduced to low levels. At the same time, whole brain regions begin to oscillate or fire rhythmically at slower frequencies. People grow drowsy. During the night, different patterns of spontaneous rhythms arise in what are called sleep stages. One, called REM sleep, is what occurs when the brain becomes very active and produces dreams. Many researchers have argued that REM sleep is when memory consolidation occurs, Dr. Borbelly said, but this may not be the case. Many popular antidepressant drugs essentially abolish REM sleep in people, he said, yet their memories are fine.
    One problem with studying sleep in whole brains is that everything happens so incredibly fast that it is difficult to see what groups of cells are doing, Dr. Sejnowski said. But the technique described last week has made it possible to study millions of cells at a time under slowed conditions. The technique, developed in the laboratory led by Dr. Mircea Steriade at Laval University in Quebec, involves severing the nerve cells around a section of tissue about the size of the tab button on a computer keyboard from the brains of anesthetized cats. The tissue is left in place, its blood supply intact. But because the clump of tissue is less complex than the whole brain, researchers can get a better handle on how the brain is wired up and oscillates during sleep. When people first fall asleep, cells in the higher cortex are stimulated by waves of activity coming from the thalamus, deep in the brain, Dr. Steriade said. Cortical cells that carry weak memory traces seem to become particularly active. As these cells fire and burst repeatedly, Dr. Steriade said, it is likely that they are going over what has been learned during the day. This rehearsal seems to go on all night as a region that encodes and holds short-term memories, called the hippocampus, relays what it has learned into the cortex.
    But the mystery remains: how do cells in the cortex physically lay down long term memories? The answer seems to lie in another sleep stage called slow-wave sleep, when the cortex, where associations and memories reside, cuts itself off from other parts of the brain and basically listens to itself. At first, cells fire rhythmically at the extremely low rate of one to four cycles per second, Dr. Sejnowski said. Then they seem to stop firing entirely, as if nothing was happening. It's in this ultra-quiet state that cells randomly burst with activity and then go quiet, he said. Using the slab technique, Dr. Steriade recently discovered that cortical cells in this quiet state are in fact quite busy, leaking tiny amounts of chemical neurotransmitters in what are called miniature synaptic events, or minis.
    Minis are ht missing link to memory consolidation, Dr. Sejnowski said. The process involves the synapses, which are tiny gaps between cells, and those gaps contain a complex machinery for strengthening or weakening intercellular connections. When brain cells are especially active during the day, their synapses are highly stimulated. At night, the few cells in a given bit of brain tissue that have been most active during the day will release the most minis. When just one of these cells releases enough minis to reach some sort of electrical threshold, it will fire a burst of signals that in turn activates synapses on all the cells it has been in contact with during the day. A chain reaction gets underway, Dr. Sejnowski said. The relatively small number of cells that were involved in an act of paying attention to a particular event will fire together. In this heightened state, signals that turn on genes are released. New proteins are produced as cells involved in the memory make stronger bonds with one another. Days, weeks or even years later, when just a few of the cells in the strengthened circuit are activated, the entire memory is recalled.
    Dr. Borbely said the new work showed that the parts of the brain that were most active during the day exhibited the slowest wave sleep at night. The process may help explain why sleeping on problems sometimes leads to creative solutions, Dr. Sejnowski said. Imagine that tow memory traces use some of the same cells. "There has always been a close connection between sleep and creativity," he said, "which may be a byproduct of the way that nature chose to consolidate memories."

Treating the Mind as Well as the Body
Bob Rosenblatt, Los Angeles Times, 11/16/2000

Mental health coverage has been the weak link in the health insurance system. Employers and insurance companies, always worried about controlling costs, often have been skeptical of the efficacy of treatments for mental health problems. Add to that the stigma and sometimes the self-inflicted shame faced by patients and their families struggling with mental illness. The result is a daunting challenge for people seeking help. There is a world of difference in the ease of treatment if the sickness is of the body rather than the mind. For someone with high blood pressure and diabetes, for example, a typical health plan allows access to doctors and hospitals without restrictions. A young woman with an eating disorder who consults a therapist or must be hospitalized faces rigid insurance system rules: probably a strict limit of 30 days a year in an inpatient mental facility and 20 visits to a counselor.
    California now has a chance to lead the way as a pioneer in offering equal treatment for both physical and mental ailments. A new state law requires parity of treatment for a specific list of mental health problems. The law applies to coverage for the 20 million California consumers who are enrolled in health insurance systems regulated by the Department of Managed Health Care. These include many health maintenance organizations (HMOs) and some preferred provider organizations (PPOs). (The law does not apply to people in traditional indemnity insurance programs and to some PPOs regulated by the California Department of Insurance. Those plans are still permitted to have different rules for coverage of physical and mental ailments.) The new law covers these ailments, as defined in the psychiatric profession's standard diagnostic manual:
* schizophrenia
* schizoaffective disorder
* bipolar disorder (manic-depressive illness)
* panic disorder
* obsessive-compulsive disorder
* pervasive developmental disorder or autism in children
* eating disorders, including anorexia nervosa and bulimia
* serious emotional disturbances in children (defined by the Diagnostic and Statistical Manual of Mental Disorders as a problem that results in "behavior inappropriate to the child's age according to expected developmental norms").

    No longer can the health plans impose a limited number of patient visits or hospital days for these ailments. The duration of stay or the number of office visits is now prescribed by the professional who treats the patient, just as it would be for an appendectomy, a heart attack or a removal of cataracts. The law was carefully written to cover certain conditions. But it specifically excludes treatments for alcoholism and drug addiction, which can be very costly.
    The new law has the potential for helping thousands of patients and their families. By assuring parity--the same availability of coverage--the families no longer will be forced to spend thousands of dollars for vital treatments. A day in a mental health facility can easily cost $1,000, and a visit to a therapist might range from $50 to $150. Daniel Zingale, director of the state's Department of Managed Health Care, said he will aggressively implement the law as a "commitment to preventive health" for consumers. "We want treatment early to prevent more costly physical ailments down the road," he said in an interview. Untreated mental and emotional problems raise stress levels that can lead to heart disease and a host of other physical problems, according to Zingale. "Treating these conditions early will pay off for the whole system" by saving money in the long run.
    Zingale's office has sent material to the health plans it regulates, and will hold a series of meetings with the organizations "to impress on them our vigilance, and our intention to keep focused on the mental health parity act," he said. He wants the health plans to make clear to all their members that the expanded coverage is available. "It doesn't do any good to have the benefit unless people know exactly what is available to them," he said. The law became effective July 1, with the renewal of health plan contracts. Since businesses typically sign one-year contracts with their plans, the law should be universally effective with all programs under Zingale's regulation by next summer.
    "This is a very big thing," said Andrew Sperling, director of public policy for the National Institute of Mental Illness (NAMI), which represents 210,000 patients and family members. "It's much stronger than the federal law; it essentially addresses major gaps in the limited federal rule." Federal legislation mandates lifetime parity. For example, a policy that pays $1 million in benefits for physical illnesses must have the same limits for mental illness. But this attempt to equalize treatments still left the health plans with the leeway to impose high deductibles or co-payments for mental ailments, or sharply curtail the number of visits during a year. In California, at least, the insurance coverage provided by the health plan can no longer be written this way. Rather than a "cookie cutter" approach, limited to 30 hospital days and 30 visits a year, California patients "can now get individualized treatments that should be more effective," said Dr. Jerry Vaccaro, vice president and corporate medical director at PacifiCare Behavioral Health, the mental health division of the PacifiCare system.
    "We know that in better than 80% of the cases, there are treatments that work," he said. New medications have had tremendous success in dealing with mental ailments. "These are the ones where there is no doubt they are biologically based," he said. "There are diseases of the brain just as diabetes is a disease of the pancreas." Many mental health advocates would have preferred general legislation, coverage that didn't single out certain conditions. But this wasn't politically workable. "There was a perception problem, a fear of the 'Woody Allen syndrome,' where people are not very sick and do not have real problems but sit on the psychiatrist's couch week after week and month after month," said Rusty Selix, executive director of the Mental Health Assn. of California, an advocacy organization. In many movies, comic director and actor Woody Allen plays a worried character whose years of psychotherapy have made him hyper-articulate in discussing his problems but still unable to solve them.
    Although there are specific illnesses mentioned in the law, ambiguity may be an issue for the category of serious emotional problems for children. Zingale acknowledged this is a gray area for both health plans and his own regulatory staff, but he is looking for what he calls an open-minded interpretation by the health plans. His department has an independent appeals process and expert advisors who will help interpret the law. But Zingale said he is aiming for an expansive interpretation of the statute as part of a general pro-consumer policy. "I would hate to see the health plans walk away from treating a mental illness just because it may not fit neatly within the list," he said. Consumers with questions about the law should check with their health plans to find out about the coverage and whether the new law immediately applies to their health program. The Department of Managed Health Care also will provide information. Call (888) HMO-2219 (466-2219). The Web site is http://www.hmohelp.ca.gov.

