Noteworthy News Articles on Mental Health Topics, July 25-31, 2000

More Recipients of Medicare to Be Cut From HMOs
Sharon Bernstein & Robert A. Rosenblatt, Los Angeles Times- 7/25/2000

The promise of managed care for Medicare recipients--that older Americans could receive low-cost comprehensive health coverage--was dealt its hardest blow yet when the federal government reported Monday that 933,000 older Americans will be dumped from HMO plans next year. The figure is about 30% higher than originally had estimated by the industry, and will bring the number of seniors dumped from HMO rolls in just three years to 1.7 million. It also raises serious questions about the survival of the Medicare HMO, an innovation that just a few years ago was heralded as a way to offer more benefits while lowering costs. "This is a real blow to the whole credibility of the Medicare HMO program," said John Rother, director of public policy for the AARP (formerly the American Assn. of Retired Persons).
    Health plans, which spent millions of dollars in the last decade wooing seniors with rich benefits and in some cases free supplemental coverage, now say they are dropping out of Medicare because the federal government is not paying enough to cover the cost of providing care. Most have severely pulled back services in all but the most lucrative areas, or dropped the program altogether. In California, 57,000 beneficiaries will be forced to either choose a new HMO or lose managed-care coverage altogether, and most of them will no longer be able to obtain prescription drug coverage. Hardest hit is Texas, where 185,000 seniors will lose coverage, more than half of the HMO members in that state.  In the late 1990s, government planners and members of Congress hoped HMOs could provide an effective tool to control Medicare costs. They had predicted that 25% of beneficiaries would eventually enroll in Medicare HMOs, a figure that now looks like an impossible dream. "In the beginning, there was great promise," said Clare Smith, executive director of California Health Advocates, a nonprofit advocacy organization for Medicare recipients. "Then, just disappointment."
    Health plans and consumer advocates alike place much of the blame for the system's crisis on Congress and the Clinton administration: Congress for appropriating too little money, and the administration for developing a tangled method for distributing it that pays too little to cover the cost of care in some parts of the country, while fueling profits in others. The Clinton administration has always denied paying too little, saying that the health plans were making significant profits, enrolling people who were healthier than average as a way to conserve funds.
Any discussion of increasing payments or rethinking the distribution system, meanwhile, has bogged down in partisan bickering.
    Karen Ignani, president of the American Assn. of Health Plans, called on Congress and the Clinton administration to commit more money to the faltering program, which health plan lobbyists say needs $15 billion more per year.
In late June, the trade association representing HMOS estimated that its members would cancel coverage for 700,000 people enrolled in Medicare HMOs, complaining that payments by the federal government were inadequate. "The fact that almost 1 million Medicare beneficiaries will be affected . . . reinforces the magnitude of this crisis and the need for action now," Ignani said. "It's time for Congress and the administration to put aside partisan politics."
    For its part, the Clinton administration seized upon the numbers to push a pet plan of its own: prescription drug coverage for the nation's 39 million Medicare recipients. That, a top official said, would ensure that seniors are spared one of the most devastating impacts of losing their HMO--the lack of coverage under traditional Medicare for prescription drugs. "The volatility of the Medicare managed-care market underscores the need for Congress to enact the president's legislative proposal to modernize and strengthen Medicare," said Nancy-Ann DeParle, head of the Health Care Financing Administration, which runs Medicare. "That way, all 39 million beneficiaries would have access to a voluntary, affordable prescription drug benefit."
    The sense of betrayal--and terror of high payments--for seniors who are dropped is palpable, said Smith, whose organization advises seniors on health-care decisions. Most seniors who signed up for Medicare HMOs cannot afford the high premiums and prescription drug costs associated with the traditional plan, which was created in 1965 and reflects what health plans looked like at that time--paying for hospitalizations only and requiring a 20% co-payment on all medical fees. Over the years, a crazy-quilt system of Medicare supplement plans has sprung up, but they are expensive, costing up to $3,000 per year. Some seniors cannot even afford the most basic one, which covers visits to the doctor. "It's total chaos here," said Wen Daniels, who advises seniors in Los Angeles and Orange counties for California Health Advocates.
    One client, Antonio Martinez of Long Beach, is a transplant recipient who relies on his Cigna HMO to pay for $725 worth of prescription drugs each month, along with the doctor visits necessary to make sure his body does not reject the new kidney. Martinez, a 39-year-old carpenter who qualifies for Medicare because of his disability, will be able to choose another HMO in the area next year after Cigna exits the market. But he finds the process unnerving and confusing. "I have no idea what's going to happen to me," he said in Spanish. "I'm most worried about the medicine for the transplant--the medicine that keeps me from having a reaction."
    Daniels reminded seniors that the cuts won't go into effect until next January, and that they do have the right to either switch to another plan or demand coverage from a company that provides Medicare supplement insurance.
Part of the problem, said several industry executives, is that managed-care plans competed so fiercely for members in the late 1980s and early '90s that most offered zero premiums and free pharmaceutical benefits. "We no longer can sustain the business with these premium wars," said Katherine Feeny, senior vice president for Secure Horizons, which is owned by Santa Ana-based Pacificare and is the nation's largest Medicare HMO. If Medicare managed care is able to stay alive, Daniels and other experts said, it likely will cost consumers more, offer fewer benefits and require a huge infusion of cash from the federal government.
    But just what form the program will take is difficult to say. Most of the remaining plans have decided to implement premiums and co-payments and cut back coverage for drugs. But that makes their plans look more like the expensive Medicare supplement programs, which, despite their high cost, offer members more freedom than HMOs, including the right to see any doctor they wish and go to any hospital. Both Pacificare and Blue Shield, which implemented such payments last year, lost members as a result. Blue Shield, for example, charged seniors in several Northern California counties $75 per month in the form of a premium last year. The money was necessary, the nonprofit HMO said, to combat high medical costs in the Bay Area and Sacramento. But with competitors charging much less, all but the sickest members switched to other plans, and Blue Shield lost two-thirds of its membership in the region.
    One intriguing but perhaps long-shot possibility is that there will be an increase in a different sort of managed-care plan, known as a preferred provider organization. These plans cost less than traditional indemnity plans but offer wider networks of doctors and hospitals than most HMOs, and one has been approved for operation next year.
"Managed Medicare in some form or fashion will be here," said Feeny at Secure Horizons. The staggering number of dropouts over the last three years, she said, is a "call to action," not only for Congress but for doctors, health plans, consumers and pharmaceutical companies, all of whom must pay a little more or charge a little less if the system is to survive. "We need to have everyone pitch in to help us make it work," Feeny said.

Groups Link Media to Child Violence
Jesse J. Holland, Associated Press- 7/25/2000

    WASHINGTON (AP) — Marking what one lawmaker called a turning point in the battle against entertainment violence, four national health associations are directly linking violence in television, music, video games and movies to increasing violence among children. ``Its effects are measurable and long-lasting,'' the four groups say in a statement. ``Moreover, prolonged viewing of media violence can lead to emotional desensitization toward violence in real life.''
    The joint statement by the American Medical Association, the American Academy of Pediatrics, the American Psychological Association and the American Academy of Child and Adolescent Psychiatry will be the centerpiece of a public health summit Wednesday on entertainment violence. ``The conclusion of the public health community, based on over 30 years of research, is that viewing entertainment violence can lead to increases in aggressive attitudes, values and behaviors, particularly in children,'' the organizations' statement says. Advocating a code of conduct for the entire entertainment industry, Sen. Sam Brownback, R-Kan., compared the statement to the medical community declaring that cigarettes can cause cancer. ``I think this is an important turning point,'' said Brownback. ``Among the professional community, there's no longer any doubt about this. For the first time, you have the four major medical and psychiatric associations coming together and stating flatly that violence in entertainment has a direct effect on violence in our children.'' The Motion Picture Association of America and the National Association of Broadcasters refused to comment Tuesday on the medical associations' statement. ``I'm not going to comment on something we haven't seen,'' said Jeff Bobeck, spokesman for the National Association of Broadcasters.
    The four health professional groups left no doubt about their feelings in the statement:
—``Children who see a lot of violence are more likely to view violence as an effective way of settling conflicts. Children exposed to violence are more likely to assume that acts of violence are acceptable behavior,'' it said.
—``Viewing violence can lead to emotional desensitization toward violence in real life. It can decrease the likelihood that one will take action on behalf of a victim when violence occurs.''
—``Viewing violence may lead to real life violence. Children exposed to violent programming at a young age have a higher tendency for violent and aggressive behavior later in life than children who are not so exposed.''
    Brownback said he hopes the statement will convince lawmakers that something has to be done about media violence. And, he said, ``I hope parents will look at this and say that they're going to have to police their children's entertainment violence content the same way they police what their children eat and other health issues.'' One entertainment violence monitoring group, The Lion & Lamb Project in nearby Bethesda, Md., cheered the statement. ``Right now, the message we're sending children in the media is that violence is OK ... that it's part of life and sometimes it's even funny,'' executive director Daphne White said. ``We're even using violence for humor now.''
    Bobeck said television now has V-chips and a rating system to help parents take control of what their children watch. ``We think more parents need to control their remote control,'' Bobeck said. But White said the entertainment industry markets video games and toys to children based on R-rated movies, has increased the violence in movies and shows that are rated for children and even previewed adult-oriented movies during children's G-rated movie. ``The industry has been actively marketing adult stuff to children while saying it's the adults' fault,'' she said.

