Noteworthy News Articles on Mental Health Topics, January 1-8, 2001

Discovery Aids Earlier Diagnosis and Treatment of Schizophrenia
Reuters- 1/1/2001

LONDON -- New imaging technology has shown that the brain's main sensory filter is smaller than normal in people suffering from schizophrenia, even during the earliest stages of the illness, British psychiatrists said Monday. Dr. Tonmoy Sharma of the Institute of Psychiatry in London said his findings could help early diagnosis and explain why schizophrenics suffer from confusion. The thalamus, the brain's hub, gets information via the senses that is passed to the correct regions of the brain for processing. People with schizophrenia often have trouble digesting that information. "If you think of the brain in terms of networks, it is like making a phone call when the line is not connected properly," Sharma said. "If there are problems with connections, information will not be passed to the correct regions [which] is vital for leading a normal life."
    Sharma the used magnetic resonance imaging technique on 67 people; 38 had suffered their first psychosis, the others were healthy.  His finding that the thalamus is smaller among those with the disorder reinforces research he published two months ago that showed schizophrenics have decreased gray matter early on in the illness. Early detection will allow early treatment and may improve recovery chances. Sharma's research is published in the American Journal of Psychiatry.

Nine Million Gaining Upgraded Benefit for Mental Care
Erica Goode, New York Times- 1/1/2001

Acting on an executive order issued by President Clinton, the federal government will begin today to offer its nine million employees improved mental health benefits equal to those for physical ailments. Federal officials' embrace of equal insurance protection for mental and physical ills represents a significant victory for mental health advocates, who have argued for more than a decade that the wide-spread practice of providing far less coverage for mental disorders is discriminatory. Treatment for alcohol and drug abuse will also be covered equally under the new policy.
    The new policy also offers further evidence that the notion of equality in coverage is gaining wider acceptance. Thirty-two states now have laws that in some way address such insurance disparities, and many large corporations provide equal coverage for their employees, believing that doing so saves money in the long run. The notion of equal coverage, referred to as parity, was also endorsed by Vice President Al Gore and Gov. George W. Bush during their presidential campaigns.
    "There has been definite progress," said Jennifer Heffron, senior director of state affairs for the National Mental Health Association, a nonprofit group. Yet Ms. Heffron, echoing the concerns of other mental health groups, said that despite such advances, true equal coverage, in its fullest sense, remained elusive. She said that many state laws included so many restrictions that they had little impact, and that in some cases, insurance companies had simply found other, more subtle ways to limit coverage for mental illness. Dr. Richard Frank, a professor of health economics at Harvard University, said: "Parity is very much symbolic, and somewhat real. But it does not fix as many problems, when it winds up on the ground, as most people thought it would."
    In offering equal coverage, federal officials hope to provide a model for employers around the country. The initiative is also likely to be monitored closely by Congress, which will probably take up the parity issue in its next session. Under guidelines developed by the federal Office of Personnel Management, private health plans for federal employees will no longer impose higher co-payments or deductibles for mental health services, or set limits on outpatient visits or hospital days for mental disorders that are lower than those applied to general medical or surgical care.
    Even a decade ago, equal coverage for mental illness seemed more a pipe dream than a practical possibility. Opponents, including the insurance industry and business groups, warned that without limits on mental health coverage, the "worried well" would spend endless years on the couch and health care costs would spin out of control, forcing many employers to forgo health insurance altogether. Yet over the last 10 years, much has changed. Increased understanding of the biological underpinnings of many mental disorders and the advent of new and better treatments have led to a greater acceptance of the idea that conditions like manic depression and schizophrenia are illnesses like any other.
    The cost-control strategies of managed care, still in their infancy in 1990, are now in widespread use. And on Capitol Hill, lobbying by mental health groups--combined with the testimonials of celebrities like Tipper Gore, who last year revealed her own struggle with depression--has garnered unprecedented attention and bipartisan support for psychiatric issues. Opposition to parity still survives. In Michigan, New York and other states, for example, repeated efforts to pass parity bills have been unsuccessful.
    The 1996 Federal Mental Health Parity Act, banning dollar limits on mental health care that differ from those for general medical care, lacks the regulatory teeth to have much real effect. But the symbolic impact has led many state legislatures to address the issue. And four states--Maryland, Minnesota, Connecticut and Vermont--have statues that not only eliminate inequalities in reimbursements but also require employers to cover mental health, define mental illness broadly, include drug and alcohol addiction, and require small employers to comply.
    Still, health care experts say that the reality of parity, as translated by lawmakers and insurance companies, often bears little resemblance to the ideal envisioned by advocates. Some state statutes, for example, contain so many loopholes that thousands of employees are not covered. Others limit coverage to specific illnesses. And even where parity legislation is broadest, some critics say, managed care has undercut the goal of equality, leaving some patients worse off than they were before. "On its face, parity is a simple issue," Ms. Heffron of the National Mental Health Association said. "But the clarity dilutes very quickly."

