Noteworthy News Articles on Mental Health Topics, May 28-31, 2000

Life After God: A Book Review of "Darwin's Worms" by Adam Phillips
Steven Marcus, The New York Times Book Review- 5/28/2000

Adam Phillips, a child psychotherapist in London, is also a gifted writer. He has become increasingly known for his artful and epigrammatic essays, many of which have been appropriately published in literary journals. Phillips will often take up a relatively unnoticed phenomenon, like tickling, or explore a commonplace yet mysterious behavior, like kissing, using some observation by Freud as a launching platform. In the case of kissing, Freud noted that a young child learns to seek sensual pleasure split off from nourishment by sucking, will subsequently turn to his own skin, on his arm or toe or thumb, as an "inferior" source of pleasure and at a still later date seek "the corresponding part--the lips--of another person." The child seems to be saying, Freud remarks, "it's a pity I can't kiss myself."
    Phillips acutely homes in on this not exactly perspicuous passage and proceeds interpretively and theoretically to work it over. What regularly attracts his attention is the cryptic in psychoanalysis itself, and he seeks it out in large part because for him psychoanalysis is an open field of discourse. No orthodoxy or exclusionary terminology constrains him. At the same time Phillips's essays incline to be ruminative rather than argumentative. They move along by association and incremental repetition rather than by progressive trails of logic. Almost invariably lively and entertaining, they are directed as well toward instructing their audience. They resemble what in the 19th century were called "lay sermons"--moral and spiritual discourses composed by someone outside the clergy within a religious and cultural context lit up by the troubled consciousness of irremediable secularization.
    Phillips's new book, "Darwin's Worms." Answers to this characterization. It consists of four brief pieces, the whole amounting to fewer than 150 pages--sermonettes for both the old and the new millenniums. A generalizing "Prologue" and "Epilogue" flank two specific excursions, "Darwin Turns the Worm" and "The Death of Freud." God having been evacuated from the intellectual universe, the mysteries of the origin and persistence of evil and suffering decline into mere conundrums. Our new world, in whose creation Darwin and Freud are momentous figures, consists of us and nature and nothing between the two. It makes no sense any longer "to talk to nature…as being divided against itself. Nature is… always on its own side." Nor can people be plausibly described as acting against their own nature or being "unnatural."
    Similar radical transformations in other global conceptions, like sexuality, childhood, competition and the past, are salient to what Darwin and Freud achieved in the way both of creating new accounts of life and the world and of compelling us to apply their redefinitions in our self-descriptions. These descriptions can no longer, for example, include redemption. Nor can they circumvent our distinctive animal nature or the fact that we die "conclusively." Both Darwin and Freud, Phillips brightly quips, were in on "the death of immortality." Neither left room for transcendence or deliverance; both gave priority of place to the transience of our lives. Death figures for both as a precondition and organizing principle--we seem to be animals "haunted by" our own and other people's absences; "birthdays remind us that we were once inconceivable." Without the consolation of belief, Phillips goes on, modern life "could be consumed by the experience of loss." Indeed, he adds, "all modern therapies are forms of bereavement counseling." Moreover, the de-deified nature that Darwin and Freud newly represented is "apparently organized but not designed." Phillips quotes Freud to the effect that "one is inclined to say that the intention that man should be happy has no part in the plan of creation." And comments that Freud wrote this "knowing that there is no plan and no creation." Hence, although Darwin and Freud are by comparison with their precursors pessimistic, neither is in point of fact particularly gloomy. Both find occasions for celebration and for praise.
    Such occasions are the subject of Phillips's two central meditations. The first is devoted to an analysis of Darwin's intense and lifelong interest in earthworms. These humble creatures embody major themes in Darwin's life and work. They exemplify the endless, fascinating, purposeless prodigality and indifferent pitilessness of nature. The lowly worm, associated traditionally with death, rot and corruption, also helps to sustain the fertility and abundance of our common mother, the earth. These tiny gardeners carry on the labor of Adam, and like the British working class transform the earth while remaining semi-invisible. (Darwin's famous capitalist relatives, the Wedgwoods, were dong similar things in their potteries.) Earthworms do so through silent, ceaseless work and by means of their digestion (Darwin was always plagued by his). In action beneath the surface of the visible world, they figure forth the earth scientist, archaeologists, sociological analysts, evolutionary theorists and psychoanalysts of the coming century: they are involved with hidden processes, with things occurring underground; but they are also excavators, sifting through and turning the soil. Symbolizing in their "heroic ordinary labor" the secular achievements of modern science and thought. Yet they are also, like Darwin's evolution itself, supreme gradualists; and like the British of the 19th century, they are dedicated to slow motion, to fragmentary reformation and piecemeal reform.
    The homily continues as Phillips addresses Darwin's last book, "Formation of Vegetable Mould Through the Actions of Worms, with Observations on Their Habits." Like Hamlet, Darwin was "obsessed by burial" and by worms, although his writing, like "Hamlet," is "counter-elegiac" and "proposes what might be called a secular afterlife." It celebrates the "inexhaustible work" that perpetuates the natural world, whose life "continues after one's own death." Although nothing in this world is intended for our well-being, it can be, "in its own way, contingently hospitable." The natural economy that obtains between worms and men is altogether "our accidental good fortune." Still, it is good fortune.
    Phillips's lesson on Freud is longer and more complex. He begins by referring to Freud's destroying, when he was 29, virtually all his personal and scientific papers, letters, notes and manuscripts, sparing only those from his family and his future wife. This personage-to-be whose work was to transform our notions of what an individual life story entails reported that he had done this to make things difficult for his future biographers. For although Freud incorporated Oedipus, the remorseless tragic detective and destructive discloser of a life plot, he also identified with the Sphinx. And as a psychoanalyst, he invented a new professional version of the Sphinx, "the one who asks, but never answers, the question."
    Enlisted in the service of Eros, the life instinct, Freud contrived new means of telling our life stories and of explaining why we are compelled to tell them. Yet we also harbor impulses to destroy our lives and their stories, impulses integral to that which they aim to obliterate. If Eros projects a meaningful story for each individual person and seeks to be the builder of cities, then Freud's grand fiction of the death instinct (which was born in 1920) aims to deconstruct the stories we make up about ourselves, leaving at best only the chaotic record of how we fall apart, and, on a large scale, presides over the ruination and fall of empires. Focusing on "Beyond the Pleasure Principle" as his scriptural text, Phillips picks out several resonating passages. First, Freud declares that for the purposes of his argument, "we are to take it as a truth that knows no exceptions…that everything living dies for internal reasons." It follows that "the aim of all life is death" and that all living entities strive to die; indeed, death appears to be an object of desire. Yet this project is not a simple, universal quest to go blotto. Each particular organism, Freud writes, "wishes to die only in its own fashion." And so even death is included among our life projects, and dying only in our own individuated way is also a form of self-realization. Having discovered this dialectical whirligig, Phillips rides it for a while until it finally stops at the death of Freud.
    Phillips interprets Freud as being skeptically disposed to suggest that biography attempts to account for too much. At the same time, Freud himself was a great narrative theorist, who found or invented theoretical scenarios and persuasive clinical explanations that were nonetheless incompatible with one another. Still, the death of Freud seemed to those who were there and to his subsequent biographers to discredit the conclusion that conflict and ambivalence were organic to Freud's systems. For the reports of this episode all stress Freud's control over things right up to the very end. Freud the organism died strictly in his own fashion. Phillips examines these "narratively coherent" biographical representations, with their inevitable references to Oedipus and Hamlet, and finds them impossibly neat. They fly "in the face of all the psychoanalytic evidence" in their endeavor to portray the dying Freud as a "heroically unified subject"--never self-divided, a unique being without an unconscious, a monument of his beliefs.

Overhaul of California Mental Health Care Stumbles
Dan Morain, Los Angeles Times- 5/29/2000

