Noteworthy News Articles on Mental Health Topics, April 1-10, 2000

Teaching Couples How To Find Happiness
Joanne Trestrail, Chicago Tribune- April 2, 2000

This is the account of an interview with Andrew Christensen, a professor of psychology at the University of California, Los Angeles, co-author (with Neil S. Jacobson) of "Reconcilable Differences" (Guilford, $23.95), which outlines an approach to couples therapy based more on the idea of acceptance than on the expectation that people will change. Christensen directs a research study of couples therapy at UCLA and the University of Washington, sponsored by the National Institute of Mental Health. An on-line survey related to that research can be found at www.acceptancesurvey.com
Q--This question of what we can or can't live with is hard, isn't it?
A--Working with couples, I often come across the notion of "settling" in a relationship, which implies accepting something less than what you wanted, deserved or could reasonably get. It's not as negative as submission, but it's close to resignation. People don't want to think they've "settled" for something. But any relationship involves a kind of settling. You're not going to get everything that maybe you once dreamed about.
Q--What's acceptance, as opposed to settling?
A--Ideally, acceptance occurs not just in spite of the differences but because of them. It's the realization that your partner is a package deal, and that some of the qualities you value and were attracted to are inevitably associated with qualities that maybe aren't so desirable.
Q--How does that play out?
A--Take ambition. If I pick an ambitious woman for my mate, there are many attractive qualities in that. She brings in a substantial income. I can be proud of her accomplishments. She can talk with me because of her knowledge of the world. And yet if she's ambitious, she might not be prone to doing all the little wifely things that I had also hoped to get. In that case, acceptance is a larger realization that I got a package and I actively chose that package, in part because she had that ambition.
Q--And that might be what drew you to her in the first place?
A--Exactly. Her gentleness and passivity may have been really attractive because they put me in the driver's seat. I enjoyed that and we worked really well together, but now, 10 years into the marriage, I'm angry that she doesn't take initiative more often.
Q--Acceptance doesn't mean "no action required"?
A--It's not passive resignation. There are some active processes involved. One is the development of a "third story." When couples are in a struggle, there's his story and her story and there's some truth in each of them, but there's a one-sided perspective, usually. Learning to generate a third story that incorporates both views and is more objective is one way people become more accepting.  Another approach is the voicing of softer feelings that have often gone unsaid. My partner is more likely to feel empathy for me if I'm able to voice not just the anger and resentment but also disappointment or feelings of neglect. There's also the strategy we call tolerant distance, where people look with more perspective on the problem and see it not just as something my partner does to me but as something that happens to both of us.
Q--What kind of change is unrealistic to expect?
A--The kind of change we raise questions about is when I'm deliberately asking, demanding, pressuring my partner to make some change in a direction that would be more satisfying to me. That kind of demand for change is extremely difficult. It often happens in the context of an adversarial relationship. There's a high likelihood of pressure/resist, demand/withdraw, push/pull--that kind of dynamic.
Q--But behavior does sometimes change, doesn't it?
A--I agree that habits can be changed. People accommodate one another to make life more smooth, but even those small changes, when they're made within an adversarial relationship, are difficult. And more fundamental changes, core changes, go against who a person is. If my wife is a really emotional or outspoken person, or if she is a gentle, quiet, passive person, those may be qualities that are central to her and have been with her for years. They aren't going to be subject to change.
Q--Don't a lot of us have trouble recognizing that certain things are out of our hands?
A--Recognizing it is part of accumulated wisdom. As people get older, they come more to positions of acceptance. They become clearer about what you can change and what you can't, what makes sense to put energy toward changing and what makes sense to leave alone.
Q--Is there anything that's never acceptable?
A--Sure. Violence, destruction or physical coercion. Also psychological, emotional or verbal abuse. And infidelity. People should never accept being humiliated or beaten up.

No Gender Difference Seen in Causes of Depression
Susan Gilbert, USA Today- 04/02/2000

Women get depressed when their relationships go bad; men get depressed when their careers take a dive, right? That's what many therapists think, but a recent study shows that this Venus-and-Mars assumption is wrong. The study -- the largest to look at gender differences in the causes of depression -- found that women and men get depressed for both reasons in equal numbers. "The notion that women deal more with dependency and men more with perfectionism is widespread in psychology," said lead study author Diane Spangler, assistant professor of psychology at Brigham Young University in Provo, Utah. But, she said, therapists who hold these stereotypical assumptions shortchange their patients. "Some issues that are important to the patient get ignored," she said. For example, a therapist might question a male patient about his career when the root of his depression is a failing friendship, said Spangler, whose study is reported in the winter issue of the Journal of Cognitive Psychotherapy. Spangler and her colleague Dr. David D. Burns, a psychiatrist at Stanford University School of Medicine, in Palo Alto, Calif., followed 230 women and 197 men who were being treated for mild-to-moderate depression with talk therapy and/or antidepressants. Before therapy and again 12 weeks later, the patients filled out questionnaires about their depression, and two key causes of depression: excessive dependence on relationships and perfectionist tendencies, like fear of failure. After 12 weeks, all the patients were significantly less depressed than they had been, and their degrees of dependency and perfectionism also declined. But there was no gender difference in dependency and perfectionism either before or after therapy.
    "Men and women get depressed over the same things -- achievement and relationship issues -- in the same proportions," said Robert Leahy, the editor of the journal and an associate professor of psychiatry at Weil Medical College of Cornell University. He called the study "the most sophisticated analysis" of dependency and perfectionism in depression. Spangler said her study doesn't dispute one widely acknowledged gender difference in depression, namely, that it affects far more women than men. But the findings indicate that women and men who are depressed should not be treated differently. Therapies targeting dependency will not be more effective in women and those targeting perfectionism will not be more effective in men, the researchers wrote. "I hope this study will help therapists see clients not in a stereotypical way but as individuals," Spangler said.

Specialists, Not Drugs, for Depressed Kids
Nicolle Charbonneau, USA Today- 04/03/2000

If your child is depressed, your regular doctor is more likely to send you to a specialist than send you to the pharmacy, says a new study. And, while primary care physicians and pediatricians handle depressed children differently, neither group is all that comfortable handling the disorder, say pediatricians at the University of Michigan. Their findings are in the April 4 issue of the journal Pediatrics. The National Institute of Mental Health says that more than 6 percent of 9-to-17-year-old youths will face depression, with 4.9 percent of them developing major depression. These more severely hit children are also likelier to kill themselves: A 1999 study suggested that up to 7 percent of children with major depression may commit suicide as young adults. In the new study, lead author Dr. Jerry Rushton and his colleagues looked at nearly 600 surveys filled out by pediatricians and family doctors in North Carolina. And their findings don't support the popular idea that doctors fall back on drugs to treat childhood depression. Overall, Rushton found that both groups of doctors were more likely to refer the child to a specialist than pull out the prescription pad. "I think that there were some concerns that maybe medications were used as an easy way out or as a substitution for other, more intensive therapies and counseling," says Rushton. "That's not the case from our study." Rushton found that 63 percent of family doctors said they often referred young patients with depressive symptoms to specialty care, compared to 85 percent of pediatricians. "Counseling is still a mainstay as part of the treatment," says Rushton. But that comes with a caveat, he adds. While a referral to a specialist may sound good, says Rushton, "there's a lot of barriers with insurance, simple geography and access to these types of professionals." Sometimes, the stigma of mental illness keeps people from getting help, says Rushton, and patients simply won't show up at a specialist's office.
    "Pediatricians and primary care givers are being called on more than ever before to be involved in assessment and management of depression and children, and ultimately, to prescribe medicines," says Dr. David Rosenberg, the research director for child and adolescent psychiatry at Wayne State University School of Medicine in Detroit.  Some doctors, however, do prescribe drugs. Twenty-eight percent of family doctors said they sometimes prescribed antidepressants before sending a child to a specialist, compared to 6 percent of pediatricians. Among pediatricians, 53 percent wrote prescriptions for antidepressants called selective serotonin reuptake inhibitors (SSRIs), including Prozac, Paxil and Zoloft. Family physicians were even fonder of these drugs; they accounted for 75 percent of their antidepressant prescriptions. The survey revealed that while doctors generally believe SSRIs are safe for children, they aren't convinced that they work very well. And they may be right, says Rosenberg. "So far, only two of the SSRIs -- [Prozac and Paxil] -- have ever been shown to be superior to placebo in pediatric depression," he says.

Managed Care Chooses Drugs Over Continuity
Susan Hall-Balduf, Detroit Free Press- 4/4/2000

Book review of "Of Two Minds: The Growing Disorder in American Psychiatry" by T. M. Luhrmann; Knopf, 337 pages, $26.95.   In 1994, the nurses on the psychiatric unit at St. John Hospital in Detroit sat down every day with each of the four patients they were assigned to and had a little talk: How are you feeling? What are you thinking about? They queried and they listened, suggested and encouraged. In 1995, the nurses, with six or more patients each, worked at the nurses station all day long, coming out only to distribute medication and ask: How are you feeling? Are you having any thoughts of hurting yourself? OK, fine. What happened? T. M. Luhrmann tells you in two words. Managed care. Luhrmann, an anthropologist, began the study of how psychiatrists are trained, which became her absorbing book "Of 2 Minds" in 1992. She had just enough time to get grounded before she witnessed the earthquake of change in health care delivery. Her title refers to the duality of psychiatric care: biomedical vs. psychodynamic, the Freud-based form of psychotherapy taught to most psychiatrists. Psychoanalysts, at one extreme, believe that medicating the patient prevents him from finding the insight he needs to become fully human. Psychopharmacologists, on the other hand, believe that mental illness is a disease that can be conquered by medicine.
    One problem, as Luhrmann points out, is that drugs don't always work. And even when they do, people often stop taking them. Psychotherapy can help patients continue to take their medications while they make the lifestyle changes that can keep them healthy longer.    Studies Luhrmann quotes have shown that therapy, in the long run, saves money. But nobody knows how to quantify psychotherapy. How much is enough? And how does it work, anyway? If you want to make a person's hospital stay cheaper, make it shorter. This is the clear goal of managed care. Get those people well and out the door. But psych patients, as Luhrmann points out, don't get well. They need continuity of care and time for their doctors to determine whether the drugs they're taking are helping. Older doctors Luhrmann spoke with expressed concern for the patients receiving this supposedly cost-effective treatment. But many of the young psychiatrists-in-training that she met toward the end of her study saw no problem with it. They were not interested in learning to do psychotherapy. It's harder than memorizing drugs, and many younger doctors take for granted the wonders of Prozac and Xyprexa, which can work wonders -- when they work. Luhrmann offers observations, not solutions. But the picture she presents is scary: When the pendulum swings away from the emphasis on treating brain chemistry and back toward treating the whole person, will there be any psychiatrists trained to give that kind of care? Most likely, there won't be enough.