Anorexia Can Strike Boys, Too
Howard Markel, New York Times- 7/25/2000

    An emaciated boy named Michael sits in a hospital bed, intently playing a video game. Only 15, he looks like a wizened old man; the color of his skin gray, his hair falling out and his arm and leg muscles all but melted away. He was referred for a possible diagnosis of anorexia nervosa. Michael has a much simpler explanation: "Really, doc, I'm fine. I just don't want to eat anything that will corrode my arteries and give me a heart attack."
    A most vexing eating disorder, anorexia results from self-imposed starvation to the point it seriously harms one's physicial and mental health. Often linked to the powerful images of impossibly thin women shown in the mass media, the problem was long thought to be almost exclusive to affluent teenage girls. Recently, physicians have begun to appreciate that anorexia has many faces and is hardly restricted to one socioeconomic class or gender. Teenage girls in search of the perfect body still make up the majority of cases. But cases have also been reported among teenagers from the rural South, African-Americans from poor urban centers and even American Indians on reservations.
    And, of course, it is not only girls who are at risk. Many boys stop eating for a variety of reasons, including participating in sports that require intense attention to weight, like wrestling and track. Each year, about a million American teenagers develop anorexia, and anywhere from 1,000 to 10,000 die from its long-term ravages. Recently I have been seeing boys and girls who do not want to eat because of a fear of the effects of fat and cholesterol on their bodies. Michael's "lipophobia" (fear of fat) began six months before we met when his beloved grandfather, an overweight man who liked his steaks rare and his vegetables deep-fried, dropped dead of a heart attack while the tow were playing checkers. Since then, Michael had studiously avoided all foods containing fat. His diet now consisted entirely of water, slices of fat-free turkey luncheon meat and--his favorite--pita bread.
    In the months before he was admitted to the hospital, Michael lost over 45 pounds and stopped his pubertal development. He suffered many other symptoms, including physical exhaustion, cold, clammy skin, a slowed heart rate, low blood pressure causing dizziness whenever he got up and severe constipation. During Michael's hospital stay a team of pediatricians, psychiatrists, nutritionists and gastroenterologists worked to fatten him up to prevent even more serious illnesses from setting in. We managed to put some weight on Michael with high-caloric milk shakes that we convinced him were cholesterol free.
    Soon enough, however, we had to discharge him. After giving his parents a menu of high-calorie foods for Michael to eat, I asked him to keep a detailed diary of his daily diet. Within a few weeks he produced an almost obsessively detailed and beautifully printed document, showing a return to pita bread. His parents said they did not know what to do. "After all," his mother noted, "you can't force a 15 year-old to eat, can you?" Each subsequent week Michael continued to lose weight. Advice from eating disorder counselors, psychiatrists and even antidepressant medications did little to arrest the process.
    It is difficult to comprehend the complex dynamics that lead to self-inflicted starvation, the vicious cycle begun by limited food intake to the point that the brain no longer senses hunger, followed by the inexorable damage to the muscles, heart, kidneys and other organs. Thanks to a better understanding of anorexia and other eating disorders, early recognition and concerted efforts by physicians, mental health professionals and--most important--family members, this deadly disorder can be conquered. But some either come to be diagnosis too late or do not respond to treatment.
    Several months after Michael was discharged, a physician from his hospital called and told me that the boy died that morning of a cardiac arrest. Despite the boy's fears, an autopsy later revealed clean and open arteries, with no cholesterol blockages. But the heart was wasted and shrunken in appearance. I grieved for the loss of a young man no one could reach. Neither medical knowledge nor pleading were powerful enough to get him to perform the simple act of eating three meals a day.

Psychologist Helps Kosovo's Children Erase Bad Memories
Erin Emery, Denver Post- 7/26/2000

    The children at the refugee camp in Hemer, Germany, sat motionless. They didn't play little games or sing songs. They were like zombies. Refugees from Kosovo, they could still hear the screaming planes and the bursting bombs. Some children were so traumatized by their memories, they didn't sleep or eat. Colorado Springs psychologist Sandra Wilson, an expert in a therapy called Eye Movement Desensitization Reprocessing, was asked to come and help. She was accompanied by a team of American psychologists, and they worked side by side with a young interpreter from Kosovo named Jeton Hoxha. One by one, 100 children, ages 5 to 16, sat down with the psychologists and Hoxha and told their stories.
    The one told by an 8-year-old girl was particularly chilling. "She described how a Serb soldier had cut her neighbor's pregnant belly open. He took the baby out and put a cat inside her stomach," Wilson said.  For six months, from September 1999 to March, the 23-year-old Hoxha interpreted every story for the American psychologists. He took no pay for his work and instead asked that the Americans help him complete his education since the University of Pristina had been bombed. After eight months of wading through bureaucratic red tape, Hoxha arrived late last week at Denver International Airport. He will enroll next month at Pikes Peak Community College in Colorado Springs and is sponsored by The Spencer Curtis Foundation, a nonprofit agency named for two of Wilson's grandchildren who died in the early 1990s. In an interview, he and Wilson explained how they tried to erase the horrible memories of the Kosovo children.
    After hearing each child's story, psychologists began applying Eye Movement Desensitization Reprocessing, or EMDR. The children, in groups of five, were given crayons and paper and asked to draw a picture of a safe place and the worst thing they had ever seen. They drew pictures of their houses before they were burned - the safe places. The worst things were depicted in pictures that showed their homes being burned. "They drew pictures of pets being killed, and tanks, guns and dead bodies. And they drew trees. When the Serbs came, the children and women were allowed to run to the trees, to the forest. The men were tortured, and after that they were told they could run for the trees. As (they) ran, they were shot down in front of the children," Wilson said.
    After drawing the pictures, the children were asked to do the "butterfly hug" - to fold their arms across their chests, close their eyes and make butterfly motions with their hands, tapping on their left shoulder, then the right.  The idea is to stimulate both sides of the the brain so that it can more effectively wash away trauma. After three two-hour sessions, the images of horror change to more positive thoughts, Wilson said. "It took three pictures before they changed back to positive," Wilson said. Hoxha said he noticed the change right away.  "How we could tell," Hoxha explained, "they're sleeping good now. No sleepwalking. They're eating good."  EMDR has been used in 55 countries and was applied after the April 19, 1995, Oklahoma City bombing. It was also provided for therapists after the Columbine High School massacre. EMDR is based on the theory that people process their experiences in their dreams. Dreaming is indicated by rapid eye movement.
    Wilson said a traumatic experience can get stuck in the right hemisphere of a person's brain, like a kidney stone. Symptoms such as depression and phobia set in, and unless there is an effort to rid that side of the brain of the trauma, a person will have difficulty moving on in life. The left side of the brain says, "You survived, it's over," she said. "Then you start to recover. It's the left-right, left-right that's important. By stimulating the brain from left to right through tapping fingers left, then right, the traumatic images turn to more positive ones." EMDR is used not only to help trauma victims but to help relieve "phantom pain" experienced by amputees, Wilson said. She has also completed a study of 64 Colorado Springs police officers and found that EMDR helps them relieve stress. The study, sponsored by the National Institute of Justice, is to be published in January.
    Wilson's work has intrigued Hoxha, who has long wanted to be a doctor. He's intrigued by psychology and psychiatry but isn't sure whether he will pursue those fields as a career. "Nobody knows what's going to be in the future, but I try to help in the future," Hoxha said. "My goal is to finish the studies, the education."

