More California Drug Offenders May Get Treatment
Greg Krikorian, Los Angeles Times- 11/1/2001

A state court of appeal unanimously ruled Wednesday that the drug treatment initiative, Proposition 36, applies to nonviolent offenders convicted but not sentenced before the measure took effect July 1. Although other appellate courts in California are still reviewing the issue, the 3-0 decision by the 2nd District Court of Appeal in Los Angeles is the first published opinion on the landmark initiative. As such, it is expected to be followed by lower courts throughout the state, legal experts say. Had the appellate court ruled that Proposition 36 applied only to drug convictions after July 1, it could have meant rehearing thousands of cases of people already in drug treatment. "It is a big decision," said Los Angeles County Deputy Public Defender Alex Ricciardulli, "because if it had gone the other way, it could have been chaos."
    The initiative, approved by 61% of state voters last November, created confusion in some jurisdictions about which defendants were eligible for treatment instead of prison time. The proposition changed state sentencing laws so that those convicted of a nonviolent drug crime could receive probation rather than face state prison or county jail. Shortly after its passage, court officials estimated that the alternative sentencing, which requires completion of a drug treatment program, could apply to as many as 16,000 defendants a year in Los Angeles County alone. But since the measure took effect, one key area of disagreement has been whether Proposition 36 applies to those who had been convicted, but not sentenced, of using, possessing or transporting drugs for personal use.
    The ruling Wednesday came in the case of 36-year-old Janet DeLong, who was denied access to a Proposition 36 treatment program after being convicted in May of possessing less than a gram of cocaine. In DeLong's case, the Los Angeles County district attorney's office maintained that because the Culver City woman was charged and convicted of her crime before July 1, she was not eligible for a drug treatment program when she was sentenced. At DeLong's sentencing on July 12, Superior Court Judge Stephanie Sautner agreed that DeLong was not eligible for drug treatment and sentenced her to three years' probation with the first 150 days to be served in county jail. But at the request of the Los Angeles County public defender's office, that sentence was blocked by the appellate court pending its decision on eligibility.
    In interpreting the term "convicted," the court said, it was mindful that when a statute is reasonably open to two interpretations, "ordinarily the construction which is more favorable to the defendant will be adopted." And because Proposition 36 precludes those who violate probation or parole from eligibility, the court added, "no rationale appears to exclude from its wide reach the limited class of defendants who, as of the effective date, had been adjudged guilty and were awaiting sentencing."
    Although the district attorney's office had challenged DeLong's eligibility for Proposition 36, it had since dropped such challenges pending the appellate court's decision. Special Counsel Lael Rubin said Wednesday the district attorney's office had no plans to seek a review of the court's decision. "It is a well-written opinion," she said.
    Even though the ruling has statewide implications, its impact on Orange County is not expected to be as pronounced as in other areas. Orange County judges started sending drug offenders into treatment several months before the law took effect--with the blessing of the district attorney's office. Dave Fratello, co-author of Proposition 36, praised the ruling, calling it "a victory for the intent of the initiative. "Over time, this issue would have evaporated by itself simply because you would run out of people who were arrested and convicted before the effective date," Fratello said. "But anything that gets more people into treatment fulfills the will of the voters, and that is why we welcome this ruling."

Mental Illness: Toll on our Kids Is Huge
Heath Foster, Seattle Post-Intelligencer- 11/1/2001

Mental illness is now the leading reason that people between the ages of 5 and 19 in the state are being hospitalized, new research by the University of Washington has found. The most dramatic growth in hospitalizations over the decade has been among younger school-aged children who are suffering from depression and disruptive behavioral problems, such as "oppositional defiant" and conduct disorder.
    Mental health experts said yesterday that these children's families often cannot get adequate health insurance coverage for the intensive counseling and therapy their troubled kids need and are ending up in emergency rooms as a last resort. "This is a call for us to respond to children's unmet mental health needs," said Sheri Hill, a developmental psychologist who helped direct the UW's annual State of Washington's Kids research effort. "We can no longer ignore this problem." Not treating mental illnesses in children until they reach the crisis stage has ramifications far beyond the emergency room, affecting schools, neighborhoods and even the ability of families to stay together, said Susan Maney, clinical director of the Children's Home Society's Cobb Center, which provides mental health treatment to children.
    Between 1990 and 1999, the most recent year for which hospital discharge data were available, the mental illness hospitalization rate for children between the ages of 5 to 14 grew from one of every 900 kids to one in 750. During the same period, the hospitalization rate for adolescents between 15 and 19 remained stable, accounting for one in every 275. In 1999, a total of 2,800 Washington children were hospitalized with mental health problems. Hill said that the kids age 5 to 14 are being hospitalized for an average stay of 20 days, a sign that they are severely ill and have been unable to get adequate mental health services in their communities.
    Depressive disorders are by far the most common mental health problems that Washington hospitals are seeing in children, accounting for 46 percent of the mental illnesses in children 5 to 14 and a whopping 67 percent in teens age 15 to 19. Depression appears differently in children than in adults, Maney said. Children are likely to become withdrawn, have difficulty relating to their playmates and adults, do poorly in school or have trouble getting out of bed, she said.
    Maney said there is no single reason why mental illnesses are being seen more often in young children. One reason is that they are being diagnosed earlier when they do end up in emergency rooms. Also, societal changes that have resulted in both parents working and separation from extended family have meant that family members are less available to pick up signs of problems, she said. A growing incidence of alcohol and drug addiction in parents has led to an increase in stressful home environments that make it more likely that kids will develop mental health problems, Maney said.
    Experts said the rising incidence of mental illness-related hospitalizations worried them because it comes at the time that the state, King County and the city of Seattle are considering significant budget cuts to human services due to the economic downturn. And it adds urgency to an amendment passed by the U.S. Senate Tuesday that would require health insurers that cover mental illnesses to treat them as they would any other physical health problem. The Congressional Budget Offices has estimated that if the measure were passed by the House, it would cause a 1 percent increase in insurance premiums.
    Mike Fitzpatrick, the Northwest regional director for the Children's Home Society, said even families that currently have health coverage are allowed only a limited amount of counseling. Because of a shortage of child psychologists and other mental health services, families often face long periods between therapy sessions and see few results.  It's often not until children act out in some dramatic way, such as hurting a sibling or schoolmate or injuring themselves, that they are taken to the hospital and get the intensive services they need, Fitzpatrick said. "As mental health resources in our local system have gotten more scarce, children have had to have a pretty severe diagnosis to get any type of service," he said.

Millions of Teens Smoke Cigarettes, Despite Laws
Jeff Carpenter, ABC News- 11/1/2001

B O S T O N— Despite laws designed to keep cigarettes away from kids, 34 percent of U.S. high school students and 15 percent of middle school students use tobacco products, government health officials say. Those figures mean more than 3 million kids between the ages of 12 and 17 are lighting up, according to the national survey by the Centers for Disease Control's Office of Smoking and Health. The survey, which included students from 29 states, posed a number of questions to teenagers about tobacco marketing, secondhand smoke and underage purchasing, as well as general use of all types of tobacco products.
    Although the statistics show the number of teens using tobacco has started to decline from record highs in 1997, experts say the numbers are still disturbing given that nearly 90 percent of adult smokers began using tobacco at or before the age of 18. "We want to emphasize, while cigarettes are the most lethal form of tobacco, adolescents are using many forms of tobacco, and potentially becoming addicted to nicotine from many sources, and will transition into cigarettes," said Terry Pechacek, head of the survey team and associate director for science with the CDC Office on Smoking and Health.
    According to the survey, most middle and high school smokers get their tobacco at gas stations and convenience stores. While the legal age to buy tobacco is 18 throughout most of the United States, the survey shows current laws to be ineffective. Approximately 69 percent of middle school students and 58 percent of high school students reported they were not asked for proof of age when purchasing cigarettes.
    Although the tobacco industry has altered its advertising, ads still lure teens into buying tobacco products, Pechacek said. "Tobacco companies voluntarily stopped outdoor billboards, but have taken these advertising dollars and put them into local convenience stores," he said.
    The study also found one of the "major predictors" of tobacco use to be whether teens spend time with other people who smoke. In the week before the survey, half of the nonsmokers were in a room with someone smoking, and approximately 70 percent of middle school students and 57 percent of high school students who smoke live in a home with a smoker.
    Experts believe that more education about tobacco in schools could counteract the bad influences these students face at home. "Overall, we're finding that many students are receiving some information, but the rate is far below what is recommended," said Pechacek.