A Question of Cost
   For it champions, parity is about fairness. Without it, they argue, parents take out second mortgages to pay for the care of a child with severe mental illness, and professionals like Kathryn Lynnes, a lawyer and environmental consultant, end up devoting much of their salaries to simply staying well. Ms. Lynnes, 43, has manic depression, a chronic illness rooted in genetics and brain chemistry that, if untreated, bounces her from suicidal depression to frenzied mania. Medication and psychotherapy have given her back her life. "With treatment, I pay taxes and own a home and I live a normal life," Ms. Lynnes said. "Without it, I probably wouldn't even be here."
    But Ms. Lynnes lives in Grand Rapids, Michigan and Michigan is a state without a parity law. So she pays 50 percent of the $175 fee for each 45-minute visit with her psychiatrist, instead of the 20 percent she would pay for a trip to her internist's office. She works for a small business and her mental health coverage is limited to $2,000 a year and $5,000 for her lifetime, in contrast to the $5 million limit applied to general medical care. To make things worse, she is still paying off the last of the $70,000 she owed to two hospitals after a particularly severe episode of illness five years ago.
    Yet if parity begins as an issue of unequal costs for some, it quickly becomes a debate about increased costs shared by all. And parity's opponents, who include the Health Insurance Association of America and the Chamber of Commerce, have traditionally argued that equal coverage is simply too expensive. Early critics based their assessments on data collected in the 1980's, when costs for mental health treatment--primarily in-hospital care--were climbing steadily, eating up as much as 10 percent of employers' total health care budgets. Borrowing a term from economists, insurers warned that unlimited mental health benefits posed a "moral hazard" to employers and insurers. If such benefits were offered, the argument went, they would be exploited and over used--simply because they were there.
    Insurers also worried about "adverse selection": people who knew they needed psychiatric treatment, they argued, would flock to plans offering good coverage. Ms. Lynnes encountered this logic first-hand, when she and her boss sought out a health plan that could give them better mental health benefits in exchange for higher premiums. Concerned about being singled out, insurance companies simply did not offer such benefits. "We looked and there really wasn't anything out there that had the coverage," she said.