Designer Drug Holds Unknown Health Risks
Bill Blakemore, ABC News- 7/26/2000

    On Saturday, federal agents intercepted 2.1 million tablets, nearly 1,100 pounds, of the drug MDMA, commonly known as Ecstasy at Los Angeles International Airport. Valued at $40 million, officials said it is the biggest Ecstasy bust in history and it marked the high point of a 10-month investigation by the Southwest Border Initiative, a multi-agency task force. "That’s 2.1 million tablets of Ecstasy that won’t go to our kids this year," Stephen Wiley, FBI special agent in charge, said during a news conference today. Three men were arrested Tuesday. Authorities were still searching for Tamer Ibrahim, 26, of Los Angeles, the alleged ringleader of the operation. They arrested Ryu "Steve" Jiha, 35, Mark Edward Belin, 28, and Damon Todd Kidwell, 29, all of the Los Angeles area. The group has been linked to several other large seizures around the world, including 700 pounds found by U.S. Customs agents in December 1999, authorities said. The cache confiscated Saturday was found in 15 boxes on an Air France flight from Paris and represented one-fourth of the 8 million tablets of Ecstasy seized in the United States this year, officials said. By comparison, only 400 tablets of the drug were seized in the United States three years ago.

Unknown Risks Across the Board
    Ecstasy, a synthetic drug manufactured mostly in Europe, is a hallucinogenic stimulant that gives its users a feeling of euphoria. The popular drug has spread beyond rave parties to college campuses and even into middle-class, professional America. Its growing pervasiveness is troublesome because the prevailing belief is that it’s perfectly safe — in part because some scientists think it might have therapeutic effects. Also, it does not produce extreme behaviors as some other illegal drugs do. It just seems to make you feel good. "My experience has been very safe with it, and everyone around me has been safe," says one 29-year-old professional who runs her own business and choose not to use her name. "I don’t know anyone who’s addicted to it or has problems with it." But a number of users do report a depression they call "Suicide Tuesdays." Dozens of people are reported to have died after Ecstasy raised their body temperature to extreme levels. And scientists who study how Ecstasy works in the brain say there is a great deal of evidence that should make us worry.

Irreversible Brain Damage
    Repeated Ecstasy exposure has been shown to lead to clear brain damage and that brain damage is correlated with behavioral deficits in learning and memory processes," says Alan Leshner, the director of the National Institute on Drug Abuse, which is a part of the National Institutes of Health. "This is not a benign, fun drug."
Normally, your brain controls mood partly by passing the chemical serotonin — in small amounts — from one brain cell to another. But Ecstasy forces lots of serotonin across the gap. Some new research suggests it leaves brain cells weakened and may cause irreversible brain loss. "We know from primates, non-human primates, that the damage lasts for years," says Una McCann, a neuroscientist at Johns Hopkins University. Some scientists, on the other hand, report Ecstasy may have benefit in strictly limited cases. "One group we’re interested in studying are individuals with end-stage cancer who have severe depression and anxiety and physical pain which have not responded to conventional measures," says Charles Grob, a psychiatrist at Harbor UCLA Medical Center. If medical use is ever allowed, it is far off. For now, government agents are battling the spread, and the myths, of a pill called Ecstasy, which for them, at least, is anything but.

Punishing Parents: Who's Responsible for a Child's Delinquent Actions?
ABC News, 7/26/2000

    If the parents of Dylan Klebold and Eric Harris — the two teenagers responsible for the massacre at Columbine — had done a better job raising their children, could the tragedy have been avoided? And should the parents be prosecuted for the horrific crimes of their children? Why hadn’t the parents seen the warning signs that their children were troubled? Had Harris’ parents never seen their son’s rage-filled Web site or the sawed-off shotgun barrel left on the bedroom dresser? These are some of the questions being raised as the parents of murdered Columbine student Isaiah Shoels and surviving victim Mark Taylor, sue the parents of Klebold and Harris for more than $250 million.
It is not unusual for the victims and families of victims to sue the parents of an adolescent criminal. Lawsuits have been raised after almost every school shooting in the past few years. What is unususal is for criminal charges to be brought against parents for the actions of their children. Increasingly, however, parents are being held criminally responsible for their child’s delinquent acts. Are parents really to blame? In a special report, John Stossel examines the question of parental responsibility by talking to parents, children, victims of crimes and the judges who are deciding where to place the blame.

Parental Responsibility Laws
   For decades, states have had laws on the books against actively contributing to the delinquency of a minor, by, for instance, providing drugs or alcohol. But new parental responsibility laws go further, holding parents responsible for how well they supervise their children. Since 1995, 25 states have enacted parental responsibility laws. These new laws are being called into play for crimes far less egregious than school shootings. In at least five states, for example, parents can go to jail for their child’s truancy, and in Hawaii, a parent can be imprisoned for a minor’s curfew violation.
    Is prosecuting parents the right response to juvenile crime? Stanton Samenow, psychologist and juvenile crime expert, thinks not. "It’s a terrible idea to make parents criminally liable for their kid’s behavior," he says. "There are kids that no parent has been able to constrain, short of staying home with that child and locking him in a room."  But Judge Marcia Morey, who helped write North Carolina’s parental responsibility law, believes it gives her the power to compel parents to keep their kids on track.
    "When parents didn’t show up to court," she says, "we couldn’t do anything to make them cooperate." Now, parents in North Carolina are required to appear at juvenile court hearings, and, in some cases, they are also obligated to pay the cost of their child’s punishment. Some parents, she says, have even spent the night in jail "for failing to help provide transportation for their kid to get to a counseling program, for failing to wake their kid up in the morning and get them to school."

How Much Do Parents Know
   Laurence Steinberg, of Temple University and co-author of You and Your Adolescent, conducted a survey of 20,000 teenagers, asking them how well their parents knew them. One-third of these teens said their parents had no clue who their friends are, how they spend they money, where they go after school, even how well they’re doing in school. Steinberg also helped 20/20 develop a survey for 9th and 12th graders from New York’s North Rockland High School and their parents. It revealed that even though these parents say they consistently spend time with their children and believed they were doing a good job as parents, they were, in many ways, as out of touch as the parents in Steinberg’s larger study.
    Because parents are often clueless about their children’s behavior, Steinberg says, and "given the fact that kids spend so much time away from their parents, it’s unrealistic to think that parents should be held responsible for each and every thing that their child does." He says that in extreme cases of parental negligence perhaps a parent should be held liable, but otherwise, "blanket laws about parental responsibility are unrealistic." Steinberg says that what kids want — even more than peer approval — is for their parents to approve of them. "Sometimes saying to your child, ‘You know, I’m not going to punish you for what you did, but I want you to know that you really let me down, you really disappointed me,’ that can be much more effective than grounding," says Steinberg. "They don’t want you to know that they want your approval, but they want your approval."