Freud: Conflict & Culture
Robin Rauzi, Los Angeles Times- 4/6/2000

Even Homer Simpson, America's animated everyman, has an appreciation for the theories of Sigmund Freud. He explains to daughter Lisa: "The important thing is for your mother to repress what happened, push it deep down inside her so she'll never annoy us again." Sitcoms, magazines and advertising routinely co-opt Freud's well-known theories: psychoanalysis, Oedipal complexes, Freudian slips, anal-retentiveness, defense mechanisms, the id, the ego and the superego. The exhibit at the at the Skirball Cultural Center, "Freud: Conflict and Culture" lays out the beginnings of these notions and their popular influences. In glass cases are Freud's handwritten manuscripts, with some translation. Next to them are TV monitors showing video clips, from silent films to "The Simpsons." Seems simple enough. But hidden in the subconscious of the exhibit, which opened Tuesday, is the criticism that dogged Freud during his career, and the controversies that linger over his work to this day.
    The exhibit was curated by Michael S. Roth, the associate director of the Getty Research Institute for the History of Art and the Humanities until his appointment last month as president of the California College of Arts and Crafts in Oakland. But back when he got involved with "Freud: Conflict and Culture" in 1993, Roth was a professor at Claremont Graduate School. During his sabbatical, he sat in on a brainstorming session at the Library of Congress. The library has the preeminent archive of Freud materials and was looking for ideas on how to build an exhibit around them. Roth was surprised that he was invited back, especially after he voiced his first idea: Design the exhibit on two levels--the conscious upstairs and the ground floor filled with dirt so that visitors would be digging around in the unconscious. The committee members vetoed dirt in the library, but they liked Roth. He'd published a book titled "Psychoanalysis and Its History" in 1987, but he wasn't affiliated with any particular school of thinking on Freud--factions he would become all too familiar with in the years to come. A cultural historian, Roth approached Freud as a man who raised important questions rather than one who concocted cures and made predictions. "The exhibition is built on this premise that Freud was most concerned with making sense of the past. And its second premise is that Freud is part of our past. So if you're going to make sense of our past, you have to deal with Freud."
    The first of three segments in "Conflict and Culture" concentrates on Freud's formative years. He was born in Freiberg, Moravia (now part of the Czech Republic), in 1856. While he was still a small child, his family moved to Leipzig and then to Vienna, where Freud would spend nearly all of his professional career. He left Berggasse 19--his office for nearly 50 years--only after the Nazis annexed Austria. During those 50 years, Freud developed the techniques of free association and dream interpretation to try to access the unconscious mind. These and his other theories--about repression, transference, sexuality and aggression--are laid out in the second area of "Conflict and Culture." Paring down Freud's work into one exhibit requires a certain amount of shorthand. Roth coped by focusing on the questions Freud asked--hoping that those are questions that will also interest museum-goers. "Like: What is the relationship between desire and identity, or sexual preference and one's history? Those are questions that remain important and interesting," Roth said. "Freud had views about those questions, and we may reject those views, but the questions, and the way he posed them, are still very much a part of our conversation today."

Freud's Concepts in 'Spellbound,' 'Simpsons'
Demonstrating how deeply Freud's concepts have seeped into popular thinking, each theory is illustrated with film and television clips, including Homer Simpson's take on repression. Others bits range from the Alfred Hitchcock movie "Spellbound" to Woody Woodpecker cartoons, from "Get Smart" to "The Bob Newhart Show."
The videos, which have proved popular at each stop of the exhibit, remind visitors how much they know about Freud's theories already. "In order to follow your favorite sitcom, or cartoon, you have to understand these concepts to get the jokes. And you always get the joke," Roth said. "Some people said these [clips] would trivialize Freud. That he's a big thinker. A deep thinker. . . . I think that 'Simpsons' moment is about as smart a take on Freud as exists in America."
    Psychoanalysis took particular hold in America in the first half of the 20th century, and the last portion of the exhibit deals with that expansion, the movement's dissidents and other critics. Freud began extrapolating his theories into broader philosophies, generally concluding that societies, like individuals, are full of conflicting and suppressed desires that result in radical disruptions. Hitler invaded Poland just three weeks before Freud died in 1939 in exile in London. The man who sought to cure neuroses of all kinds could never kick his own cigar habit, and suffered for years from cancer of the jaw. Freud's doctor gave the 83-year-old a lethal dose of morphine.  The intensity of the disagreement over Freud's theories--even 55 year after his death--became clear during the gestation of "Freud: Conflict and Culture." Peter Swales, a historian of psychoanalysis known for asserting that Freud seduced his sister-in-law, got wind of the scheduled exhibit through an acquaintance working at the Library of Congress. Concerned that his and other views disparaging Freud would be swept aside, Swales mailed out a petition stating that the show should "adequately reflect the full spectrum of informed opinion about the status of Freud's contributions." About 50 people signed it, including Oliver Sacks, Gloria Steinem and Frederick Crews, the author and editor of two recent anti-Freud volumes. "The petition was probably something I would have signed," Roth said with a laugh eased by a five-year distance from the event. The climate in 1995, however, was charged by the recent scaling-back of a Smithsonian exhibit on the Enola Gay bombing and other cases of museum backpedaling. Academia, too, was deep into battles over political correctness. When word came late that year that "Freud: Conflict and Culture" was being delayed for at least 12 months, Roth was disheartened. James Billington, the librarian of Congress, has always maintained that the postponement had nothing to do with the petition or other complaints. No matter how it appeared, he said, the delay was caused by the need to raise enough funds from private sources. Library exhibits are not paid for with public funds. "There were a lot of people who said we shouldn't do it. There were some that questioned whether taxpayer money should even be spent housing Freud's collection. And the more protest you have like that, the firmer your stand is," Billington said. But as the months dragged on, even Roth got nervous.
    "After a while, it became clear to me that Freud was not the issue here. Freud will survive all of these critics. . . . Here was an exhibit postponed and being threatened with indefinite postponement on the basis of the objections of publicity-seeking critics who had no idea what was in the show. They were self-consciously manipulating professional colleagues in order to stop something that they imagined they would disagree with when it came out.  "That, I thought, was a dangerous political tendency that was not about Freud but about our public culture."  So he met with Billington, ready to resign as curator if the library didn't set a date for the show. But Billington needed no persuading. He set a date. "Freud: Conflict and Culture," first slated for December 1996, finally opened in October 1998. Looking back, Billington insists that the show was never at risk of cancellation. Swales says his petition was not an attempt to get the show axed. The negative effects of Freudianism aren't in the exhibit, but he's gratified that the opponents "put it on the record that we thought it was a load of [expletive]." Swales didn't go to see the show, either. "I didn't bother," he said. "It'd be a bit like inviting a gourmet to go eat at McDonald's." As for Roth, he came away feeling that it all turned out OK. "Maybe the show isn't worthy of the moment," he said. "But we were able to stand on principle and do a show we feel good about. That's a good precedent." Everyone stuck to his guns. Not much changed. Except one thing: Now a lot of people had heard about a little exhibit called "Freud: Conflict and Culture." "People actually said, 'Did you engineer this controversy at the beginning of the show?' Because it's been so helpful for attendance," Roth said. Certainly visitors arrived at the Library of Congress, and later at the Jewish Museum in New York, looking for the source of all this brouhaha. Some, no doubt, left disappointed.
    The dozen glass cases hardly seem filled with anything radical, especially by today's art world standards. The largest items re-create his office: his desk chair, an analyst's couch covered with a rug. Above each document case is a quotation about Freud, such as Frederick Crews', from 1988: "Freud was already a pseudo-scientist from the hour he published 'The Interpretation of Dreams.' " Or French philosopher Jacques Derrida's, from 1980: "How can an autobiographical writing, in the abyss of an unterminated self-analysis, give birth to a world wide institution?"
It may not satisfy anti-Freudians, but the setup works: the origin of the theories below, the questions about them still hanging overhead.

Freud Had His Own Response to Critics
Dr. Peter Kramer, a psychiatrist and professor working in Providence, R.I., contributed an essay to the book published in conjunction with the exhibit. He said he likes the density of the show and the way it weaves history and popular culture but remains ambivalent about its subject. Freud took brave career risks to search for what he thought was the truth, Kramer said. On the other hand, he was blind--or willfully turned a blind eye--to the shortcomings in his own research. "What's interesting is how many of the details are wrong, or we don't believe. We don't think sexual drives are the main or sole motivating force in childhood development. We think attachment is more important, probably." But, Kramer said, "Public awareness is very sensible. It's not like penis envy is Freud's legacy. It's more things like character armor or unconscious motivation that have survived. And sexual drives."  Toward the end of his career, Freud was trying to shape his legacy, in part by discrediting his critics. In one letter, Freud responds to Carl Jung's accusation that he treats his followers like patients by suggesting that Jung is neurotic.  "His late texts, the more he knows, the more skeptical he became about your ability to really know anyone," Roth said. "He didn't think people had better methods than his. . . . [But] he had this weird combination of skepticism and arrogance."
    In the last panel is a photograph of Freud reading into a BBC microphone. There is copy of the hand-written manuscript he was reading. And coming from a speaker is the strained sound of Freud's voice, speaking with great difficulty because of the cancer. The words are vaguely audible throughout the gallery, but only when a visitor is standing at the last panel do the speaker's identity and meaning become clear. "I discovered some important new facts about the unconscious in psychic life, the role of instinctual urges and so on," Freud reads, in slow, deliberate English. "People did not believe my facts and thought my ideas unsavory. Resistance was strong and unrelenting. In the end I succeeded in acquiring pupils and building of an International Psychoanalytic Association. But the struggle is not over yet." Certainly the statement sums things up. For Roth, the sound wafting through the museum is also a metaphor for all of "Freud: Conflict and Culture." "Whether you know it or not, Freud is in the air," Roth said. "It may not be a good thing, actually. Some people don't like it; some visitors think, 'What the hell is that? Why do I have to hear that?' But there it is. It's in our language, in the air we breathe. And the way in which you can come to terms with something, even to reject it . . . is by paying attention to it. "That, of course, is a very Freudian notion."