The Picture Changes
   A decade ago, fears about the cost of parity were difficult to dismiss. But today those fears have proved to be largely groundless in states that have equal-coverage laws. The reason, experts say, is the wide-spread influence of managed care. In every case, the equalization of mental health benefits has come hand in hand with tightened management. Vermont's statute, for example, specifically provides insurance companies with the option of bringing in managed care for mental health treatment, even if benefits for physical health care are not similarly managed.
    "No place has or ever will implement parity without an increase in the managed care element," said Dr. Darrel A. Regier, an expert on parity and the executive director of the American Psychiatric Association's Institute for Research and Education. As a result, most insurance companies have been able to meet the requirements of parity laws while keeping cost increases at a minimum. In a comprehensive analysis of the impact of parity submitted to Congress in June, the National Mental health Advisory Council, a panel that advises the National Institute of mental Health and the secretary of health and human services on mental health issues, found that on average, parity increased total health insurance premiums by 1.4 percent--far less than the 10 or even 15 percent predicted by critics. Other analyses have yielded similar numbers.
    Ronald E. Bachman, an actuary at Price-Waterhouse-Coopers who has analyzed expected costs for more than 30 states considering parity legislation, said he believed that providing parity for both mental illness and substance abuse raised total health care costs on average 2.5 to 3.5 percent. Parity for mental illness alone raises premiums 2 to 3 percent, Mr. Bachman said. And if anything, he said, his estimates are high. "How many examples do you need to show that mental health does not break the bank?" Mr. Bachman asked.
    Insurers who will offer equal coverage to federal employees under the new guidelines also said they expected the costs of increased coverage to be manageable. "If it's effectively managed, we think we can bring this in at a reasonable cost," said Stephen W. Gammarino, a senior vice president for Blue Cross and Blue Shield Association's federal employee program, which covers four million employees. Mr. Gammarino said his company estimated that increased mental health coverage would add about 2 percent to premiums.
    One reason parity has proved to be economical, Dr. Regier and other heath care experts say, is that managed care has greatly reduced hospital stays, especially the long hospitalizations common for adolescents 10 years ago. But Dr. Regier added that in some cases, the quality of care may have suffered and overall access to benefits may have grown more limited as a result of managed care. Under many managed care plans for mental health, patients must choose from an approved list of practitioners or forfeit equal coverage, and must seek authorization before receiving treatment and at regular intervals thereafter.
    Parity may also bring indirect savings. Studies have found that access to mental health services can offset general medical costs, decrease absenteeism, reduce the psychiatric disability claims made by employees and offset court and prison costs. The Chevron Corporation, for example, found that it saved $7 for every dollar it spent on an employee assistance program offering mental health resources, according to a 1997 report. And researchers at Johns Hopkins University found that insurance plans with the highest financial barriers to mental health treatment experienced a greater number of disability claims related to mental illness.
    Yet many opponents of parity remain unconvinced by such statistics. The Health Insurance Association of America, for example, argues that even small premium increases add up, forcing some employers to drop their insurance. "Mandates add cost," said Richard Coorsh, a spokesman for the association. In Michigan, where business and big labor unions are united in opposing insurance mandates, a package of five parity bills was introduced in the state House of Representatives in 1998, but never made it out of committee. Larry Horwitz, the president of the Economic Alliance of Michigan, a lobbying group that represents both business associations and labor groups like the A.F.L.-C.I.O., said his members objected to parity not only because of the cost, but also because they believed it would infringe on freedom of choice--for example, by limiting what benefits labor unions can trade off at the bargaining table. "I should be able to make my own judgments on what I want covered, and it should not be imposed upon me by state regulators," Mr. Horwitz said.

State Laws and Their Limits
   Concerns about cost and government intrusion may have kept parity statues off the books in many states, but they have also shaped the laws that do exist. The 1996 federal parity law, for example, does not require employers to provide mental health coverage. Small businesses, and those where costs would increase more than 1 percent as a result of equal coverage, are exempt. And the law says nothing about unequal co-payments or deductibles. Many state statues also exempt small businesses or those in which costs would increase beyond a set percentage. And 19 states restrict parity to a narrow list of mental illnesses.
    In Texas, for example, a 1997 law signed by Gov. George W. Bush provides equal coverage only for schizophrenia, paranoia, bipolar disorder, major depressive disorder, obsessive-compulsive disorder and depression in childhood and adolescence. It does not cover drug or alcohol addiction. Rhode Island's 1994 statue restricts parity to "serious mental illness" that "current medical science affirms is caused by a biological disorder of the brain and substantially limits life activities." When states limit coverage to certain illnesses, children are often left out, M. Heffron said. "The laws usually focus on severe mental illnesses which don't manifest themselves until late adolescence," she said. Reducing the impact of state statutes even further, companies that self-insure are exempt under the federal Employment Retirement Income Security Act from state insurance laws, and exception that in some states leaves 80 percent of employers beyond parity's reach.
    Noncompliance by employers is another problem. A congressional report released last May found that thousands of businesses were violating the federal law. Of employers in 26 states surveyed by the General Accounting Office, 14 percent--or between 9,000 and 13,000 employers--continued to set lower lifetime dollar limits for mental health treatment. Thousands more merely substituted limits on covered days of hospital care or visits to a mental health professional for dollar limits. Senator Pete V. Domenici, Republican of New Mexico, who co-wrote the 1996 law with Senator Paul Wellstone, Democrat of Minnesota, said he hoped to persuade Congress to close some loopholes and expand the legislation when it comes up for reauthorization next September. A strengthened bill he suggested, might require equal co-payments for mental and physical illness, and prevent companies from setting day and visit limits on care. But it almost certainly will stop short of requiring employers to carry coverage for mental illness, or removing the exemption for small employers. "I'm not going to say that's real parity," Senator Domenici said.