More Americans Try To Quit Smoking
David Pitt, Associated Press- 7/27/2000

    ATLANTA (AP) -- Americans are trying to quit smoking four times more often than they did in the years before the introduction of nicotine gum, patches and other products that help people kick the habit, the government reported Thursday. The Centers for Disease Control and Prevention analyzed data from pharmacies and over-the-counter purchases of smoking cessation products to conclude that Americans made more than 8 million attempts to quit smoking in 1997 and 1998, the latest years available. That's up from about 2 million in 1991, the year before the introduction of the nicotine patch.
    In 1998, the nicotine patch accounted for 49 percent of the drug-assisted attempts to quit, nicotine gum 28 percent and Zyban -- a prescription drug -- 21 percent. The nicotine inhaler and nasal spray accounted for less than 3 percent. The CDC said attempts to quit increased nearly every time a new product was made available. The CDC said the survey may overestimate attempts to quit because the numbers are based on sales data rather than questioning users. It's also impossible to determine if smokers were buying the product to quit or using it as a substitute for smoking in places where it is banned.  The CDC, which says about 48 million U.S. adults smoke, did not track how many of the attempts to quit failed.
    Having a variety of products helps smokers find ways to quit, said Rod Todd of the American Cancer Society.  ''Smokers are always looking for something that will be helpful and you never know with product might work the best for a particular smoker,'' he said. About 70 percent of people who smoke want to quit and 35 to 45 percent of them will try to quit in any given year, Todd said. It's common for smokers to go through several cycles of attempting to quit, going back to smoking and then trying to quit again.  ''We know that all of these work and they've been shown to work,'' said Saul Shiffman, a professor at the University of Pittsburgh's smoking research group. ''The challenge is getting people to use them. Even though these products work and people are so eager to quit smoking, too few people use these treatments.'' The CDC recommended that smoking-cessation products be included as an insured medical benefit. The report also said decreasing the cost of treatment could increase the number of people who try to quit. ''The prevalence of smoking is higher among persons of low socio-economic status and access to these treatments must be assured to these populations,'' the report said.

Insanity Finding Sought in Killing
Ralph Ranalli, Boston Globe - 7/28/2000

    Luis Erazo 's slide into madness began quietly, with the nagging fear that his boss at a Chelsea supermarket was making fun of him and laughing behind his back, according to court testimony. It climaxed a year later on the morning of Dec. 6, 1998, when - convinced that his wife was part of a conspiracy to poison him - he wordlessly picked up a knife and plunged it into her chest, killing her in full view of his 6-year-old stepdaughter, according to testimony.
    What happened to Erazo, two psychiatrists said, was such a textbook example of paranoid delusional psychosis that a Suffolk County prosecutor and defense lawyers took an extraordinary step yesterday: They both urged a judge to declare Erazo not guilty of murdering Maribel Caraballo, by reason of mental defect. Suffolk Superior Court Judge Diane Kottmyer said she will decide by next Friday whether to accept the recommendation. If she does, Erazo would then be referred for a 60-day evaluation at Bridgewater State Hospital to determine whether he should be treated in a locked psychiatric facility.
    Elizabeth A. Keeley said that in her 17 years as a prosecutor, it was only the second case she could remember where both sides agreed that a killer was not legally responsible for his crime. ''It is not the usual occurrence that two doctors would both conclude - that a defendant suffered from a major disease which made him not criminally responsible,'' Keeley said. But the victim's niece, Diana Caraballo, 23, said relatives are having a hard time comprehending that Erazo may do no prison time for the death of his soft-spoken, gentle wife. ''We're not saying he's completely sane,'' she said. ''But he knew what he was doing'' when he killed her.
    Technically, what happened in Kottmeyer's courtroom yesterday was a jury-waived criminal trial. But prosecutor Keeley presented no evidence other than police reports, hospital records, witness statements, and the testimony of the state's psychiatrist, Dr. Malcolm Rogers of Brigham and Women's Hospital. Defense attorney James M. Doyle presented only one witness, Harvard Medical School professor Prudence Baxter. Both psychiatrists said essentially the same thing - that Erazo, 33, truly believed his wife wanted to kill him. Unlike defendants who only claim to have heard voices after they are arrested, Erazo had a documented history of frightening auditory hallucinations and tried to get medical help.
    Erazo immigrated to the United States in the mid-1990s and found work in the meat department of the Market Basket supermarket in Chelsea, where he met Caraballo, a divorced single mother, according to testimony. They were soon living together and later married. Around Christmas of 1997, Erazo began to fear that his boss at Market Basket was trying to get rid of him because he was ''doing too good a job,'' Rogers said. Erazo knew that his feelings didn't make sense, and their irrationality frightened him, the psychiatrist said. His condition soon worsened, however. Voices began telling him that he should take charge, be ''the boss'' at the supermarket, even president of the United States, the doctors said. He started believing that his Market Basket superiors were ''doing witchcraft on him,'' Baxter said, and, finally, plotting to poison him.
    In reality, however, his managers considered him an exemplary employee and tried to talk him out of taking a new job at the Boston Coffee Cake Co. bakery in Woburn. For a time, at Boston Coffee Cake Co., the voices went away and he was less fearful. One day, however, he felt dizzy after eating lunch, an incident that he ''interpreted as proof he was being poisoned,'' Baxter said. His paranoid delusion expanded, both doctors testified, to include his new supervisors whom he now believed were in league with his old ones, according to testimony. Caraballo, meanwhile, had elected to keep her job stocking the supermarket's health and beauty aisles, a decision that may have cost her her life.
    At home, Erazo insisted that someone was trying to poison him, but his wife's efforts to change his mind - combined with her employment at Market Basket - only fed his paranoia. Their inability to conceive a child also may have contributed to his delusion, Rogers said. When the couple learned that his sperm count was low, Erazo was certain that poisoning by his wife was responsible. On Nov. 25, 1998, a doctor at an East Boston health clinic prescribed Prozac for Erazo, recommended he avoid eating lunch at work, and scheduled a follow-up appointment for him. Erazo never showed up. Two or three days before the stabbing, Rogers said, Erazo was consumed by thoughts of dying and of killing his wife. The sight of her preparing breakfast on a Saturday morning that December may have been the last straw. He allegedly stabbed her as she cooked. Caraballo staggered from their Chelsea apartment, collapsed, and bled to death on the sidewalk. ''It was his intense fear that unleashed the attack on her,'' Rogers said.

Prosecutors Demand Drugs For Weston
Bill Miller, Washington Post- 7/28/2000

    Federal prosecutors urged a judge yesterday to order that Russell Eugene Weston Jr. receive medication to curb his mental illness, saying it is their only hope of eventually bringing him to trial for the killings of two Capitol police officers. "There could not be a more compelling state interest than in the adjudication of the murder of two law enforcement officers," said Assistant U.S. Attorney David B. Goodhand, adding the government's rights outweigh Weston's arguments to remain drug-free. Defense lawyers contended that medicating Weston against his will would create an ethical dilemma not only for the court but also for his doctors. If Weston's condition improves to the extent that he is mentally competent for trial, he could wind up facing the death penalty. In short, they said, getting better might kill him. The two sides yesterday wrapped up a four-day hearing in U.S. District Court that focused extensively on Weston's current mental state and potential for treatment. On one issue, the doctors agreed: Without medicine, Weston's delusions will only get worse.
    Weston, 43, a Montana man with a long history of mental illness, has been deemed mentally incompetent to stand trial for the July 24, 1998, slayings of Jacob J. Chestnut and John M. Gibson. He has told psychiatrists he killed the two men and stormed into the U.S. Capitol to save the world from cannibals and deadly disease. His goal that day, he said, was to retrieve a "ruby red satellite system" that can reverse time. Although Weston was arrested immediately after the shootings, the prosecution's case against him has never reached the first critical stage. Weston hasn't been found mentally able to even enter a plea in the case let alone aid his attorneys and prepare for trial. For the past two years, he's received virtually no psychiatric treatment because neither he nor his lawyers will agree to put him on anti-psychotic medication. Defense lawyers have blamed the potential of execution for the stalemate. If prosecutors would agree not to seek the death penalty, they have said, the defense team would change its views about medicating him. But prosecutors said they cannot make a decision about the death penalty without a host of psychiatric examinations to assess Weston's condition at the time of the Capitol attack.
    Goodhand urged Judge Emmet G. Sullivan yesterday to rule that medication for Weston was necessary to make him fit for trial and to ensure the safety of Weston and others. He said the "unpredictability of Weston's illness, the unpredictability of his delusions" made Weston a continuing danger to himself and others. Sullivan set no timetable yesterday for a decision. No matter how he rules, however, the case is likely to remain at a standstill because of appeals. Besides raising ethical issues, defense lawyers A.J. Kramer and Gregory Poe contended Weston has a constitutional right to remain free from medication and hasn't harmed anyone while in custody. They also argued it would be difficult to ensure Weston gets a fair trial if a jury is not able to see him in a full-blown state of mental illness. The lawyers have recruited several psychiatrists to lay groundwork for an insanity defense.
    Weston, who for years has suffered from paranoid schizophrenia, has had a severe form of the illness since 1996, according to psychiatric testimony. Since his arrest, his condition has deteriorated and his delusions have gotten worse, doctors said. Sullivan ordered last year that Weston receive medication, but defense lawyers blocked any action with an immediate appeal. In March, an appellate panel sent the case back to Sullivan for further review, leading to the hearings this week. Weston was in court each day, staring blankly at the judge and witnesses. He has been housed at a federal prison psychiatric hospital in Butner, N.C., kept separate from other inmates. He is watched around-the-clock by officers stationed just outside his cell who take notes every 15 minutes about his activities. Prison staff members testified that Weston has become increasingly withdrawn, rarely speaks to anyone and, for a stretch last winter, cocooned himself tightly in his blankets. Sally C. Johnson, an associate warden and psychiatrist, testified that staff members are frightened of Weston because he has become "more menacing" and belligerent in his insistence that they leave him alone. Johnson did not predict how long Weston would require medicine to regain competence. She said a decision to medicate him now did not mean he would remain on drugs through any trial or beyond. Those issues would be explored later, she said.