States Told to Make Megan's Laws Tougher or Lose Federal Funding
Liz Sidoti, Associated Press- 11/1/2001

COLUMBUS, Ohio -- The federal government has ordered Ohio and 13 other states to make their Megan's laws stronger or risk losing millions in grant money. Making their laws consistent with the federal Megan's Law is one of 17 requirements for states to receive a federal grant that pays for crime prevention and victims' assistance programs in communities nationwide. The U.S. Bureau of Justice Assistance notified the states in June that they would lose 10 percent of their annual grant beginning next year if they did not change their sex-offender registration laws by October. The National Criminal Justice Association, which is working with the states on the problem, said it is uncertain if any of the 14 met the deadline.
    For Ohio, which receives about $19 million a year, the loss would be nearly $2 million. ''It might not seem like a lot, but communities are counting on this money for programs that have proven to be a success,'' said Domingo Herraiz, director of the Ohio Department of Criminal Justice Services. Sheriffs and police departments can use the money to pay for task forces, community policing efforts, victims' advocacy projects or treatment programs for drug- and alcohol-addicted offenders.
    All 50 states and the federal government have passed some type of sex-offender registration law since 1994 when 7-year-old Megan Kanka, was raped and murdered by a convicted sexual offender who lived near her family's New Jersey home. States had until last month to change their laws to require sex offenders to register with local authorities for life. In some states, sexual offenders are required to register for only a certain length of time, not life, and can ask a court to terminate the registration order, which also is against the federal law.
    ''Some states have faced difficulty because their Legislatures didn't want to change the law. For the most part, that's been the problem,'' said Cabell Cropper, executive director of the National Criminal Justice Association. Besides Ohio, the states are Alabama, Indiana, Maryland, Massachusetts, Montana, Nebraska, New Jersey, New Mexico, New York, North Dakota, Texas, Virginia and Washington.
    Virginia said it believes its law already is in compliance. Texas also believes it is in compliance and is contacting the federal government to find out why the state was named. A bill in the Nebraska Legislature would make the necessary changes and is awaiting debate. In Ohio, only offenders labeled sexual predators are required to register for life, and they can petition a court to throw out that designation. Habitual sexual offenders must register with authorities for 20 years, and sexually oriented offenders for 10 years. Officials said the state is trying to round up support for the changes among lawmakers and sheriffs and has asked the government for more time.
    On the Net:
U.S. Bureau of Justice Assistance: http://www.ojp.usdoj.gov/BJA/
National Criminal Justice Association: http://www.ncja.org/

Aetna Fined for Slow Pay to Health Care Providers
Associated Press, 11/2/2001

AUSTIN -- Health insurance company Aetna Inc. was fined $1.15 million Thursday and ordered to pay restitution to physicians and other health care providers who were not promptly paid. Texas Insurance Commissioner Jose Montemayor said the Aetna organizations failed to pay disputed claims while conducting audits and also failed to keep complaint records. Aetna Life Insurance, Aetna U.S. Health Care Inc., Aetna U.S. Health Care of North Texas Inc. and Prudential Health Care Plan Inc. were told to work with several networks contracted by Aetna to make the payments within 60 days.
    A spokeswoman for Hartford, Conn.-based Aetna said the company pays more than 99 percent of its claims within the 45 days allowed by law and is committed to improving service. ''Aetna is disappointed that this fine was levied against us because we work very diligently to pay claims in a timely fashion,'' said company spokeswoman Karen Michlewicz. ''We will make every attempt to be fully compliant with the Texas law.''
    In September, Montemayor adopted tougher rules to make health insurers pay doctors more promptly. The adoption came after Gov. Rick Perry angered some physicians by vetoing a bill in June that would have done many of the same things. Perry has said the recently adopted rules are better because the bill would have spiked insurance costs by undermining the settling of disputes through arbitration rather than costly lawsuits.

Medical Marijuana Crackdown Begins in California
Greg Winter, New York Times- 11/3/2001

Armed with a favorable ruling from the Supreme Court, the Bush administration has begun its first major crackdown on the distribution of marijuana for medical purposes, according to Justice Department officials. In recent weeks, agents in California have uprooted a marijuana garden run by patients; seized files of a doctor and lawyer who recommended the drug for sick clients; and raided one of the state's largest cannabis clubs, in West Hollywood, where more than 900 people suffering from ailments such as cancer and AIDS bought the drug.
    The enforcement, three years after the last federal raid on a "medical marijuana" club in Oakland, represents the Justice Department's renewed attempt to impose federal drug laws in states that have legalized marijuana use for people who are sick or dying. Basing its efforts on a Supreme Court decision last May, which rendered the distribution of marijuana through large cooperatives illegal, the Justice Department said that more actions probably will follow, despite its focus on fighting terrorism. "The recent enforcement is indicative that we have not lost our priorities in other areas since Sept. 11," said Susan Dryden, a department spokeswoman. "The attorney general and the administration have been very clear: We will be aggressive," Dryden said.
    The raids have enraged local officials, who sometimes help the clubs. West Hollywood, for example, co-signed the mortgage for the Cannabis Resource Center that was raided last month, and helped to get the club listed as a member of the chamber of commerce. "This was a serious effort to provide relief for people who were ill," said Steve Martin, a councilman in West Hollywood. "The Bush administration is forcing sick people to become criminals because they will have to go out and buy illicit drugs to survive."

Prozac Patent Expires, Making Cheaper Generic Available
Susan Kreimer, Houston Chronicle- 11/3/2001