The Risks of Managed Care
   The senator from New Mexico would get no argument from Dr. Ken Libertoff, who, as executive director of the Vermont Association for Mental Health, led the campaign for a state parity law so comprehensive it would offer a model for the rest of the country. "Partial parity laws mean a continuation of strong discriminatory practices," Dr. Libertoff said. Yet when parity is broad-based, as it is in Vermont, he said, it can have a profound impact. "I think the bill is working, and it's working on several levels," Dr. Libertoff said. "No. 1, companies are complying. And No. 2, the major argument used against parity over the last decade has been the cost factor, and the initial findings form Vermont are very positive."
    In fact, Vermont's statute has bade a good first impression on patients like Anne Donahue, who in 1993 plunged into a serious depression and, after five hospitalizations, was left with $17,000 in unpaid hospital bills. Like most health insurance plans at the time, Ms. Donahue's policy treated mental illness differently than it treated other medical conditions. With her fourth hospitalization, she exceeded the plan's 30-day yearly maximum on the number of days in the hospital it would cover, and her insurance company refused to pay. "I had never even dreamed that there were distinctions," said Ms. Donahue, who has a law degree from Georgetown University and was teaching high school science and religion at the time of her illness. "You don't think 'Is heart disease covered?' when you have a heart attack."
    Ms. Donahue told her story to lawmakers in Montpelier, and joined those who in 1997 campaigned for passage of a state parity bill. Now that the law has passed, she said, she no longer fears that another severe episode of depression, an illness that often recurs, might push her into bankruptcy. "There's a whole stress factor involved in having to worry and battle for your insurance coverage when you're in the midst of an illness that is very specifically affecting the way you can cope in the world," she said.
    But not everyone in Vermont is happy with the way parity has played out in the three years since its implementation. In particular, the management of mental health benefits built into the legislation--a compromise added to make the bill acceptable to budget-conscious lawmakers, according to Dr. Libertoff--has some professionals hopping mad. "I think that it's good we have parity," said Dr. Richard Root, and educational psychologist in Springfield, Vt. and a former president of the Vermont Psychological Association, "but the fact is that personally it is not what I really thought it was going to be." Since the law passed, Dr. Root said, he has had difficulty persuading insurers to authorize needed treatment for his patients. And while before parity his fee for an hour of psychotherapy was $85 to $90, he now collects $63 an hour, the fee deemed reasonable by the managed care companies.
    Dr. John Matthew, an internist in Plainfield, Vt., said he also believed that in some cases the stepped-up management had been bad for his patients' mental health. In one instance, Dr. Matthew recalled, he had to make six calls to an 800 number to get a managed care company to authorize a single visit to a psychiatrist for a 9-year-old girl with manic depression. "I could have gotten six visits to a cardiologist without any questions being asked," he said.
    Benefits for psychiatric services are often managed through a different set of procedures than are other forms of medical treatment. Many insurers, for example, farm out the management of their mental health benefits to companies that specialize in containing psychiatric costs by establishing provider networks and reviewing treatment. And under many insurance plans, an employee who wishes to consult a psychiatrist or psychotherapist must get authorization from a "gatekeeper" for a specified number of initial visits. If the practitioner feels that more sessions are necessary, a detailed justification for further treatment must be filed, and the patient's progression is monitored at regular intervals.
    "I think that the kind of managed care that's done for mental health care doesn't exist in any other branch of medicine," said Dr. Jonathan L. Weker, a psychiatrist in Montpelier who is the chairman of an independent panel established by the state to review managed care complaints. In the right hands, health care experts say, such practices can ensure that patients get the right treatment from the right person, and that treatment continues no longer than medically necessary. Wielded by less expert or less responsible bureaucrats, however, the same procedures can ignore a patient's long-term welfare, or the judgment of providers about what type of care is needed.