SACRAMENTO--Efforts to overhaul California's long-troubled mental health system are faltering as the Assembly pares back proposed spending for a variety of improvements and Democratic lawmakers struggle over how much authority government should have to treat severely ill people who refuse care. A bill by Assemblywoman Helen Thomson (D-Davis) that would make it easier to treat people against their will in extreme cases is heading for a vote in the Assembly as early as this week. But before sending the measure to the Assembly floor, the powerful Appropriations Committee stripped it of its funding. Thomson's legislation, AB 1800, is sure to divide legislators and mental health advocates for the rest of the year. Meanwhile, the fight over funding is coming to a head as legislators and the governor turn their attention to the budget for the new fiscal year beginning July 1. The state Senate is pushing for a $300-million increase beyond the $2.5 billion that Gov. Gray Davis proposes for California's mental health care system.
    However, in its $100-billion version of the new state budget, the Assembly fell in line with Davis' plan by trimming $110 million from an array of programs. For example, the lower house cut back the expansion of a program operating in three counties that seeks to persuade homeless mentally ill people to enter treatment. In another instance, the Assembly eliminated all funding for a proposed program that would offer outside help to people who care for mentally ill family members. The Assembly action last week came despite statements by several lawmakers at the start of the year that they intended to greatly boost funding for mental health care. Their statements followed news accounts in The Times and other publications detailing long-standing failings in California's mental health care system. "It's still record money," Assembly Speaker Bob Hertzberg (D-Sherman Oaks) said. "It is a balancing, in terms of what we can do against other priorities."
    As the Assembly was limiting increases for the care of mentally ill people, it boosted other health care programs. The lower house proposes to pay doctors and dentists more for treating poor people, increase health coverage for children of parents whose employers don't offer insurance, and grant 10% pay raises for nursing home workers.  "I'm not pleased at all," Thomson said. "Again, mental health takes a back seat to health care, even though mental health should be part of the overall system." About two dozen bills aimed at overhauling the system are wending their way through the Legislature. But without money, many of them would be little more than shells even if they are signed into law by Davis. Sen. Martha Escutia (D-Whittier), for example, has introduced a bill to create a "respite" program for people--generally parents--who care for mentally ill family members. The price tag is $10 million, a fraction of the overall budget, which will approach $100 billion. In such programs, outside workers care for an ill person for an evening, or for a few days or weeks, while family members take a break. The Senate's budget includes the $10 million; the Assembly stripped the money. The difference will be resolved in the coming weeks as legislative leaders and Davis negotiate final details of the spending plan.
    "Some people are saying wait till next year," said Bruce Saltzer, an advocate of the respite idea. "No way. Am I going to tell families in the mental health system to wait another year? It's not fair to them." In a bit of irony, the Assembly proposed to grant a 33% wage hike for respite workers who help parents or siblings who care for relatives who are mentally retarded or have other developmental disabilities, at a cost of $25.7 million. "My sense is that mental health took an exceptionally large hit," said Saltzer, executive director of the Assn. of Community Mental Health Agencies, representing 52 nonprofit mental health care providers in Los Angeles. "We thought the Assembly was going to be very supportive."
    Meanwhile, lawmakers are locked in a fight over the question of involuntary treatment. The issue has so flummoxed lawmakers that they have delayed releasing a report detailing problems and needs in the system. Senate President Pro Tem John Burton (D-San Francisco) pushed to establish the committee and asked that it produce the report by May 1. He had hoped the report would support his argument that the system needs far more money. Committee members are battling over one section in the lengthy report that includes a recommendation that the committee endorse new programs for "involuntary patients." As the report describes the concept, courts would order that such people undergo treatment after concluding that they are a danger to themselves or others. They would be living on their own or with family members, rather than in locked institutions. Thomson, co-chair of the select committee, refuses to embrace the report if it ignores mention of involuntary treatment, something she sees as a key part of any overhaul of the system for treating severely mentally ill people. However, Assemblyman Darrell Steinberg (D-Sacramento), another committee member, opposes Thomson's approach and has voted against her bill, which would revise the state's 30-year-old commitment law by making it easier to impose treatment on the severely mentally ill.  Steinberg is the leading proponent of a program that seeks to persuade homeless mentally ill people to agree to treatment by offering them housing and other help. "The problem is not the law," Steinberg said. "The problem is that we have been living with an underfunded and fragmented system which has turned people away. AB 1800 could and would catch people in the involuntary system who are amenable to treatment on a voluntary basis, if we provide the service.

Study Shows Drug Prices Have Doubled in Last 3 Years
Washington Post- 5/29/2000

Think the government is right in saying that drug expenditures are rising at double-digit rates? Well, such statistics don't show the half of it, says a study sponsored by a new advocacy group, RxHealthValue. Spending on prescription drugs has more than doubled in the last three years among the people studied by RxHealthValue, rising from $204 annually per person to $436.  While government figures ordinarily include those who have insurance and those who don't, the Rx group's sample of 1.4 million contained only people with insurance, which typically includes a prescription plan. Among these people, drug costs are rising by about 25% a year. And the Rx numbers show that if you've got drug benefits, you're likely to use them. And use them. And use them:
* The number of people using prescription drugs grew 3.5% a year, from 60% of the overall sample to more than 66%. This trend was greatest among people ages 45 to 65.
* The number of prescriptions per person grew 14% annually. In the most extreme case, the typical person 65 or older received 23 prescriptions in 1999, compared with 16 in 1996.
* Once patients start taking a drug, they take it longer--30 days, or 12% longer in 1999 than in 1996.
    RxHealthValue, a coalition whose members include health insurers, labor unions and employers, aims to assess the value, not just the price, of prescription drugs. Its study was conducted by a Brandeis University institute and PCS Health Systems, a coalition member that is a subsidiary of Rite Aid. Inflation did not add significantly to the spending increase. But new drugs--medications that came on the market after the study began--played a huge role in the higher spending. These new drugs accounted for more than one-third of the overall increase.

The Rise in Drug Prices is Causing the Public to Ask Why
Linda Marsa, Los Angeles Times- 5/29/2000

Dorothy and Clarence Cardella, a retired couple in their 70s living in Pasadena, pay more than $300 a month out of pocket for prescription drugs to maintain their health. Clarence has had two heart surgeries and requires costly medications, while Dorothy takes drugs to treat her diabetes and a thyroid condition. Medicare covers their doctor bills and any hospital visits, but the federal health program doesn't cover prescriptions. While the Cardellas' household income is fixed, the cost of their medications is anything but: The prices just keep going up. Recently, Dorothy's doctor suggested a new insulin drug for her diabetes. It costs $230 a month. The cash-strapped Cardellas can't afford it, so Dorothy's doctor has given her free samples. "At this rate," she says, "we'll soon be broke."
    The Cardellas' situation is hardly unique. Prescription drug prices are rising much faster than the rate of general consumer inflation. The burden for this ballooning bill falls most heavily on those who can least afford it--older Americans living on fixed incomes, and the working poor with inadequate or no health insurance. Most Americans don't feel the rise in drug prices directly because they purchase prescription medicines through their employee health plans or their HMOs, where they don't pay the full price, often making only a $10 or $20 co-payment. The rise in drug prices does hit this group indirectly: Many health insurers have blamed higher drug costs as the reason behind hikes in medical premiums or restriction of benefits.
    But drug inflation is felt most keenly by people like the Cardellas, who are among an estimated 15 million Medicare recipients who pay out-of-pocket for arthritis medications that ease their pain, or heart drugs that help them stay alive. (The Cardellas could get drug coverage by joining a Medicare HMO, but they have long-standing relationships with doctors who aren't in HMOs.) So they and millions of others essentially pay retail for their medications. And it is this group of people that has prompted consumer groups, politicians and the elderly to question why medicines cost so much and why prices keep going up.
    Are there legitimate reasons behind this trend? Or are we just being gouged? Experts say there are a host of factors nudging prices upward, including the shift of patients into HMOs, and increased costs for advertising and research and development. One reason why retail prices are going up is the rise of managed care, which now covers 60% of the insured population in the United States and an even higher percentage in California. Large HMOs and other managed care plans use their bargaining clout to demand discounts when they make bulk purchases of prescription drugs. Pharmaceutical companies, critics say, have tried to recoup some of this lost revenue by charging more to patients who have no one to bargain on their behalf--people without drug coverage who must pay full retail prices. This practice is known in the health industry as cost shifting. Another factor is that the new generation of designer drugs is expensive to produce. When Genentech introduced Activase, a genetically engineered drug that dissolves artery clots that can cause heart attacks, the price was $2,200 a dose. Company officials defended the cost, citing very high research and development expenses. Creating a complex, genetically engineered drug versus producing a conventional drug is like the difference between making a $20 watch and crafting a fine Swiss timepiece.
    Indeed, the process of taking a drug from the laboratory to the patient's bedside is a lengthy one, requiring as much as 15 years and costing from $300 million to $500 million. And success is not guaranteed. Often there is a vast difference between how a compound behaves in the test tube and how it acts on humans. New drugs typically require three phases of tests on human subjects to demonstrate that they work and don't produce serious side effects. Most therapies founder along the way, perhaps proving less effective on humans than when tested on animals, or producing unexpected toxic effects. Only one medicine out of five makes it through human clinical tests, said Jeffrey Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, an industry trade group in Washington, D.C. For drug companies, these research duds are a necessary cost of doing business, much as a dry well is to an oil-exploration company. The drug makers argue, however, that prices for the one in five therapies that do make it to market must compensate for the costs associated with those that don't. Consequently, the successful drugs have higher prices. How exactly pharmaceutical firms set prices for a particular drug is a closely guarded trade secret; it's safe to say, however, that the price often bears little relation to development or manufacturing expenses for the that product.
    When new drugs are patented, competitors are prohibited from copying the drug for 17 years. Because it may take 10 years or so from the time of patent for a new drug to reach the market, however, the patent protection may be lost several years after the drug actually goes on sale. The idea behind patent protection is that it encourages innovation by giving companies the market to themselves for a while so they can recoup their development costs. "While drugs are under patent, pharmaceutical companies act like any other monopoly and charge what the market will bear," says Jeffrey McCombs, a pharmaceutical economist at USC. "But that doesn't make them bad guys." And drug makers' pricing practices aren't much different from those of other industries that have a monopoly. What is different, though, is that even when rival products are introduced, prices usually don't tumble. What's more, prices of older drugs continue to rise, even after, presumably, they've made their money back. That's because a drug's effectiveness--how well it works--not cost, is the key selling point when it comes to medicine.
    Consequently, the drug companies shelled out $8.3 billion in 1999 for advertising and promotion in order to influence treatment decisions. Physicians are barraged by information aimed at convincing them that a particular drug is the best. Pretty soon, these new treatments become the accepted standard practice. And even when equally effective drugs that cost less are introduced, doctors tend to continue giving their patients the more expensive medicine, which means prices remain high. In recent years, drug companies have also boosted efforts to pitch their products directly to consumers in TV, radio, magazines and newspaper ads to create brand-name awareness. In 1999, the industry spent nearly $2 billion to persuade patients to ask their doctor about products such as Zyrtec and Allegra, both allergy treatments, and Premarin, an estrogen supplement for post-menopausal women. This strategy seems to work. According to a 1999 study by the National Institute for Health Care Management, the 10 most heavily advertised drugs accounted for about 22% of the total increase in drug spending between 1993 and 1998. But a byproduct of these promotional campaigns, says Frank Clemente of Public Citizen, a consumer health watchdog group in Washington, D.C., is that "the most heavily advertised drugs are the ones whose prices increased the most."