When Innocence Can't Relieve Remorse
Brooke A. Masters, Washington Post 7/28/2000

For months after her collision, Frances M. Smith continued to have visions of the bicyclist who ran a red light and crossed in front of her Dodge Shadow on Independence Avenue. Calvin Henry, 36, would show up in her dreams. Smith would feel his presence in her Lanham home. In the days after she learned that Henry had died of his injuries, she said, it was like being caught in perpetual rewind, as Henry seemed to crash through her windshield again and again. There is nothing that Smith, 49, could have done to prevent the Oct. 27 accident, D.C. police said. She had the right of way and wasn't speeding. But for nine months, she has lived with the knowledge that her car helped take another person's life. "I'm not over it. I'm learning to deal with it. It's like nothing I have ever experienced," Smith said. "A stranger can come into your life for a few seconds, and your whole life is changed."
    Drivers such as Smith are America's forgotten traffic victims. Investigators tell them they weren't at fault in a fatal accident, but that only goes so far. Their lives are often irrevocably changed. Many suffer flashbacks and nightmares, and some develop post-traumatic stress syndrome, drivers and mental health specialists say. "I wound up getting a new car, because I couldn't deal with my car," said Smith, 49, who says she has become a workaholic since the accident, because her job at the Department of Health and Human Services is "kind of like therapy." Innocent drivers largely face the aftermath alone. If they need help, they must find it themselves, because police are focused on punishing negligent drivers, and advocacy and support groups concentrate on crime victims and their families. "People [think about] the poor dead guy and his family, but we need to look at the driver who, through no fault of her own, is involved in an accident and somebody has died," said Sgt. Pat Wimberly, who runs the Fairfax County police accident reconstruction unit. "There is a lot of survivor guilt. . . . Most people have never seen a dead body before. Most people have never seen somebody in absolute agony, suffering." And it can happen to anyone who gets behind the wheel, traffic experts point out. A drunk pedestrian may stumble onto the highway; a rushed office worker may dart out from behind a parked car. "Sadly, you become a victim of another person's choice," said Portia Cox, victim services manager for the Prince George's County police.
    Local authorities say they do not track fatal accidents in which the surviving drivers were not at fault, but statistics kept by the National Highway Traffic Safety Administration offer a window into the phenomenon. In 1998, 2,812 pedestrians and cyclists were killed in motor vehicle accidents in which the driver was sober and did not receive a ticket and police did not cite any driver behavior as contributing to the crash. Between 20 percent and 40 percent of people involved in serious motor vehicle accidents have symptoms of post-traumatic stress disorder, which can include flashbacks, sleeping problems, panic attacks and emotional numbness, said psychologist Edward B. Blanchard, who has written extensively about car accidents. Half of them get over it within six months, he said, "but for those that do not, it can go on and on and on." "It's a traumatic event, and people will assume some responsibility even though they are not to blame," said Blanchard, a professor at the State University of New York at Albany. "If I had just been more careful; If I had just come along 15 seconds later. It is human nature to engage in that kind of thing."
    That is how Ann Divecha feels. The Falls Church mother of two says she cannot get over the "what ifs." What if her minivan hadn't come down that street in Falls Church at just that moment? What if there hadn't been wet leaves on the road? What if she had caught more than just a glimpse of the bicycle? But by the time Divecha heard the thump, it was too late. Her 11-year-old neighbor, Hannah Knudsen, had slid down a hill, crashed into the side of the minivan and lay dying on the ground. "I'm not thinking about it all the time anymore," Divecha, 36, said. "But I think if I ever felt something hit the car again, I'd freak out."
    Mental health experts say that crash participants are more likely to suffer lasting psychological problems, if they have previously been depressed, suffered post-traumatic stress syndrome before or if they are injured themselves in the accident. Substance abuse can also be a key danger, say counselors at Metro, who work with train and bus operators after fatal accidents. That's because drivers may not realize that their flashbacks and other troubles are common reactions, and they may try to self-medicate with alcohol or prescription drugs. "It's important to tell people, 'This isn't inappropriate. What you're feeling is perfectly normal,' " said counselor Willie Wise, who worked with four such Metro operators last year. "There's a lot of guilt, a lot of anxiety, a lot of depression and a lot of fear that this may happen again."
    For some drivers, the immediate aftermath of the collision is as traumatic as the crash itself. For most, it is the first time they had ever had serious dealings with the police, and the close questioning makes them feel under suspicion and criminal. Although police officers try hard to reassure innocent drivers, several of those interviewed said they worried what their friends, neighbors and co-workers would think. They also worried they might be sued--something that occasionally occurs even when police conclude that the victim was at fault. Paul Snyder, 53, who was hit head-on in Loudoun County when another driver crossed the center line, thought everyone would assume he was in the wrong, because he was driving a truck. "Some of it's the fault of the truck drivers but some of it's not. When you've got a big load, you can't stop as fast as a car," said Snyder, who lives in Winchester. "Some of these people are in such a big hurry to get somewhere, and they get nowhere instead."
    Smith dreaded going to the office, because most of her co-workers had walked past the accident site, only blocks from their building. Divecha worried that her son Devin, 6, might be teased, especially after she learned that Hannah's little sister rode the same bus and attended the same elementary school. Because she lives only a few blocks from both the crash site and from the Knudsen family, Divecha said, she felt strongly that she could and should not withdraw from their shared community. Instead, she went to see Hannah's parents, learning in the process that she had once purchased Hannah's old tricycle at a yard sale and her own children now use it. Divecha also brought her son to Hannah's memorial service to help him understand that real-life crashes--unlike the ones on television--have real consequences. Both gestures meant a great deal to Hannah's family, said her uncle Eric Knudsen. "The two sides' meeting did a lot to help both sides heal. . . . Being able to console [Divecha] and tell her it wasn't her fault was just good" for the family, Eric Knudsen said. "There are things in life that are not avoidable." Eventually the immediate effect of the crash diminishes, drivers said. Divecha has put away the sympathy cards she received. "So many people said to me, 'Gosh, it could have been me.' That was helpful," she said. Smith no longer sees a counselor regularly. Snyder has recovered from the stitches he received in his accident. But little things serve as painful reminders: seeing another cyclist, going through the same intersection, hearing about a similar crash on the news.
    Fairfax management consultant Jill Armstrong, 28, said she never wants to go out to dinner on Valentine's Day again, because that was what she and her fiancée were doing when she hit a pedestrian who had already been knocked down by another driver in 1999. When she sees pedestrians dart out into traffic or stand in a very narrow median, she said, "It really makes me cringe. It makes me want to stop the car and say, 'Do you know what you're doing? People have died for this.' "