Study Confirms Perfectionism Is a Strong Trait of Anorexics
Ephrat Livni, ABC News- 11/17/2000

In the largest study of its kind, an international group of researchers, led by Dr. Katherine Halmi of the Eating Disorders Program of New York Presbyterian Hospital in Manhattan, examined the relationship between anorexia and perfectionism in 322 women from the United States and Europe. She concluded the extent of perfectionism was directly associated with the severity of victims’ anorexia nervosa. Linking perfectionism and anorexia could help researchers establish if there is a genetic trait that predisposes a person to eating disorders, explains Dr. Suzanne Sunday, an assistant professor of psychiatry at New York Presbyterian and one of the study’s co-authors. "A lot of the evidence [linking perfectionism and anorexia] is anecdotal," she says. "Now we have hard data in a very large sample."
    In order to find a genetic susceptibility for anorexia, researchers sought patients with relatives who also suffered from eating disorders, and enlisted both in the study. Participants responded to questions on three different standardized tests related to eating disorders, perfectionism and motivation to change. The study was published in the November issue of the American Journal of Psychiatry. "Perfectionism is present commonly in the backgrounds of persons with anorexia nervosa, suggesting its role as a predisposing personality trait," study co-author Dr. Michael Strober, director of the Eating Disorders Program at UCLA School of Medicine, said in an e-mail to ABCNEWS.com. "It is suspected that this personality trait may be a marker of genetic risk factors." Perfectionism may be a flag for susceptibility to anorexia, but whether anorexia is genetic or environmental, or a mixture of both, remains an open question. In a follow-up study, the scientists will look for possible correlations between the patients’ behavior and their genetics.

Never Skinny Enough
An emotional disorder that manifests itself in the body, anorexia nervosa affects about 8 million Americans, 7 million of whom are women. It is characterized by starvation, compulsive exercising and often by an absence of menstrual cycles. Patients may become preoccupied by food and even engage in food rituals such as cutting up their servings in tiny pieces. Anorexics have a distorted perception of their body and continue to lose weight or obsess over keeping it down long after they have dropped below acceptable levels for their height and age. Essentially, anorexics can never be skinny enough.
    "I see anorexia as one of many manifestations of having a perfectionistic personality," says Dr. Steven Hendlin, a clinical psychologist in Irvine, Calif., and author of When Good Enough Is Never Enough. Hendlin says a perfectionist is someone who habitually thinks that anything short of perfection in his or her performance is unacceptable. In the case of anorexics, that means living up to unreasonable standards of beauty. To distinguish between a healthy desire to excel and perfectionism, Hendlin uses the example of a runner who wins a track meet but does not beat his own personal record. The perfectionist, he says, is motivated by fear and focuses on his failure, while the achiever revels in the moment of victory and uses the good feeling to fuel further successes.
    Sara Rosin knows about the relationship between perfectionism and weight loss firsthand. The 22-year-old native of Frankemuth, Mich., suffered from anorexia in high school, and then in college developed bulimia — an eating disorder characterized by binge eating, frequently followed by purging through vomiting, abuse of laxatives and/or diuretics, or fasting. "I’ve always been a typical, type-A personality," Rosin says, meaning she is high-strung. In an essay Rosin wrote for the National Association of Anorexia Nervosa and Associated Disorders newsletter, she describes the struggle overachieving anorexics experience. "Somehow when females heard the message ‘You can be anything you want to be,’ they inferred that to mean ‘You should be everything you possibly can be! Oh — and don’t forget to be the best at it all!’" A cross-country runner in school, Rosin says her perfectionism drove her to always push herself harder. "I felt like if I could do three miles, good. If I could do five miles, better." Conversely, when it came to food, the less she consumed, the better. When her weight fell to 76 pounds, Rosin finally realized her all-consuming drive could kill her. Untreated, anorexia can be fatal. The most common cause of death in a longtime anorexic is low serum potassium, which can cause an irregular heartbeat and eventual heart failure.

Nature vs. Nurture
Hendlin says anorexics learn as children that they will not be loved unless they are perfect. He is convinced perfectionism is due to nurture, not nature. "[Perfectionism] is not a trait," he says. "It’s learned by what you do as a kid and it always has to do with authority figures." But many experts believe life experience is only one of the factors that influence whether a person will have an eating disorder. Dr. Walter Kaye, a professor of psychology at the University of Pittsburgh Medical Center and another of the study’s co-authors, says, "A lot of people diet in this society, but not everyone ends up with an eating disorder." Kaye and his fellow researchers now suspect anorexia may be linked to the family of genes associated with serotonin, a neurotransmitter connected to mood. By analyzing study participants’ DNA, they hope to find patterns that are similar in anorexic family members but different from those of people without eating disorders.
    Finding a genetic marker for anorexia could help to better target treatment for the disorder — possibly with drugs. Treatment for anorexia currently consists of hospitalizing patients to get their weight back up, followed by therapy, which can continue for years.  Today, after extensive therapy, Rosin says she still has to check herself for negative thought patterns and unrealistic expectations. She is wary of the messages she hears from herself and others about women, weight and perfection. "I basically realized I am not perfect," Rosin says. "Life’s not perfect. I don’t want to be perfect. I realized I am happy with what I have."