Detroit Court Has New Path for Drunk Drivers:
Bill Laitner, Detroit Free Press/Detroit News- April 6, 2000

Frustrated by seeing the same drinking drivers return to his courtroom again and again, an Oakland County judge wants to try something new. It's called drug court, a program of tight oversight and intense drug treatment, which costs more in the short run but ultimately saves money and prevents the mayhem caused by repeat offenders, said Novi's 52-1 District Judge Brian MacKenzie. The approach, cofounded by U.S. Attorney General Janet Reno when she was a Florida prosecutor, is used in about 700 courts nationwide. But most programs, including those already used in Wayne and Macomb counties, target nonviolent drug offenders. MacKenzie has aimed at drinking drivers. "What do I do with people who come into my court and are true alcoholics? "I can lock them up, but the truth of the matter is, 90 days in jail doesn't change anything. I see them come back," MacKenzie said.
    His proposal for a drug court in Novi is one of a few nationwide to involve Mothers Against Drunk Driving, in planning and, later, in monitoring the program. MADD's Oakland County chapter has given $3,000 to send MacKenzie and his two fellow Novi district judges, a MADD activist and a substance-treatment therapist to a drug-court training conference in San Francisco in June. An additional $10,000 for the training and for planning the project was approved last month by the State Court Administrator's Office. Novi's plan was one of five Oakland County drug-court projects approved last month for planning grants, said Margie Good, a management analyst in the court administrator's office in Lansing. The others are located in:  Waterford, proposed by 51st District Judge Phyllis McMillen, Troy, proposed by 52-4 District Judge Dennis Drury, Oakland County Circuit Court, proposed by Judge David Breck and Oakland County Family Court, a juvenile drug court proposed by Judge Edward Sosnick.
    This fall, officials from each court will request start-up funding from federal, state and county agencies, Good said.  Novi's drug court, for example, will need more probation officers -- it now has seven -- to provide intensive supervision, but it may save money by requiring fewer and shorter jail sentences, Mackenzie said. Operating a drug court costs $2,000 to $2,500 annually per defendant, while jailing a defendant for a year costs more than 10 times that, said Susan Weinstein, spokeswoman for the National Association of Drug Court Professionals in Alexandria, Va. Most funding for drug courts comes from federal grants. Congress appropriated $40 million for drug courts in 1999 and 2000, and President Bill Clinton has requested $50 million for 2001, Weinstein said. A drug court in Charlotte, near Lansing, was one of the first in the nation to focus on drinking drivers, Weinstein said. In 2 1/2 years, that drug court has seen its recidivism rate drop from nearly 50 percent, "which is fairly close to the national average," to about 10 percent in the last year, said Eaton County District Judge Harvey Hoffman. "We attack the problem with a lot of incentives and a lot of sanctions. If they show up with a dirty breathalyzer result, we give them a weekend in jail," Hoffman said. Michigan also has drug courts in Berrien and Kent counties, a state court official said.
    MADD activist David Easterbrook of Troy, whose daughter was killed by a drunken driver in 1997, said learning about drug court helped change his view of how best to punish a drinking driver. Easterbrook, who will attend the training session with MacKenzie, no longer says all drunken drivers should be locked up for lengthy sentences, he said. He learned that substance-abuse treatment is essential to keeping drinking drivers from repeating their crimes, he said this week.

Book Attacks Popular Anti-Depressant Prozac
Associated Press, 4/6/2000

INDIANAPOLIS--The maker of the anti-depressant Prozac is condemning the latest book about the drug, calling the criticism a fear-mongering publication filled with half-truths and personal anecdotes. The author of Prozac Backlash, released in bookstores Wednesday, claims the popular anti-depressant and similar drugs are overused and dangerous — and could be toxic to the brains of patients. "We already know enough to indicate these drugs should be prescribed far more cautiously," writes Dr. Joseph Glenmullen, a psychiatrist in Cambridge, Mass.
As the book hit store shelves, Eli Lilly and Co. issued a criticism of its own. "Dr. Glenmullen’s book is a collection of half-truths, omissions, errors and personal anecdotes," Lilly said in a written statement.

Lilly Calls Book Dangerous
The Indianapolis drug maker began marketing Prozac in the late 1980s. Since then, the anti-depressant has become one of the best-selling drugs in the world. Lilly officials worry "the book is a fear-mongering publication that may prompt those with depression to abandon their medication and seek medically unproven alternatives." Because of that, Lilly spokesman Jeffrey Newton said the book is dangerous. But Glenmullen writes there is danger ahead for many patients who turn to antidepressants to cure woes that he says don’t warrant mind-altering medications.
Glenmullen filled his book with case studies of patients who’ve suffered from what he calls anti-depressant "backlash." These include sexual dysfunction, memory loss, grotesque facial tics, anxiety and suicidal tendencies.

Debating the Studies
Glenmullen warns the Prozac class of drugs could go the way of cocaine, some tranquilizers and other "mood brighteners" that were found to be toxic to the brain. Such allegations provoked sharp responses from Dr. Steven M. Paul, one of Lilly’s top scientists. "We’ve never found anything like that," Paul said of the notion that Prozac might be toxic. "It couldn’t be further from the truth." Paul rejected the book’s claims that Prozac can cause disfiguring facial tics. Prozac can cause muscle twitches in some patients but to say it causes the severe tics described by Glenmullen "is unconscionable," said Paul, group vice president of Lilly Research Laboratories and a former scientific director at the National Institute of Mental Health.
    This isn’t the first time Lilly has defended Prozac. In the early 1990s, the Church of Scientology raised criticism.
Dr. Peter R. Breggin, a Maryland psychiatrist, wrote two books critical of Prozac in 1994 and 1999. Prozac Backlash is packed with footnotes, which could indicate the debate may come down to a question of whose studies to believe. For example, Glenmullen cites studies showing the Prozac class of antidepressants cause sexual dysfunction in up to 60 percent of users. Paul contends Prozac causes "20 to 30 percent, max" of mild to moderate sexual dysfunction. "For every footnote he cited [showing high rate of sexual dysfunction] I can show you other citations with larger numbers of patients that say just the opposite," Paul said.
    The book worries officials at the National Mental Health Association, said Laura Young, vice president of community services. "My fear with books like this is it scares people away from getting the really important treatment they need ... and they may mess around with herbal alternatives." Glenmullen, a graduate of Harvard Medical School, said in his book he believes Prozac and similar drugs do help some people, and he still prescribes the drugs to some patients.

The Drug Dilemma
Linda Marsa, The Los Angeles Times- 4/7/2000

The increased use of powerful psychiatric medicines in children under 6 has raised concerns about over-medication and long-term effects. With so many unknowns, parents face an agonizing choice. Teri Burley realized her 2-year-old son, Tanner, was out of control when he threw his brother, Tayler, off the jungle gym in the schoolyard playground, breaking the older child's arm. From the time he was a baby, Tanner had been a blur of activity. "He was into everything and rarely slept," says Burley, adding that she and her husband took turns staying up throughout the night because they never knew when their overactive child would awaken. "But we figured he was just energetic." The playground incident was a watershed, however, and preschool officials felt compelled to expel Tanner. "They said he was too much of a liability," recalls Burley. Desperate for answers, the Burleys shuttled their child from one pediatrician and psychologist to another near their home in Whittier. But no one could determine what was wrong in a child so young. Finally the Burleys were referred to a clinic at UC Irvine, where Tanner was diagnosed with attention deficit hyperactivity disorder, or ADHD. The UC Irvine doctor prescribed Ritalin, a stimulant that has a calming effect on hyperactive kids and helps them to focus. Burley kept the prescription in her purse for days before she filled it, and it took her several days more before she could bring herself to give her toddler the drug. "My husband and I agonized, but we felt we had no choice," recalls Burley. "It was either remove him completely from society or dope him up with drugs to make him manageable."
    The Burleys are not alone in their dilemma. Parents of very young children who show signs of mental disturbance face a difficult choice. Should they do nothing, in hopes that this is merely a phase--the so-called terrible 2s and 3s--that their child will outgrow? Or should they give their toddlers psychiatric drugs--none of which have been tested on children under 6--to control what may seem to outsiders to be garden-variety problems of childhood? Growing numbers of parents are choosing the latter option, though often reluctantly. A study published in the Journal of the American Medical Assn. in February revealed an alarming rise in the use of powerful, mood-altering psychotropic drugs among children ages 2 to 6. The use of stimulants like Ritalin in this age group more than tripled from 1991 to 1995. Further, prescriptions for antidepressants such as Prozac doubled, and those for clonidine, an adult blood pressure medication used as a sleep aid for kids with ADHD, spiked significantly. These troubling results prompted First Lady Hillary Rodham Clinton last month to announce plans for a $5-million research project to be conducted by the National Institute of Mental Health, or NIMH, on the use of these medications in preschoolers, and to convene a conference on the issue in the fall.