Mental Illness Tied to Risky Acts
Chris Cunningham, Reuters- 7/28/2000

NEW YORK—Young people who suffer from common psychiatric disorders, including depression, schizophrenia and substance dependence, are much more likely to engage in risky sexual behavior than their peers, according to a study in the July 29th issue of the British Medical Journal. "Psychiatric disorders and risky sexual behaviors occur in the same people at age 21 with unusual prevalence," Sandhya Ramrakha and others write." Although risky sexual behavior and sexually transmitted diseases are common among this age group, a disproportionate burden is carried by those with psychiatric disorders."
    Ramrakha, a research fellow at the University of Otago Medical School in Dunedin, New Zealand led a research team that looked at several psychiatric conditions and aspects of sexual behavior in more than 900 21-year-old men and women. They used data from an ongoing longitudinal study in New Zealand that has been assessing the participants' health and behavior since they were 3 years old. The participants had all been recently re-assessed at age 21, the age that mental health problems and risky sexual behavior tend to be most apparent, Ramrakha told Reuters Health.
    The type of psychiatric condition seemed to dictate the nature of the unsafe behavior. Participants with anxiety disorders were more likely to report sexually transmitted diseases, while those with manic diseases were more likely to have sexually transmitted disease and risky sexual intercourse. But the young people with depression, antisocial disorders, substance dependence, and schizophrenia were more likely to experience all three--unsafe sex, sexually transmitted disease, and early intercourse.
    The authors speculate that depressed young people might have risky sex because they feel hopeless or have low self-esteem. In contrast, someone with an antisocial personality might carelessly spread a sexually transmitted disease. Furthermore, a young person who suffers from both depression and antisocial behavior may show even greater inclination for these behaviors.  The researchers did not find differences in sexual activity between men and women, nor among different socioeconomic groups. "There may be sex or class differences in risky sexual behavior, and in mental disorders," Ramrakha said, "but the link between risky sexual behavior and mental health is the same for boys and girls, rich or poor."

Commenting on Ramrakha's study in a BMJ editorial, David L. Bennett of the Royal Alexandra Hospital for Children, in Sydney, Australia, suggested that just as alcohol and drug consumption may increase the chance that young people will indulge in unsafe sexual behavior, a psychiatric condition might interfere with their ability to assess risk or take precautions. Bennett said the current study emphasizes the need to identify high-risk young people with health conditions, because they will likely have many other problems before they finish high school.  "The coordination of services at all levels needs to be considered, including school counselors and clinics," Ramrakha said.

Mental Hospital Settles Lawsuit
Kirk Mitchell, Denver Post- 7/29/2000

The Colorado Mental Health Institute in Pueblo has agreed to settle a lawsuit by paying $400,000 to the families of two patients who committed suicide in the hospital's forensic unit, a state official says. The lawsuit, filed in April 1999, blamed the suicides of Terry Wilkerson, 45, and Michael Riley, 28, on hospital doctors, nurses and administrators. The hospital provided substandard medical and psychiatric care, the lawsuit says.
    Wilkerson, who hanged himself in a broom closet in 1997, and Riley, who hanged himself in a bathroom in 1998, were among four patients who killed themselves in a 15-month period. The hospital will pay $250,000 to Riley's mother, Jacquelin Riley, and $150,000 to Wilkerson's family, said Liz McDonough, spokeswoman for the Colorado Department of Human Services. Of the money going to the Wilkerson family, $96,000 will be placed in annuities for Wilkerson's three children.  Kathleen Mullen, a Denver attorney who represented the families of the patients, declined to comment.
    Riley killed himself on April 15, 1998, after repeatedly asking his doctor, David Johnson, to take him off of Haldol, the same psychotropic medication he was using when he attempted suicide before, the suit says. A "dreary, overcrowded, unsafe and untherapeutic environment" didn't prevent Riley from hanging himself shortly after he was caught with a sheet in the bathroom, the lawsuit says. When Wilkerson's wife, Rebecca Wilkerson, warned Dr. Matthew Goodwin that her husband was suicidal, Goodwin said her husband was under a suicide watch. In fact, he hadn't been for five months, the lawsuit says.

Federal Study Finds Serious Heroin, Crack Epidemic in Baltimore
Associated Press, 7/29/2000

BALTIMORE (AP) A federal study has found that Baltimore has one of the most serious drug problems in the nation, and city officials say they hope to use the information to seek more federal aid to combat drug use and crime.  The Drug Enforcement Administration's three-month study found that Baltimore is a major market for South American heroin that is ''significantly'' purer than the national average. The DEA assessment was requested by Police Commissioner Edward Norris this spring and delivered to department managers last week. Based on DEA intelligence and statistics, as well as independent research, the assessment said Baltimore leads the nation in heroin use and has one of the most severe crack cocaine epidemics in the nation. The use of the designer club drug ecstasy has rapidly increased, particularly among suburban users. 'It confirms a lot of the suspicions we had,'' Norris said. ''The drug problem is more serious than most major cities in America.''

Norris said requests for aid might include asking for more DEA agents in Baltimore, more money for drug-enforcement police and more money for drug-treatment facilities for addicts. Baltimore is estimated to have at least 60,000 drug addicts, or about 10 percent of the population. Police say drugs are a factor in eight of every 10 city homicides. With federal help and an aggressive anti-drug strategy, Norris and Mayor Martin O'Malley said, they believe the drug epidemic will be under control in two to three years. Baltimore also continues to lead the country in both heroin- and cocaine-related hospital emergency room admissions, according to the DEA.

New Drug of Choice Hits Maine Streets
Associated Press, 7/30/2000

PORTLAND, Maine--A highly addictive prescription pain reliever known as OxyContin is hitting Maine's streets from South Portland to Washington County. When used legally, the opiate is prescribed to relieve chronic pain accompanying cancer or surgery recovery. But on the streets, where it's known as ''oxy,'' the drug can produce a high so close to heroin that its black market use is soaring ''It's more addictive than any pill I know of,'' said Christopher Coughlin, who was caught in May with a gym bag full of heroin and OxyContin. ''There's a lot of it on the street right now. It's the drug of choice,'' said Coughlin, 32, who is serving eight years in Maine Correctional Center in Windham.
    During the past 12 months, the Maine Drug Enforcement Agency has arrested 156 people for crimes involving prescription drugs, twice as many as the previous year. Police say the demand for OxyContin drove the increase. Signs of the drug's increased use are also visible in hospitals and clinics. The Recovery Center at Mercy Hospital in Portland sees new OxyContin addicts nearly every day, said nurse practitioner Jane Boyer. ''It's very, very difficult to quit,'' said Boyer. ''People who begin using opiates don't realize what they are doing to themselves.''   Coughlin describes withdrawal as ''having the flu times 1,000.'' In bad cases, withdrawal lasts a couple of weeks.
    At Portland's Discovery House, a methadone clinic, about a quarter of the 400 patients are Oxy addicts, said John Destefan, the program's director. ''We've seen a steady increase in the last couple of years,'' Destefano said. Users crush the small white OxyContin pills to remove the time release coating, then snort or inject the powder. To get the drug, addicts steal prescription pads and fool doctors by feigning severe back pain. Some break into homes where they suspect somebody has an OxyContin prescription.
    Last month, two armed men in South Portland broke into an apartment and demanded that a 52-year-old man hand over his OxyContin. They left with the pills and remain at large. And in Millinocket in March, two masked men broke into an elderly couple's home, knocked the woman to the floor and tried to steal a bottle of OxyContin from her purse. The intruders fled when she screamed for her husband.
    In February, U.S. Attorney Jay McCloskey sent a letter to 4,800 health care providers in Maine warning them about ''serious problems across the state regarding the misuse of OxyContin.'' A federal study using Medicaid statistics ranked Maine second in the nation in per-capita use of OxyContin. The surging demand for the drug mirrors a rise in heroin use in the state. Purdue Pharma of Norwalk, Conn., started marketing OxyContin in 1996.