A Delicate Balance
   In a 1997 speech to a meeting of the American Psychiatric Association, Dr. Howard Goldman, a professor of psychiatry at the University of Maryland, called the partnering of parity and managed care "a Faustian bargain." What is given to patients by the nominal expansion of benefits, Dr. Goldman said, may in some cases be taken away y the practice used by management companies to contain costs. Researchers are only beginning to tease out, however, exactly how much is lost and how much is gained by the marriage of parity and managed care. Some studies suggest that in states that already use management strategies to control the costs of mental health treatment, parity laws have had a beneficial effect.
    "If you don't have parity and you have a heavily managed system," said Dr. Regier of the American Psychiatric Association's research and education institute, "you have a double whammy against patients: not only higher co-payments and restrictions, but also the gauntlet of medical necessity determinations and more frequent reviews that come with management." Parity, when it arrives, removes the arbitrary limits on care, and may increase the number of people who have access to treatment. In one study, for example, researchers found that the combination of parity and managed care led to an increase in the number of adults and children who used outpatient mental health services. (The length of time patients spent in outpatient treatment stayed the same, the study found, and the use of inpatient hospital beds declined.)
    In other states, however, where managed care enters on parity's arm, equal-coverage laws do not seem powerful enough to dampen the impact of cost cutting by managed care companies, Dr. Regier said. And researchers still do not know what effect, if any, parity has on the division of costs between private health plans and the public mental health system, which has traditionally cared for the most severely ill--and thus most expensive--patients. One possibility is that with parity legislation, patients are able to stay in the private sector longer, reducing the burden on taxpayers, who foot the bill for public-system care. But the shifting of expense, some experts point out, could also go the other way, if insurers use managed care to push more severely ill patients into the public system, to be cared for by community mental health centers, state hospitals and federal subsidy programs like Medicaid.
    What is clear is that, parity or no parity, insurers continue to do what they can to control the expense of mental health treatment, and to avoid attracting the most expensive patients. Yet for many who depend on their health insurance to offer lifesaving help in times of crisis and to keep them afloat when the crisis has passed, parity in any form is worthwhile. "Without parity," Kathryn Lynnes said, "you don't even get to argue about managed care."

Woman Helps Others Cope With Suicides of Loved Ones
Detroit Free Press, 1/1/2001

SAGINAW, Mich.-- Barbara J. Smith was devastated when her older brother took his life. Now she helps others cope with the pain of losing a loved one to suicide, and tries to keep suicidal callers alive. When her brother shot himself 20 years ago, his death created a passion in her for helping others overcome the grief, guilt and helplessness of suicide, she said. In 1990, she formed Saginaw Survivors of Suicide, where she leads meetings twice monthly. "There was no other place for survivors to go," said the 39-year-old Thomas Township resident. "I was looking to help other people." She also mans a suicide prevention hotline, managing 20 hours a week of volunteer work while caring for daughters Crystal, 15, Heather, 13 and Malinda, 8. "I always volunteered for things that meant something to me and touched my heart," she told The Saginaw News for an article published Monday. Smith also is vice president of the Michigan Association of Suicidology and has helped coordinate its annual conference for nine years. She also has spoken to more than 5,000 teens in school groups through the Yellow Ribbon Program, which works to prevent teen suicides.  Smith, whose husband, Frank, is a 21-year veteran of the Saginaw County Sheriff's Department, helped formed the agency's Wives Club.
    Suicide is a leading cause of death in the United States; the national rate was 11.31 per 100,000 in 1998, the most recent figure available from the federal Centers for Disease Control and Prevention. Suicide is the third-leading cause of death for teen-agers. According to federal estimates, one of every five high school students has thought seriously about attempting suicide, and one in 14 has made an actual attempt. Barbara Smith's sister-in-law, Judy Smith, nominated her to The Saginaw News as one of its 2000 Saginawians of the Year. She was one of the five selected. "I've never met a person like her in my 58 years," said Judy Smith. "She just seems to care more about other people than herself. You don't see that very often in a person."
    Barbara Smith said she just hopes her daughters will carry on her example of helping others. "I need to feel that every day I did something worth getting up for," she said. "I tell my kids that you do what is right. If you feel that something needs to be changed, then you have to change it. "Life is short. Make it fun, and leave an impact."
    On the Net: http://www.mentalhealthscreening.org