'Everyone Wants to Point Fingers'
Some blame the sharp increase on managed care, saying pediatricians who aren't trained to spot symptoms of mental illness are encouraged to dispense pills rather than refer children for costly therapy. Others accuse harried parents of being too busy to adequately discipline rambunctious kids. Teachers and day-care workers share the blame, they say, for insisting that toddlers be docile in their overcrowded classrooms. But some experts and parents say the increase in prescriptions for young children is a legitimate trend, driven by the increasing sophistication and diagnostic accuracy of mental health professionals. "Everyone wants to point fingers," says Julie Magno Zito, the principal author of the JAMA study and a professor of pharmacology at the University of Maryland in Baltimore. "But it's really the result of a confluence of [these] factors." The sharp uptick in the use of these drugs in very young kids "does seem to neatly coincide with the ascendancy of HMOs," says Joseph T. Coyle, chairman of the department of psychiatry at Harvard Medical School in Boston. But it is also true that scientists now have a much better understanding of the delicate mechanisms of brain chemistry, an advance that in turn has engendered more acceptance of the use of drugs to treat behavioral disorders. Additionally, the diagnostic guidelines for ADHD and its milder cousin, ADD (attention deficit disorder), once considered problems that only affected boys, have broadened. Now many young girls who aren't hyperactive but do have persistent problems concentrating take Ritalin too, which may account for some of the increase. Further, with public school resources steadily shrinking, parents complain that they are under tremendous pressure to make their kids conform. Clearly, medication is called for to help severely impaired kids. But they're a tiny fraction of the population, say experts, certainly not the 1% to 2% of preschoolers now taking such medication.

Lack of Test Data Troubles Experts
One of the things that disturbs experts most is that these drugs have never been tested on such young children. Consequently, there's no data on their safety and efficacy, their potential side effects (Ritalin, for instance, can cause nervousness and insomnia, and clonidine used in combination with stimulants has been linked to heart problems in children) or their long-term consequences in this age group. "Essentially, this is a vast uncontrolled experiment," says Larry D. Sasich, a pharmacist and research analyst for Public Citizen, a health-care watchdog group in Washington, D.C., "and these children are the guinea pigs." What's equally alarming is that early childhood is the key stage of neurological maturation, with the brain undergoing 90% of its growth during the first five years of life. "The chemical messenger system that is affected by these drugs plays an important role in regulating brain development," says Coyle. "Where will these kids be in 10 or 20 years? We just don't know." Despite the lack of scientific proof, however, desperate parents feel the benefits far outweigh whatever future risks there may be.
"Sure, we worry about the long-term effects," says Burley, whose older son, Tayler, now 10, was later diagnosed with ADD (the disorder seems to run in families). "But at age 2, Tanner was already a social outcast. No one wanted to play with him, not even his cousins, because he was too rough. It was pitiful. Now, at age 9, he's happy and in control. So we've made a conscious decision that it's better to have a shorter, enjoyable life, than [possibly] a long, miserable one."
    Although there is no reason to believe that the medicines could shorten a child's life span, Shelley Dorman understands the fear of the unknown when deciding what is best for her child. She too, however, has chosen to give her child psychiatric medication. Her 10-year-old daughter, Holly, had been a precocious child who started walking at 6 months. But by 5, Holly would throw such intense temper tantrums that she was suspended from kindergarten. "At first, I thought she was bored and people were picking on her--until she flew into a rage at home," says Shelley, who lives in Palm Springs. Months of intensive counseling didn't help, and Holly's behavior veered wildly between violently destructive and suicidal. "When you're pulling your 6-year-old out from underneath a car because she wants to kill herself, you have to do something," says Shelley, who, like other parents in similar circumstances, was criticized by friends and family for giving her child drugs. After several years of experimenting with different combinations, Holly, who was diagnosed with bipolar illness, was finally stabilized by two powerful psychiatric medications, neurontin and seroquel. "Now she acts like a normal child," says Shelley. "The medication has truly saved her life."

When Is Misbehavior a Clinical Disorder?
Still, some physicians worry that kids are indiscriminately being given prescriptions rather than counseled to manage their behavioral problems. "With very young children, it's hard to distinguish hyperactivity from just being a nuisance, but everybody rushes in to fix and nobody tries to understand," says Barbara M. Korsch, a professor of pediatrics at USC and a pediatrician at Children's Hospital. "Are we now giving youngsters Prozac when they have a bad hair day or using Ritalin as a new solution for poor classroom etiquette?" Despite the lingering question of whether we're truly over-medicating young kids, a 1999 NIMH survey revealed that 5.1% of children meet the diagnostic criteria for ADHD, yet only 12.5% of those kids were being treated with stimulants. "I know no one believes this, but we're probably under-prescribing," says Richard L. Ferman, an Encino psychiatrist who specializes in ADD. "Of the estimated 10 million children and teenagers in the United States who suffer from mental illnesses, studies have shown that only one in five are being given medication." The upcoming NIMH study, which will track youngsters taking Ritalin and other psychiatric drugs, may clear up some of the confusion surrounding the use and effects of these mood-altering medications. But the test results are at least five years away. In the meantime, anxious parents with toddlers exhibiting abnormal behavior will have to look elsewhere for guidance. "They should be seen by a specialist in psychiatric disorders in children," cautions Harvard's Dr. Coyle. Teachers and pediatricians aren't trained to make these diagnoses, he adds, "and drugs should be used only as a last resort when everything else has failed."
    That was the strategy Elizabeth Harris, a Los Angeles psychologist, adopted when her 5-year-old was diagnosed with ADD. "I was adamantly opposed to using drugs," says Harris, who instituted an intensive behavioral management plan for her child. The program worked well at home, but her child continued to act up at school. So she tried neurofeedback, a form of biofeedback, to help her child concentrate. It worked for several months, but soon her child's problems came rushing back. At that point, Harris felt medication was the only alternative, and her child now takes Adderall, a stimulant similar to Ritalin. "I was at the end of my rope," says Harris, whose 7-year-old is now doing well. "But I feel comfortable with my decision because I exhausted every other option."

They Threaten, Seethe and Unhinge, Then Kill in Quantity
Ford Fessenden, The New York Times- April 9, 2000