Consumers have spent a small fortune on this immensely popular green-and-white capsule, longing for a cure-all to combat depression or other mental disorders. Now they don't have to dig as deep into their pockets. Since Aug. 2, when Eli Lilly & Co.'s last patent on Prozac expired, several drug companies have launched less-expensive generic versions of the blockbuster antidepressant. That means savings to anyone who once shelled out big bucks for the drug that has become a household name. An even bigger price cut can be expected next year as more companies are allowed to market their forms of Prozac, known chemically as fluoxetine.
    Already, retail giants Eckerd, Kmart, Kroger, Walgreen and Wal-Mart have seen as many as 80 percent of Prozac customers nationwide switch to generic substitutes. The savings are 20 to 40 percent. Here in Houston, the estimated savings are on par with national statistics. A Chronicle telephone survey of 10 area pharmacies found that a 30-day supply of the 20-milligram generic capsules fell within the lower end of the range. The generic supply averaged $71.77, or 21 percent less than the $89.93 cost for the brand-name drug. That's how much a person on a one-pill-a-day regimen can expect to save in a month's time by taking the generic.
    Although most consumers appear willing to give the more economical option a try, a few still wonder if a generic is identical to the original product. "You don't know if they have the same quality control as the brand-name laboratory," said Houstonian Peggy Sichenze, 52, who takes a higher dosage of Prozac for obsessive-compulsive disorder. "I have initial skepticism."
    Other medicines may appear in generic form soon, including allergy medication Claritin and the world's top-selling prescription drug, $6 billion-a-year Prilosec, which treats persistent heartburn. The stakes for drug makers are high: Patents of more than 100 prescription medicines with annual sales of about $40 billion are set to expire between this year and 2005. But so far, Prozac is the biggest blockbuster medicine to lose patent protection, dramatically cutting into Lilly's $2.6 billion in annual sales of the drug. Lilly and other makers of brand-name drugs, however, have hardly put all their eggs in one basket. On the contrary, they're working to bring more lucrative medicines to market and counter the loss in sales from their best sellers. Indianapolis-based Lilly, which has a handful of promising medicines in its pipeline, hopes that investors will see beyond its most recent dismal earnings and remain committed over the long haul. In the first three weeks, Prozac's share of prescriptions plummeted from nearly 22 percent to 7.9 percent, according to research by Credit Suisse First Boston Corp.
    On the other hand, Barr Laboratories, the Pomona, N.Y.-based maker of the generic 20-milligram capsule, the most widely used dosage, is reaping a windfall in sales. And top-performing mutual funds have added shares of its stock to their portfolios. Cashing in on copycats of Prozac are three manufacturers in addition to Barr: Novartis' Geneva Pharmaceuticals of Broomfield, Colo.; India-based Dr. Reddy's Laboratories; and Par Pharmaceutical, a Spring Valley, N.Y.-based subsidiary of Pharmaceutical Resources that distributes generic drugs. The Food and Drug Administration granted sales exclusivity to each for 180 days on different formulations: Barr, the 20-milligram capsule; Geneva, the 10-milligram capsule; Dr. Reddy's, the 40-milligram capsule; and Par, the 20-milligram and 10-milligram tablets.
    For managed-care companies, encouraging consumers to switch to generics is essential in curbing the skyrocketing costs of prescription drugs. "People can get the drug that they need to stay healthy at a far lower cost," said Dr. Glenn Stettin, vice president of clinical products at Merck-Medco of Franklin Lakes, N.J., which owns 13 mail-order pharmacies nationwide and manages prescription drug benefits for employers and health plans. About 80 percent of its customers taking Prozac who use home delivery changed to a generic alternative in the first week, he said. As a result, the company expects to save plan sponsors and members more than $40 million in the next six months.
    Express Scripts, a St. Louis-based pharmacy benefits manager, noted $3 million in savings over the first two months for managed-care organizations, insurance companies and major employers. Consumers saved $175,000 during that time in lower co-payments for the generic fluoxetine, said Dan Cordes, vice president of pharmacy services. Some 45 percent of Express Scripts' larger employer clients have preferred-generic programs. So, if employees opt for brand-name drugs once generics are available, they must pay the price difference. About 90 percent of its mail-order prescriptions are being filled with a generic, compared with 60 percent of those dispensed through its retail pharmacy network, Cordes said. Pharmacists have more time with mail-in prescriptions to call doctors and get permission to substitute Prozac with the generic fluoxetine.
    Major pharmacy chains and retailers also have encouraged customers to consider a generic and informed them that the lower-cost option is available in their stores. "We're promoting the generic through some in-store signage," said Julie Fracker, a spokeswoman in Kmart Corp.'s headquarters in Troy, Mich. "The signage in each store compares the price of the brand-name Prozac against the generic version and then actually calculates what the savings would be."  At least one Houston-area Walgreen store conspicuously advertised the availability of the generic outside the store. More than half of Prozac customers switched, but a small number were reluctant, said Debbie Platts, pharmacy supervisor for the stores' north Houston district.
    "One of the biggest misconceptions about generic drugs is that customers equate them with generic canned goods, when in reality, they meet the same standards as the brand name," she said. "Typically, the generic companies don't have all the advertising costs." Only one customer went back to the original Prozac at Rice Pharmacy in the Rice Epicurean Market at 3745 Westheimer. The elderly man didn't notice any change with the generic, but a friend told him he seemed to be sleepy, pharmacist and owner Jim Gready said. A lot of it can be psychological.  "If he doesn't think something is going to work as well, generally it doesn't," Gready said.
    Psychiatrists have heightened patients' awareness of the generic as well. Some didn't need to; their patients broached the topic. "Almost every patient on Prozac has asked me about the generic," said Dr. George Santos, president of the Houston Psychiatric Society and medical director of West Oaks Hospital, a private psychiatric facility. "I've only had a handful of patients who insisted on staying with the brand name. Part of it is, a lot of people feel generics are not as effective as brand names," Santos said. "However, most people have a general sense that it's not necessarily based on any hard-and-fast scientific research."
    So, can a consumer bank on a generic working the same as the brand-name drug they're accustomed to? "In general, it should work practically as well," said Dr. Rahn Bailey, an assistant professor of psychiatry at the University of Texas Medical School in Houston. "It's not an exact fit. There can always be a few people who might not respond clinically as well. From a clear scientific standpoint, there can be some minor differences."
    Yet in the opinion of Dr. Ivan Spector, chief of psychiatry at Park Plaza Hospital, a bigger disparity exists. Only 10 percent of his patients taking Prozac have tried the generic. About half went back to Lilly's drug after their depression worsened. "It's the difference between getting the brand name of a real watch versus a replica. You're getting someone else's copy of the real product," Spector said. "The good part of the generic is it makes it available to a larger number of people. The bad part is the quality often suffers." In complying with the Food and Drug Administration's regulatory process, Barr Laboratories and other generic-drug companies simply have to prove "bioequivalence" -- matching the brand manufacturers' medicines in the release and absorption of active ingredients. If so, they can rely on the brand's safety and efficacy data and avoid costly clinical trials.  The law that made it feasible for generic-drug makers to produce drugs whose patents had expired is the Hatch-Waxman Act, passed in 1984, after being sponsored by Sen. Orrin Hatch, R-Utah, and Rep. Henry Waxman, D-Calif.
    Marketing strategies are aimed at doctors and pharmacists who pitch the generic to patients. More than 150 million capsules were shipped to drugstores and wholesalers in the first two days of the launch. Once each generic manufacturer's 180-day exclusivity expires on a specific dosage or formulation in February, other companies can jump into the market, a boon for consumers as prices are expected to drop precipitously. "Sure, we won't keep every customer," said Bruce Downey, Barr's chairman and chief executive officer. "But we'll be the largest seller of generic Prozac. This was probably the largest pharmaceutical launch in history." Barr's fiscal first-quarter profits jumped, as revenues more than tripled on sales of its fluoxetine, soaring to $315.3 million from $103.1 million a year earlier. The company beat the consensus analyst forecast, earning $67.1 million, or $1.80 per share, for the three months that ended Sept. 30. That's up significantly from $10.4 million, or 28 cents per share, last year.
    For Lilly, the outcome has been the opposite. In the comparable quarter, the company's net income fell to $570.1 million, or 52 cents a share, from $778.8 million, or 71 cents, in the same period a year ago. Sales of all its products rose 2 percent in the quarter to $2.87 billion from $2.81 billion in the previous year. In an effort to retain Prozac's market share, Lilly sought relief in two ways: by creating a weekly 90-milligram formulation and marketing the drug under the name Sarafem, for women with a severe premenstrual disorder. Neither has attracted many consumers. "With nearly two months of Prozac sales data available, the erosion in prescriptions is the most severe ever for a blockbuster product in our industry," Sidney Taurel, Lilly's chairman, president and chief executive officer, acknowledged in a statement dated Oct. 3 on the company's Web site. He added, "Our strategy has been to make the investments necessary to maximize the value of our promising pipeline in order to drive top-tier earnings-per-share growth coming out of the Prozac era and deliver superior shareholder value in the long term."
    Lilly is pinning its hopes on several other experimental medicines to offset the loss of the vanishing monopoly on Prozac that it has enjoyed since the drug's release in the United States in 1988. In late October, Lilly announced it will hire more than 5,000 sales representatives by 2004. That will increase by nearly 40 percent the force of employees who call on doctors to promote its drugs. How successful these strategies will be in Lilly's arsenal against competition is a matter of opinion among analysts. Since Prozac copycats hit the market in August, there has been "far more rapid acceptance of the generic version than we've ever seen," said Robert Uhl, a specialty pharmaceutical analyst who follows the generic-drug industry for Leerink Swann & Co. in Boston. What's good for consumers is clearly bad for Lilly. "Their Prozac franchise is basically destroyed, gone in a puff of smoke, so to speak," Uhl said. "The real thing they needed to do was have blockbuster drugs ready to come out of the chute and onto the market before the generics hit."
    Leonard Yaffe, an analyst of brand-name pharmaceuticals who follows Lilly for Banc of America Securities in San Francisco, contends the company will weather this storm quite well. Among Lilly's other rainmakers, he said, is Zyprexa, a pricey medicine for schizophrenia. Sales have surpassed Prozac's, even though the market for the antipsychotic drug is smaller. Its cancer-fighting agent Gemzar also shows promise. "We think they will be one of the fastest-growing drug companies in 2003 and thereafter," Yaffe said. "Investors are looking farther out and are quite pleased with the prospects."