West Battles to Stem High Suicide Rates
Chryss Cada, Boston Globe- 1/2/2000

FORT COLLINS, Colo. - Ever since her fiancée drove his pickup truck to a lonely stretch of Arizona desert and shot himself with his rabbit-hunting rifle, Maxine French has asked why. ''There are answers,'' French says, ''but none of them are enough.'' It's a question that echoes incessantly along the Rocky Mountains and across the open plains of the West. For almost a century, the suicide rate in the Mountain States has been the highest in the country, as the region's isolation and a tradition of rugged individualism make a lethal combination. The suicide rate of 17.2 per 100,000 people in the states of New Mexico, Arizona, Colorado, Utah, Nevada, Idaho, Wyoming, and Montana is nearly double the 9.6 rate in New England. And it puts the Mountain States on par with Russia, China, and Kazakhstan, which have the world's highest suicide rates.
   The period after the holidays is a particularly deadly time. ''We usually see a spike after the holidays,'' said Bev Thurber, director of the suicide prevention center in Colorado's Larimer County, which has one of the highest teen suicide rates in the country. ''People tend to hold on for the holidays.'' But factors leading to suicides are present year-round, nowhere more so than in the West, where health specialists say the problem has reached ''epidemic'' levels. ''That one geographic area has such a dramatically higher rate tells us there are common denominators to investigate,'' said Dr. John Fildes of the Las Vegas-based Suicide Prevention Research Center, which is funded by a grant from the Centers for Disease Control. ''Each provides hints to solving this riddle.''
    ''Suicide is what happens when people think they are out of options. And in the West, there are fewer options,'' Fildes added. The vast majority of people who commit suicide suffer from mental illness, often major depression, according to the American Foundation for Suicide Prevention, a research organization. But in the West, there is less access to mental health professionals and other support.
    Other barriers to getting help are self-imposed.  ''He was a country boy, who wasn't going to ask for help,'' French said of her fiancée. ''He believed a man should pull himself up by his bootstraps.'' It's a story Stephanie Finley has heard again and again as she traveled through Colorado this summer talking to those touched by suicide. ''There is definitely a rugged individualism out West,'' said Finley, who organized the Colorado Office of Suicide Prevention last summer. ''We still have that pioneer mentality, that we can do it ourselves. Add to that the stigma associated with mental health, and you have people deciding not to go in for help.''  To try to destigmatize suicide, Finley's office is operated under the state's public health, rather than mental health, department.
    In Wyoming, the bulk of the state's draft suicide prevention plan focuses on reducing the stigma of seeking help for mental illness.  ''If you live in a rural area and seek out help for mental illness, you are more likely to be `found out,' and once you are found out it is more likely that your entire social network will know,'' said Robert Beeson, president of the Rural Mental Health Association, a national organization for mental health professionals.
    Even those who want professional help might not get it. ''Untreated mental illness is the number one cause for suicide,'' Beeson said. ''And in rural areas, there is a low availability of professional help.'' The American Association of Suicidology, a nonprofit group with members ranging from researchers to therapists to survivors, has also made this connection. In a recent study, the states with the highest suicide rates also had the lowest number of mental health professionals per capita.
    Another factor may be the lack of people in general. The Mountain States, six of them among the country's 20 least-populated, are strung together by long stretches of wind-battered highways where signs of inhabitance can be hundreds of miles apart. Isolation can be especially difficult for teenagers, for whom suicide is the third-leading cause of death nationwide (compared with the eighth-leading cause for adults). A 1984 article in the Western Journal of Medicine noted that ''youthful suicides are most prominent in the western United States and particularly in the intermountain region.''
    ''She was different,'' Dennis Bogett said of his daughter Sonja, who committed suicide at age 15. ''In more rural areas, people value conformity. I think it was hard for her to find other kids like herself.'' Bogett added, ''My daughter had a lot of anger; she was a perfectionist who was always very hard on herself.... All her life we felt like we were fighting to keep her alive. Eventually, we lost.''
    Though traditionally more sparsely populated, the population of the Mountain States has been surging. A Census report last week showed that five of the six fastest-growing states are in the region. Immigrants may find themselves isolated. ''In high-migration areas like the West, people are at more of a risk,'' said Finley. ''When they move, they leave behind their safety net. The people who might recognize the warning signs in a loved one aren't there to notice.'' French said she and her fiancée had moved to Arizona just before his suicide because ''he wanted to get away.'' French now lives in Colorado and is a volunteer with the Larimer County Suicide Prevention Center.
    In Nevada, which has the nation's highest suicide rate, one unique factor may be gambling. Suicide rates are up to four times higher in cities with legalized gambling than in comparably sized cities without it, according to a 1997 study by David Phillips, a professor of sociology at the University of California in San Diego. The rate of visitors who kill themselves in Nevada is also four times the national rate.
    Work on reducing suicide continues, with no single answer or solution in sight, or even expected. But government agencies' approach to the problem has made a marked shift in recent years. For the first time, the surgeon general is approaching the issue as a health concern, holding meetings across the country last fall to devise a national suicide prevention strategy. And researchers are about to embark on the heart of their study - extensive interviews with suicide survivors. ''Suicide is not an irrational or inevitable act,'' said Fildes. ''It is a public health problem of ever-growing proportion, which requires the same level of commitment that has been provided to cancer and cardiac disease.''
    ''It took 200 years to eradicate small pox, which is a single organism,'' said Dr. Alan Berman, executive director of the American Association of Suicidology. ''Suicide is infinitely more complex, and quality research on it is only in its infancy. It's not something we will ever fully eradicate.'' As a veteran of the search for answers, French says he knows the road ahead is a long one, but one that must be taken. ''No matter how frustrating and painful, we have to keep asking, `Why?''' French said. ''Answering the question means fewer families will find themselves having to ask it.''