Quieting the Voices Inside
Bill Briggs, Denver Post- 11/18/2000

"Four out of five voices in my head tell me I'm sane," it proclaims. Diane smiles at the wacky sentiment, as she steps into the store near her Littleton home. She smiles because there are no voices in her head these days; haven't been for a long time. And that means she is sane. Not cured, mind you, but sane. "I see it as a burden that has been lifted," Diane says with a tinge of wonder. "I think I am doing well." She is savvy and funny, yet lonely and misunderstood. She is the face of today's schizophrenic, part of a growing legion of patients who are doing much better thanks to new medicines, yet are trapped by the remnants of their illness. Like thousands of others with the disease, Diane feels blocked from society's mainstream by the stigma of mental illness and by the economic hardships spawned by her lifelong disorder. "It's frustrating because I was ill for so many years, but I will never get out of poverty," Diane says. "I will never own a home. And you know, the American dream is elusive to me." At its roots, schizophrenia is a brain disorder, scientists say, just as multiple sclerosis, Parkinson's disease or Alzheimer's disease.
    But while Parkinson's, MS and Alzheimer's have snared movie stars and, consequently, the media limelight, there's no corresponding list of famous folks with schizophrenia. That may be because schizophrenia often strikes so young - at adolescence or the early 20s - and is so profoundly debilitating. People with the disease often suffer such terrifying symptoms as being tormented by hidden voices, or believing others are reading their minds, controlling their thoughts or plotting to harm them. According to mental-health experts, about 1 percent of the population will develop schizophrenia during their lifetime - which translates to about 40,000 in Colorado.
    Diane's thoughts began to unravel 30 year ago when she became convinced that her mother wanted to poison her, that the Mafia was tailing her and that the radio was speaking to her. Those ugly notions were as real to Diane as the sun and air are to a healthy person.  "It's 100 percent what you believe at the time, and it is scary," she says. With the help of a new wave of drugs that finally shut off that horror show inside her head, Diane seems to have escaped the darkest corners of schizophrenia. It has been seven years since her previous breakdown. Doctors say she'll have to take the medication every day for the rest of her life. "There is no way I would not take it, because I have so much at stake," she says.
    At 49, she is well past the days when her 7-year-old daughter had to mother her until Diane grew so confused the cops came and took her to another hospital. She has found a small but protective circle of friends with whom she talks politics, art and movies. Her small Littleton home is full of books and art. She has a tomato patch outside and a talent for creating wispy images in watercolor and charcoal. She has a life. But while her mind is sharp and her thinking clear, Diane hasn't been able to reclaim a normal existence.  Let's start with her name. It isn't Diane. Although she allowed photos to be taken for this story, she didn't want her name printed. The pictures, she hopes, will make the point that real people - folks who try hard and care about the world - can get this brain disease just like others get cancer or diabetes. But she wanted to retain some anonymity because she knows how many in society still view schizophrenia as a character flaw, something to be mocked, pitied or, worse, feared. She doesn't reveal her illness to anyone except those very close to her. "I'm not sure I'd want people in the workplace to know because of the stigma," she says. "Like they think I'm going to go into a McDonald's and shoot everybody or something." In an attempt to shake some of those misconceptions, the Arapahoe/Douglas Mental Health Network asked Diane to tell her story to The Denver Post. She agreed. "We thought it would really help (to take) a close look at someone who has it so people could understand better what it is," says Scott Williamson, spokesman for Arapahoe/Douglas, a private, nonprofit organization headquartered in Littleton. The network provides treatment services for substance abusers and the mentally ill. Diane has received counseling and therapy there for several years.

On the Fringe
But just beyond the stigma, Diane's meager lifestyle also has kept her on the fringe, she says. It is a threadbare existence that starts and ends with her illness. She is smart enough to earn a fat paycheck. But the stress of a full-time job could cause the symptoms to return, she says. Simply put, working 9 to 5 may be hazardous to her health. Though Diane has earned an associate's degree in computer science, she's not currently employed. It is, she says, an inescapable trap, a frustrating and discouraging side effect of schizophrenia.
    She survives on a web of federal programs: $500 a month in disability payments, food stamps, Medicaid and subsidized housing that covers most of her rent. She budgets her money religiously, but something as minor as a $300 car problem can blow her whole month. What's more, if she works even part-time and earns "too much," she can endanger her disability benefits. "There are a number of things I worry about, and one is losing Social Security because I'm doing too well. My doctors laugh at that. But I do worry about it." All of that has effectively pushed her to society's edge and kept her there.
    "It's a shame it took so long to get her evened out," says Susan Liebgott, a close friend who has known Diane since the days when she ventured in and out of reality. "She could have been a normal person if the right stuff had come along earlier." Diane and her life were, in fact, dripping with normalcy back in the 1970s. As with most schizophrenics, the illness probably was a genetic defect that lay dormant in her brain, just waiting for the right stress to knock her brain chemistry out of whack. She was raised in cushy neighborhoods on Long Island by "good parents." Her father was an oral surgeon. She says she was sensitive, fun-loving and happy. There was nothing to foreshadow the disorder that seemed to begin when a boyfriend beat her up. "That upset me a lot," she says. "It might have started the (brain) chemistry going." (She immediately left the relationship).
    After the assault, Diane returned to her parents' home, craving soothing voices and a warm place to land. Instead, she continued to feel "rotten," she remembers. She couldn't sleep. Her thoughts seemed to turn ugly overnight. She began to believe that her mother was not really hers and that this impostor was going to poison her. "My mother knew (my fears)," Diane recalls. "This sounds crazy, but we both have these crooked teeth on the bottom. To try and prove to me once that she was my mother, she pulled down her lip to show me the teeth." Diane slipped further into the haze of schizophrenia, walking in circles or sitting for hours. Her parents admitted her to a New York City psychiatric hospital where she was given the anti-psychotic drug of the day - thorazine. It did little, she says, but make her feel like she was "in a semi-coma."