Voices in His Head Muted, A Killer Rejoins the World
Blaine Harden & Nina Bernstein, New York Times- 7/31/2000

    Until this month, Dennis Sweeney was the only killer in New York State who was required by law to go twice a month to a mental hospital for a six-hour sleepover. Around midnight, he drove to a state hospital in Middletown, N.Y., said hello to the duty nurse and picked out an empty bed on the third floor. He woke himself at dawn, walked out of the hospital and returned to the carefully calculated anonymity of his small-town life. This odd and empty ritual, which he has performed without fail for more than five years, was the end-game in a legal and psychiatric odyssey that began two decades ago when Mr. Sweeney committed a crime that dumbfounded a generation of Americans who came of age in the 1960's.
    On March 14, 1980, he walked into a law office in Rockefeller Plaza and shot dead Allard K. Lowenstein, the former congressman whose liberal passion helped shape a decade of civil-rights and antiwar activism. Mr. Lowenstein had been his friend and mentor. But after his arrest, Mr. Sweeney told psychiatrists that he was convinced by voices in his head that Mr. Lowenstein was part of a Jewish plot to destroy him. After a quick diagnosis of paranoid schizophrenia, Mr. Sweeney was found not guilty by reason of insanity and packed off to a state mental hospital.
    As Mr. Sweeney's sleepovers at the mental hospital suggest, the laws and procedures that define insanity and have ruled his life for more than a third of his 57 years are often arbitrary and sometimes useless. The process, too, has a history of being turned upside down in response to public fear, populist politics and sensational crimes like the shooting of President Reagan. The treatment of the man who killed Al Lowenstein spans an era of wholesale change in the insanity defense in America. While the very meaning of insanity was being rewritten in legislatures and reinterpreted in the courts, Mr. Sweeney was living in Middletown, about 70 miles northwest of Midtown Manhattan, and making what his psychiatrists describe as a rare and impressive recovery.
    The dental crowns that he gouged out of his mouth with a hacksaw blade in the early 1970's--in an attempt to silence the voices--have been replaced. Mr. Sweeney has said the voices disappeared more than a decade ago, and doctors at Middletown Psychiatric Center say they believe him. Hospital furloughs have allowed him to find a job as an employment counselor. He rents a house with a fine view of the Shawangunk Mountains. He is active in the Unitarian Universalist Church in Middletown and managed a Habitat for Humanity project there that built a house for a disabled couple. For about a year, court records show, he has been romantically involved with a woman who works as a counselor to the mentally ill and has told her about his violent past. He refused repeated requests to grant an interview for this article.
Justice Brenda Soloff of State Supreme Court in Manhattan has been tracking Mr. Sweeney's progress for more than 15 years, and on June 30, she ordered a conditional release that will end his sleepovers at the mental hospital. Those visits were a legal fig leaf, she said, covering the reality that he is "an inpatient in name only." In her decision, the judge concluded that "for six years, without medication, Dennis Sweeney has been building an ever more complex, satisfying and successful life in the community."

Changing Attitudes: Reagan Attack Tilted Legal Landscape
   Mr. Sweeney's recovery and return to everyday life would, in all likelihood, have been impossible had he pulled the trigger after John W. Hinckley, Jr. shot President Reagan in 1981. Mr. Hinckley was later found not guilty by reason of insanity--a decision that roiled public opinion and prodded politicians to act. In 1984, Congress sharply raised the bar for the insanity plea. It changed the test of incompetence from whether defendants appreciated their acts or could control their behavior to a more restrictive standard: Did they know right from wrong? Congress also shifted the burden of proof. Where once the prosecution had to establish reasonable doubt about an insanity plea, the defense now has to show convincing evidence to support the plea.
    States followed the federal lead, with two-thirds restricting the defense. Twelve states adopted a guilty but mentally ill verdict, 7 narrowed the test for insanity, 16 shifted the burden of proof, and 25 tightened release rules for those found not guilty by reason of insanity. New York State narrowed the test and shifted the burden of proof. Changes in the law followed a sea change in public attitudes, according to legal scholars, as the insanity defense generated mounting skepticism, Psychiatrists who testified as expert witnesses also retooled the way they judged the sanity of people who committed murder.
    "Before Hinckley, our approaches erred on the side of finding insanity," said Dr. Park Dietz, a psychiatrist who has been an expert witness, usually for the prosecution, in some of the most notable insanity defense cases of the past 20 years, including Mr. Hinckley's, Jeffrey Dahmer's and the Unabomber's. "The approach launched in 1981 would, in the Sweeney case, have looked very specifically at whether he knew Lowenstein was a man who could be injured or killed by shooting, and whether he knew that the police would come and want to punish him." By that standard, several psychiatrists said, Mr. Sweeney was sane when he killed Mr. Lowenstein. And by that standard, had he shot Mr. Lowenstein after 1984, Mr. Sweeney would have probably been found guilty of murder, sentenced to life in prison and would still be behind bars.
    Even for those found not guilty by reason of insanity, the notoriety of a crime itself--irrespective of a patient's recovery from mental illness--often governs the length of confinement in mental hospitals. If Mr. Sweeney had shot someone who was not famous, he probably would have won a conditional release from Middletown Psychiatric Center several years earlier, according to researchers who study forensic law. "These people tend to silt up in the system," said Henry Steadman, a sociologist who worked for the New York State Office of Mental Health for 17 years and whose specialty is assessing the risk of releasing mental patients. "They have committed heinous offenses, the public is afraid of them and prosecutors are reluctant to release them. The political valence in these cases significantly impedes the practice of good psychiatry."
    The determination that a once homicidal patient no longer suffers from a dangerous mental illness is an art, not a science, and mental health experts agree that it is subject to error. "Predicting a harmful event such as violence is very much like predicting harmful weather--estimates rather than guarantees are all that can be expected," said John Monahan, a psychologist and professor of law at the University of Virginia who specializes in risk assessment.  That Mr. Sweeney is an excellent risk, as judged by mental health professionals, is of little comfort to Mr. Lowenstein's survivors. His widow and his children say they are afraid of Mr. Sweeney, as do two of his own former friends. Court records show that Mr. Sweeney had told friends about his ability to pull the wool over the eyes of psychiatrists. Asked if Mr. Sweeney might now be covering up his violent delusions, two risk assessment experts said it was highly unlikely. They said that psychiatrists tend to err on the side of caution. But they said no one, except Mr. Sweeney, could be absolutely certain.

A Life Unravels: Before the Voices, Idealism and Courage
   Until it was ruined by the voices in his head, the life of Dennis Sweeney had been shaped by idealism and by his own considerable courage. He grew up in Portland, Oregon, the only son of working-class parents who separated when he was an infant. His father, a military pilot, was later killed in Korea. Dennis grew up bookish, athletic and handsome. He won a scholarship to Stanford University. At Stanford he met the charismatic Mr. Lowenstein and became one of his disciples. When his mentor asked him to go to Mississippi in 1963 and join the civil rights movement, Mr. Sweeney went. For most of the next three years, he devoted his life to the movement. While he was working in McComb, Mississippi, his house was dynamited. Mr. Sweeney made a name for himself as thoughtful, effective and quietly fearless, according to "Dreams Die Hard," a book about Mr. Sweeney and Mr. Lowenstein by David Harris, a friend of both men.
    In 1964, the book said, he came to share the feelings of black activists in Mississippi who felt patronized by white Northern liberals like Mr. Lowenstein. The idealistic student turned against his loquacious mentor. The break was given a nudge when Mr. Sweeney, according to an account he later told several friends, was asked by Mr. Lowenstein to share his bed. It was an invitation offered to a number of Mr. Lowenstein's male acolytes, according to a friend of Mr. Lowenstein, Mr. Harris's book and other published reports, but friends say Mr. Sweeney found it especially disturbing.
    As the civil rights movement gave way, for white liberals, to protests against the Vietnam War, Mr. Sweeney's life came undone. A marriage failed. His friends said he took a lot of LSD. According to prosecutors in New York and Mr. Harris's book, Mr. Sweeney helped to burn an ROTC clubhouse at Stanford in February 1968, and was questioned about it, but never charged, by the FBI. In the 1970's, after he dropped out of college and lost touch with most of his friends, Mr. Sweeney began telling people about an electrode planted in his head. He gouged out his bridge work. He declined voluntary psychiatric treatment in Oregon. He assaulted a former friend in Boston. He confronted Mr. Lowenstein about the voices. Finally, after the death of his stepfather, for which in his delusional state he blamed Mr. Lowenstein, he applied for a permit to buy a handgun. He bought the gun in New London, Connecticut and drove his pickup through a rainstorm to keep an appointment with Mr. Lowenstein in Manhattan.