Parents Pass On Mental Illness
Charnicia E. Huggins, Reuters- 1/2/2001

NEW YORK—The children of parents with panic disorder or major depression are at increased risk of developing the same disorders that afflict their parents--even at a very young age, according to researchers in Boston. Other studies have suggested that such disorders can pass from parent to child, but Dr. Joseph Biederman of Massachusetts General Hospital and colleagues wanted to clarify the patterns of their transmission. In particular, they wanted to assess whether a general "anxiety proneness" ran through certain families, or if disorders are inherited more specifically. Overall, "parental panic disorder and major depression conferred a significant risk for dysfunction and emotional distress in their offspring," the authors report in the January issue of the American Journal of Psychiatry.
    According to their study of 380 children, children of parents with panic disorder exhibited higher rates of panic disorder and some other anxiety disorders than children of parents with no anxiety or mood disorders. Children of parents with panic disorder also exhibited a higher rate of agoraphobia--a disorder related to fear of public places and open spaces--than children from unaffected families. A similar trend was observed in children of parents with both panic disorder and major depression. Children whose parents had major depression also exhibited higher rates of major depression. These children were nine times more likely to exhibit major depression than children with unaffected families. Social phobia was also more common among children whose parents were treated for major depression and among children whose parents were treated for both panic disorder and major depression than among unaffected families.
    The findings offer "mixed support" for the idea of general "anxiety proneness" running through families, the authors note. They conclude that follow-up studies are needed to determine whether these children's problems "will confer further vulnerability," as well as to seek out the factors that affect the continuation of the disorders in adulthood. "We believe that this knowledge can lead to the development of preventive and early intervention programs aimed at children at risk," Biederman told Reuters Health. "We believe that this information will be useful to clinicians treating adults with these disorders, to those treating children with behavioral and emotional problems, to pediatricians and family physicians interfacing with growing children and their parents, as well as to affected parents themselves and public health officials," he added.