Yearly cycle
It was the start of a 20-year pattern for Diane, an almost yearly cycle in which she slowly broke with reality, became immersed in paranoid fantasies for two to three months, went into a hospital, then slowly returned to the real world. She was hospitalized about 20 times but, in each case, her disease seemed to go into a natural remission, she says. "I think it just ran its course," only to return months later. While trapped in the clenches of a delusion, her sputtering thoughts made Diane hear and see things that weren't there. Fellow shoppers in the supermarket became Mafia hit men. Cars motoring past her house became evil people taunting her. Songs on the radio delivered secret messages meant only for her ears. Worst of all, a small cast of voices ridiculed Diane from inside her own head. They shredded her nerves and invaded her sleep, worsening her condition. She remembers thinking that certain presidential candidates knew all about her private pain and the mafiosos on her tail.
    "It just came and went. Between the episodes, I was normal." Back to sanity, she found a new boyfriend and, in 1978, they had a baby girl. Three years later, the couple ended their relationship and Diane came to Colorado with plans to become a nurse and raise her daughter in Littleton. But for a single mom without a car, living on welfare and taking classes at Arapahoe Community College, there was stress. And that stress often brought on a break with reality. "I remember we used to call it, "getting sick,' that Mommy was getting sick," recalls her daughter, now 22. "Since I was 7, a lot of times it was me taking care of her. She'd be my mom. Then she'd start hearing voices and acting very childlike, and I'd have to become (like) her mom." After a few months of hospitalization, "she would get better and come home, and then she would be in control rather than me telling her what to do." When Diane was sick, her daughter developed a morning ritual. Before leaving for elementary or middle school, the girl picked out her mom's clothes and ordered her to "stay here and don't go anywhere." "Of course," her daughter says, "she would leave." Diane sometimes showed up at her daughter's school, mumbling about the Mafia or bringing one of her child's stuffed animals. The girl was repeatedly embarrassed in front of her friends. She also was frustrated because she couldn't get authorities to commit her mom until Diane became incapable of caring for herself. That often took a week or two.
    The little girl often turned to her mother's psychiatrist for help hospitalizing Diane. Once she went to a police station begging for assistance. No one stepped in, however, until neighbors complained that Diane was too loud or that they were fed up with her wild 3 a.m. phone calls. With her mom in the hospital, Diane's daughter was temporarily placed in foster homes, with family, or with her mother's friend, Susan Liebgott. "She was the kind of kid who never used this as an excuse," Liebgott says. "She didn't take advantage of her mother's confusion in any way. It was hard for her to be at home when her mom was sick, but she didn't want to leave her." Not long ago, Diane's daughter graduated from college, moved out of her mom's home and got a job at a camera store in Colorado Springs. She and her mother remain close and talk on the phone weekly. When she thinks back on childhood now, her visions are of playing with other kids, not wrestling with her mother's illness. "I remember once when I was 9, the police came and said to me, "You're so brave.' I was like, "What are you talking about? This is just how life is.'
    Oddly enough, both of their lives changed for good with the airing of a made-for-TV movie in 1994. Titled "Out of Darkness" and starring Diana Ross, the film told the tale of a once-promising student who suffered from schizophrenia. The character also was raising a daughter. The eery similarities caught Diane's full attention. So did the happy ending: Ross' character fully recovered after being prescribed a new drug called Clozaril. Diane asked her doctor if she could try Clozaril; he agreed and Diane began swallowing four yellow pills before bed each night. The voices and fantasies stopped. Just like that, Diane took back her life.
    Up through the 1980s, psychiatrists typically gave schizophrenia patients "major tranquilizers" such as Haldol. While those older drugs still work for some folks, as many as half of all schizophrenics don't respond to them. When Clozaril hit the market 10 years ago, it vastly changed schizophrenia treatment. For thousands of patients, it effectively silences the symptoms without the muscle tremors and stiffness caused by other medications. It sparked a fresh generation of drugs called "atypical antipsychotics," which are sold under the names Risperdol, Zyprexia and Seroquel. Experts say they help patients concentrate, communicate and reason. With their help, electrical impulses, the essential fragments of human thought, can move more smoothly from brain cell to brain cell.
    While doctors are careful not to paint Clozaril or the others as a "breakthrough," the new remedies are working wonders for thousands who couldn't find relief before, experts say. Some patients describe their thinking as "much clearer." Others report "it's like being reborn."  "The change in medications ... has just been stunning in terms of our being able to get a handle on this disease," says David Briggs, head of the Arapahoe/Douglas Mental Health Network. "People are more often able to live independently, function pretty much normally. It has been dramatic." While a cure remains a distant hope, the new drugs have, for many, rendered schizophrenia "a disease much like diabetes, a disease a person has to manage for their entire life," Briggs says. But the prescriptions are vastly more expensive than the old-fashioned tranquilizers. A month's supply of Haldol costs between $25 and $80 depending on the dose needed. A four-week prescription for Clozaril runs between $320 and $850. Medicaid pays for Diane's pills. It's one more government program she banks on to keep healthy. But like other schizophrenia patients who are unable to work full time, the disorder makes her fully dependent on that federal money. Because she hasn't been able to work, she has also been isolated from people, friends say.
    "The toll that I think has been most tragic on her is the social toll, the social skills," Liebgott says, who met Diane 10 years ago when the women worked on a local theater production. "But she is witty, very current and political, just a good friend. Most of all, she is so unbelievably positive. My God, is she positive." Maybe that's because Diane senses a slight shift in society's own backward thinking, a growing acceptance of people with mental illnesses--an understanding that they didn't ask for these troubles and that many are trying to make a life despite them. "This is a brain disorder. A lot of people think there's something wrong with your character, that I'm not a worthy person," she says. "Lately, though, I've been meeting people to whom schizophrenia doesn't matter. And I've got to say, that's a new one on me."