Former User of Klonopin Sues Doctors
Michele Kurtz, Boston Globe-11/4/2001

Allison Aron needed some help sleeping. She was in college and had just lost her best friend to cancer. She paid a visit to her psychiatrist, who prescribed Klonopin, and every night Aron popped a little blue pill. It didn't dawn on her to ask whether the antianxiety drug - the same type as such better-known medications as Valium and Xanax - could cause her harm, or what might happen if she stopped taking it. And she says that the doctor and a subsequent psychiatrist - who for years prescribed her the drug strictly over the telephone - didn't warn her either.
    When she tried six years later to gradually kick what had become a six-pill-a-day routine, she found herself in the throes of terrifying withdrawals. Numbness crept into her hands and feet, sleep eluded her for weeks at a time, and she suffered panic attacks. Aron hasn't had a Klonopin since 1999, and still the 29-year-old Framingham resident says she's in therapy for some ongoing withdrawal symptoms. Bolstered by family members, Aron recently filed a medical malpractice lawsuit against her two former doctors, contending they got her hooked on Klonopin without telling her she could grow dependent on it.
    The suit comes at a time when Klonopin has become increasingly popular among American physicians. Between 1994 and 1999, prescriptions for Klonopin by emergency room doctors and primary care physicians doubled to more than 3 million, a jump considerably higher than for other popular antianxiety drugs. But with that increased popularity has come growing concerns. Some critics argue that Klonopin and similar drugs are being prescribed too liberally, and worry that more and more anxiety-ridden Americans will seek the prescriptions to help calm fears ignited by Sept. 11. They argue the drugs are dangerously addictive. ''Let's say a woman's son is going off to war, and she's prescribed one of these drugs [for anxiety],'' said David Angueira, Aron's attorney. ''Let's say the war lasts for four years. At the end of four years, what do you have? Another hooked patient.''
    But many psychiatrists contend that the drugs, among the most popular psychiatric medications on the market, work wonders when used properly and are overwhelmingly safe. They warn that unreasonable concern about medications like Klonopin will scare physicians away from prescribing it for people who need it most. ''The idea that these drugs turn citizens into addicts is fiction,'' said Dr. Carl Salzman, a professor of psychiatry at Harvard University Medical School and chairman of a national task force that examined the safety of benzodiazepines - the family of drugs to which Klonopin, Valium and Xanax belong - a decade ago. ''And in fact, these medications are the safest psychiatric drugs we have.''
    The emerging debate in the United States about the safety of Klonopin and other benzodiazepines follows a similar one that has raged in Europe for years. Doctors prescribe benzodiazepines differently: some believe in doing it for no more than a couple of weeks; others see its use in longterm care. According to materials of the American Psychiatric Association, benzodiazepines are widely misunderstood, and an ''inappropriate fear of addiction'' has caused some doctors to underprescribe the drugs. Many psychiatrists in this country say few people are at risk of real addiction to benzodiazepines besides those who are already prone to addiction.
    Klonopin, the brand name for clonazepam, was introduced in the United States in 1975 by Roche Pharmaceuticals as a drug for seizures. It was part of the benzodiazepine family that gradually replaced barbiturates as the safer choice for tranquilizers or antianxiety drugs. Historically, women have been the primary users of tranquilizers, once popularly known as ''nerve medicine'' and later as ''Mothers' Little Helper,'' after the 1966 Rolling Stones' song. More recently, celebrities such as pop singer Stevie Nicks have gone public with their dependency on benzodiazepines, saying their long-term use sapped their creativity and ambition.
    Doctors frequently prescribe the pills for people with short-term anxiety problems or to help with sleep during travel, said Dr. Gerald Rosenbaum, interim chief of psychiatry at Massachusetts General Hospital who has written about Klonopin. The drug slows down the central nervous system and decreases nervous excitation. ''They're the standard of care for acute, emergency, antianxiety, antitrauma,'' Rosenbaum said. After the attacks on the World Trade Center, teams of caregivers prescribed quantities of benzodiazepines to people whose family members worked for Cantor Fitzgerald, which lost about 700 employees, Rosenbaum said. Officials with Roche Pharmaceuticals say that's just the kind of short-term anxiety problem Klonopin is designed to treat. Prescriptions written for any longer can be tricky. In fact, company materials alert doctors that sufficient studies have not been done on patients who take Klonopin for more than nine weeks, said Shelley Rosenstock, Roche's director of public affairs. The materials also warn that patients should not stop using the drug abruptly. Yet some psychiatrists and general physicians prescribe Klonopin and similar drugs for longer periods. In some cases, it's appropriate as a maintenance drug for people who have long-term anxiety disorders and for whom antidepressants are problematic, Rosenbaum said.
    For Aron, the prescription started as a temporary sleep aid, but she continued refilling it. When she had other problems - such as severe premenstrual syndrome - she says her doctor told her to take more of the drug and called in higher-dose prescriptions. ''Bottom line, I don't know why I was taking it,'' said Aron, a makeup counter manager at a large retailer. When she finally came off of the drug after checking herself into a hospital, she said, she emerged from a fog to find her life had essentially been on hold for years. ''I should not have to be slowed down like this,'' she said, explaining why she chose to file a lawsuit two weeks ago against Dr. Arnold Kerzner and Dr. Thomas Laage, both psychiatrists in Belmont. According to Aron's lawsuit, each of them prescribed her Klonopin for years but never told her she could become dependent on it and suffer serious withdrawals. Laage's attorney, William J. Dailey Jr., would not comment on the case but said his client ''enjoys a wonderful reputation.'' Kerzner could not be reached for comment.
    Two months ago, Aron started ''Benzos Anonymous,'' a support group at McLean Hospital for people who have struggled with dependency on benzodiazepines. Roger Weiss, a psychiatrist who runs the alcohol and drug abuse treatment program at the hospital, said the group is a comfort to people who suffer from the odd withdrawal symptoms associated with benzodiazepine users such as ''itching in their teeth.'' Several psychiatrists interviewed last week said they know of no proof that withdrawal symptoms can last for years. But Aron and others said they speak from experience.
    Geraldine Burns, 46, of West Roxbury, is also suing her former psychiatrist in Middlesex Superior Court, saying that she experienced horrible problems during the 10 years she took Ativan, another benzodiazepine, and when she tried to discontinue it. Dr. Alan Wartenberg, the medical director of the addiction recovery program at Faulkner Hospital, said all benzodiazepines cause physical dependency and doctors who prescribe them should warn their patients that some people experience painful withdrawals. When discontinuing the drug, doctors should carefully taper their use, he said. ''Unfortunately most doctors are much better at putting patients on drugs than taking them off,'' Wartenberg said.

Baby Starves to Death on Los Angeles Foster Care System's Watch
Evelyn Larrubia, Los Angles Times- 11/4/2001

By the time he died, Danzel Bailey's full cheeks had hollowed. His ribs, facial bones and the knobby bones of his spinal cord all protruded. The skin of his buttocks and thighs hung in deep folds. There were bald spots on his head. He had no teeth. Danzel was 11 months old. He weighed 12 pounds--the average weight of a 2-month-old. He had wasted away in a child welfare system intended to protect him and the county's other 40,000 foster children.
    In Danzel's case, that system placed him in the care of his grandmother, who was sentenced to prison in September for child abuse. It assigned him a social worker, who was recently fired. Beyond them, others are left with a conflicting set of feelings and responsibilities. Danzel's doctor, who is facing a complaint filed with the state medical board, stands by his actions, and others remain convinced they did everything they could. But some are haunted by their failure to intervene, and some are left dismayed at the missteps and oversights that allowed Danzel to die.
    "After all these months," said Anita Bock, head of the Los Angeles County Department of Children and Family Services, "I'm not sure that I can explain it." For her and others, the case is especially troubling because Danzel did not die suddenly in a burst of violence, but rather over a period of months. Despite the opportunity that time presented for social workers and others to spot his deteriorating condition, the county's child welfare system could not keep Danzel alive long enough to celebrate his first birthday. Today, his case has become a cautionary tale. Bock has used it to help instruct social workers on how to protect young children--and on the consequences of failure.
    Here, according to interviews and county and court records, is the story of Danzel's death: His mother, Felicia Bailey, was like many mothers tangled in the county dependency system. A high school dropout addicted to drugs since she was a teenager, she was pregnant with her fourth child at 25. The first three had been taken away by the county Department of Children and Family Services after allegations of severe neglect due to drug abuse; one was born testing positive for exposure to cocaine. This one, Bailey wanted to keep. "I already understand I can't get the other kids, but I want my baby," she told a social worker. To that end, she enrolled in an outpatient rehab program and had a few prenatal doctor visits.