Consumer Groups Push for Controls
The continued rise in prescription drug costs has touched off intense political debate on how best to give people like the Cardellas relief. Some politicians and consumer groups have pushed for some form of price controls. Not surprisingly, drug companies oppose price regulation. They contend it would curtail innovation in an industry that invests upward of $24 billion annually on research. "The drug companies," says William S. Comanor, a pharmaceutical economist at UCLA, "are not going to spend the $300 million or so it takes to develop a drug if the government is telling them what to charge."
    Others, though, say this is a scare tactic. "If there are reduced revenues, it might have some impact on research and development," says Ronald Pollack, executive director of Families USA, a consumer health group in Washington, D.C. "But the drug makers have far more latitude than they would have you believe." Pollack and others note that the pharmaceutical industry is the most profitable industry in America--with a level of profits that is three times higher than that of many Fortune 500 companies. Drug makers insist that such hefty profits are needed to pay for research that could produce therapies or cures for cancer, Alzheimer's disease and a host of other illnesses.
Says Trewhitt of the drug industry trade group: "It's very important to get a decisive return on investments. Otherwise, people won't put their money in research-dependent ventures that have such a high failure rate."

Taxpayers Shoulder Much of the Risk
But is that accurate? The reality is that U.S. taxpayers--not the companies and their shareholders--are shouldering a lot of the risk. The federal government pays for the bulk of the research by funding studies by the National Institutes of Health and through grants to academic research centers, such as USC and UCLA. This money pays for much of the highly speculative basic scientific research that results in quantum leaps forward in our understanding of diseases. And these discoveries become the springboard for devising new therapies. In contrast, most drug company research is aimed at developing products, not basic research, said Public Citizen's Clemente. And much of the research backed by corporations is aimed at developing "copycat" drugs to compete with successful medicines, rather than on basic research, he said. A 1995 Massachusetts Institute of Technology study found that 11 of 14 new drugs introduced in the prior 25 years that were considered significant therapeutic advances were derived--at least in part--from government-funded research.
    So are drug prices inflated? The answer depends upon whom you ask. Drug company executives and some health care economists argue that even the costliest medications are an incredible bargain. Many breakthrough drugs have revolutionized medicine, they say, enhancing the quality of life, leading to shorter and less costly hospital stays, and putting patients back on their feet faster. The average heart disease medication, for instance, costs $1,200 a year. That, however, is far cheaper than a $40,000 bypass operation, not to mention the inestimable benefits of avoiding surgery. But Dorothy Cardella, like many other older Americans, is fed up. "The situation is really depressing," she says. "Every time I turn around, it's more bills with no end in sight."

Lawsuit Charging Priest With Sexual Abuse Joined by 25 Men
Joseph B. Frazier, Associated Press, 5/29/2000

PORTLAND, Ore. (AP) Twenty-five men have accused a Roman Catholic priest of abusing them as children.  At a news conference Monday, Doug Ray said that from the third or fourth grade until he was a freshman in high school, his parish priest subjected him to ''an incremental scale of sexual abuse as bad as one can imagine, and worse.'' Joe Elliott claims he had a similar experience with the same priest, the Rev. Maurice Grammond.   ''My parents entrusted us to Grammond believing this would be the last place harm would come to us. He and the church broke that trust,'' Elliott said. Elliott, 41, was the first to accuse Grammond in a lawsuit in December. Others joined gradually, with 13 joining in Friday. Ray and Elliott said they were molested during the 1970s in Seaside, where Ray is a city councilman. Elliott is a hairdresser in Portland. Both sat in front of enlarged photos of themselves as grade school students and seemed on the verge of tears at times. Several other plaintiffs were present but kept their anonymity.
    The archdiocese issued a statement on Friday saying it confronted Grammond after an accusation in 1991 and that Grammond denied the claims. ''The Archbishop sent him for professional assessment and suspended him of all priestly ministry,'' the statement said. Grammond has not been charged with any crime. Attorney David Slader said the statute of limitations prevents criminal prosecution of Grammond, who is 79, and living in the Alzheimer's unit of a retirement center in suburban Portland. But he said civil suits can be pursued for up to three years from the time a victim ''discovers...significant injury in his life'' resulting from molestation.  The lawsuit, which seeks at least $4.6 million for each defendant, was filed against Grammond, the archbishop and the Archdiocese of Portland and others.
    The archdiocese is accused, among other things, of failure to notify parishioners of Grammond's past molestations of boys, failure to monitor his activities and advise authorities and failure to have other adults accompany Grammond on camping trips and other youth activities. Slader said the case is the biggest of its kind after the case of the Rev. James Porter of Massachusetts, who was accused by 99 people of molesting them while they were children in the 1950s and 1960s. He pleaded guilty in 1993 to molesting 28 children and was sentenced to 18-20 years in prison.

Illinois Program Aims to Detect Child Abuse
Jeff Coen, Chicago Tribune- 5/30/2000

More than a month before 5-year-old Arturo Barrera suffered a fatal head injury when he was thrown to a kitchen floor, the Illinois Department of Children and Family Services received a tip that the child was a possible abuse victim. A caseworker contracted by DCFS went to the boy's Chicago home and did not find signs of abuse. Nor did an examination by a family doctor, who dismissed the child's suspicious eye injury as the probable result of an accidental fall. But in fact, court proceedings have revealed, Arturo had been beaten for weeks before his 1996 murder. His mother is serving a 40-year prison sentence for her role in the child's death; her live-in boyfriend, who was accused of hurling Arturo to the floor for jumping on a couch, has filed an appeal after being sentenced to 52 years in prison for the killing.
    It is cases like Arturo's that have prompted a coalition of parents, doctors and DCFS officials to initiate a program designed to link caseworkers in Cook County with doctors who specialize in recognizing child abuse. No one can say for certain whether the new program, set to launch in October, would have saved Arturo. But those planning the program said it will improve the investigation of such cases and save lives. "Absolutely, that is the type of situation we are talking about," said Dr. Emalee Flaherty, medical director of the protective service team at Children's Memorial Hospital, where Arturo died. "More questions should have been asked." The new system is designed to give social workers immediate access to medical expertise in possible cases of severe child abuse. Those doctors will be able to provide swift analysis of whether a child's injuries are consistent with abuse cases, DCFS officials say. As a result, caseworkers will be able to decide quickly whether children must be removed from their homes for their own protection.
    As it stands now, agency caseworkers initially work with the doctor who treats a child's injuries--generally not a specialist. A more detailed analysis may not come until weeks later, and in cases like Arturo's, that might be too late.  Ed Cotton, DCFS deputy director of child protection, said he believes the pilot program, which will focus on head trauma cases, will save lives. If successful, it could be expanded to other parts of the state next year. "We want our staff working with the most accurate and complete information, and very quickly, when making decisions concerning the safety of children," Cotton said. "That would be a big move forward." The state has set aside more than $940,000 for the program's first year. That money will be used to hire two full-time case coordinators and pay for medical evaluations. The budget also includes funds to expand education on child abuse, such as a two-day conference on shaken baby syndrome.  DCFS hopes to eventually expand the pilot program across the state, with the help of federal dollars.
    Cotton said the last time DCFS attempted to offer its caseworkers better access to medical experts was about 10 years ago, when a screening nurse was hired to refer cases to a list of physicians. That effort fell apart, Cotton said, because the doctors were on-call and were not paid for their work. The new program has funds to pay the doctors and facilities for their time, Cotton said.  Under the plan, the two program coordinators will be alerted when DCFS learns about a potential case of head trauma from abuse in Cook County, generally through an abuse hot line or from doctors who treat the children. The coordinators then will hook up doctors, caseworkers and police to investigate. Doctors working on the program say it will create a uniform, comprehensive medical review of some of DCFS' most difficult cases. "The bottom line is that these kids all deserve a complete evaluation right from the start," said Dr. Jill Glick, director of child protective services at the University of Chicago Children's Hospital. "It isn't happening now, and we have children who have suffered from the inadequacies of the current system."
    The doctors said the plan eventually may include a certification program for doctors who treat abused children, perhaps through the Illinois chapter of the American Academy of Pediatrics. The effort is the result of work by the Child Protection Team Task Force, an alliance of doctors, law-enforcement leaders and DCFS supervisors brought together by the Gabriella Elise Manzardo Child Protection Foundation. The foundation was established by Laura Manzardo of Elmhurst after her 15-month-old daughter's death in October 1998, allegedly at the hands of a day-care provider. No one was charged in the Gabriella Manzardo case for a year. Ultimately, Mazna Baraz, a day-care provider from Elmhurst, was charged with the little girl's slaying. She has pleaded innocent and is awaiting trial.
    Laura Manzardo wonders whether the case would have moved faster if expert medical analysis had been more available. She also believes a system like the one under development would have turned up evidence of other suspicious injuries allegedly suffered by other children at the day-care center, and possibly prevented her daughter's death. "There were so many times when I didn't recognize warnings, and there were agencies involved that didn't recognize it," Manzardo said. "I realized our situation wasn't an isolated one, and I realized that when mistakes are made, children die. We can save other children. Otherwise, Gabriella died in vain." Organizers said the task force and the foundation also would try to train more emergency physicians, police, social workers and first-time parents to recognize early signs of abuse.
    Planners of the Cook County pilot program said they drew inspiration from similar programs in Florida and Virginia, where leading doctors are working closely with police and social workers. In Florida, a multidisciplinary team that has brought physicians, nurses, psychologists, attorneys, police and state social workers together has been handling cases since 1979. "I can say I know there have been hundreds of times over the years where we have been the force behind the removal of a child from an abusive home," said Patsy Buker, an executive director in the system. "I know we now have better assessment and diagnosis of child abuse."
    In Virginia, four leading hospitals have been working for five years with law enforcement to improve the investigation of child sexual-abuse cases. Now, the same system is being applied to cases of physical abuse.  Manzardo said she would like to see hospitals in Illinois supply better teaching materials. With so many young children in day care, Manzardo said, the task force should work to give parents information they can use to recognize trouble signs. In her own case, Manzardo said, she and her husband failed to recognize the significance of suspicious bruises on their daughter, believing it was the result of typical childhood falls. Manzardo has quit her job to run the GEM Foundation full time. "People ask me all the time how I can deal with my grief and do this, but I honestly don't know how I couldn't do it," Manzardo said. "Make no mistake--the children need us. Gabriella didn't have a voice."