How Do You Cure A Sex Addict?
Amy Guip, New York Times Magazine- 1/19/2000

Once, sex addicts were treated with pillories and guillotines and gleaming clams, but what used to be a moral problem is now a medical one, and this is no surprise. Our understanding of sexual compulsion has followed the same trajectory as our understanding of melancholia and moodiness. It's all in the brain. New scientific theories are shedding an interesting light on the biochemistry of perversion.
    Dr. Martin Kafka treats and studies paraphiliacs at McLean Hospital in Belmont, Mass. Paraphilias are disorders characterized by persistent deviant sexual arousal--think exhibitionism, fetishism and pedophilia. Closely related to paraphilias are what Kafka calls the paraphilia-related disorders (P.R.D.'s). Those suffering from P.R.D.'s are, in common vernacular, sex addicts, who may not be breaking the law but are driven by libidos so excessive that they are pinned beneath their weight. Dr. Kafka, senior attending psychiatrist at McLean Hospital and a clinical assistant professor at Harvard Medical School, where he lectures to residents on hypersexuality, is a nationally renowned expert in his field. He has published 14 papers on the subject. In his practice he sees about 40 patients a week, more than three-quarters of whom have what by current cultural standards at least are perversely heightened libidos. His most serious cases are sexual predators; his "lite" cases include the old standbys of masculine misery, compulsive porn-watchers, compulsive clients of prostitutes, men incapable of monogamy.
    Kafka started out at McLean in 1983 as the medical director of the cognitive-behavior therapy unit, which is a fairly grand beginning, given that McLean is to mental hospitals what Harvard is to colleges. In fact, McLean is affiliated with Harvard, and its gracious grounds reflect that. Originally, Kafka worked with women who had eating disorders. "One day, a sex offender was admitted," Kafka says. "There were no other beds in the hospital, so they put this guy on my unit, with all the eating disorders, and that's when I had my eureka moment. I began to see that the sex offenders were just like the bulimics. Both groups were suffering from a disregulation of appetite. I began to think that paraphilias and the P.R.D.'s are to men what eating disorders are to women.
    In fact, there are interesting inverse relationships between eating disorders and sexual impulse disorders. The sex distribution of paraphilias and related disorders is about 95 percent male, 5 percent female, whereas the sex distribution for eating disorders is the opposite. Both disorders involve difficulty experiencing satiation, as well as a general disregulation of appetite drives. " So you have to look at total sexual outlet as one way of diagnosing a paraphiliac or a P.R.D.," he says. "How many times does he masturbate a week? What are the number of orgasms he has per week. "What's the average amount a man masturbates?" I ask. "Three," he says, "It varies." In one study, 33 percent of normal men admitted to having rape fantasies. In another study, penile tumescence was measured for both normal men and convicted pedophiles when both groups were shone deviant stimuli. Twenty-eight percent of those in the normal group were sexually aroused, some of them by pedophiliac images.
    One of Kafka's most significant contributions to the chemistry of perversity may be that he has been able to look beyond the obvious culprits--our grease-based sex steroids--to the more nuanced chemical messengers and the complex roles they play in mediating our desires. In a 1969 study published in Science, a scientist shoots up some rats with parachlorophenylalanine, a compound that lowers serotonin levels in both blood and brain. Within minutes of its administration there's a veritable drought of serotonin. What happens to the rats? They become sexually aroused. The mount each other compulsively. Conversely, feed rats a serotonin-laced snack, thereby raising their levels, and almost all sexual appetite disappears. "In other words, this isn't just about testosterone," Kafka says. "It used to be thought sexual deviants had just testosterone abnormalities, but they may really have serotonin abnormalities. It may be that the lower the serotonin, the higher the sex drive, or it may be something much more complex, that sexual deviance is linked to an as yet unidentified disregulation affecting the serotonin system."
    Other studies on male animals bear this hypothesis out; before copulation, there is an increase in dopamine and a decrease in serotonin. Post-copulation, the opposite occurs. If this proves to be the case in the human species as well, after sex, man may be experiencing a serotonin surge. Kafka calls his theory of sexual impulse disorders "the monoamine hypothesis" because he is looking at the central role our monoamines--dopamine, norepinephrine and, specifically, serotonin--play in mediating desire. One of he more interesting studies he cites involves castrated rats that are injected with parachlorophenylalanine, which depletes central nervous system serotonin, and are subsequently able to resume normal mounting behavior with little or no testosterone additives. In other words, at least as far as animal analogues go, serotonin deprivation and its hypothesized partner, depression, appear to be powerful aphrodisiacs.   "The brain is such an incredibly complex organ, so largely beyond our understanding," says Dr. Laurence Kirmayer, professor of psychiatry at McGill University. "It's ridiculous to think that any one chemical causes is responsible for this or that. It's patently reductive." But Kafka isn't so sure. "Of course it's complex," he says. "All of these systems are interrelated. But because these men respond so well to drugs like Prozac or other SSRI's--selective serotonin reuptake inhibitors--which alter serotonin transmission in the brain, it's reasonable to point to that monoamine as central in sexual impulse disorders."
    That Kafka treats male sexual impulse disorders biologically is nothing new. "Chemical castration," the administration of testosterone suppressing compounds that eradicate desire, has been used legally in this country for some time. However, Kafka does not want to castrate his patients. What he aims to do is far nobler, complex and chemically questionable. He aims, through the use of serotonin selective drugs, to whitewash deviance but somehow spare conventional sexuality. Drugs like Prozac and Paxil specifically target the serotonin systems, thereby avoiding the widespread side effects of the older generations of antidepressants. But in Kafka's conceptualization, selectivity has reached new heights. Kafka claims that the drugs are capable of reducing or eradicating pathological desire while preserving or enhancing what are culturally considered "normal" sexual urges. How can this be? Does deviant lust reside in one part of the brain, affiliative, conventional lust in another? Is a man's erection when he fetishizes powered by, say, the pituitary, while some other, friendlier lobe raises the tumescent tissue when he makes love? Kafka is by no means claiming this as fact, but his statements imply that it is one of myriad possibilities. "You give a man with sexual problems Prozac," I ask, "and his deviance disappears while his affiliative sexuality emerges?" "I've seen it happen, over and over again," he says.
    Dr. Peter R. Martin of the Addiction Center at Vanderbilt University elucidates. Using MRI's, Martin, along with his colleague Dr. Mitchell Parks, has begun studying the parts of the brain involved in arousal. "If we can classify what parts of the brain are involved in normal arousal," he says, "then maybe we can see if these parts are different in normal volunteers versus men with sexual addictions or paraphilias." He has a hunch that "sex addicts" may show activation in larger--or smaller--portion of the brain in response to a stimulus than a normal volunteer. On an MRI color-coded image, the aroused paraphiliac brain might look like a lobe of scarlet activity, whereas the aroused normal brain might look like, well, a normal brain. If this proves to be true, then in sexually addicted men sex may bleed into the brain's more general geography, and thus such brains may be more capable of turning everyday events, even objects, into erotic events.
    Common wisdom has it that the sexually compulsive or the sexually deviant were often themselves victims of abuse. "The fact is," Kafka says, "only one-quarter to one-third of my patient population suffered physical or sexual abuse, and many of them had unremarkable childhoods, as far as I can see." Which is why Kafka, who acknowledges the need for a multimodal approach and does refer men for psychotherapy, treats his patients with medication. Prozac and its chemical cousins have been hailed as many things: antidepressants, PMS drugs, better-than-well drugs. Here's a new use for them, as far as I can tell--chemical castrators. This idea flies directly in the face of Kafka's pioneering efforts, which are meant to restore normal sex drive while wiping out deviance. There is another possibility. The selective serotonin reuptake inhibitors work in the treatment of paraphiliacs and sex addicts because they dampen if not destroy all libido, along with all sorts of other excessive behaviors. It make sense that one day Prozac may be approved for chemical castration. "Sexual dysfunction is not he same as chemical castration," Kafka says. "These men can function sexually--it's just sometimes difficult. Furthermore, chemical castration came out of a need to punish these guys, whereas my aim is to help and value these men."
    Why or how Prozac blunts sexuality is open to speculation. Animal studies clearly show a correlation between raised or altered serotonin and diminished sexual appetite. In addition, both serotonin and dopamine do an intricate dance with our hormones, priming neural pathways so that they can respond to testosterone. "I don't think that the SSRI's are really capable of restoring a normal sex drive," Dr. Martin of Vanderbilt University says. "We all know that the SSRI's cause sexual dysfunction. The sex addict, or the 'overly sexed' man, may have such a large portion of his brain dedicated to arousal that a blunted sex drive just looks like a normal sex drive, which is much different from the idea of two separate sexual systems, one for deviance, one for affiliation. The SSRI's really need to be studied."
    In 1985, a group of scientists reported on a brain damaged subject who could recall everything but the names of fruits and vegetables. This case, among others, has raised the possibility that our brains are modular and store information in category-specific locales. And this modular notion of brain function appears to expand beyond the domain of language recall. Other scientists have written extensively about separate memory systems, short term versus long term, declarative versus implicit. Why, then, might not forms of sexual appetite, or desire, be divided as well? There has been one reported case of a patient with a right thalmic-hypothalmic infarction that led to hypersexuality and another of a midbrain hypothalmic glioma leading to pedophilia. Women who develop seizure disorders, which are often linked to lesions in a specific part of the brain, may also display exhibitionistic behavior. There is a very rare disorder called Kluver Bucy syndrome, in which the amygdala is damaged and the patient may experience intense sexual desire for objects--pins, cups, etc.
    Kafka doesn't know, and he isn’t afraid to say so. "But it is interesting to speculate that normal male sexual arousal resides in one area of the brain, deviant sexual arousal in another, and that the SSRI's work by targeting one arousal system while sparing another," he says. "That's an interesting, plausible hypothesis, and one that wouldn't surprise me." Another possibility is this: the higher the intensity of any drive, the more polymorphous its manifestations. The SSRI's may work in paraphilias and sexual addiction not by deleting but by pruning, so that the person's core sexuality is finally free to emerge. This hypothesis lies close to the idea some psychiatrists hold that the paraphilias are simply another form of obsessive compulsive disorder and that the SSRI's work not because they target sexual arousal but because they reduce ruminative thoughts and repetitive behaviors in all kinds of conditions. "I hate that idea," Kafka says. "The paraphilias and P.R.D's are not a form of O.C.D. People who have O.C.D. do not have an appetite-disregulation disorder. O.C.D. is not about appetite. Sexual-impulse disorders are all about appetite."