Shaky From Birth as a Crack Baby
When Danzel was born on May 9, 2000, at Martin Luther King/Drew Medical Center, he weighed 7 pounds, 1 1/2 ounces and measured 19 inches, healthy but just slightly under average. He had no drugs in his system. But Danzel shook--a telltale sign, authorities said, that he, like the others, had been exposed to drugs. Social workers decided he'd be safer in foster care. He was only days old when he arrived at the Inglewood home of retirees Lee and Minor Hanson. Lee Hanson held the baby and talked him through his jittery nights, took him to the doctor for the slightest problems, took lots of pictures. "That's his big butt right there," Lee Hanson said, as she flipped through a photo album of the 24 foster children for whom she has cared during the past 2 1/2 years. Beneath one of Danzel's pictures is the tiny hospital bracelet he wore when he arrived at her house. "He was my sweetheart," she said.
    Like many babies exposed to crack, Danzel was a good eater. He gulped down formula and, when he started solids, delighted in applesauce and banana pudding. Still, authorities sought to move him to a relative's home in the belief that children fare better with family than strangers licensed as foster parents. State law requires that welfare agencies looking for suitable homes give preference to relatives, who, like all foster parents, are paid several hundred dollars a month to care for young children.
    Finding a relative to raise Danzel was not easy. His father was unknown. His great-grandmother cared for his two oldest siblings and, according to a relative, couldn't take any more. Social workers identified his 54-year-old grandmother, Sarah Jones, as the most likely relative. Jones initially told authorities she couldn't take a newborn. She was already raising Danzel's brother, then a little more than a year old. County welfare workers, then the courts, had placed the older boy in her care when he was days old.
    Weeks later, Jones changed her mind and agreed to take Danzel, according to court records. She declined to comment for this story. At first, Danzel's social worker hesitated about sending him to his grandmother, who lived in a triplex in South-Central. The social worker told the court in a June 2, 2000, report that Jones' small one-bedroom apartment was "not appropriate" for Danzel. Already, the grandmother, Danzel's 17-month-old brother and the boys' teenage aunt all slept together in the home's full-size bed. The social worker recommended that Danzel stay in foster care. At a hearing that day, the judicial officer agreed, but ordered the county to help the grandmother get a crib. The court file noted that Danzel could be placed at the grandmother's house once that condition was met. A few weeks later, his social worker reported back to the court that Jones had acquired a bassinet for the baby and that the department was working on getting the family a crib and toddler bed. In a subsequent hearing, the judge ordered that the 6-week-old Danzel be united with his grandmother, who had never visited him in foster care, according to Hanson.
    Both the court and the Department of Children and Family Services knew Jones had been arrested several times between the 1960s and 1993 on suspicion of assault with a deadly weapon, battery and robbery. Only one case ended in conviction--a misdemeanor battery in 1974, according to agency records. The dependency system often has to contend with past arrests by relatives willing to care for children. In some instances, a criminal history can block an adult from adopting or becoming a foster parent, but the nature of Jones' record and the fact that her one conviction occurred so long ago made it an easily cleared hurdle. In 1999, as Jones began the process of adopting Danzel's older brother, officials dealt with her arrest record by having her sign an affidavit "to effect that she has never handled any deadly weapons," according to a court report.

Growth Right on Track Before Custody Transfer
The day Danzel was to move in with his grandmother, Aug. 17, his foster mother, Lee Hanson, took him to the doctor early in the morning to get medicine for a runny nose. According to the pediatrician, Danzel weighed 13 1/2 pounds, right on target. Other than a small weight loss of a few ounces after a brief illness, he said, Danzel had been growing at a steady pace those first months of his life. That same day, Hanson snapped a final picture of Danzel sitting on a red velvet chair, dressed in white, all cheeks and eyes. She would later proudly display the photo in a frame. "When he left I said, 'See you later, Bailey,' " Hanson said. "He just smiled."
    About the same time, Danzel was assigned a new social worker, Sheila Armstrong, after the previous social worker was transferred to another office. Armstrong took the baby from Hanson's house and left him at his grandmother's apartment with his medical records and supplies, according to her case notes. She told the grandmother that Danzel had a follow-up doctor's appointment scheduled a week later. The grandmother did not take him, and there is no record that Armstrong, who declined to comment for this story, pursued the matter.
    On Aug. 29, days after Danzel was placed in his new home, the family services agency's child abuse hotline received a complaint that the grandmother abused crack cocaine and alcohol and that for years there had been no gas or heat in her apartment. The caller identified herself as Felicia Bailey, the name of Danzel's mother, who denies making the call. An after-hours social worker went to Jones' house, checked the kitchen cabinets and found an "adequate food supply." The grandmother denied using drugs. The social worker did, however, confirm at least one of the caller's allegations: Jones had no gas, and thus no heat or hot water. Jones told the social worker that the main gas supply line was out, but that the gas company was working on fixing it. In the meantime, she was cooking on a two-burner hot plate. The social worker took her word. "No child safety concerns/issues that places minors at immediate risk/danger at the time of investigation," the after-hours worker wrote. "It will also be followed up by [Armstrong]." Records do not show any follow-up.
    In fact, the grandmother had lied, according to Los Angeles police. Detectives said that the gas company, tired of quarreling with Jones over unpaid bills and unauthorized reconnections, removed the meter years ago and put a seal on the line leading to her apartment. Bock, head of the child and family services agency, said the emergency social worker should have made phone calls to confirm Jones' explanation and get some assurances that the home would soon have hot water and heat--clear health and safety issues--before leaving Danzel with his grandmother.

A Big Weight Loss Between Checkups
Jones also failed for three months to take Danzel to a doctor. When she did, she arrived without his medical records, according Jack Vossoughazad, who runs a South-Central clinic under the name Jack Azad. His staff put Danzel on a scale and recorded his weight: 10 1/2 pounds. He had lost three pounds, nearly a quarter of his weight, in the three months since his last checkup. Azad said there was no way for him to know of the dramatic weight loss because he had no records of the baby's earlier examination. He said he assumed Danzel was just another of the underweight, but generally healthy, foster children he sees daily. Danzel's length was about average for a boy his age, 26 inches. Azad gave the baby his immunizations and sent him home.
    Medical experts say Danzel's weight alone--even without comparative information--should have raised a flag. He was seven pounds below the average weight for a boy his age. He was so underweight he had fallen off the pediatric infant growth curve. "Concerned? I was concerned. That's why we asked the caretaker to bring him in regularly for follow-up," Azad said in an interview. Documents show he asked Jones to bring Danzel back in a month. But the grandmother did not come back the next month. Or the following month. Or the month after that. Azad said he cannot be blamed for that failure. "This office is not in Beverly Hills to have five people sit down and calling people to come in," he said.
    Danzel's social worker, meanwhile, gave no indication in her brief monthly visitation notes that the baby was deteriorating. She repeatedly referred to him as appearing "healthy and happy" and of being "nicely dressed" and "well groomed." In one report, last December, she said the child was "developing age appropriately and is progressing well." Many social workers, who are burdened with heavy caseloads, produce visitation notes that contain such shorthand assessments. But Armstrong's were "not worth the paper they're written on," according to UCLA professor Jorja Prover, who reviewed the file for The Times and who has been training the county's social workers for nearly a decade. "I cannot believe that they let this total lack of information pass by," Prover said of Armstrong's supervisors and the judicial referee overseeing the case.
    Such reports are crucial because they essentially provide the only contact some players within the system have with youngsters in county care. Children under age 4 are not required to be brought to court in dependency cases. There is no record of Danzel appearing before the judge. At the same time, lawyers appointed to represent children limit their work to the courtroom. They do not make home visits and, by law, are not supposed to engage in social work.
    In Danzel's case, his county-paid lawyer never saw him. The private firm did, however, send its own social worker to the home in January for an announced visit. On this, her only trip to the house, she noted no problems. "She said he was beautiful and seems on target developmentally," said Haley Karish, Danzel's last lawyer. The social worker, who quit after having a second child, could not be reached for comment.
    Although the social workers reported nothing unusual at the grandmother's home, neighbors had a starkly different view. They say, for example, that anyone who entered the house would had to have been struck by the smell. "It's a phenomenal scent," said Alicia Smith, 28, who lived next door to Jones in the same triplex. "You know how something stinks when it's rotten?" Smith and other neighbors say they never saw Jones bring her grandson outside. But they would see him occasionally when his mother picked him up for visits. "He was crying kind of strange, like he was hoarse," Smith recalled. "He looked sick. He didn't look like a normal baby," agreed Sheila DeBaun, 30, the other neighbor in the triplex. "You try to give people the benefit of the doubt, not get into their business," DeBaun explained. "I've never called the county or welfare on nobody, but that's one person I should have called on. "Every night I pray. I ask God to forgive me for what I've done because that could have been prevented," she said. "We were totally wrong."
    Danzel's mother said she too noticed her youngest son was skinny, but she never thought he was starving. Also, she said, she thought she couldn't take him to the doctor because she didn't have custody. She was, however, allowed to have unmonitored visits with her son after months of supervised visits and success in staying off drugs. "All I remember is you can see his ribs. It scared me a little bit," Bailey said. She also said he did not seem clean when she saw him. "When I had him, he smelled like mildew. He smelled like an old, nasty towel," she said. "I was being naive or something. At the time I didn't think anything was wrong."
    In October of last year, Bailey called the county to complain about her mother, saying she was barring visits with Danzel. She also accused her of using drugs, according to the county case file. The social worker, Armstrong, said in her notes that she had reprimanded Jones for not allowing visits. There was no indication in the file that she addressed the drug allegation with Jones. While it is not uncommon for dueling relatives to make false drug abuse accusations in retaliation, the neighbors were also concerned. "I never saw her do drugs," DeBaun said, but added that she visited the house when it was filled with smoke from crack. "I've walked in . . . and it's cloudy as mud." Also, Jones gave her grandchildren drug- and alcohol-related nicknames. Danzel was "Caine--as in cocaine," DeBaun said; his brother, "Six-Pack."
    Jones took Danzel to Azad for another checkup in March, four months after his last doctor visit. Again the staff weighed him and noted Danzel had gained four pounds, but he had come no closer to normal. The average 10-month-old boy weighs 21 pounds. Danzel weighed 14 1/2--the average weight of a 4-month-old. The malnutrition also had apparently begun to retard his bone growth. In the preceding four months, he had grown only half an inch, to 26 1/2 inches long--the average length of a 6-month-old boy, dropping him off the charts for length for the first time. But to Danzel's pediatrician, the weight gain was a sign of progress and health. Azad gave the baby his shots and asked Jones to bring him back for a checkup in two months. Danzel didn't live that long.
    In April, a month after that last visit, the social worker walked into Jones' apartment and noticed for the first time that something was very wrong with Danzel. "He did not appear to look right," Armstrong wrote at the end of her unusually descriptive notes. She asked Jones whether the baby had been sick and was told he had not been. Rather than send him for immediate treatment, Armstrong left Danzel in the home and returned to the office to talk to her supervisor. They decided to refer his case to a public health nurse who works with Children and Family Services. The social worker told the nurse, Sue Killian, that Danzel "looks too little, like a small baby." "I asked if she felt it was a medical emergency and should he be seen right away?" Killian wrote in her April 13 notes on the case. "She said 'no,' but she was 'very concerned,' and would transport the child to any appointments I would make, even on her day off." Armstrong assured her there was no suspicion of abuse, according to police.
    Then Killian called the grandmother. "I questioned her about the child's development. I asked if the baby was crawling, babbling, saying words, pulling up on objects, or attempting to walk. She said 'no' and I told her that was concerning, he should be doing these things," the nurse wrote. "I told Ms. Jones the baby was very small for his age and didn't appear to be developing as expected. I wanted to have him evaluated by specialists." Before she could make the medical appointments, she said, she needed Danzel's medical records. On April 13, she started making calls to the doctors who had treated him. Ten days later, she was still calling around. By then, it was too late.