A Rapid Diagnosis: Spitting Out the Devil Into a Plastic Cup
   After Mr. Sweeney was arrested and taken to jail on Rikers Island, psychiatrists had no trouble with a diagnosis. He kept trying to "spit out the devil" into a plastic foam cup. Mr. Lowenstein was not really dead, he claimed, and was still out to get him. Persecutory delusions are classic symptoms of paranoid schizophrenia. Anyone with his diagnosis would today be treated with a mix of powerful psychotropic medications, psychiatrists say. What puts Mr. Sweeney "outside the curve" of standard treatment said Dr. Robert H. Berger, director of forensic psychiatry at Bellevue Hospital Center, is that for almost two decades his recovery had been without drugs. 
    Since 1985, his recovery has been so seemingly free of the usual symptoms of schizophrenia that examining psychiatrists, including Dr. Berger, have questioned whether he was misdiagnosed. They wondered if he might have had some other mental disorder. In the end though, two generations of doctors have concluded that everything in his history fits the pattern of schizophrenia. The chronic disease is a gradually deteriorating onset of auditory hallucinations and psychosis. Still poorly understood, it is attributed to genetic vulnerability, brain chemistry imbalance and life stresses, sometimes including the effects of drugs like LSD.
    Hundreds of studies of patients with schizophrenia have reported recovery rates ranging from 10 percent to 50 percent, with or without medication. The National Institute of Mental Health, however, now says no more than 20 percent of schizophrenics ever fully recover. The capacity to calmly obtain a gun permit and make an appointment for murder does not square with popular notions of insanity, but psychiatrists say it does fit the profile of paranoid schizophrenics. They typically appear far more normal than other psychotics because, outside of delusions, most of their thinking remains intact. To protect themselves from perceived enemies, they are adept at deception.
    Deception had been a recurrent concern in Mr. Sweeney's case. By 1985, his treating psychiatrists said he showed no signs of illness. Describing him as "alert, intelligent, friendly, respectful and cooperative," they wanted to transfer him from a maximum-security hospital to a nonsecure one. In court hearings the following year, however, evidence emerged that Mr. Sweeney was lying to his doctors. He confided to Charles Hinkle, an old friend from Oregon, that to win his release he falsely said he no longer heard voices. By then, court records show, Mr. Hinkle was afraid of his friend. When Mr. Sweeney found out in 1986 that Mr. Hinkle had told prosecutors about the voices, he angrily broke off their friendship. Ten years latter, Mr. Hinkle told a psychiatrist involved in the case that he hoped Mr. Sweeney would never be allowed back in Oregon. When Mr. Sweeney learned about this, he wrote Mr. Hinkle a furious letter, calling the statement "disgustingly shrewish." Mr. Hinkle, a lawyer in Portland for the American Civil Liberties Union, declined to comment.
    Psychiatrists who specialize in murder consider Mr. Sweeney's case particularly rare. "I would have to say that his is the only case that I have personally examined where I believe there had been a spontaneous remission from schizophrenia without medication," said Dr. Dietz, who says he has examined thousands of murderers. He advised the court in 1993 that Mr. Sweeney would most likely be ready for release within a year. Immediately after the doctor gave his recommendation, however, he pulled aside Mr. Lowenstein's widow, a psychiatric social worker, and gave her a private warning that he routinely imparts to families of victims: No good can come of any contact between your family and Mr. Sweeney.

A Troubling Encounter: Her Father's Killer Offers an Explanation
   Kate Lowenstein was 9 when Mr. Sweeney killed her father, but family friends say she was determined to attend a hearing this year on Mr. Sweeney's release. It was a way, somehow, to represent her father's life. In the courtroom during a recess, Mr. Sweeney looked her straight in the eye and walked over. Mr. Sweeney was "fairly certain" he recognized the young woman in the last row, he later told the court. Ms. Lowenstein was astonished that he knew her. At most, he had seen her once before, when she was a toddler and he was deep in his delusions. He would tell the court that he "just felt like it was one of those situations where the silence was unbearable and I wanted to say something." No one else in the courtroom was watching. He started by offering an apology, according to court records.
    "Do you know what you did to me? Ms. Lowenstein asked in reply. He said that he did not. "You broke my heart," she told him. Leaning closer, he tried to explain why he had done it. She seemed frozen by distress by the time lawyers ran over to her. Outside the courtroom door, she broke down. The words of Mr. Sweeney's explanation, as she wrote them down, were: "The only reason I did what I did was to stop something terrible from happening. You can't understand that, but I had to do it. I had to stop it."
    Prosecutors have repeatedly delayed Mr. Sweeney's release, turning up information overlooked by his changing cast of therapists. "It's not a question of whether we worked hard to keep him in," said Ralph Fabrizio, a prosecutor. "We tried hard to see what was going on." They fought to retain Mr. Sweeney's fictional inpatient status at Middletown Psychiatric Center, Mr. Fabrizio said, because legally it made it easier to reel him back in, if he tried, for example, to contact members of the Lowenstein family. Prosecutors say they want a tight enough leash on Mr. Sweeney to keep him from slipping through what they call a gap in the law. Once he is granted conditional release, he cannot be recommitted just for breaking conditions imposed by the court. A judge would have to rule that he was dangerously mentally ill.
    There is, though, an alternative--a petition for involuntary civil commitment. In practice, officials at Middletown Psychiatric said, this option, which requires the signatures of two psychiatrists, is routinely used to bring in patients on conditional release who are judged to be regressing. To the prosecutors, the courtroom encounter with Ms. Lowenstein was a disturbing illustration of Mr. Sweeney's poor judgment, if not his skewed thinking. They wanted to get it on the record. But when Mr. Fabrizio told Ms. Lowenstein he might have to call her as a witness, "she just turned ashen," he said. They both knew what the psychiatrist had told her mother.

The Cusp of Freedom: Weaving a New Web of Life and Love
   In Middletown, it took Mr. Sweeney eight years to convince psychiatrists at a maximum security mental hospital that he was a good risk for transfer to a nonsecure facility. It took three more years for him to convince officials at Middletown Psychiatric Center that he was a good risk for unescorted furloughs. Since then, Mr. Sweeney had had to convince people in a semirural community of 50,000 that he is not dangerous. It has not been easy. Publicity cost Mr. Sweeney his first job, counseling mentally disabled adults at an agency called Crystal Run Village, when a reporter told administrators that he was writing a story about a psychotic murderer working with vulnerable people. "The handwriting was on the wall and people were running for cover," said Mark Lukens, then executive director at the agency. "We told Dennis about the story and he resigned."
    Mr. Sweeney started over, working as secretary, lumber store clerk and carpenter. It took him six years to land a job he really wanted, as an employment counselor. Meanwhile, he joined a church and told its members about his illness and the murder. When the same newspaper, the Times Herald-Record, in a 1994 article about the local hospital, mentioned him in passing as a "notorious patient," Mr. Sweeney complained in a letter to the editor. "It has not been my experience that people I have met over the past two and half years bear me hostility or begrudge me a life, as long as I do not represent a potential danger to the community or anyone in it," he wrote. He went on to accuse the newspaper of trying to sabotage his chances for work or friendship. Since then, Mr. Sweeney had been mentioned twice in the paper for his work with Habitat for Humanity.
    Several psychiatrists familiar with Mr. Sweeney's life said that the best insurance that he will not slip back into dangerous mental illness is the web of work, home and love that he appears to have woven for himself in Middletown. Even psychiatrists who do not find Mr. Sweeney to be a charming person--and there are several--say his release is sound on medical grounds. "He is an obsessive-compulsive man who is very intellectualized, not a warm, mushy, caring person," said Dr. Alan J. Tuckman, one of the examining psychiatrists who recommended release. "But that's not the standard. If somebody is going to have recurrent schizophrenic episodes, they are not going to occur every 20 years." As part of his conditional release, the precise terms of which are still being argued in court, officials at Middletown Psychiatric Center say Mr. Sweeney will continue in psychotherapy and will be visited at home at least twice a year. He has been ordered to stay away from the Lowenstein family and from two former friends who fear him, Mr. Hinkle and the man he assaulted in Massachusetts.