Doctors Pay Big to Keep Drug Off Streets
Kim North Shine, Detroit Free Press- 5/30/2000

Clinton Township veterinarian Paul Turkal calls his clinic's pharmacy Ft. Knox. There's no bullion inside the fortress-like room, but rather a drug as good as gold to thieves. Ketamine, a sedative used primarily to tranquilize cats during surgery, has made veterinary offices nationwide popular with burglars and armed robbers, police say. That's forcing veterinarians such as Turkal to play an expensive game of keep-away from the thieves who sell the hallucinogen on the streets as Special K, Cat Valium and K-Hole.

    Buyers, police say, are often school-age kids and young adults looking for a cheap high, often at nightclubs or middle-of-the-night parties called raves. As with the more notorious club drug gamma hydroxybutyrate, or GHB, Ketamine is used as a date rape drug. It is poured into the drinks of unsuspecting victims, who are rendered unconscious or paralyzed. "I have a daughter now," said Turkal. "I don't want this happening to her or anyone." Turkal has sunk $50,000 into his pharmacy security system, $90,000 total on the clinic. The pharmacy is the only room in the clinic with floor-to-ceiling cinder block walls. A security camera and motion detectors look down from corners of the room. Only Turkal has the access code that opens the pharmacy door and the keys that unlock the double-lock safe containing the Ketamine and other controlled substances. The staff has also been trained to spot suspicious people. Often thieves posing as pet owners visit the clinics to get a lay of the office and break in later, police and veterinarians say.  "This is something that has become much more prevalent in the last year or two. I would imagine vets are being much more cautious now because the word is out on this stuff," said Dr. Peter Prescott, executive director of the Michigan Veterinary Medical Association. Prescott and others say they suspect some veterinarians are selling the drug. Some states have fined or revoked the licenses of veterinarians for trafficking Ketamine, which is used to a lesser extent on dogs, horses and humans.

Trafficking, thefts increase
Last summer, the Drug Enforcement Administration responded to the climb in illegal distribution of Ketamine by classifying it as a controlled substance, which means veterinarians must keep track of the drug and be able to provide an accounting to the DEA.   "There were break-ins all over the place: Auburn Hills, Troy, Birmingham, some in Sterling Heights and Warren," Oakland County Sheriff's Sgt. Joe Duke said. Three Rochester Hills veterinarians had Ketamine thefts two summers ago. A little more than a year ago, five St. Clair Shores clinics were broken into within several weeks of each other. Only Ketamine was taken.  Turkal says a cocaine-addicted man crawled in through the kennel door of the clinic about a month ago in the middle of the day.   "I was going into surgery, and the girls started screaming," Turkal said of his office staff. "He had a silver thing in his hand. I thought it was a gun. So I pulled the coat over this guy's head so he couldn't get to his arms. He was a 38-year-old man, high on crack. He had a crack pipe and steel wool." The man was arrested.
    Detroit veterinarian Ivan Gadjev hasn't had the same satisfaction. There still are no suspects in the armed robbery of his clinic April 7. He was shot in the chest, arm and abdomen. He nearly died. "He didn't get a chance to get my money or my Ketamine. I shot at him," said Gadjev, 62. Gadjev is recovering at his Farmington Hills home. One bullet is still in his side, and he doesn't know if he'll perform surgery again because of wounds to his right hand and arm. He may close the Northland Veterinary Hospital, which he bought in 1974. "Usually they're after the money. They're after the sedatives and the narcotics and that Ketamine in the last couple of years," Gadjev said. Ketamine is a nationwide menace.

Emergency-room visits
Cases of abuse and overdose are turning up in emergency rooms in greater numbers since 1994, according to the Substance Abuse & Mental Health Services Administration, a division of the U.S. Department of Health and Human Services. In 1994, there were 19 cases of Ketamine use reported in emergency rooms nationwide. The number jumped to 149 the next year and in 1996 dropped to 81. In 1997, however, the number of cases rebounded to a record-setting 318. In 1998, the last year for which figures are available, emergency room visits that involved Ketamine use dropped to 209. The drugs GHB and Ecstasy far outnumbered Ketamine with 1,282 and 1,142 cases, respectively, reported in emergency rooms in 1998. All three drugs can kill by stopping the heart or causing a coma.
    In March, police in Lake County, Ill., broke up a Ketamine theft ring believed to be responsible for a rash of burglaries throughout the Midwest. Two 19-year-olds and a 16-year-old were charged with four counts of burglary. The 16-year-old claimed to be making $2,000 a week selling the drug. Closer to home, two teens were suspects in the Jan. 31 break-in and theft of Ketamine from a Smith's Creek veterinary clinic in St. Clair County. Less than a month later, the teens, Brian Baer, 17, of Port Huron and Thomas Eppley, 19, of Ft. Gratiot, put a hunting rifle to their heads and killed themselves after a high-speed chase in Texas.
    Ketamine is a newcomer to the illicit drug scene, Michigan State Police Sgt. Jerry King said. A typical 10-milliliter vial of Ketamine, a clear liquid, is enough to drug about 30 people, depending on their body weights. Ketamine is usually injected, but it can also be mixed with tobacco or marijuana and smoked, King said. It is also poured into drinks. "When I first got to this job about spring 1999 is when I got involved with Ketamine. It was just starting to impact Michigan in a bigger way," said King, who works in drug use prevention. "It's not as well-known as some of the other club drugs, but when it starts to hit home is when you start having deaths in your state." Veterinarian Turkal said he's phasing out Ketamine. But for some veterinarians the alternative drug is too expensive. 'We've thought of putting out a sign that says "We don't have Ketamine, so go somewhere else,' " Turkal said.

Support Group Program Helps Businesswoman Take Control of Her Life
Lauralee Ortiz, Detroit Free Press- 5/30/2000

When the heart murmurs started in 1993, Charmaine Schulman of Birmingham was afraid she was physically ill. What happened in the years that followed made her wish that she was. It wasn't her heart that was ailing, doctors told her. It was her brain.  Schulman is among the 51 million Americans who struggle with mental illness at any given time. Hers took the form of depression and got worse. "I was afraid of making a mistake," she says. "So afraid that I closed myself off to the world. I would stay in my room and beat my head and fists on the wall until they would bleed."  Seven years after a breakdown kept her bed-bound and wishing she were dead, the Birmingham resident is loving life again and running her own hair salon, thanks, she says, to a 63-year-old self-help program called Recovery Inc. The program teaches participants how to identify and self-manage negative thoughts, feelings and habits that can lead to emotional discomfort and disturbing physical symptoms. It was developed in 1937 by the late Dr. Abraham Low, a Chicago neuropsychiatrist, and is taught in support group settings all over the world. Presently, there are 30 such meetings throughout metro Detroit every week, says Carolyn Dirker, a Recovery leader in the Detroit area.
    Schulman says she is proof of Low's motto: "There are no hopeless cases, only helpless ones." By learning and practicing the Recovery method, she not only got out of bed but also became a group leader. "I'm back to work. I own my own business and I am enjoying it greatly," she says. "That's a long way from having to surrender the keys to my car because I couldn't make rational decisions and tried once to drive over the top of a Porsche." Schulman is aware of the stigmas attached to mental illness, but she's one of a growing number of people willing to attach a name and face to it. She hopes that others will hear her story and see that they can get better, too. "Mental illness is something people don't understand," she says. "They tell you to pull yourself up by the bootstraps, go shopping or snap out of it and everything will be OK. "If it were only that simple," she says.
    The National Mental Health Association defines mental illness as a "disease that causes mild to severe disturbances in thought or behavior, resulting in an inability to cope with life's ordinary demands and routines." There are more than 200 classified forms. Among the most common are depression, bipolar disorders, dementias, schizophrenia and anxiety. Symptoms may include changes in mood, personality, personal habits and social withdrawal, as well as physical symptoms such as heart palpitations, shortness of breath, itching and muscle aches. Problems often are triggered by excessive stress, physical illness, genetic and biochemical imbalances, or any combination of these. The good news, the mental health association says, is that with proper care and treatment, such as psychiatric counseling, medication and support groups, many people with mental illness learn to cope or recover.
    At her worst, Schulman had no desire to get out of bed or take a shower. As a result, she lost two successful businesses and alienated herself from family. "The brightest thought in my days was 'Maybe I'll die,' " she says. "The saddest part was when I woke up every morning to find out I was still alive. I used to envy people who had terminal illness. And when I would see a funeral procession go by, I wished it was me about to be buried."  For more information about the Recovery Inc. program, go to  www.recovery-inc.com  