Spanked for Crying on Last Night Alive
The last day Danzel was seen alive, April 21, his great-aunt Sadie Childs slept at Jones' home on the couch. She told authorities she saw Jones feed him a scrambled egg at about 8 p.m., then offer him a bottle of formula, which he refused. Later, Jones put him to sleep on a folded foam mattress pad on the floor of her bedroom, under a window. This, relatives told authorities, was his bed. Jones' teenage daughter told authorities Danzel was crying that night, so Jones spanked him. As she hit his bottom, his head hit the wall. He threw up. The teenager said they cleaned up the vomit and put him back down to sleep.
    The next morning, about 10:30, the teenager said, she found the baby with one eye open and one closed, lying in his makeshift bed. She took him to her aunt, Childs. "I said, 'It's time to call 911. He don't look right,' " Childs said during a criminal court hearing. Danzel was "very cold and his mouth looked twisted and he didn't look alive." He was not crying, not making any noise at all. Childs said the grandmother looked stunned. For 10 minutes they waited for the ambulance and did mostly nothing, she said: "I put my hand on his mouth to see if any breath was coming out." Was there, the prosecutor asked? "Very little."
    When Danzel arrived at the emergency room, his right eye was severely bruised and swollen, Dr. Robert Sandoval told authorities. He had a soiled diaper that seemed as if it had not been changed for a long time. He had dirt between his toes and fingers. Danzel was pronounced dead in the emergency room. "I would describe him as unkempt," Sandoval said in court. "Usually babies do not have a bad odor. This baby did."
    A county pathologist described scars and scrapes covering his body: on his face, back, upper right and left shoulders, the backs of both arms and the front of both legs. He also had open sores on his genitals, which the pathologist attributed to a diaper rubbing against skin fragile from malnutrition and dehydration. He had no body fat. Deputy Medical Examiner Dr. David B. Whiteman noted that there were fresh injuries to the baby's head and face, but that they were not the direct cause of death. He determined that Danzel died of starvation and pneumonia, which developed in his final hours.
    When Los Angeles police detectives investigating Danzel's death arrived at Jones' house, they found about three cases' worth of empty Colt 45 beer cans. Danzel's foam "bed" and blankets were in the trash. The only food in the house was a package of frozen chicken. A broken bassinet leaned vertically against a bedroom wall.

Murder Charge Against Grandmother Reduced
A new social worker assigned to investigate the death said Jones' teenage daughter, who suffers from Down's syndrome, had a "distinct body odor," as did Danzel's 2-year-old brother, who was in a soiled diaper. The social worker took them both into protective custody. As she investigated, she overheard authorities interviewing Jones. "I didn't do nothing to that baby," she heard the woman say. "I swear to God!"
    Police arrested Jones and prosecutors charged her with murder. In September, Jones pleaded no contest to the lesser charge of child abuse causing death. In exchange, prosecutors agreed to an eight-year prison sentence, two years shy of the possible maximum for those reduced charges. "We would have had a hard time proceeding with murder because she was taking him to the doctor and allowing the social worker to see him," said Deputy Dist. Atty. Laura Walton-Everett.
    The social worker also faced repercussions. She was fired in September. "There are no excuses in this case," said Bock, head of the Department of Children and Family Services, who questions whether Armstrong saw Danzel as often as her reports indicated. "The social worker simply failed to do her job. How is it that you don't know the difference between an 11- or 12-month or 6-month-old and an infant, which is what this little baby remained until he died?" Bock says she hopes his case will be a lesson to young social workers. Addressing a group of interns recently, she posted Armstrong's assessment of Danzel as "happy and healthy" on a board, then circulated the medical examiner's photos of his shriveled body.
    Armstrong and her supervisor, Sandy Hamilton--who was suspended for 30 days--are appealing their cases to the county Civil Service Commission. A union spokesman described Armstrong's punishment as too strong for a worker with an "exemplary record" who tried to do the right thing. Children and Family Services reviewed Armstrong's other cases and found no problems. "Making a determination of the medical state of the child--she can't do that. She shouldn't be expected to do that," said John Garfield, spokesman for Service Employees International Union Local 535. "I think, yes, there is a definite line where a social worker has to take responsibility for what happens to a child, but I don't think it was her full responsibility. I think the nurse has to take some of the fall for it. I think the doctor has to take some of the fall for it. I think the system has to take some of the fall for it." The prosecutor said she filed a complaint with the state medical board about the doctor's inaction. She said she continues to work on the case.
    With so many missed opportunities to save Danzel's life, many are anguished by a sense of a collective failure. "The perplexing part of it," said Bock, is this: "What is going on, not just in our agency, but with these medical professionals and everybody else, that this could happen?" Bobby Black, the lawyer who defended Jones, agrees. "Why can't anybody show me that they did anything, however slight," he asked, "just to show us that they were even moderately concerned?"

Mental Health Counselors Gear Up for Potential Crisis in New York
Geraldine Sealey, ABC News- 11/5/2001