They are not drunk or high on drugs.  They are not racists or Satanists, or addicted to violent video games, movies or music.  Most are white men, but a surprising number are women, Asians and blacks.  Many have college degrees, but most are unemployed.  Many are military veterans.  They give lots of warning and even tell people explicitly what they plan to do.  They carry semiautomatic weapons they have obtained easily and, in most cases, legally.  They do not try to get away.   In the end, half turn their guns on themselves or are shot dead by others.   They not only want to kill, they also want to die.   That is the profile of the 102 killers in 100 rampage attacks examined by the New York Times in a computer assisted study looking back more than fifty years and including the shootings in 1999 at Columbine High School in Littleton, Colorado and one by a World War II veteran on a residential street in Camden, N.J. in 1949.  Four hundred twenty-five people were killed and 510 people were injured in the attacks.  The database, which primarily focused on cases in the last decade, is believed to be the largest ever compiled on this phenomenon in the United States.
    Though the attacks are rare when compared with other American murders, they have provoked an intense national discussion about crime, education and American culture.   The Times found, however, that the debate may have largely overlooked a critical issue: At least half of the killers showed signs of serious mental health problems.   The debate was most intense last year, which began with echoes of gunfire in a Salt Lake City television station in January and ended with seven Honolulu office workers dead in November.  In between there was a berserk rampage by an Atlanta day trader that left 12 dead and 13 injured.  A self-styled fascist attacked a Los Angeles day care center.  Seven people died as a hymn ended in a Fort Worth church.  Probably the most shocking were the shootings by two students at Columbine High School who burst into suburban classrooms and killed 13 and wounded 23.  The teenage killers were much like the adults The Times studied, but with important distinctions that may bring a better understanding to the problem.  As the anniversary of that crime, April 20, approaches, the questions about crime and culture will inevitably reverberate again.
    The Times set out to examine as many of these killings as possible in an effort to learn what factors they and the people who carried them out shared.  While many possible causes have been cited, including violent video games, a decline in moral values and the easy availability of guns, there has been little serious study of this explosive violence.   The Times included only rampage homicides--multiple-victim killings that were not primarily domestic or connected to a robbery or gang.  Serial killers were not included, nor were those whose primary motives were political.  These are among the findings: While the killings have caused many people to point to the violent aspects of the culture, a closer look shows little evidence that video games, movies or television encouraged many of the attacks.  In only 6 of the 100 cases did the killers have a known interest in violent video games.  Seven other killers showed an interest in violent movies.  In a decade that had a sharp decrease in almost all kinds of homicides, the incidence of these rampage killings appears to have increased, according to a separate computer analysis by The Times of nearly 25 years of homicide data from the Federal Bureau of Investigation.  Still, these killings remain extremely rare, much less than one percent of all homicides.  Society has turned to law enforcement to resolve the rampage killings that have become almost a staple of the nightly news.   There has been an increasing call for greater security in schools and in the workplace.  But a closer look shows that these cases may have more to do with society's lack of knowledge of mental health issues, rather than a lack of security.   In case after case, family members, teachers and mental health professionals missed or dismissed signs of deterioration.
    Whether they happen in a school, in a mall, in a crowded train or in a workplace, these crimes have been characterized in a language of incomprehension--"senseless," "random," "sudden," "crazy."  By contrast, murder in the heat of domestic passion or a tavern argument, in the desperation of armed robbery or in the cold calculation of gang competition, seems to make "sense."  But in reviewing court records and interviewing the police, victims and sometimes the killers themselves, The times found that these killings, too, have their own logic, and are anything but random or sudden.  The rage that boiled over into homicide was clearly building in many.  Of the 100 cases reviewed, 63 involved people who made threats of violence before the event, including 54 who threatened specific violence to specific people.  Richard Farley, for example, who was fired in 1987 for harassing a female coworker, told acquaintances he was going to kill the people who had come between him and her before storming into his former workplace, killing seven.  James Calvin Brady told psychiatrists he wanted to kill people, just days before he went on a rampage in an Atlanta shopping mall in 1990.
    "These are not impulsive acts," said J. Reid Meloy, a forensic psychologist at the University of California at San Diego.  "They are not acts of affective violence, where they drink a lot and go kill someone.  There's a planning and purpose, and an emotional detachment that's very long-term."  Yet there was often a precipitation event in addition to histories of failure and mental illness--a spark that set off the tinder, and gave the crime the appearance of being at the same time deliberate and impulsive.  "You can see someone who is morbidly depressed for a long time and they have a suicide plan in place, but the timing is determined by impulse," said Kay Redfield Jamison, a professor of psychiatry at Johns Hopkins School of Medicine and author of "Night Falls Fast: Understanding Suicide."   By far the most common precipitator was the loss of a job, which was mentioned as a potential precipitator in 47 cases.  A romantic issue--a divorce or breakup--was present in 22 cases.   "Some men see the loss of a job, or the loss of a mate, as irrevocable and catastrophic, something they can't get back or attain again," said David Buss, author of "The Dangerous Passion: Why Jealousy is as Necessary as Love and Sex" and a professor of psychology at the University of Texas at Austin.  "They set out on a course to inflict the maximum cost on their rivals, even sometimes killing the woman."
    An analysis of the data base found several recurring elements in rampage killings, including some that surprised the experts.  Perhaps the aspect that most set these crimes apart, aside from their spectacular nature, was this: Regular criminals try to get away with their crimes.  More that a third of regular homicides went unsolved in 1997.   But among the 102 killers in the Times database, not one got away.    Eighty-nine never even left the scene of the crime.  In 1995, for example, after he killed three people at the Ohio trucking company where he had worked, Gerald Lee Clemons walked to the parking lot and leaned against his car calmly until the police arrived.  In 1997, Michael Carneal, a 14-year-old, killed three and wounded five at a school in Louisville, Kentucky.  Then he laid down his gun and said, "I'm sorry."  More tellingly, 33 of the offenders killed themselves after their crimes.  Nine tried or wanted to commit suicide, and four killed themselves later.   Nine were killed by the police or others, perhaps committing what some refer to as "suicide by cop."
    Dr. Jamison said: "The link between suicide and homicide is a very real one, and it hasn't been studied nearly enough.  It has always struck me about Columbine, people forget they committed suicide.  And that's understandable--it was the least important thing from the public point of view.  Anthony Barbaro, a 17-year-old Regents scholar in upstate Olean, N.Y., offered a glimpse into this suicidal impulse in the note he left before he hanged himself with a knotted bedsheet in the county jail.   He was awaiting trial after firing random shots out the window from the third floor of his high school, killing two passers-by and a school custodian, and wounding nine others.  "I guess I just wanted to kill the person I hate most--myself," he wrote.  "I just didn't have the courage.  I wanted to die, but I couldn't do it, so I had to get someone to do it for me.  It didn't work out."
    One of the most remarkable insights to emerge from the survey is how much these killers differ from the typical American murderer.  Half of all murderers in this country are black.  Eighty percent went to high school and no further.  Most often killed someone they knew, or while committing another crime, like a robbery.  The rampage killers, on the other hand, were white, by far, though 18 of the 102 were black, and seven Asian.  The racial profile of the rampage killers is close to that of the entire population.  The rampage killers were overwhelmingly male--but not entirely.    Six were female and they exhibited many of the same disturbed, aggressive characteristics of the males.  Here again, however, was a distinction from regular murderers, who are about twice as likely as rampage killers to be women.  The rampage killers were far more likely to have a military background, and to kill strangers.    There are intriguing age differences as well.  The rampage killers were older than regular murderers, with more in their 40's and 50's and fewer in their 20's, compared with the typical killer.  Of the rampage killers who were over 25, a third had college degrees.  Another third had some college education.  Only nine had less than a high school diploma.  And there seemed to be no urban bias for these crimes, as there is for other violent crimes; 31 were in suburban areas, 25 were in small towns or rural areas.  Forty two of those surveyed committed their crimes in urban areas.
    That profile--a group that is largely suicidal, and shows few of the demographic patterns of poverty and race associated with regular crime--suggests that mental illness plays a huge role, psychiatrists say.  "Mental illness does not vary in different races, but socioeconomics do," said Dr. Lothar Adler, director of a psychiatric hospital in Muhlhausen, Germany, and author of "Amok," a book on multiple murder.  The Times found much evidence of mental illness in its subjects.   More than half had histories of serious mental health problems--either a hospitalization, a prescription for psychiatric drugs, a suicide attempt or evidence of psychosis.  Of the 24 who had been prescribed psychiatric drugs, 14 had stopped taking them when they committed their crimes.  Mr. Clemons, for instance, ran out of drugs a week before his crime, according to relatives.  Recent studies have shown that the mentally ill are no more violent than other people, except when they are off their medications, or have been abusing drugs or alcohol.  Indications of mental illness were far more common among the 100 cases than was evidence supporting popular explanations that emerged in the days after some of these spectacular events.   Violent video games or television were mentioned in only a handful of cases.   Three killers showed an interest in the occult.  Racist ideas were apparent in the backgrounds of 16.  But 48 killers had some kind of formal diagnosis, often schizophrenia.  Some of the diagnoses came after examinations by psychiatrists in trial preparations--which did not usually help in their defense, as only eight avoided conviction on grounds of insanity.  Twenty-five killers received diagnoses before their crimes, which illustrates another recurring issue: They do not just suddenly snap.   Many have long histories not only of mental illness but of failure and dislocation.  
    In spite of their education levels, for instance, a striking number--more than half--were unemployed.  "The high education level is one thing I hadn't anticipated, and the link to unemployment is another thing I didn't realize," Professor Blumstein said.  "One of the things that education does is raise expectations, and raised ones are more readily frustrated."  For people without the emotional resources to accommodate it, frustration "can lead to rage, can lead to suicide," Professor Blumstein said.  These crimes are not new.  Public rampage killings first entered the national consciousness with Charles Whitman, who stood on the University of Texas's tower in 1966, firing his rifle at students, killing 14 people.  Nor are they peculiarly American.  The best scientific thinking, in a field that is admittedly understudied, now holds that multiple, public murder occurs at a fairly constant level across time and cultures. What some people call "running amok," a term first used in Malaysia to describe frenzied, indiscriminate killing, has been observed in many cultures, with weapons as varied as grenades and tanks in addition to high-powered handguns.  "Even though homicide rates and suicide rates are very different from country to country," said Peter M. Marzuk, a professor in the department of psychiatry at the Weill Medical School of Cornell University, "the rates of murder-suicide are really the same throughout the world." 
    Yet there is a strong impression that they have become more common.  In an effort to confirm the trend, the Times analyzed F.B.I. reports of all homicides since 1976.    Each year there were 15,000 to 22,000 homicides, but very few involved three or more victims.  That universe shrank even more, to just a few dozen, when the Times weeded out those involving robbery or gang violence and those in which the primary victim was a family member.  What is left is the closest thing there is to a census of rampage killings--about one-tenth of one percent of all killings.  And it shows that in the 1990s, they increased.  Their number remained fairly consistent from 1976 to 1989, averaging about 23 a year, only once going above 30.  But between 1990 and 1997, the last year for which data was available, the number averaged over 34, dipping below 30 only once , in 1994.  "in the early 90's, for some reason, it increased, and seems to have a different level since," said Steven Messner, a criminologist at the State University of New York at Albany, who reviewed the numbers at the request of the Times.
    There are many possible explanations.  But the shift coincides, roughly at least, with a trend of increasing availability of more lethal weapons.  In the late 1980s, the production of semiautomatic pistols in the United States overtook the production of revolvers, and with their larger ammunition magazines and faster reloading, semiautomatics have added to the potential for mayhem.  The effect may be apparent in the number of deaths per murderous incident, which suddenly increased in 1993 and has remained high since, according to the analysis of F.B.I. data by The Times.  "you have drastically increased the ability to inflict death and injury," said Tom Diaz, author of "Making a Killing" and a senior policy analyst at the Violence Policy Center.  "That means you can shoot more rounds faster and easier, what they call spray and pray."  In the Times study, wielders of semiautomatics inflicted more injuries.  The ratio of maimed to killed victims was 50 percent higher than for those who used other weapons.  Yet, the increased availability of high-powered weapons may not explain everything.  Some kinds of multiple murder have declined or remained static.  Killings of three or more people to cover up another felony, like robbery, have not increased, for example.  Neither have multiple killings of relatives.    The number of incidents in which three or more died and the principal victim was a family member has remained fairly steady, around 30 cases a year.
    "It used to be the most common type of this violence was in the family," said James Alan Fox, author of "Overkill" and one of the nation's foremost experts on mass murder.  "Now it's no longer true.  It's in the workplace and in the schools."  Experts believe the crimes may be feeding on each other, particularly in the area of saturation coverage by cable television.  Fourteen of the killers expressed knowledge about their predecessors.  For example, Ladislav Antalik, a Czech immigrant who killed two former co-workers and then himself after being fired from his job in Research Triangle Park, N.C., in 1994, had a newspaper article in his car describing a previous massacre.  The Columbine killers talked of doing it bigger and better than it had been done before.  William Kreutzer, known as Crazy Kreutzer, as he set out to mow down a company of soldiers at Fort Bragg with an assault rifle and a semiautomatic pistol, told a friend he knew what the record number of multiple killings was. 
    But beyond the question of whether one event triggered the next, experts say the recent increases in these crimes strongly suggest a social contagion.  "Why do you get a lot of people doing the same thing?" said Joseph Westermeyer, a psychiatrist at the University of Minnesota who has studied epidemics of explosive murder in other cultures.    "I think there is this copycat element."  Dr. Adler, in his book, documented two cases of soldiers running amok with a tank in Germany in the 1980s after a widely publicized tank attack there.  Army security was increased, and "tank amok never happened in Germany again," Dr. Adler said.  An angry, depressed, unstable, perhaps mentally ill person picks up a gun because it has become a known alternative.  "Something that as inconceivable to many people suddenly becomes conceivable," Dr. Messner said.  "The transmission mechanism seems to be nothing more or less than that it's an idea that's in the air," said Philip Cook, a professor of public policy at Duke University, who has studied social contagions.    "So you have these kind of catastrophic consequences from what seems a minor change in the environment."