Recovery Stresses Staying in Control
Lauralee Ortiz, Detroit Free Press- 5/30/ 2000

Recovery Inc., is a self-help program for people with anxiety and emotional disorders. The international nonprofit, community-based organization, developed in 1937, is headquartered in Chicago and governed, operated and supported by lay volunteers who have sought help from and been trained in the Recovery method. Participants come from all walks of life and include people who are still under a doctor's care, those just released from the hospital, some who have been diagnosed with anxiety disorders and more who are tense, have angry temperaments or emotional outbursts, for example. The method includes practical techniques for identifying and managing negative thoughts, feelings, beliefs and habits that can lead to emotional discomfort and disturbing physical symptoms.
    One of the first steps for participants is to learn that their threatening sensations can be endured and their impulses controlled through what the group's founder, Dr. Abraham Low, called "will-training." The will, he said, serves only one purpose -- to accept or reject ideas, thus stopping or releasing impulses. In "Mental Health Through Will Training," Low gave the following example: "Suppose an idea lodges itself in the brain, suggesting danger.... It is then for the will to decide whether or not danger exists. If the will accepts the idea, that thought mobilizes feelings of insecurity. With it come all the rebellious sensations and vehement impulses. "If, on the other hand, will rejects the notion, all the fears and notions that could have followed don't manifest." Low and his followers believe that this method of recovery helps people get through the trivialities of the day -- the things that seem to wreak the most havoc in their lives.
    In group sessions, participants learn to spot inconsistencies and fallacies of language. They are taught a new language that's devoid of defeatist and alarmist words such as "uncontrollable," "intolerable" and "unbearable," as well as expressions such as "splitting headache," which could make an emotionally disturbed person think of a brain tumor. The suggested expression is "head pressure." Until patients can do this on their own, they get a lot of help from group participants. First, someone gives an example of a triviality in his day and how he reacted. Others offer feedback to help him look at the situation objectively.
    The goal, of course, is for participants to acquire the skill to spot the symptoms in their initial stages. "In the beginning, the spotting will have to be done consciously and laboriously, but with continued practice and experience, the process will become relatively automatic and spontaneous," Low wrote. He recommended that patients stick with the program for at least 6 months to learn and become comfortable with the method.

New Web Sites Altering Visits to Physicians
Milt Freudenheim, New York Times- 3/30/2000

After her 9-year-old daughter developed severe acne and an older daughter also had intractable skin problems, Seema Cicerone began to wonder whether her children had inherited their conditions. She told Dr. Larry Basso, her longtime physician and an internist at the Palo Alto Medical Foundation, and he dialed up a web site for physicians created at Stanford University. Dr. Basso quickly found information on the girls' disease--congenital adrenal hyperplasia, a hormonal imbalance--and printed out 20 pages of descriptions, recent research and treatment descriptions for Ms. Cicerone and her husband. They consulted pediatric specialists and eventually found a low dose drug regimen that solved the problem. "It was absolutely wonderful to have all the stuff there at your fingertips," Mrs. Cicerone said. "We could go to see the endocrinologist from a point of knowledge."
    The web site, which Stanford first made available to outside doctors earlier this month, is the latest entry in a race to transform visits to the doctor by providing a wealth of online clinical information for physicians. Several other top medical schools are preparing sites of their own, and there are several commercially operated sites in operation as well. These web sites reinforce a doctor's knowledge, suggest diagnoses, and provide on-the-spot answers to patient's questions about their symptoms.
    In addition, the new web sites may significantly improve medical care for patients who live far from leading medical centers. A doctor in rural Idaho using one of the new web sites can learn about the latest treatments for any disease just as quickly as a doctor on staff at Stanford or Columbia-Presbyterian Medical Center in New York. In the process, the new web sites and all the other medical information becoming available online have the potential to alter the relationship between patient and doctor. "There's a tremendous amount of information about my patients in the computer," said Thomas H. Lee, an internist and cardiologist who is the medical director for 1,000 doctors at the partners Community Health Care network in Boston. "It's almost inevitable that as they ask me questions, my eyes glance over to the screen and I press a couple of keystrokes to get more insight into the answer. Sometimes my eyes don't glance back so quickly." Dr. Lee added: " I do think that something can be lost both in terms of learning what's going on with the patient and in communicating to patients." But help from the computer to prescribe the right dosage of the right medication is also of huge value, he said. "The best doctors are going to figure out how to do both."
    Amy Whitley, a second grade teacher in Springfield, Mo., asked her doctor last winter about Relenza, an inhaler for flu symptoms that was advertised on TV. "He had never prescribed it before," she said. "He sat right there at the computer and worked it up on this Internet line." She got a prescriptions and a printout that she said was very helpful. Experts on Internet health care developments say the ultimate goal, which is probably at least several years away, is to meld online patient records with information from textbooks and journals and guidelines suggesting treatment. "The long term big bang in health care will come when the data about the patient and the knowledge are completely interwoven," said Dr. Bill Detmer, who pioneered in making Medline, a huge government database, available on the Internet in 1994.
    Doctors can subscribe to e-Skolar, the Stanford service, for $240 a year, the cost of one or two print subscriptions to medical journals. E-Skolar is exploring the sale of sponsorships to drug companies, which might give subscriptions to the doctors that the manufacturers are already courting. Drugmakers spent $11.5 billion last year on marketing to doctors, the consulting firm McKinsey & Company estimates. Two services operated by medical publishers, MDConsult and Ovid, also charge fees. Among the commercially operated sites, Medicalogic/Medscape, which is supported by advertising, is free. HealtheonWebMD has lined up sponsors, including DuPont and Microsoft, to pay for subscriptions for physicians.
    Not coincidentally, these sites sometimes emphasize information on conditions that can be treated with the sponsors' drugs. Glaxo Wellcome, for example, sponsors a portion of the WebMD site devoted to irritable bowel syndrome, which raises awareness of a problem that may be treated by a Glaxo drug. Nonetheless, primary care doctors say they appreciate the ability to get information online faster than they can by calling a colleague or opening a textbook that may be outdated. The latest medical web sites, like Stanford's, are designed to find answers rapidly for doctors who may have little computer expertise. "In the past, I might spend a couple of hours trying to find answers," Dr. Basso said. "Now, in two minutes I could have the answer."
    "When you encounter a really weird illness, you can just flame the stuff up on your net," said Dr. Newman, a specialist in pulmonary problems. Dr. Ted Shortliffe, who recently left Stanford to become chairman of the Department of Medical Information at Columbia University, said, "A good caring physician will often tell a patient, 'I have to look this up, talk to someone'" and respond in a subsequent appointment or refer the patient to another physician. But if the answer is available when the question is asked, he said, "health care pays for one less visit, maybe unnecessary referrals to specialist don't have to occur, and the physician is more efficient."
    For their part, managed care companies, which, on average, allot doctors in their networks 8.5 minutes for each patient visit, welcome any service that can help doctors shorten office visits even more to make time for other patients. The companies are also interested in innovations that promote "evidence based medicine"--procedures validated by rigorous clinical trials or by results from long usage--as a route to cost effectiveness. "Good medicine is less expensive," said James Hudak, an information technology executive at United Health Group, a managed care company. "We will support both consumers and physicians getting access to evidence-based medicine." Several big managed care companies, including United Health Care and Humana are planning to join the race to provide online medical information for doctors.
    Big medical groups and many managed care companies, including United, already try to persuade doctors to pay attention to costs by telling them how their choices of drugs and diagnostic tests and referrals to specialists compare with regional averages and other doctors in the same health plan. If these companies get involved with the new sites, they would have another avenue to communicate with physicians. Stanford's site can answer a question raised by a patient 87 percent of the time, according to Dr. Kenneth Melmon, who developed e-Skolar for Stanford. He said speedy response was essential because doctors are desperate to become more efficient, partly due to pressures from managed care. Doctors demand responses from these online services within seconds, or they walk away, according to a survey conducted by McKinsey. "Doctors are looking to increase their efficiency and the quality of care," said Steven P. Halper, a Wall Street health care analyst at Donaldson Lufkin & Jenrette. "It is a huge and underserved market. Over time, we think it will evolve into several leading companies," he added. Indeed, Harcourt General, the training and publishing company, has just said that it would become sole owner of MDConsult by acquiring the rest of the online service from Wolters Kluwer, a Netherlands based company that also owns Ovid and such medical publishers as Lippincott Williams & Wilkins.
    Technology officials at a number of medical centers have reacted positively to the Stanford announcement. John Hopkins said it would soon introduce its own information web sites for physicians. Meanwhile, Harvard's teaching hospitals are testing e-Skolar, which includes access to DXplain, an aid to diagnosing a disease that was developed at Massachusetts General Hospital, alongside the hospital's system of electronic patient records. "We're very excited" about the possibilities, said Dr. Robert C. Goldszer, chairman of the computer advisory group at Brigham & Women's Hospital in Boston, which has put information about drug orders and lab results on line. "It's a really good idea, a real plus," said Dr. Brent C. James, a vice president of Intermountain Health Care, a technologically advanced medical system in Salt Lake City. "The technical problem would be to integrate it with what we already have."
    The success of the online medical information services will hinge on how often doctors use them, said Jon Duane, the chief West Coast health care consultant for McKinsey. To keep doctors clicking in, Medscape emails weekly newsletters telling specialist about the latest developments in their fields. MDConsult even provides a synopsis of the latest episode of the popular television show "ER," to prepare physicians for questions from viewers among their patients.