N E W Y O R K— The 20-person staff of Mt. Sinai Medical Center on New York City's Upper East Side, like many mental health clinics here these days, is stretched thin. Since Sept. 11, Mt. Sinai staffers are fielding a growing number of calls to a special World Trade Center mental health hotline. They're counseling more clinic visitors than their usual 60,000 a year. They're preparing brochures and organizing conferences about trauma. And, with the help of about 60 physicians deployed into the field, they're training thousands of teachers and guidance counselors about how to spot kids in distress. "The staff has put in thousands of manpower hours," said Mt. Sinai's medical director Dr. Deborah Marin. "There's tremendous demand."
    And this is only the beginning. Mt. Sinai's clinic, like others across New York, is gearing up for a flood of need as the city approaches a potential mental health crisis. The scope of the trauma is unprecedented in the United States, and some counselors question whether the system here can handle the numbers of New Yorkers who may eventually need help. Using formulas derived by the federal government following disasters like the 1995 Oklahoma City bombing, the New York State Office of Mental Health estimates that as many as 1.5 million New Yorkers could need some kind of mental health help in the aftermath of Sept. 11.
    New York psychologists say they are already seeing shock, depression and anger in many individuals — the early stages of grappling with trauma. Predictably, those who are closest to the disaster — survivors, witnesses, and those who lost family members, friends and co-workers — are suffering the most. "We are seeing problems with sleeping, low mood, increased startle response, a sense of foreshortened future, and a sense of doom," said Dr. Gabriella Centurion of the Cabrini Mental Health Center in lower Manhattan, which has seen a 10 percent increase in its clinic population since Sept. 11. Many of Cabrini's clients live in high-rise buildings, and many saw the twin towers burn and collapse after being rammed by hijacked jets.
    But mental health experts say it often takes months, or years, for some traumatized individuals to notice troubling symptoms or to seek help. "Everybody I know in the mental health community in New York is gearing for later this year, or months from now, for the suicides and nightmares," said Harold Takooshian, a psychologist at Fordham University. Several months after a mass trauma, people who managed their emotions earlier on may find themselves unexpectedly depressed, irritable, unable to sleep, fighting with partners, unable to enjoy everyday pleasures or filled with a general sense of malaise. Many may ignore early signs of distress, are not aware of mental health services, or only come forward later as assistance from family and friends, intense in the immediate aftermath of a disaster, begins to wane. "I think we haven't yet seen what the impact will be," said Dr. Alan Siskind, executive vice president of the Jewish Board of Family and Children's Services, which has dispatched 160 crisis teams so far to corporations, schools and synagogues.
    Neal Cohen, the New York City health commissioner, warned Congress a few weeks after Sept. 11 that despite the city's massive effort to extend immediate mental health relief, the region's long-term needs would be daunting. "The task before us is enormous," Cohen told a Senate panel. "Virtually every New Yorker is experiencing high levels of stress." The recent anthrax scares only add to the stresses of already shaken New Yorkers, and complicates the work of mental health counselors. "How the specter of bioterror feeds into this is something we're struggling with," Marin said.
    Trauma experts say up to one-third of those closest to the World Trade Center disaster could suffer from post-traumatic stress disorder, a condition characterized by a persistent re-experience of traumatic events. "What we know about PTSD is it is long-lasting," says Carol North, a psychiatry professor at the Washington University School of Medicine in St. Louis, who has studied dozens of disasters, including Oklahoma City. "But it is eminently treatable, so it's important to get mental health treatment."
    The mental health needs of children also pose a unique challenge for the system. As many as 10,000 children may have lost parents in the World Trade Center disaster, which killed an estimated 4,500 people, and an unknown number of kids were witnesses. Even children with no direct connection to the terror attacks could show symptoms of trauma, and part of the challenge will be educating teachers, school administrators and parents about recognizing children in distress.
    Dr. Steven Marans, who heads the National Center for Children Exposed to Violence at Yale University's Child Study Center, spoke to a mother recently whose 15- and 16-year-olds didn't want to talk about their feelings about Sept. 11. But they were becoming more mesmerized with the HBO series Band of Brothers about World War II. The teens' mother realized this was their way of giving expression to what was going on around them, Marans said.
    Reaching children will involve "screening [them] across different dimensions to get a very basic notion of where they're at in terms of psychological adjustment," he said, "not just once but to be able to follow up and see how they're doing down the road so we're not just waiting for the most dramatic symptoms to emerge indicating the need for intervention."
    There is also reason for concern, some experts say, about at-risk populations who were already under-served by mental health services. Immigrants with language barriers, the unemployed, those who already had serious mental illnesses and the socially isolated may be more difficult to reach.
    In the short term, a $22.7 million grant from the Federal Emergency Management Agency is funding mental health outreach programs for up to 60 days after Sept. 11, and the state is applying for more money that should fund services for up to nine more months. This money will largely be used for mental health education and referral services, not for traditional psychological counseling. Even with the millions in short-term aid, some experts say the system may not be equipped to handle the psychological needs of New Yorkers down the road. "The system that's in place can barely handle the severe and persistently mentally ill," North said. "Add to that the new needs [from Sept. 11], and the system can't possibly do it."
    Although Siskind believes the city mental health system has been doing a "remarkable" job in handling the initial response to the crisis, he is wary of how the system will handle coming demand. Due to the economic downturn, city and state agencies are expected to face budget cuts, and financial troubles will make philanthropic support less reliable as well. "There needs to be more thinking of long-term mental health needs," says Siskind, who is on the executive committee of the board of directors of the Coalition of Voluntary Mental Health Agencies Inc. Despite much concern for the mental health of New Yorkers, though, trauma experts say it's important to remember how hardy communities can be. Indeed, New York has already shown the world its resilience. "I am always amazed at what these horrible adverse events do to bring out people's strength, the altruism, the heroism," North said. "Most people after these events heal. They don't forget, they heal."

More Mentally Ill Filling Maine Jails
Associated Press, 11/4/2001

PORTLAND, Maine -- An increasing number of mentally ill Mainers are filling the county jails after committing petty crimes. ''It's a crisis,'' said Kennebec County Sheriff's Department Capt. Raymond Wells. ''Jails have become the new state hospitals.'' Previously, many offenders suffering from depression, paranoia, schizophrenia and other disorders were treated in state hospitals. But during the 1990s, the state scaled back the size of those institutions.  Since then, more mentally ill offenders have been winding up in jails across the state. Maine jails and prisons have two or three times as many mentally ill inmates as the national average.
    About a quarter of all prison and jail inmates in Maine are receiving treatment for mental illness, one of the highest proportions in the country. Nationally, the proportion is about 10 percent. Cumberland County Jail estimates that 35 percent of its inmates receive treatment for mental illness. ''It's a really sad situation,'' said Eleanor Grover, who works in the Lincoln County Jail helping inmates suffering from drug and alcohol abuse. ''We can't give these inmates the help they need to treat their illness. Sometimes, they'll scream all night.''
    Many of the inmates are jailed after committing petty crimes like trespassing, disorderly conduct or disturbing the peace when they're off their medications and acting irrationally, said Carolyn Carothers, director of the National Alliance for the Mentally Ill of Maine. Police arrest them to get them off the street and help calm them down.  Once they're in jail, some of the inmates attempt suicide after searching for sharp tools to slash their arms or hang themselves with sheets, blankets or clothing. Some suicidal inmates are transferred to observation or medical cells, where they are given blue paper outfits and thick, suicide-proof blankets, and guards can watch them around the clock. Inmates who continue to rage, cry and smash their skulls against cement walls are taken to restraint chairs and tied up. Sagadahoc is the only county whose jail does not have a restraint chair.
    Jailers sometimes try to get inmates temporarily transferred and stabilized at a state mental hospital or the Supermax, the state's secure prison lockup in Warren. But most of the time, the state's two mental health hospitals say they don't have any empty beds. And judges send inmates with only extreme behavior problems to the Supermax.  ''We're beyond frustrated and angry,'' said Androscoggin County Sheriff's Capt. John Lebel. ''This summer we had a guy here for 40 days. He was suicidal, banging his head against the wall, ripping the stitches out of his wrist. When we put him in the restraint chair, he'd bite the inside of his mouth and spit blood at everybody. ''Clearly he had mental health problems. Yet, the state hospital says they have no beds for this guy,'' Lebel said.

Court Ruling Shields Threats Told to California Therapists
Stuart Pfeifer, Los Angles Times- 11/5/2001