How Youngest Killers Differ: Peer Support
Ford Fessenden, The New York Times- 4/9/2000

When 16-year-old Evan Ramsey strode into the lobby of his high school in Bethel, Alaska, in 1997 and shot a popular basket ball player in the stomach, there were already spectators gathered on the mezzanine above--students that he had told to be there to witness his "evil day." Some may not have known exactly what was to transpire, but at least two students at Bethel Regional High had been intimately involved in the planning of Mr. Ramsey's crime, in which two people died. One student showed Mr. Ramsey how to load the shotgun the day before. The other carried a camera to record the event, but forgot to use it. Such goading, sometimes even collaboration, is not uncommon among the school-age killers who ware part of The New York Times's study of 100 rampage killings in the United States in the last 50 years. It is one of the principal factors that set them apart from adult killers.
    For the most part, the adults were loners, who planned their crimes surreptitiously, even though they almost always broadcast their intentions. Some of the teenagers, on the other hand, sought, and often obtained, reinforcement from their peers and boasted of their plans. In the most extreme cases, including the shootings at Columbine High School, teenagers actually killed together. All of the adults killed alone. In two other cases involving teenagers, including Mr. Ramsey's, collaborators were prosecuted, and in least two more, the police have said they believed schoolmates or friends played a role. As the county approaches the anniversary of the killings at Columbine, which crystallized public horror over rampage killings, this distinction is crucial to understanding, and even preventing, school shootings, many experts say. A continuing study by the Secret Service's National Threat Assessment Center of 40 cases of school violence over the last 20 years has reached some of the same conclusions. The study, done in conjunction with the Department of Education found that teenage killers often communicated their plans or shared their feelings with other students, on sharp contrast to the pattern of adults.
    In most ways, rampage killings involving young offenders are no different from those involving adults, The Times found in compiling its database. Young killers are as likely to strike in small towns as in big cities. Both groups are mostly white, but with some blacks and Asian-Americans. Both favor semiautomatic weapons. But in other compelling ways, the teenage killers differ, While serious mental health problems are common among them, fewer commit suicide after their crimes, The Times found. The younger killers are less emotionally detached and more susceptible to peer influence, experts said. Overall, school violence is declining. The number of homicides and assaults at schools is down. But a series of mass killings at schools in the last four years has seemed to present the country with an ugly new face of school crime--the sudden, explosive rampage killing. Although these shootings seem new, the Times study shows that teenage rampage killers were around far before the recent trend. Anthony Barbaro, an honor student, killed three and wounded nine at his high school in Olean, N.Y. in 1974. Sixteen year old Brenda Spencer, using a rifle given to her for her birthday, killed two and wounded nine at an elementary school near her house in San Diego in 1979. "I don't like Mondays," she told reporters. "This livens up the day."
    Serious mental problems were reported in the histories of ten of the 19 teenagers in the Times study. Two had been in psychiatric hospitals. Six showed evidence of psychotic delusions. Five had seen a mental health professional, and four had prescriptions for psychiatric drugs. "I think it's quite possible that you're seeing incipient mental disorder," said J. Reid Meloy, a forensic psychologist at the University of California at San Diego who has just completed a study on juvenile rampage killers. "But a lot of times it will be minimized or not identified as readily as adults." Dr. Anthony Hempel, chief forensic psychiatrist at the Vernon campus of North Texas State Hospital and Dr. Meloy's co-author, said the fact that many of the adolescents were able to work with others was a strong argument that they were less likely to be mentally ill, or at least that their illness was in the early stages. "When people pair up to commit one of these, the odds of a major mental illness go way down," Dr. Hempel said. "Very few people who don't have a mental illness can get together and plan something with someone with a major mental illness."
    Some experts say that for many adolescents the plan to kill is a way of thinking about getting even, so the point is to discuss it. "kids talk to kids about this stuff because fantasy is a process," said Frank C. Sacco, director of a mental health clinic in Springfield, Mass., who is researching school violence. The companionship may even make the crimes possible. "Pairing then allows them to do these acts where acting alone doesn't," Dr. Meloy said. "It give them courage or stamina." But the fact that peers know in advance may make it easier to head off potential crimes. And immaturity may also point the way to hope for prevention. "What we found is they're not as tightly wrapped emotionally when they do mass murder," Dr. Meloy said. "Given their emotional ability, they would be more accessible to interventions and treatment."

Fury, Not Facts, in the Battle Over Childhood Behavior
Erica Goode, The New York Times- 4/9/2000

Are toddlers being plied with Prozac, Ritalin and other powerful drugs for behavior problems no more severe that sticking pennies into the VCR, throwing peas at the dinner table or refusing to go to bed on time? The hand-wringing in recent weeks over a study that documented an acute increase in the prescription of psychiatric medications--primarily stimulants and antidepressants--for preschoolers over a five-year period would suggest just that. Some mental health professionals have painted young children as the latest victims of a culture obsessed with syndromes and disorders. And politicians have seized the opportunity to condemn the "overmedicating" of the nation's youngest citizens. On March 20, Hillary Rodham Clinton announced a major federal initiative to reverse the trend. Yet, as often happens when science goes to Washington, the complexities that underlie the study's findings have been slighted in the public debate. And while concern over the rise in prescriptions is warranted, outrage may be premature. In fact, scientists know almost nothing about the children who are receiving such drugs, or the circumstances under which the medications are being prescribed. The study in question, for example, published in the Journal of the American Medical Association, did not analyze information about the children's diagnoses or the specialties of the physicians who wrote the prescriptions. What little researchers and clinicians do know suggests that the increases cannot be solely attributed to reckless prescribing by doctors hell-bent on tagging a psychiatric label on every child who walks into the consulting room.
    While pressure on parents and the current popularity of diagnoses like attention deficit hyperactivity disorder and depression undoubtedly play a role, it is also clear that at least some proportion of very young children taking psychiatric drugs have severe troubles. And in may cases, the drugs are given as a last resort, prescribed in the hope of protecting the child's safety, ensuring the safety of others or offering relief to a toddler whose life is being swallowed up by symptoms. "I think the general public doesn't understand that we're not talking about kids who won't stay in the grocery cart," said Dr. Marsha D. Rappley, and associate professor in pediatrics and human medicine at Michigan State University and the lead investigator in a smaller 15-month study of medication use in preschoolers with attention disorders. "We are talking about very disturbed behavior." Dr. Rappley said, "And these children need help." Dr. Rappley's study, which tracked 223 children under the age of three who were enrolled in a Michigan Medicaid program, has been cited in the public debate as one more indication that very young children are being drugged unnecessarily. Yet a closer look at the study, one of the few to offer clues to who these young pill takers are, does not entirely bear out that view. True, Dr. Rappley and her colleagues found that 57 percent of the children were given psychiatric medications. And of that group, 45.7 percent were prescribed more than one drug. In all, 30 combinations of 22 psychiatric medications were observed. But the researchers also found that almost half the preschoolers in the study suffered from diabetes, asthma or other major chronic illnesses in addition to attention disorder. Almost half had other psychiatric problems, including developmental or language delays, emotional disturbance and autism. Five percent were victims of child abuse or other traumas. And 40 percent were treated for an injury during the study period, 12 percent on more than one occasion. "This cannot be dismissed as bad behavior on the part of doctors who want to medicate children," Dr. Rappley said. "It is not that simple."
    Dr. Peter S. Jensen, director of the Center for the Advancement of Children's Mental Health at the New York State Psychiatric Institute, said the level of severity found in the Michigan study meshed with his own experience. "Most parents are terribly frightened and loath to put a child on medication, and it's the kind of thing they would do when everything else has been tried," Said Dr. Jensen, who added that medication is usually combined with behavior therapy or parenting classes. In one case he recalled, a three year old showed an escalating pattern of severe aggression, eventually wounding another child in his day care center with a butter knife. "We know that 6 to 9 percent of older kids have severe emotional disturbances," Dr. Jensen said. "Do we think it happens out of the brow of Zeus? Where were these kids at the age of 3 or 4 or 5? To my mind, the crime is not that these children are being put on medicine, but that we don't have the data to know what we are doing."
    Indeed, scientists' ignorance is at the core of the problem. Investigators have no idea, for example, how prevalent severe mental disorders are among the very young, what the best ways to treat such illnesses might be or which children are most vulnerable. And even when doctors prescribe medication in a last ditch attempt to help a very disturbed child, they are operating in a data vacuum; little or nothing is known about the effects of psychiatric drugs on the developing brain or the long-term impact on social relations, academic achievement or personality in young children who take such drugs. And most of the medications have not been specifically tested or had their dosages calibrated for young children. As Dr. Julie Magno Zito, an associate professor of pharmacy and medicine at the University of Maryland and the lead author of the recent journal study, commented when asked about the prescription increases: "We don't have any benchmarks to know if this is or is not a problem." In addition, the line between normality and clinical illness in a three year old is rarely clearly defined.
    Dr. Alison Gopnik, a developmental psychologist at the University of California at Berkeley, said many aspects of behavior--like impulse control, the ability to focus and empathy--vary greatly from child to child, and develop at different ages. Dr. Gopnik said she was disturbed by "the idea of doing this in preschoolers, where the medical evidence isn't there." "I don't think parents always have a good idea of what just normal preschooler behavior is," she added. Increasingly, Dr. Gopnik said, there is a "mismatch between what children are like just as children, what schools require from children and the time and energy parents have to negotiate that difference." Psychiatrists still know little, if anything, about diagnosing specific mental disorders in preschoolers. Studies indicate that such diagnoses are often fluid, changing as the child grows older, though severe behavior problems often persist. Given the lack of hard data, few experts would dispute that the sharp increase in prescriptions for toddlers is disturbing, particularly over so brief a period. Nor would most deny that the trend raises larger social and ethical questions. Dr. Zito, for example, said that at some point, society must decide how far down the age scale the medical model, which relies on diagnoses of illness and is likely to see drugs as the appropriate treatment, should be extended. "We are generalizing from adults to school-age children and now from school-age children to very young children."
    For his part, Dr. Jensen, who was a former associate director for child and adolescent research at the National Institute of Mental Health, says the federal government shares much of the blame for the dearth of knowledge about how to evaluate the use of drugs. Federal agencies, he said, have not yet provided high levels of research funding to study children's mental health. That may be changing. Responding to the outcry over Dr. Zito's study, the National Institute of Mental Health said it would spend $6 million over the next five years to study whether Ritalin is safe and effective for children under six. And the White House is planning a conference next fall on mental illness in preschoolers. Eventually, scientists may learn whether the increase in drug prescriptions charted by Dr. Zito and her colleagues represent overmedication or appropriate--in some cases, lifesaving--treatment for young children. Outrage is easy; it is harder, and more expensive, to find real answers.