Courts Turn to Video System for Protecting Abuse Victims
Associated Press, 11/20/2000

PORTLAND, Maine--Victims of domestic abuse may be able to seek protection orders without having to confront their abusers in court thanks to a grant awarded Pine Tree Legal Assistance. The U.S. Commerce Department awarded a three-year, $374,996 grant to develop a video-conferencing system between courthouses and shelters for abuse victims. The system that will be developed would allow the victims to obtain their court orders, as well as legal advise, by going online instead into a courthouse. Initial hookups will be established at the West Bath and Belfast district courts by next Oct. 1, with Lewiston to follow, under the pilot project, according to Nan Heald, executive director of Pine Tree Legal Assistance.
   ''The point is to provide safety to victims,'' Heald said. ''We hope that this is successful and that the state will add funding to expand it statewide.'' More than 6,000 petitions for emergency protection from abuse orders are filed in Maine courts each year, according to Pine Tree Legal Assistance. While domestic abuse cuts across economic lines, most victims are low-income people left particularly vulnerable when they flee domestic violence in their homes. State statutes require judges to meet with victims, who must go to court, where they often are confronted by alleged abusers, creating the potential for intimidation and violence. Video conferencing would eliminate the need for victims to enter court to obtain a protection order.
    ''There's a huge problem of people needing to get a court order who are exposed to physical violence by their abusers,'' she said. The grant, one of 35 presented to nonprofit organizations nationally, will be matched by coordinated efforts and contributions. In Maine, these will include the Maine Bar Foundation, Maine Judicial Department, Maine Coalition to End Domestic Violence and Legal Services Corp. Legal Services Corp. has given a $100,000 grant to Pine Tree Legal Assistance to develop a new Internet Web site to provide legal forms, information and links to legal services and state agencies.

Reversal of Sex-Offender Rulings Sought
Kirk Mitchell, Denver Post- 11/20/2000

Colorado's attorney general asked the state Supreme Court on Monday to reverse rulings that would allow up to 1,600 sex offenders to be released early from prison and parole. It would be "absurd" to let sex offenders escape parole when lawmakers actually were trying to increase parole through a 1996 sentencing law, Attorney General Ken Salazar's office said in court papers regarding five related cases. Salazar is asking the court to reconsider its Sept. 18 decision after officials said the ruling could mean offenders convicted between 1993 and 1998 might be cut loose early from supervision.
    The Court of Appeals and Supreme Court had ruled that a law passed in 1996 made parole discretionary and not mandatory. Because of conflicting, flawed and confusing language in the law, the courts found that a sex offenders' parole term actually couldn't exceed the remainder of his prison sentences. For example, a child molester who served four years of a five year prison term could only be placed on parole for a year. According to the rulings, most sex offenders would not have to serve any parole or would serve less time than they would under a five-year mandatory parole law passed in 1993.
    But a Salazar spokesman said the courts' rulings don't reflect legislators' intent when they adopted the 1996 law. "We're hoping to show the court that the legislature intended to impose more parole, not less," spokesman Ken Lane said. "Throughout the last decade, the intent of the General Assembly in enacting legislation in this area has been to ensure the public safety by requiring increased" parole, Salazar's brief says. In 1993, the legislature required offenders to serve five years on parole after they completed their prison sentence, the briefs say.
    To show that in 1996 lawmakers wanted to stiffen parole terms for sex offenders, Salazar cites several statements made by lawmakers during legislative hearings. Among them is a Senate Judiciary Committee exchange between Sen. Dottie Wham, R-Denver, the sponsor of the HB 96-1161, and Ray Slaughter, the then-executive director of the Colorado District Attorney's Council.  Wham asked: "Ray, this allows them to be kept under supervision longer? Is that right?" "That is correct," Slaughter answered. The brief also says that the 1996 law mistakenly said that it not only affected sex offenders after the bill was passed but also those beforehand. The courts' rulings stem from sentencing appeals brought by five defendants who challenged their parole terms. The next step in the matter is for their lawyers to file response briefs next month to Salazar's paperwork. The Supreme Court has not yet set a date to hear oral arguments.

Sister of O.J. Simpson's Slain Ex-Wife Plans Shelter in Dearborn, Michigan
Detroit Free Press, 11/21/2000

DEARBORN, Mich. (AP) -- Working with local leaders in a large but often culturally secluded community, the sister of O.J. Simpson's slain wife hopes to bring a shelter for domestic violence victims to this city. Denise Brown envisions a Nicole's House in Dearborn. The shelter would provide long-term lodging, job training, child care and other help for women trying to escape abusive relationships. The shelter is named after Brown's sister, Nicole Brown Simpson, whose abuse at the hands of former football player Simpson was documented in her diaries and in court records that emerged after her 1994 death. Brown hopes to build other Nicole's House shelters in Minnesota, Wisconsin, California and Vermont. Plans for the Dearborn shelter are contingent upon sponsorship by a prominent community group representing Arab-Americans, who account for about one-quarter of Dearborn's 90,000 residents. "The cycle of violence knows no income or race barriers," Brown told The Detroit News for a Tuesday story. "But Dearborn is certainly a good candidate for a shelter."
    Domestic abuse is a touchy subject among Arab-Americans, who tend to maintain a close-knit but private community that is suspicious of outsiders, said Dr. Adnan Hammad, health and medical director for the Arab Community Center for Economic and Social Services (ACCESS). Recent efforts to raise awareness of the issue has helped reduce the number of abuse complaints, said Hammad, who questioned the usefulness of a women's shelter. "Solutions have to come from within the community. Shelters may be perceived as prisons, not a benefit," he said.
    Helena Maza, however, said she thought the Dearborn shelter would be helpful to women in the situation she was able to escape.  Maza was 17 when she married a Lebanese-American man nearly twice her age. She was encouraged by family members who said the man offered security in the form of a house and a good job. But after the wedding, Maza said he prevented her from shopping alone or talking with her family. "I didn't have a mind of my own. I was a woman being treated like a girl," said Maza, 29, also a Lebanese-American. Now divorced and raising three children, Maza frequently speaks with other Arab-American women who feel trapped in troubled relationships. "Its just the way many of (the men) are raised. Their fathers were like that and the fathers before them. They like the control," she said.
    Nicole's House, which Brown and local organizers hope to open next year, would not be the first response to domestic violence within the Arab-American community. Dearborn police have joined with ACCESS and other Arab-American organizations, women's groups and Oakwood Hospital in forming the Arab-American Coalition Against Domestic Violence. The coalition has worked to educate victims and abusers who came forward voluntarily or through the courts. This year, hundreds of Arab-American men charged with abuse will attend 32-week court-ordered workshops on anger management and domestic relations, an official said. Oakwood Hospital is distributing thousands of bilingual help cards in hospital restrooms, giving battered women advice on how to break free from abusers. Hospital officials informally track potential abuse by monitoring the number of cards missing, a spokeswoman said.