Researchers Seek Explanations, Coping Strategies for Bad Childhood Behavior
Christine Cosgrove, CNN- 5/30/2000

For the first eight months of his life, Matthew cried 18 hours a day. As he grew older, he terrorized baby-sitters, throwing tantrums or locking them out of the house. At age 4, his response to a time-out in his room was to kick the door down or climb out a window. His behavior was so difficult that his pediatrician phoned Matthew's mother every morning for a year to find out how she was coping. "I think he called because he was so afraid we would do something to Matthew," says his mother, Diane.
    For years, parents and scientists alike have wondered whether some children are born bad and, if so, why. Now research is finally uncovering some of the biological traits that may be the cause of troubled behavior. At the same time, new educational techniques are helping parents steer difficult children away from a path of violence. About 10 percent of children are born, like Matthew, with a mix of "challenging traits," says registered nurse Helen Neville, director of the Inborn Temperament Project at Kaiser Permanente in Oakland, California. These children are easily frustrated, very sensitive, emotionally intense and have difficulty coping with change. "The parent who thinks this is an obnoxious, stubborn, difficult kid who just needs to get some sense knocked into him or her is going to be in a real war with one of these kids," says Neville. "The child's self-esteem is going to suffer. And that's what we think is the setup for conduct disorder."
    Conduct disorder is a complex mix of behavioral and emotional problems in youngsters, according to the American Academy of Child and Adolescent Psychiatry. Kids with conduct disorder typically are cruel to animals and to people. They are destructive, deceitful and often uncontrollable. In some children, the bad behavior tapers off as they grow older. But other children will grow up to become violent individuals whose childhood conduct disorder will be reclassified after age 18 as antisocial personality disorder (APD), a diagnosis common to those charged with violent crimes.

Gray matter
Is such violence the result of nature or nurture? The answer is likely both. Recent studies have found that the bodies of pathologically violent people often differ from those of less violent people. Using magnetic resonance imaging, Adrien Raine, a psychologist at the University of Southern California, recently found that men with APD had 11 percent less gray matter in the prefrontal cortex of their brains compared with men without the disorder. Researchers have long known that people who behave normally may become violently antisocial when their prefrontal cortex is injured in an accident. But Raine's study, published in the February 2000 issue of Archives of General Psychiatry, is the first to suggest that people may be born with this type of brain damage.
    Meanwhile, University of Chicago researchers studying boys between the ages of 7 and 12 who had been sent to psychiatrists because of bad behavior found that the boys had lower levels of the stress hormone cortisol than did boys without behavioral problems. The researchers, whose work was published in the January 2000 issue of the Archives of General Psychiatry, speculate that the boys are less sensitive to stress and are therefore less bothered by the consequences of behaving badly. Does this mean that children are genetically prone to be "bad" and that environment plays no role? Not at all. It may be that drug use, poor health care during pregnancy or a difficult childbirth produce these biological traits, says Dr. Bruce Perry, a psychiatrist at Baylor College of Medicine. And one study reported in the April 2000 issue of the Journal of Personality and Social Psychology found that children who played violent video games were more likely to behave violently. Based on such findings, researchers believe that it's possible to reverse the violent course that many of these children are taking.

'Spirited' children
Diane and her husband were finally able to help Matthew after they enrolled in one of Neville's classes for parents of "spirited" children at Kaiser Permanente. "The basis of our program is, 'Let's get in there while the brain is very malleable and do the very best we can for these kids,' " says Neville. The class teaches parents how to understand their child's temperament and to work with, rather than against, a child's strong emotions. For example, parents of a toddler who refuses to get dressed might learn that the toddler wants to be more independent and is frustrated he can't dress himself. Instead of wrestling with the child, they might learn to offer him a choice of clothes, giving him some feeling of control. If a child has trouble with transitions, parents would learn to give five minutes warning before asking her to stop one activity and start another. If a child is easily frustrated, parents might learn to break tasks into easily managed parts. Instead of saying, "Clean up your room," the parent would say, "Let's get the toys off the rug."
    The techniques were based partly on a study in which psychiatrists Stella Chess and Alexander Thomas followed more than 100 babies throughout their childhood to analyze which parenting approaches were most successful. They published their findings in 1986 in the book "Temperament in Clinical Practice," published by Guilford Publications. The advice resembles what you might find in any good parenting book, Neville says. But it isn't easy to put into practice and "the more extreme the child, the more important the techniques." There are few children as "extreme" as Matthew was. And at 9, he is still a handful, but his mother says he is "delightful, bright, articulate about his feelings, the star of his class and a natural leader. Everybody loves him. And I think that's because he does manage himself so well. He's been taught how to talk about what he needs." If you ask Diane if the root of Matthew's behavior is biology or environment, she will say it's biology. Her second child, now 6, was "completely different" from the moment of birth. "We're the same two parents in the same house with the same rules, and we have two completely different little beings." But then she adds that environment -- the one she created to accommodate her son -- has made all the difference.

Heroin's New Fix and Why It Matters to You
Donna Leinwand, USA Today- 5/31/2000

WASHINGTON -- Scientists are ready to usher in a generation of anti-addiction drugs that could significantly improve the prognosis for the nation's 1 million heroin addicts at a time when use of the opiate is rising.  Analysts say the new drugs are superior, less-addictive alternatives to methadone, the once-a-day narcotic that has been used for decades to block the craving for heroin's euphoric effects. ''This could be the biggest advance in the last 10 years,'' says Alan Leshner, director of the National Institute on Drug Abuse, part of the National Institutes of Health. ''It will tremendously add to the clinical toolbox. We're very optimistic. Everyone's very excited.'' The new medicines are emerging as federal officials prepare to give physicians more authority to dispense drugs that help addicts, a move that could dramatically change the face of drug treatment across the USA. By shifting the focus of treatment from methadone clinics to doctors' offices, health officials say they hope to better serve a new generation of heroin addicts, including tens of thousands of suburban teenagers, who often are reluctant to visit urban clinics.
    The moves by government and science reflect not only officials' alarm at the recent rise in heroin use, but also longstanding frustrations with methadone and the way it is distributed. Methadone, the most common treatment for heroin, is just as addictive, many doctors say. Addicts who drink daily doses to curb heroin cravings often can't give up methadone without going through a painful withdrawal. Scientists and health officials say the new drugs could diminish methadone's role as well as that of clinics, which usually are in run-down neighborhoods because no other areas will have them. A combination of two drugs in a once-a-day pill could be approved by the Food and Drug Administration as early as September. The combined drugs mute the craving for heroin and throw users into withdrawal if they try to abuse the pill by smashing it, adding liquid and injecting it like heroin. Some test subjects have reported mild side effects such as nausea. Another drug, which is injectable, is being tested. It lasts 30 days, blocks cravings for heroin and, by not letting heroin into the nervous system, makes it nearly impossible for a relapsed user to overdose. The drug could be on the market by 2002.
    Federal officials, while excited over the promise of such drugs, acknowledge that they are not a cure-all for heroin addiction. Anti-addiction drugs should be one part of a recovery program that also includes psychological treatment, vocational training and social rehabilitation, says Barry McCaffrey, director of the White House Office for National Drug Control Policy. Westley Clark, director of the Center for Substance Abuse Treatment, a division of the Department of Health and Human Services (HHS), compares drug-addiction treatment to diabetes treatment. Besides taking insulin, Clark says, a diabetic must watch his diet and exercise. Though Clark expects the new drugs to help thousands, he agrees that addicts also need counseling to address social and psychological problems.  ''It's not as simple as, 'Give it a pill and it's fixed, hallelujah,' '' Clark says. ''None of these things are a panacea.''
    Heroin is purer, cheaper and more popular than it has been in three decades, thanks largely to what amounts to an underground sales campaign by traffickers in Colombia and Mexico. Young adults, along with suburban middle- and high-school students, have driven the rise in heroin use over the past several years. Heroin use remains rare overall. A University of Michigan study last year indicated that about 2% of U.S. youths ages 12-17 had tried it. However, that was more than double the rate of 1992. In 1997, the latest year for which such statistics are available, the number of addicts seeking heroin treatment in the USA surpassed the number of those seeking treatment for cocaine problems, federal officials say. In 1999, an estimated 240,000 addicts sought treatment.