Chicago School Provides Unique Antidote for Depression
Bonnie Miller Rubin and Judith Graham, Chicago Tribune- 4/9/2000

Of all the high schools on the North Shore that have attracted national attention, only one is virtually unknown to the public. With no sign, no chest-thumping banners proclaiming athletic or academic prowess, even the neighbors are unaware of its existence. Yet every day its presence saves lives, the students say. For 12 years, that has been the mission of the Evanston Northwestern Healthcare Adolescent Day School. Long before the complicated subject of teen emotional disorders burst into the national spotlight in highly atypical incarnations--school shootings in Littleton, Colo., Springfield, Ore., and elsewhere--the day school has provided a safe harbor for depressed teens who are struggling to learn while maintaining their emotional equilibrium. Tucked away on the second floor of a nondescript Glenview office building, this is not a psychiatric unit or a drug treatment center--although many of the students have battled those demons as well--but a fully accredited high school, with algebra and term papers. But there is little of the pain of the typical high school experience: There is no cafeteria to sit alone in, no lockers to be slammed up against, no towel-snapping jock culture or rigid caste system of cliques from which to be ostracized.  At a time when the demand for alternative programs is escalating, schools like this one are extremely rare, expensive and labor-intensive. Even in the Chicago area--home to some of the most prestigious university psychiatric departments in the country--the number of places where severely depressed youngsters can receive an education in a therapeutic setting can be counted on one hand.
    Certainly the challenges to success even in such an indisputably high-quality program illustrate the complexity of the malady among teens. "Anytime I wasn't sleeping, I was in hell," said J., 16, who suffers from severe depression and can't remember a time when she didn't feel lonely. Her friend, also a junior, chimed in: "The worst is when harassment spread to my family, like the time some kids dumped regurgitated food on our car." Between them, the two girls had run through every conceivable educational configuration--from boarding school to home school--with little to show for it but a blinding sense of worthlessness. That all changed, however, when they arrived at the school. With just 20 students, it is one of the area's most elite schools: no sign, no listing in the phone book or directory assistance. Each year, only half the applicants are admitted, yet many keep their affiliation a secret. And while it draws almost exclusively from the North Shore, this educational institution has little in common with its highly competitive neighbors. At a school for the emotionally fragile, the goals are considerably humbler, but infinitely more complicated: to bestow self-esteem, to learn how to handle stress, to become productive members of society and to ensure they can't harm themselves or others, said Dr. Louis Kraus, Evanston's director of child and adolescent psychiatry. Indeed, while other high schools measure their success in the number of state sports titles and National Merit scholars, the staff trots out different statistics. In 12 years, they've lost only one student to suicide. One too many, of course, but rather remarkable considering that almost all the students have a history of severe depression or bipolar disorder. Many have already attempted suicide; or have taken up "cutting" or sniffing inhalants or whatever form of self-destruction is currently in vogue, while families lurch from crisis to crisis. "When I got him into the program, I realized that I was no longer scared of the phone," one mother said. "It was the first time I exhaled in months. This is as good as it gets." And even then, there are no guarantees.
    Only 25 years ago, it was widely believed that children couldn't be depressed because they lacked psychological maturity. Today, about 1 in 10 teens will experience some form of depression or bipolar disorder, according to the American Academy of Child and Adolescent Psychiatry. Because of advances in brain science and breakthroughs in medication and psychotherapy, doctors have more tools in the arsenal than ever before. Millions of people with depression lead normal lives with the right treatment. Yet barriers to care such as stigma, accessibility, cost and a shortage of skilled professionals still loom large, keeping half of those with emotional disorders from ever getting the help they need, according to the first-ever Surgeon General's Report on Mental Health, released last year. Locally, the wait for teens to see top mental health professionals can exceed six months--if they can get an appointment at all--and prescribing psychiatric drugs has become a booming business even for preschoolers, even though their long-term effects on developing bodies and brains have never been documented. The first large-scale study of teens and the newest generation of anti-depressants-- the selective serotonin uptake inhibitors (SSRIs) better known by the brand names Zoloft, Prozac and Paxil--only recently got under way. Experts say depression is on the rise and occurring earlier. Whether the numbers reflect a real increase is open to question. Are doctors becoming better at diagnosing the condition? Or are we less tolerant of behavior quirks? Are we too eager to turn every behavior quirk into a full-blown psychosis, ready to be probed? Even though much remains unknown, over the last decade researchers have learned that depression is a sign of an imbalance in brain chemicals called neurotransmitters and that genetic factors can put some more at risk than others. The earlier the disease begins, the more devastating it can be, just as juvenile diabetes is a more virulent strain than the adult-onset variety.
    Gender plays a part too. Before age 12, boys and girls are affected equally. Then, with the passage into adolescence, twice as many girls are diagnosed with the illness, a pattern that will continue through middle age. Environment also is closely linked, because the susceptibility may lie dormant until triggered by external factors. But a divorce in the family, a break-up with a boyfriend or a college rejection letter generally can't cause a bout of the illness.  However, few have the time--not parents, not overwhelmed school personnel and certainly not clinicians under relentless pressure from managed-care companies to boost the bottom line--for the painstaking, delicate task of separating ordinary teenage volatility from brain wiring gone awry. When it comes to treatment for "children and teens, we only have beginning clues," said Dr. Myrna Weissman, professor of psychiatry at Columbia University's College of Physicians and Surgeons in New York. "We are where we were with adult depression in the 1970s."

End of self-assurance
Sitting in a cramped office at the North Shore school, one 15-year-old--dressed preppily in a T-shirt and khaki pants--described her early years as "really well-adjusted." Then, with the onset of puberty, something happened, A. said, and the self-assured girl vanished into a brooding young woman "who thinks too much." To these roiling emotions, add the pressures of high school and making new friends. As a freshman, she attended a vaunted private school in the city, commuting from her North Shore home by train, "which made me feel like a miniature adult." Her parents transferred her to a nearby suburban high school, but by then, all she felt was a numbing emptiness. She defies every stereotype of mental illness: exceedingly bright, exuberant and talented enough to have appeared on the Goodman Theatre stage. But she's also on lithium, which alleviates explosiveness, and has done several stints at a psychiatric hospital.  After a week or so, when they're stable, the kids usually return home. But without a transition school placement to provide scaffolding, all the medications, talk therapy and nurturing evaporates. Plunk them down in the same environment, experts say, and it isn't a matter of if a crisis will occur, only when. "I hated everything about high school. The way it crushes your spirit, the impersonalness, the hurriedness, the way you feel totally invisible," said A., drawing her knees to her chest. "In a traditional school, the popular kids can relax, but 99 percent of the rest of us can't. Here, everyone cares about you, so your troubles just sort of melt away. The last month and a half is probably the most relaxed I've felt about school in my entire life." And if such a place didn't exist? "Oh, that's easy," she says matter-of-factly. "I would have killed myself." Before the day is over, it would be a sentiment that is echoed repeatedly.

Rise in teen suicides
It is a misconception that suicide is rare among teens, that it comes out of nowhere, that there is so much that researchers don't know. In truth, doctors know a great deal. That it ranks as the third leading cause of death among teens and young adults. (More die from suicide than from cancer, heart disease, AIDS, pneumonia and influenza combined.) That suicides among 15- to 19-year-olds have more than tripled over the last four decades, soaring from 2.7 per 100,000 teens in 1950 to 10.5 in 1995, according to the most recent data from the Youth Risk Behavior Survey of the Centers for Disease Control and Prevention. Clinicians also know that major depression and suicide are inextricably linked. More than one out of three kids with the diagnosis attempts to take their own lives, according to University of Pittsburgh researcher Dr. Maria Kovacs. In 1997, some 5,000 U.S. high school students made attempts that were serious enough to require medical attention. Girls try more often, but boys--who usually choose weapons over pills--are more successful. And the heartache doesn't end with puberty. New research tracing the arc of depression over time shows that it can recycle again and again, inflicting psychological scars that last a lifetime. Teens with the illness are twice as likely to turn into depressed adults and 14 times more likely to attempt suicide over the course of their lifetimes, according to a study by Weissman and nine colleagues published last May in the Journal of the American Medical Association. Yet, for all the research, depression and suicide remain stubbornly entrenched. "The growing gap between available services and the need for care makes the mental health of children and adolescents probably the most neglected of health-care needs in this country," said Mark Weist, an associate professor at the University of Maryland School of Medicine and a member of the Children's Congressional Caucus.