Study: Mentally Ill Smoke More
Ephrat Livni, ABC News- 11/21/2000

People with mental illnesses are twice as likely to smoke cigarettes as other people and consume nearly half of all cigarettes smoked in the United States, a new study says. The Harvard University and Smith College research, published in the latest issue of the Journal of the American Medical Association, suggests a need to target smoking prevention strategies for the mentally ill, an especially vulnerable population. The study found that 41 percent of all mentally ill people smoked cigarettes, compared to 22.5 percent of people who had never been mentally ill. Patients with more severe mental illnesses, such as schizophrenia and depression, had the highest likelihood of smoking heavily, says study author Dr. Karen Lasser of the Harvard School of Public Health in Cambridge, Mass. Lasser is a postdoctoral student in the school of public health and a physician. The findings are based on data from 4,411 respondents aged 15 to 54 years old in an 1991 and 1992 congressionally mandated survey of psychiatric illness. The information in the survey has the latest available data about mental illness and smoking. Lasser says the results confirm what health-care workers observe daily in psychiatric facilities — that many of the patients smoke. She says she hopes such quantifiable data on the number of mentally ill Americans who smoke will help public health policy makers to target smoking cessation programs and funds for the mentally ill.

Tobacco Part of Psychiatric Culture
Experts say mentally ill people smoke so much because tobacco has become part of the culture of mental health facilities. "Institutions, especially state-run, have used tobacco as a reward [for mentally ill patients]," explains Dr. John Bachman, a clinical psychologist and nicotine dependency researcher in Menlo Park, Calif. "Management has said it won’t be responsible for depriving them of the few pleasures they have left." Smoking rates among the mentally ill are higher because there is not much social and cultural stimulation in their lives, he adds, asking, "What does lung cancer in 20 years mean to a hallucinating patient now?"
Bachman says nicotine has a dual effect — both soothing and stimulating, depending on what state of body or mind the smoker is in. Psychiatric patients tend to be on medications that can dull them, so they often use cigarettes to stimulate themselves out of a drug-induced stupor, he says.

Nicotine Replacement Therapy
Although the mentally ill may be a difficult population to wean off cigarettes, new treatments, such as nicotine patches, are now available to help them. Using nicotine patches or gum, so that patients continue to get the stimulation they seek without the health risks of smoking, may be especially effective in helping mentally ill smokers quit, says Dr. Jack Henningfield, an associate professor of psychiatry at John Hopkins University Medical School in Baltimore, Md., and contributor to several U.S. Surgeon General reports on tobacco cessation. "A decade or two ago we didn’t have anything to offer [the mentally ill], but now we are on safer footing," he says.
    But since cigarette smoke makes the body metabolize medication more quickly, smoking cessation for the mentally ill must be monitored by a health professional so drug doses are adjusted accordingly, adds Hennigfield. Smoking cessation programs for the mentally ill should include both medication and therapy, he says. The study found that 37 percent of mentally ill smokers successfully managed to kick the habit, as compared to 42.5 percent for people with no history of mental illness, suggesting that targeted smoking cessation programs could be effective. Lasser says raising cigarette taxes could serves as a smoking deterrent for the mentally ill because they tend to have a lower income level. Tax revenues could then be used to fund smoking cessation and other programs for mental illness and to support counter advertising campaigns.

Big Tobacco Targets Vulnerable
There have been no studies that have examined the effect of cigarette advertisements on the mentally ill. But Lasser says the tobacco industry targets psychologically vulnerable people as part of their market. In her study, she cited internal marketing documents from the R.J. Reynolds Tobacco Company, in Winston-Salem, North Carolina, describing smokers who smoke for "mood enhancement" and "positive stimulation." "The marketing study implied that smokers used nicotine for depressive symptoms, stating that smoking ‘helps perk you up’ and ‘helps you think out problems,’" the study reports. R.J. Reynolds spokeswoman Carole Crossler declined to comment, saying the company had not had an opportunity to review the study. Spokespeople for Phillip Morris, headquartered in New York City, also declined to comment.

Sensation Seeking Smokers
Reuters, 11/21/2000

People who thrive on the burst of adrenaline that comes from a roller coaster ride or skydiving may be more likely to smoke than those who seek solitude and calm, suggests another smoking study. According to the report in the November issue of Experimental and Clinical Psychopharmacology, these people — known as sensation seekers — experience more intense feelings from nicotine than those without this personality trait. ‘‘Sensation seeking may be related to risk of becoming a smoker because these people experience greater positive as well as adverse effects from nicotine," says Dr. Kenneth A. Perkins, the study’s lead author. "This leads them to try smoking again and again.’’ Perkins says that over time, these people become tolerant to the adverse effects of nicotine and may be able to tolerate higher doses.
    Study results might help to develop programs that target teens who smoke, the researchers suggest. Perkins, from the University of Pittsburgh School of Medicine in Pennsylvania, and colleagues determined sensation-seeking elements of personality through a questionnaire. The investigators measured physiological responses to nicotine, such as heart rate and blood pressure, after individuals used a nasal nicotine spray at varying doses on three occasions. The study participants, including 37 nonsmokers and 55 smokers aged 21 to 40 years.

Warning Signs Were All There at Columbine
M.E. Sprengelmeyer & Michele Ames, Scripps Howard News Service- 11/22/2000

DENVER -- Eric Harris and Dylan Klebold announced their violent plans for Columbine High School in veiled threats, cryptic clues and strange behavior -- but nobody put all the pieces together until gunfire erupted. About 11,000 pages of police reports released Tuesday show numerous warning signs that were missed or ignored before the worst school shooting in U.S. history left 13 victims and the two gunmen dead April 20, 1999. Witnesses recount to police many encounters with Klebold and Harris that foreshadowed the rampage to come, but the signs weren't taken serious until the killing was done.
    Among the missed warning signs:
* Harris told a co-worker at Blackjack Pizza he was collecting propane tanks and wanted to blow up the school.
* Klebold wrote in a creative-writing class about a man with loaded guns hidden beneath a black overcoat, "ready for a small war with whoever came across his way."
* The day before gunfire and explosions rocked the Littleton, Colo., campus, a prospective teacher on a job interview claims she overheard students in trench coats talking loudly in the halls about "detonating something" the next day.
    To critics, the documents are more proof that warning signs were ignored. "Your first reaction is to say, 'What if all these people had called the police?' " said parent Judy Brown, who warned police a year before the shootings that Harris boasted on the Internet of wanting to kill people. "Well, we did call the police. And they didn't do their job." But others who knew the shooters said what people might consider warning signs seemed at the time like innocuous teenage angst. Alyssa Sechler, who took German class with Harris, told investigators he included a drawing of a guy holding a gun with a note in her yearbook. The reports include new details on what Harris and Klebold allegedly told their co-workers at Blackjack Pizza, where they boasted of bomb making and made contacts to obtain guns. At the school, Klebold wrote in February 1999 about a man in a black trench coat who systematically mows down a row of college prep students and then sets off an explosion miles away.