Problems with methadone
Methadone, the most common treatment for heroin addiction, occupies opiate ''receptors'' in the body that can crave heroin. Methadone gives users a mild high that does not interfere with their ability to work or function. Most users become dependent on it. Methadone programs, which have been around since the 1970s, have had only moderate success. A study published recently in the Journal of the American Medical Association said that 50% of those in a San Francisco methadone program had used an illicit opioid drug such as heroin, opium or morphine at least once a month while in treatment. Scientists called the finding ''not encouraging.'' New treatment drugs have surfaced periodically, but they haven't been enough of an improvement over methadone to have much of an impact. The last new product, called LAAM, was released in 1993. It is similar to methadone except that it needs to be taken only once every three days. Just 5,000 recovering addicts across the nation are being treated with it.
    Addiction experts say the newest drugs offer much more hope. The drugs, which are new formulations of drugs already approved for other uses, are far more difficult to abuse than methadone because they are much less addictive. There also is less risk of death by overdose because the new drugs don't depress breathing. Doctors in hospitals use an injectable form of one of the drugs, a mild narcotic called buprenorphine, to treat pain.   Although manufacturers have not priced the new drugs, they will be more expensive than methadone, which no longer is under patent restrictions and costs just pennies a dose. The combination pill nearing FDA approval is called Suboxone, and is made up of buprenorphine and naloxone. Buprenorphine competes with heroin for space on the opiate receptors in the brain and body, which douses any high that heroin provides. It also blocks withdrawal pains by keeping the receptors occupied. The naloxone remains inactive unless a recovering addict tries to abuse the drug by crushing it into a powder, adding a liquid and then injecting it. The activated naloxone starts an extraordinarily painful withdrawal. In effect, it punishes those who misuse their treatment.
    The FDA is reviewing drug applications for the combination pill and another one containing only buprenorphine; both are produced by Reckitt & Colman Pharmaceuticals of Richmond, Va. Versions of the drugs have been given to addicts in France, where the approval process for drugs is less complicated than in the USA. ''This is cutting-edge because it's different from methadone,'' says Charles O'Brien, chief of psychiatry at the Philadelphia VA Medical Center and an expert on treating heroin addiction. ''You almost can't overdose on heroin when you're on buprenorphine. It's really been a huge success. People can function totally normally and be very alert if it's properly dosed.''
    Another drug, NALTREL, manufactured by DrugAbuse Sciences in Los Altos, Calif., is a time-released, injectable version of naltrexone, which blocks heroin from binding to receptors in the body. That prevents the user from getting high or overdosing. The FDA has approved daily naltrexone tablets to treat heroin and alcohol abuse. The injectable version, designed to last 30 days, would eliminate daily trips to methadone clinics and, health officials hope, increase the number of addicts seeking treatment. Drug Abuse Sciences is conducting clinical trials in substance-abuse patients this year and intends to file for FDA approval in early 2001, company documents indicate.  ''It's a wonderful drug. Even if addicts take a shot of heroin, they won't feel it,'' O'Brien says. He adds that the drawback of the new drugs is ''that doctors have to learn to prescribe (them) properly.''
    The promise of less-addictive treatment drugs has fueled the efforts to shift treatment from clinics to doctors' offices. Federal rules prohibit doctors from prescribing narcotics to treat addictions to other narcotics anywhere except clinics regulated by the Drug Enforcement Administration (DEA). Methadone regulations require addicts to stop in each day at one of about 900 clinics nationwide to retrieve their daily dose. Officials say that is a discouraging burden, particularly for relatively stable addicts who have recovered enough to hold down a job or care for a family.
    Methadone clinics have become a common target of ''Not In My Back Yard'' debates. Seven states have banned them. Many of the clinics are in drug-infested neighborhoods -- to get their daily dose of methadone, addicts must face temptations outside. ''There are a lot of people who would rather not come to methadone programs,'' O'Brien says. ''You're going to a place with a lot of heroin addicts. They offer to sell you heroin right outside the door of the clinic. By taking it out of that environment, it will open up treatment to more people who don't really consider themselves addicts, people who consider themselves nice, normal Americans who don't want to be hooked.''

'Time to change the rules'
When Erin Allen, 21, of Wilmington, Del., sought treatment for her heroin addiction in 1997, doctors had little more to offer than therapy and methadone. Allen bounced in and out of detoxification programs, her mother, Marie, recalls. Allen spent four months on methadone but grew tired of daily visits to a Wilmington clinic.  ''I know methadone helps tons of people, but it wasn't helping Erin,'' Marie Allen recalls. ''She had to go every morning. She would have to wait in line an hour, an hour and a half. She didn't want to be on methadone the rest of her life.'' Erin suffered a fatal overdose of heroin three days after leaving a treatment program. Now her mother wonders whether other drugs, and another approach to treatment, could have saved her.
    The methadone program is ''a 30-year-old system,'' Clark says. ''It's time to change the rules.'' HHS officials say the DEA now is willing to do just that, and allow certified physicians to prescribe drug-treatment medication. Instead of lining up each day at a clinic, an addict could get a prescription from a doctor for several days of treatment drugs and pick them up at a pharmacy. Health officials expect to officially announce the policy changes soon. Sens. Carl Levin, D-Mich., and Orrin Hatch, R-Utah, have proposed legislation that would bypass some regulatory hurdles and let some physicians dispense buprenorphine and combination drugs once the FDA approves them.
    Law enforcement agencies fret that recovering addicts who are allowed to take medication home will sell or trade it for street drugs. ''With naloxone, it's almost non-addictive,'' Levin says. ''It's got almost no street value, unlike methadone, which is addictive.'' McCaffrey says that the benefits of increasing access to methadone, and eventually other treatment drugs, outweigh any risks of increased abuse. He said that the longer addicts don't get treatment, the more it costs society. Many users will steal to feed their habit and wind up in jail, lose their jobs and end up on welfare, he says. Prison costs taxpayers about $26,000 a year per inmate, he says, while drug treatment costs $18,000 annually. ''From a taxpayer's perspective, it makes more sense for you to get the chronic addict into treatment.'' Moving addiction treatment into doctors' offices and out of clinics represents a giant leap for science, Leshner says. ''Ten years ago, you could not speak about treating addiction in a doctor's office because people just thought it was a failure of willpower: 'You don't need a doctor, you need someone to yell at these people,' '' he says. ''Science is teaching us that this is a medical illness."

12-Step Program for Homosexuality Raises Controversy
ABC News, 5/31/2000

"It absolutely tore me apart inside," he says. "There was this battle — these two lives going on and I didn’t want the one." For Winters, 35, it was impossible to reconcile these two worlds. "I don’t believe a person can be born a homosexual because that’s not the plan God has," he says. After losing his job as a spiritual leader with a college campus ministry and then living a promiscuous gay lifestyle, Winters turned to a treatment facility near Memphis, Tenn., called Love in Action. Working off the premise that there is no such thing as a healthy homosexual relationship, the group uses a 12-step program similar to Alcoholics Anonymous. As members share painful experiences — addiction to homoerotic pornography, group sexual encounters, unhealthy relationships with parents — the others signal their understanding and remind one another that they are loved by God. The program teaches that by surrendering to a higher power, adherents can let go of certain thoughts and habits, and God will give them the strength to change.  "God has, in his infinite wisdom, decided that things like slander and adultery and homosexuality and murder and rape probably won’t work well in a civilized society," says Dr. Duff Wright, a staff psychologist at Love in Action.  Love in Action acknowledges that it may not help a man get rid of his homosexual desires but, rather, his homosexual behaviors. It believes that the desire to have sex with another man is not sinful, but acting on that desire is.

A Controversial Approach
But critics of such programs, like Dr. Robert Cebaj of the University of California-San Francisco, say homosexual behavior cannot be changed. "We’ve never had evidence you can change what people think or feel or desire deep down," he says. Cebaj says Love in Action’s approach is damaging. "I’ve mainly seen people harmed by psychological aspects of it: the sense of guilt, the sense of shame, the sense of embarrassment and then the combination of anger and depression," he says. "I have never seen good come from these programs." The American Psychiatric Association agrees that this type of therapy runs the risk of harming patients, and a former Love in Action participant tells 20/20 he tried to kill himself while in the program. "For me, sexuality is built into your whole soul, your spirit, your whole being," says the Love in Action graduate who asked that his identity to remain concealed. "I’ve just battled with God for 40 years, and all I know is that when I finally decided I’m not going to live dishonestly anymore, I’m not going to pretend to be a heterosexual male, that’s finally when my spiritual life became more peaceful."