Stress factories
In the year since the slayings at Columbine High in Littleton, Colo., Americans have searched for an answer to vexing questions: Why do high schools--especially resource-rich, homogeneous suburban institutions --breed so much pain? Who are the ticking time bombs? And, without an X-ray or a biopsy, how do we pinpoint them before they go off? If there is any Columbine legacy, it is that it sparked a dialogue, previously confined to mental health circles, Kraus said. "It got all of us talking about what we will tolerate in terms of bullying, prejudice and scapegoating. People here are more apt to call now and say, `We have the same demographics as Columbine. We're a community at risk."' It can take years for an outcast to grow isolated, for anger to fester and harden and turn into violence. But in today's super-size institutions with enrollments of 2,500 or more, school personnel are stretched too thin to be diagnosticians in all but the worst cases, said Kevin Dwyer, head of the National Association of School Psychologists. The association recommends a ratio of one social worker for every 750 students and one psychologist per 1,000 students, but many school districts don't employ any psychologists at all, Dwyer said. "That's nothing more than institutional child neglect." While only a fraction will actually commit violent acts, when you add an accumulation of other risk factors such as negative media images, drugs, access to weapons or being branded "a reject" just one time too many, the risk increases exponentially.
    Dan Meehan, a social worker who has been at the day school since its inception, cites the accounts of videotapes by Eric Harris and Dylan Klebold, made with rage at full boil, before their suicide mission at Columbine.  "When you listen to what the boys are actually saying, it's `No one actually let me belong. That they made fun of how I looked, my face, my hair, my shirt. I moved a lot. I never felt connected.'" Keeping kids from falling through the cracks, though, is a labor-intensive proposition. The per-student expenditure of $25,000 for the Glenview school, which is about four times the state average, is paid by the teens' home school districts, and even then it doesn't cover the entire tab. Evanston Hospital makes up the difference. Admission requires the recommendation of a psychiatrist, plus the home school district must sign off on the arrangement by agreeing that it is unable to accommodate the teen's special needs or provide the necessary services. To force some school districts to pay, parents sometimes take legal action. Despite all the hurdles, twice as many kids apply as there are slots. The faculty consists of four teachers, four case managers, a psychiatric nurse and two child psychiatrists, all of whom work together to oversee the educational and therapeutic needs of students during their stay, which can last anywhere from six months to two years. Whatever the title, the work is personal and intimate because a staff member gets to know the student's fears, hopes, dreams and a flood of other feelings that people usually turn inward. There's little here that resembles the students' former schools, which is precisely the point. Eavesdrop on a conversation and you'll hear kids debate the merits of Zoloft versus Prozac. Or the practices of one psychiatric hospital over another ("Didn't you just hate the way they'd go right to the restraints?") "Regular" school doesn't have an administrator like Carol Hynes, a registered nurse whose official nametag says "clinical coordinator," although "Mother Hen" would be more accurate. While school nurses cannot dispense so much as an aspirin, Hynes can administer a variety of psychiatric drugs should a student suffer from an acute anxiety episode. They also don't have teachers who are willing to bag the lesson plan when the mood isn't right. "Sometimes, I'll just look at them and sigh, `It isn't a math day, is it?"' said Annali Duffin, who teaches four classes, ranging from prealgebra to calculus. The schedule also includes daily meetings with social workers and weekly family therapy sessions. And while there are troubled families, there are also an equal number of "Leave it to Beaver" parents, whom the students readily praise for their support. "I'd be pretty upset if my kids did this to me," admitted D., a senior. For their part, the parents are grateful for the school's existence, even as they mourn its necessity. While there are myriad settings for kids with physical maladies, behavior problems and learning disabilities, finding a placement for a kid whose emotional thermostat is broken is far trickier.
    Increasing the number of such programs was one priority cited by Surgeon General David Satcher in his recent report on mental health. Until that happens, though, the choice is limited, as J.'s parents discovered when they found no vacancies. Desperate and with just a few days before the beginning of the school year, they ended up sending her to a special needs high school in Carbondale. Two months later, she was back home. D., an honor-roll student whose SAT scores are among the highest in the nation, struggles with depression. He attends the therapeutic school and then shuttles back to his regular school, which not only allows him to seamlessly participate in extracurricular activities but is so accommodating that some kids are unaware that he spends his day elsewhere. He doesn't advertise his mental illness, but he isn't ashamed, either. "When someone says, `You're so smart, what do you have to be depressed about?' I usually tell them that I'm smart enough to know I have a problem and I'm dealing with it."  A self-confessed perfectionist, D. always struggled with some feelings of sadness and anxiety, but still managed a veneer of normalcy. But at the end of his junior year, feeling swamped by his emotions and uncertainty about the future, he became paralyzed, unable to get out of bed. All summer long, he went through the usual regimen of hospitalization, medication and therapy. Everyone, D. included, thought he'd land on his feet and return for his senior year. But by the third day, he was weeping uncontrollably. "I'm trying to viewing this as a bump in the road," he says gamely. Now, instead of applying to Ivy League colleges, he is considering a post-high school program in Boston that allows students to ease into work and living on their own. His parents are warm, thoughtful people who still seem a little stunned by their sudden immersion into the mental health system. While the primary objective is for D. to get well, said his mother, it's painful to accept the diminished picture of the future, to reconcile the snapshot that all parents carry in their heads with reality. "Luckily, you start stepping down gradually, in little half-steps," she said, the words sticking in her throat. "If it happened all at once, I don't think any of us could get out of bed."

Room to be different
The 20 kids at Evanston Day School all referred to themselves as "different," a difficult label to wear in hallways that embrace conformity. In a few years--and with the right interventions--their doctors hope they'll be able to choose from a broad spectrum of environments. Perhaps the fidgety and frenetic ones will wind up making millions in the trading pits; the sleepy ones will find jobs where they can clock in at noon, and the loners may shine as artists.  Still, there will never be enough slots in alternative institutions to accommodate all the social pariahs, never enough compassionate teachers to send them out into the world with a stronger sense of self or lunchroom monitors to stop the taunts and the bullying. Rather than wring our hands and wonder why teens have changed so much, it is more instructive to ask why school has changed so little, experts said. "There'll be less violence when we make school a more supportive place," said Meehan, who wears a gray ponytail and a tranquil demeanor. "In a climate where inclusiveness and cooperation is woven into the fabric of daily life, there's less of a chance of a Columbine happening." Despite the national debate sparked by school violence, Meehan doesn't expect to see an overhaul any time soon. We'll do the easy stuff--the metal detectors, the dress code and the security guards, he said, but we won't do much to alter the culture. Frank DeAngelis, Columbine's principal, acknowledged as much as his school's own new security system was being installed: "I think where the money needs to be spent is educating our students about tolerance, about respecting one another, about communication," he said. That's especially true in the nation's highly competitive communities, where the focus is on the stars "and no one can just grow up to be a mailman," Meehan said. "All that sorting, ranking and weighting means someone has to be No. 1 and someone has to be 700, and that takes its toll."

Use of Anti-Depressants Is a Long-Term Practice
Gary Langer, ABC News- 4/10/2000

One in eight American adults has taken Prozac or a similar antidepressant — most of them for longer than the three months of continuous use for which these drugs were trial-tested, an ABCNEWS poll has found. Twelve percent in the national survey said they had taken such drugs, and six in 10 of them said it had been for more than three months. The median was six months, and 46 percent said it’d been for a year or more. Among non-users, moreover, 25 percent reported that a close friend or relative had taken such medication, most for an even longer period of time.
The drug users, and those who know a user, overwhelmingly said the medication had helped. Nonetheless, most were unaware that this class of antidepressants has been trial-tested by the Food and Drug Administration only for three months of continuous use. Most also said they have not had therapy or counseling in conjunction with the medication, something many mental-health professionals recommend. This poll was conducted as part of a report by ABC News Correspondent Kevin Newman to be aired as part of the April 10 edition of World News Tonight with Peter Jennings. Newman reports that many adults may be overusing antidepressants without knowledge of possible long-term side effects.

Depression
Among all Americans, 15 percent in this poll said they feel "really depressed" once a week or more often than that; an additional 17 percent, once a month. Combined, that’s one in three adults. Feeling depressed, naturally, correlates closely with the use of antidepressants. Among people who feel depressed at least once a month, 28 percent have taken Prozac or similar drugs. Among those who are depressed less often (or never), that falls to five percent. Women are twice as likely as men to say they’ve taken an antidepressant, 16 percent to eight percent. Women also are more likely to say they have a relative or close friend who’s taken such drugs, 30 percent to 19 percent. It’s an open question whether men in fact are less likely to take such drugs, or simply are less inclined to discuss it. This poll also finds more use of such drugs among lower-income Americans.

Length of Use
Thirty-nine percent of those who’ve used such drugs say it’s been for three months or less. At the other end of the spectrum, 18 percent say it’s been for more than two years; 26 percent for 1-2 years; and 17 percent for four to 11 months. Some people count: One respondent said it’d been "221 days." In any case, since they represent self-reporting, these figures probably are superior to the length-of-use estimates by people who have close friends or relatives using such drugs. Those people report more long-term use — 70 percent say it’s been more than a year.
In any case, it’s worked: Sixty-seven percent of users say the medication has helped them, either a great deal (39 percent) or somewhat (28 percent). Similarly, among those who have a friend or relative who’s taken such drugs, seven in 10 say it helped.

Lack of Counseling
Most of those who’ve taken such drugs — 59 percent — say they have not had counseling or therapy along with the medication. Reported counseling is higher, however, among those with a friend or relative who’ve used the medication; in this group, 55 percent say counseling has accompanied the medication. (On one hand, users have more direct knowledge; on the other, some may be reluctant to discuss having had therapy. Respondents to this survey were assured confidentiality.)

Knowledge
There’s a lack of knowledge — and among users, a misunderstanding — about the testing of such drugs’ safety for long-term use, defined here as more than three months. Among all Americans, 42 percent incorrectly think such drugs have been tested for long-term use; among users, that rises sharply, to 72 percent. Finally, respondents were asked whether they felt long-term use is OK because of the benefits, even with a lack of studies to prove its safety; or whether long-term use should be limited until studies show it’s safe. Among all Americans, just 26 percent said that given the benefits, long-term use is OK, even without safety studies. But among those who’ve used these drugs, support for long-term use despite the lack of studies nearly doubles, to 51 percent.

Methodology
This ABC News poll was conducted by telephone March 15-19 among a random national sample of 1,027 adults. The results have a three-point error margin. Field work by TNS Intersearch of Horsham, Pa.