Depression in Older Adults Can Go Straight to the Heart
Bob Condor, Chicago Tribune- 11/22/2000

Americans have become too casual about depression and its treatment. On one hand, experts contend too many people are taking prescription antidepressants without formal diagnosis. Meanwhile, the same experts say an even bigger number of Americans are going undiagnosed with symptoms that could be treated with drugs and psychotherapy. Older adults fit most frequently into the latter category, a fact to keep in mind during the approaching holiday season. There's something about feeling lonely or isolated when everyone else appears to have places to go and people to love them. Up to 30 percent of people age 65 and older experience such depression symptoms as loneliness, irritability, lack of concentration and sleeplessness. Yet only 1 percent of those with symptoms are treated with antidepressants or therapy. Researchers are beginning to find there is more at stake here than mental health, which, of course, is enough. A growing body of evidence is associating depression with increased risk for cardiovascular disease.
    The most recent study, published last month in Circulation: Journal of the American Heart Association, followed 4,493 people age 65 and older for six years. All subjects were initially free of heart disease. The researchers found those individuals who reported feeling symptoms of depression most often were 40 percent more likely to develop heart disease than individuals who reported depression symptoms less often. It is the first large study to focus on older adults. "This study establishes that symptoms of depression are an independent risk factor for coronary heart disease in older individuals," says Dr. Curt Furberg, one of the study's authors and a professor of public health science at Wake Forest University in Winston-Salem, N.C. "This doesn't mean that depressive symptoms are a cause of coronary heart disease, but that the presence of depressive symptoms predicts the development of the disease."
    Furberg and his colleagues speculated there are three possible explanations for why depression can increase heart risk: Depression is linked to less exercise (which is documented as a way to offset depression) and more smoking (smokers scored higher on depression scores in the study) among other bad health habits. A depressed individual typically faces more mental stress, which may increase plaque formation and vessel blockages. Depression is theorized to increase production of free radicals (unstable substances in the body that can destroy healthy cells) and fatty acids. Both can damage the lining of blood vessels and place a person at greater risk of sudden death.
    What researchers don't know at this point is whether treating depression can prevent or slow the development of heart disease in the elderly. Just how to treat depression in seniors is a matter of debate. A good place to start is noticing any changes in behavior among loved ones in our lives, says Dr. Myles Sheehan, a geriatrics specialist at Loyola University Medical Center in Maywood. "The first thing is to understand that change in mood should not just be ascribed to old age," says Sheehan. "People who withdraw from life, have difficulty sleeping and lose interest in daily activities and hobbies are depressed."
    Sheehan says recognizing possible depression symptoms should be considered as important to discovering if your parent, relative, friend or neighbor is having chest pain or shortness of breath. The holiday season is a prime time to spot changes in behavior, such as the person who formerly enjoyed attending parties or going window shopping and who now declines such invitations. "I have people who come in practically every week with a new ache or pain," says Sheehan. "Those pains are real, but the root cause may be depression rather than some physical problem."
    Once a person recognizes depressive symptoms in, say, an aging parent, the road doesn't get easier. The next step is talking about the behavior. "I am finding older folks are less resistant to talking about their feelings and potential symptoms," Sheehan says. "It is OK to be frank." Sheehan says one effective approach is suggesting to an aging person to "go over a few things with the doctor." You can explain that thyroid problems might be the root of behavior changes. Or you can suggest that a checkup will rule out physical causes of the sadness or anxiety. In any case, Sheehan says the newest versions of antidepressants pose fewer side effects in older persons and that a combination of medication and therapy can often work best. "Probably the most important thing we can all do for the older adult in our lives is to stay involved with them," says Sheehan. "We can take them shopping or make sure to set up dinner date. We can ask their advice and make them feel loved."

Suicide Attempts Put Financial Burden on Society
Sarah A. Webster, The Detroit News- 11/26/2000

DEARBORN — Twenty-four years ago, an auto worker shot himself in the stomach with a .357 handgun, hoping to end his depression over a romantic break-up and work conflict by ending his life. When he arrived by ambulance at Oakwood Hospital, a bullet lodged in his spine, the 21-year-old tearfully begged the emergency room doctor: "Let me die." Doctors saved his life instead, and taxpayers who bankroll the Medicare program for the elderly and disabled have paid for his health care — including at least 13 major surgeries — ever since. His medical bill has been so enormous that he doesn’t know how much it is. One of his surgeries, a total hip replacement, cost $65,000.   His case serves as a keen illustration of how some violent injuries are an ongoing drain on the health care system. Not all victims can simply be stitched up and made whole again. For some, treatment lasts the rest of their lives.
    The Dearborn native, who walks with a limp as a result of his injury, agreed to talk to The News, but insisted on anonymity. Telling the truth publicly, he said, would force him to confront his longstanding cover-up — that he was in a motorcycle accident — and his shame over living on the dole. The ex-auto worker was declared disabled by the Social Security Administration in 1987, entitling him to a $650 monthly government check. Although he said that it is barely enough to live on, he likely will collect over $300,000 in Social Security payments during his lifetime. "It’s embarrassing," he said. "There’s a good deal of guilt and shame. I’m crippled. I’m in pain."
    As the examination of violence turns from crime to health, suicide takes a prominent role. Self-inflicted injuries were the most deadly form of violence, or intentional injury, in Michigan between 1981 and 1998, killing 19,312 Michiganians, according to the Centers for Disease Control. Homicides and killings by police killed 17,945. Self-inflicted injuries are the second most common category of violence treated at Metro Detroit hospitals, according to a Detroit News analysis of hospital records. Sixteen percent of the 51,585 cases of violence treated at area hospitals were for self-inflicted injuries. Hospitals charged at least $41.3 million to treat those cases in 1998 and 1999.   Even in cases where a suicide is successful, some hospital care is usually given.
    Overdoses and poisonings are the most common type of self-inflicted injury treated by area hospitals. They account for 48 percent of the cases and $17.5 million of the charges in this category of violence. Self-inflicted firearm injuries, however, are the most expensive self-inflicted injury. They average $33,898 per case in Southeast Michigan, and are more expensive to treat than gunshot wounds inflicted by another, which averaged about $13,520 per case. That is because self-inflicted gunshot wounds usually are at closer range, and to a more life-threatening area of the body, such as the head, chest or stomach.
    The single gunshot wound that injured the former auto worker, for example, paralyzed his right side, partly below the hip and completely below the knee. The resulting nerve damage causes him almost constant pain. He spent nine months in the hospital after his injury and learned to walk again, with the help of rehabilitation experts. Blue Cross Blue Shield, his insurance carrier at Ford, picked up some of the early costs. Then the taxpayer-supported Medicare program, which will cover his care for the rest of his life, kicked in. Medicare pays 80 percent of his bills, and requires him to foot the remainder. "The 20 percent adds up like you wouldn’t believe," he said. A drug company has agreed to give him, free, $180 in monthly drugs. He told his doctor he couldn’t pay for the medication out of his monthly disability allowance, and Medicare does not pay for prescription drugs.
    The federal government doesn’t know how many people supported by taxpayers were injured deliberately, by themselves or by others. Nor does anyone know how many people survive suicide attempts, because no agency tracks non-fatal injuries in Michigan or the U.S. — a major flaw in the nation’s surveillance of violence, health experts believe. The American Association of Suicidology estimates there there are about 25 suicide attempts for every successful completion. "There are many more people who survive," said Dr. Rachel Glick, a staff psychiatrist at the University of Michigan Hospital, where self-inflicted injuries were the most common form of violence.