The Way 'Out'
Clients like K.C. Winters, however, argue that the program has changed them for the better and helped them to lead a less conflicted life. "I’m not damaging myself. I feel more confident, more in character with who I am and who I desire to be," says Winters. "I’m happier; I’m more peaceful. Those were things I never had before in trying to live in both these worlds and justify homosexuality with Christian faith." The program’s director, John Smid, also points to his own life as proof that Love in Action can work. Smid divorced his first wife, with whom he had two daughters, to live with a man and then lived an openly gay life for four years. Though he sometimes experiences attraction to other men, he says, "I choose not to act on it." Now, remarried to a woman for 10 years, Smid says, "Being heterosexually married to my wife, not acting out outside of that marriage, not committing any form of sexual improprieties in my life, I’m finally at peace." Likewise, Winters says Love in Action helped him to find a sense of wholeness and a closer connection with God that has replaced his compulsion for sex with men. By better managing his thoughts and desires, he says, he can focus on "what God created me to do."

Review: 'Of Two Minds: The Growing Disorder in American Psychiatry' By T.M. Luhrmann
Laura Miller, CNN- 5/31/2000

When Andrew Goldstein pushed Kendra Webdale in front of a New York subway train in January 1999, he brutally and pointlessly ended the life of a 32-year-old stranger. He also demonstrated, in the most horrific terms, the burgeoning crisis in American psychiatry. A schizophrenic with a history of dangerous impulses, Goldstein frightened even himself, and he had pleaded with state psychiatric centers to provide him with the treatment he needed to help him stay on his medication and out of trouble. But over and over again, he was turned away by hospitals that could not justify the expense of inpatient and outpatient services for a man whose illness was supposedly controllable with drugs alone. It was Webdale who finally paid.
    T.M. Luhrmann's impressive "Of Two Minds" is far more than a simple indictment of the negligent way we have come to treat acute mental illness in this nation, but that's one of the more urgent notes it sounds. An anthropologist who set out in 1989 to write an ethnographic account of the way psychiatrists acquire the basic skills of their profession and come to regard their work and their patients, Luhrmann happened to pick a time when the field was undergoing deep and disturbing changes. In the early 1980s, doctors who espoused what Luhrmann calls a "biomedical" approach to treating mental illness, regarding madness as an organic disease best controlled with drugs, supplanted those who hewed to the "psychodynamic" model rooted in the "talk therapy" that Sigmund Freud pioneered. The biomedical model also appealed to managed health care companies, Luhrmann writes, because "psychopharmacological approaches seemed cheaper and more like the rest of medicine."
    For anyone at all interested in how shrinks are made, the first half of Luhrmann's book is a fascinating account. A former medical student, she embarked on four years of field work that included "more than sixteen months of full-time, intensive immersion" -- that is, for more than a year she lived as a psychiatric resident, attending classes, working at a hospital, even seeing patients and undergoing therapy herself with a training psychiatrist. It's always a bit unsettling to be reminded how medical residents are "taught" their jobs -- a mother-bird strategy in which fledgling doctors are shoved out of the nest on the theory that the best way to learn to fly is to just do it. And Luhrmann's detailed, nuanced descriptions of the way teams of doctors work together as groups ("Shame is a common teaching tool in medical education") remind you how valuable anthropology can be in the rich, specific knowledge it contributes to the culture.
    In the second half, though, when Luhrmann tackles the split between biomedical and psychodynamic psychiatry, she kicks "Of Two Minds" into an even higher gear. The conflict between the two approaches is a debate between "two profoundly different notions of what it is to be a person," she explains, and it takes up "some of our oldest philosophical dilemmas." Luhrmann can move from the politics of backbiting gossip among psychiatric nurses (it's usually worse in the less hierarchical psychodynamically minded hospitals) to an explication of the disagreement between David Hume and Immanuel Kant over the roots of moral judgment without ever being less than impeccably lucid and fair-minded -- which only makes the breakdown she chronicles that much scarier. "You have the opportunity of seeing our profession in the beauty of its great sunset," a psychiatrist tells Luhrmann, who witnesses the virtual dismantling of the inpatient psychiatric unit at an urban hospital. "This is chaos and confusion," the unit director announces as the staffing and budget cuts take effect. "In these circumstances, we will kill someone!"
   Luhrmann presents conclusive evidence that a combination of psychopharmacology and psychotherapy is often the only truly effective way to treat acute mental illnesses -- a conclusion that even the biomedical psychiatrists she talks to agree with -- yet managed-care budget cutters prefer to deem drugs a cure-all. But above and beyond these practical concerns, Luhrmann insists, the simple "disease" model of mental illness diminishes all of us. The ideals of psychodynamic psychiatry are based on the belief that "the mastery of bad circumstances is inherent to what a person is ... the sense of a person is of someone who has overcome suffering in a particular way and forged a specific path through life." We live in a society obsessed with blame, and the disease model offers an attractive out once the finger-pointing begins. But we retire the notion of responsibility at our peril. By treating severe mental illness as a permanent misfortune that eclipses a person's self but isn't part of that self, the biomedical model threatens an individual's humanity. It's a subtle, abstract argument that Luhrmann renders, in heroically plain language. It's also one we can't afford to ignore.

Oregon Adoptees Granted Access to Birth Records
Sam Howe Verhovek, New York Times- 5/31/2000

Seattle--More than 18 months after Oregon passed the nation's first voter-approved law allowing all adult adoptees access to their birth records, a Supreme Court justice ended an emotional, legal-appeals process today and cleared the way for the law to take effect this afternoon. A group of birth mothers had sued to block the law, contending that it would violate promises made years ago by adoption agencies that their identity would never be revealed against their will to the children they had given up for adoption. State officials announced today that they would begin processing requests for birth certificates from any adoptee 21 or older who was born in the state.
    The state Health Division said it had already received requests from more than 2,200 adoptees for the records under a provision set up by the law, Measure 58, which was approved in November 1998. But those applications have not been acted on pending the outcome of the challenge to the law, which was upheld earlier this year by the state's Supreme Court. Justice Sandra Day O'Connor today rejected an emergency request from thee birth mothers to delay the records law's taking effect, and the state said it would probably start mailing out copies of birth records by the end of the week. In many cases, of course, adoptees and birth parents have sought out each other, using one of a growing number of registries and web sites that foster such reunion. But the Oregon case, by giving adoptees absolute rights to their records even if birth mothers never sought contact, set off a turbulent debate over whose rights should take precedence.
    Adoptees have cast access to their birth certificates as a right that might answer basic questions about the circumstances of their birth and perhaps the medical histories of their biological parents. "People are very mindful of their roots and where they come from," said Berry Price, a 56-year-old machinist who, as an adoptee, cheered Justice O'Connor's action today. "Bringing somebody into the world without giving them background on their situation, their ethnic origin and so forth, I think that's wrong. You have this hole in your background, and you feel a need to fill it in." Mr. Price knows that his birth mother may well be dead and that the name on his birth certificate may be fictitious anyway. Nonetheless, he has filed his application and is eagerly awaiting word.
    On the other side of the debate, a group of six anonymous birth mothers has fought vigorously against the law through their Portland-based lawyer, Franklin Hunsaker, himself the father of five adopted children. Mr. Hunsaker said today that his clients were "extremely disappointed, scared and even angry that their rights have been ignored by voters and the courts." And he pleaded with adoptees to respect the wishes of those biological mothers who have filed a separate state form indicating that they do not wish to be contacted. That request is not legally enforceable. The only good reunion is one based on mutual consent, where both sides want it to happen," Mr. Hunsaker said in a telephone interview. "So if there's a request there," he said, meaning a preference not to be contacted, "my clients would plead with adult adoptees not to trample on their rights. Please honor it."
    Thomas McDermott, an adoptive father who is the lawyer for the law's supporters, said he disagreed with the critics who said the law would set off a spate of incidents in which birth mothers were contacted against their will, a prospect that one of the women suing to block the law said had given her "flashbacks and nightmares." Mr. McDermott said he believed that most adoptees would not pursue a meeting if they knew their parents did not wish to meet them. "I think that it would take a rather unusual adoptee to pursue that," he said. "Why would you go somewhere when you're told you're not welcome?" However, he added, in the great majority of cases, biological parents welcome such overtures. In Oregon, according to the most recent records released by the Health Division, 40 birth parents have filled out a form indicating that they desire contact from the children they gave up for adoption, and 16 have requested no contact.
    Oregon is unique in having a voter-passed initiative opening up the birth records. But at least three other states (Tennessee, Alaska and Delaware) have various provisions, either passed in the legislature or mandated by the courts, allowing adoptees access to their birth certificates. And Kansas has never had an explicit prohibition against such access. Such records do not automatically enable an adoptee to find a birth parent. In some cases, birth mothers managed to have their names omitted from the birth certificate, and in other cases a name alone would not be enough information to allow the birth parent to be found. In Oregon, where the courts found that birth mothers had no constitutional right to keep their biological children's birth certificates confidential, some of the anonymous mothers argued in court papers that they were afraid that their husbands or children might now discover long guarded secrets that could cause turmoil in their families. And lawyers for those opposing the law said that some of the birth mothers had been raped, and that a call from the person who resulted from that crime would be traumatic.
    The birth mothers who brought the case have not been identified publicly. One, using the name "Mary" wrote in a letter to The Oregonian earlier this year that she was horrified by the law. "Soon, for $15, the state may simply hand over your identity to the adult you placed for adoption as an infant 21-plus years ago," she wrote. "In a few days, the very promises we built our lives upon may be up for sale." But the law's supporters were jubilant, saying the law properly extended t adoptees the right to gather information about the most basic of questions: where did they come from?