People who threaten during therapy sessions to commit violence cannot be held criminally liable for their threats, a California appeals court has ruled in a decision that divides mental health experts and law enforcement officials. The ruling follows two recent cases in which patients were prosecuted for making "terrorist threats" after telling their doctors they were angry enough to commit murder.
    Many counselors praised the ruling, arguing that the whole point of therapy is for people to express their true feelings and that the prosecutions--if allowed to stand--would have a chilling effect on their sessions. Protection against prosecution is all the more important now, they argue, because increasing numbers of employers, courts and schools are sending people to counseling and anger management sessions to deal with their problems. "If you place patients at risk for talking about their violent fantasies . . . then you're providing a strong disincentive for them to discuss these issues," said Paul Appelbaum, president-elect of the American Psychiatric Association and chair of the psychiatry department at the University of Massachusetts.
    Therapists in California are still required by law to warn potential victims if a patient makes a credible threat of violence. Threats made directly to a victim are also open to prosecution. But some in law enforcement believe that these laws aren't enough and that the appeals court decision represents a step backward. "If this stands, then you leave the victims without a way to protect themselves," said Superior Court Judge Pamela Iles, who hears all domestic violence cases in south Orange County. "These threats aren't just 'I'm going to hit you' or 'I'm going to hurt you.' They're 'I'm going to kill you.' And these people carry out their threats."
    The appeals court ruling stems from the case of a Los Angeles County Jail inmate who was convicted of making a terrorist threat for telling a jail psychologist he wanted to kill his estranged girlfriend. The 2nd District Court of Appeal overturned that conviction last month, saying it's bad public policy to punish patients for expressing homicidal thoughts. "Instead of exposing their thoughts for treatment, they might repress them and act on them," Justice Arthur Gilbert wrote. "Such a result would not further the interests of victims, psychotherapy or the criminal justice system."
    The state attorney general's office, which had defended the right of local prosecutors to bring charges related to statements from therapy, decided last week that it will not ask the state Supreme Court to review the opinion, saying it doubted the outcome would be any different. This means the appeals court ban will become law throughout the state. Prosecutions of people who make threats in therapy are rare, though one Orange County case is now generating controversy.
    Orange County prosecutors said they are now reviewing the appeals court ruling before deciding on Nov. 16 whether to move forward with "terrorist threats" charges against Frank Gardner, a former San Clemente High School teacher. Gardner was arrested in February after telling staff at an Orange County hospital that he felt like taking his gun and killing his supervisors. Gardner went to the hospital to seek psychiatric care. Prosecutors charged Gardner with making a terrorist threat, a felony. He spent two months in jail before a judge eventually lowered his $500,000 bail.
    Gardner, 50, visited South Coast Medical Center shortly after his supervisors told him he was being disciplined for sexual harassment. He told a nurse and later a doctor that he needed to be in a "safe place," was extremely angry and wanted to kill his supervisors. During a preliminary hearing earlier this year, Gardner recalled telling them, "I really don't want to hurt anyone. I need help." Because Gardner had guns at his home, prosecutors feared he may have intended to carry out his threat. Authorities also allege that Gardner knew the hospital staff would relay the threat to his supervisors.
    Deputy Dist. Atty. Mike Fell said he considers the case against Gardner sound, noting that a judge heard some of the evidence and determined it should go to trial. But Gardner's lawyer, Stephen Klarich, said the whole case has gotten out of control. "They should have put him under observation," Klarich said, "but instead, it snowballed into a criminal case, and nobody wanted to dismiss it."
    It is a crime in California to threaten another person with violence. However, the person making the threat must believe his words will reach the intended victim. Such cases are usually filed when a threat is expressed directly to a victim, either verbally or in writing. For a quarter century, therapists in California have been required by law to notify possible victims when a patient makes a threat of violence. The state has the most demanding requirements in the nation when it comes to such threats. California therapists must notify both police and the victim; in most states, one or the other will suffice. California's law, inspired by a 1974 slaying that followed a threat in therapy, was intended to protect possible victims, not to prosecute patients for making threats, said USC law professor Erwin Chemerinsky. "It's a long way from saying, 'We want therapists to warn people,' to saying, 'People who confess thoughts to therapists become terrorists,' " Chemerinsky said. "You turn therapists into arms of the police departments."
    Other mental health professionals fear that prosecuting people like Gardner might discourage people from seeking treatment and from honestly discussing their feelings. They say people often make threats in the heat of anger that they would never carry out. "When you start prosecuting people for everything they say, for what they think, that's not going to benefit anyone," said Nancy Clark, whose Orange County counseling program offers anger management and chemical addiction treatment. "From a therapy perspective, how are people going to get help and benefit from talking to a therapist if they have to worry that that person is going to be turned against them?"

Mentally Ill Cycle Through System
Patrick Hoge, San Francisco Chronicle- 11/4/2001

Buford George, 53, is a diagnosed schizophrenic with violent, criminal capability. The Chronicle found him on the sidewalk along Mission Street in downtown San Francisco. George came to the Bay Area from rural Mississippi more than 30 years ago to attend Oakland's California College of Arts and Crafts on a scholarship. For the past two decades, though, he's been one of San Francisco's mentally ill homeless, in and out of jail, prison and mental institutions.
    For more than a year, until he recently vanished, George was a daily sight near the Metreon at Fourth and Mission streets, his 6-foot, 242-pound frame stretched atop a constantly evolving collection of old luggage and clothing. George, who speaks mostly in unintelligible mumbles, has been arrested at least a dozen times in downtown San Francisco, starting in February 1979 when he was picked up for begging, disturbing the peace and resisting a police officer. Since then, he has been charged with a variety of crimes, including making a false bomb report, assaulting a firefighter and possessing drugs.
    In 1980, George was sent to state prison for false imprisonment and assault after he entered a women's rest room in the financial district and attacked a woman. Two people who heard screaming pulled him off the victim. The jury deadlocked on a charge of attempted rape. Court records show that George has had numerous commitments to state hospitals and San Francisco General Hospital. Between 1984 and 1986, he was placed under conservatorship at Napa State Hospital. The average annual cost of state hospitalization is close to $100,000.
    In the summer of 1998, George was arrested after a police officer saw him standing in a doorway in the 100 block of Eddy Street, putting crack cocaine into a glass pipe. George was sent to Patton State Hospital. After 15 months of treatment, doctors found George capable of understanding the charges against him and aiding in his defense. However, Patton Medical Director Dr. James Rosenthal cautioned court officials that "a speedy trial is important for maintenance of trial competency." George pleaded guilty. "I just can't even begin to tell you how common this is," said Douglas R. Korpi, a San Francisco court psychologist who has found George incompetent to stand trial on at least two occasions. "This is what you deal with daily."
    In 10 years, the number of prisoners requiring mental health treatment has increased by 77 percent, according to San Francisco jail officials. They estimate 160 people a year who would accept mental help are discharged without any follow-up. Last year, 5,600 inmates -- most homeless -- were treated at a cost of about $3 million, said Jo Robinson, the jail's program director for psychiatric services. About 80 percent had substance abuse problems. And many had been jailed more than once.
    Decades ago, people like George would likely have been indefinitely committed to a state mental hospital, but California in 1967 passed the Lanterman-Petris-Short Act, a bipartisan reform bill that helped empty the state's mental hospitals and limited its right to detain people based on their behavior. The law says that only people who are imminently dangerous to themselves or others, or so gravely disabled that they cannot care for themselves, can be picked up and held for 72 hours for treatment and evaluation. In severe cases, the hold can be extended to 14 days or longer, but only after proceedings before a judge. Similar reforms swept the country as part of a movement to prevent warehousing people in hospitals when they could live independently with community-based support.
    But governments almost uniformly did not adequately fund the promised community-based care. An added factor was an increasing shortage of low-cost housing starting in the late 1970s. San Francisco lost 18 percent of its residence hotel rooms in just four years. State officials now estimate that 50,000 homeless people in California are mentally ill.
    San Francisco has the highest per capita rate of involuntary psychiatric holds of any county in California, with 9,013 people held for at least 72 hours of observation in the 1999-2000 fiscal year, according to a draft 2001 application for federal homeless funds. Virtually all those detained come to San Francisco General, which calculated its psychiatric costs for homeless people at more than $8 million last year.
    Most are quickly released because they either stabilize, or doctors find that they aren't sick enough to be detained, said Dr. Bob Buckley, a supervisor at San Francisco General's psychiatric emergency room. Buckley recalled one woman who was brought in 100 times. When homeless, mentally ill patients are discharged, nurses try to locate housing, but they acknowledge sending people to the streets with nothing but referrals to shelters.
    Anguished family members of mentally ill people have been campaigning to give government more authority to force people like George to accept outpatient mental health treatment - particularly if they have a history of failing to follow treatment programs. For two years, Assemblywoman Helen Thomson, D-Davis, has sought legislation allowing a judge to order patients to follow treatment programs when not hospitalized. Her bills have been blocked by state Senate President Pro Tem John Burton, D-San Francisco. Thomson's proposal could ultimately affect all 20,000 people who had two or more 72-hour or 14-day holds in a year, plus many others. But she proposes starting with a $35 million program that would affect 3,000 people a year. Burton sides with a patients' rights movement that argues society should live up to its promise of community-based treatment before taking away the civil liberties of the mentally ill. A former psychiatric nurse, Thomson agrees more voluntary services are needed, but says that strategy alone would still leave out people who refuse treatment.
    Burton has championed a state program that offers voluntary support services and housing to mentally ill people who are homeless or are at risk of becoming homeless or incarcerated. The program is expected to treat 5,000 people statewide this year. As part of that program, San Francisco got $2.3 million this year for its Mobile Outreach Support and Treatment Team to treat 120 mentally ill people who are either homeless, or at risk of becoming homeless or incarcerated. Rusty Selix, director of the Mental Health Association in California, estimates that it would cost California $350 million a year to house and treat the 50,000 homeless mentally ill people the state believes exist. "We may never come up with the money to do it . . ." Selix said, "even though it works."