Report: 1 in 10 Kids Suffers Severe Mental Illness
ABC News, 1/3/2001

A report released today says too often children who wind up in jail had mental health problems that went unnoticed or untreated until too late. Fewer than one in five problem children get treatment for any mental health problems, the report adds. "If children can’t learn, can’t develop appropriately, then it’s going to interfere with their whole life," said Surgeon General David Satcher. "Clearly it is a crisis."  Satcher’s newest call adds to his report a year ago declaring mental disorders a major undertreated problem for adults and children. It comes amid a recent backlash against one prominent childhood problem, attention deficit hyperactivity disorder. Lawsuits charge ADHD is overdiagnosed to push the drug Ritalin to children who merely are rambunctious. There is some over-treatment, but also "there are many children who could benefit from medications as well as behavioral treatment," Satcher said, identifying ADHD and depression as leading mental disorders affecting children.
    According to the report, regular pediatricians treat most affected children and report difficulty referring serious patients to mental health specialists, including appointment waits of three to four months. Some communities offer no child mental health services at all.  In one study, some children with emotional disorders didn’t get proper school services until age 10. Just as for adults, insurance coverage for children’s mental health is spotty. Advocates told of parents who relinquished custody so their children could receive welfare-funded therapy. One juvenile detention center study found over two-thirds of detainees had a psychiatric disorder. Yet the juvenile justice system seldom screens children for treatable illnesses.
    The report urges mental health training for doctors, teachers, welfare and juvenile justice workers, and better access to care. Satcher said Medicaid is developing community models for mental health services, and that the federal justice and education departments will work with health officials on training. Also, the National Institute of Mental Health increased research funding on children’s disorders by $33 million this year.

Connecticut Will Support Overhaul of Children's Mental Health Services
Associated Press, 1/3/2001

HARTFORD, Conn.--The Rowland administration is supporting a $33 million plan to overhaul the state's mental health services for children. Calling the shortage of adequate mental health services for children an ''acute crisis,'' Gov. John G. Rowland's budget chief, Marc Ryan on Tuesday said the plan would allow Connecticut to implement a statewide system of community services at the same time that it adds residential beds for more seriously disturbed children. The state Department of Children and Families, the primary overseer of children's mental health services, has been authorized by Ryan's office to select the private providers who would run the new programs.
    ''My staff keeps asking me, 'Where is the money coming from?' and my response is always the same: 'It's coming,''' said DCF Commissioner Kristine Ragaglia. But just how much money is coming, and when, remains unclear. Ryan said Wednesday it was unclear how much funded would be available because of the state-mandated cap on spending. State officials said they spend 70 percent of the $207 million now allocated for children's mental health on inpatient services the most expensive way to treat children. It leaves little money for the more preventive, community-based services that would help keep children in their homes and out of the hospital. As a result, some mentally ill children are stuck in emergency rooms and psychiatric hospitals longer than they need to be, while others who need treatment must wait in shelters or juvenile detention centers because there are no beds available. Some receive no treatment at all or are sent to live in residential treatment centers out of state because there are no options for them here.
    The plan calls for a major expansion of the DCF program that is designed to keep children in their communities while they're being treated. It includes the creation of emergency mobile response teams, which would go out to a home day or night if a child were having a psychiatric crisis. Teams consisting of licensed social workers and psychologists would ''de-escalate the situation,'' Ragaglia said, or remove the child to one of the special ''safe homes'' DCF is planning to create for these children. Safe homes would provide a place for children to stay and be treated while preparing to return home or while waiting for a residential bed to open up. The final component of the $33 million plan is the creation of 50 new ''sub-acute'' beds in existing residential treatment centers around Connecticut. Ragaglia said the beds would be used for two purposes: to move children out of hospitals and to bring home some of the estimated 500 children currently being treated out of state.
    If proposed by Rowland, the plan would likely receive support from leaders in both parties, lawmakers said. ''It's the right move, it's a smart move, and it's long overdue,'' said Senate President Pro Tem Kevin Sullivan, D-West Hartford. ''If this is actually new money, as opposed to reallocated money, or smoke and mirrors, I'll be thrilled.'' The governor's spokesman, Dean Pagani, wouldn't comment Tuesday on what would be included in Rowland's budget, but said the fact that Ragaglia and Ryan are proposing a $33 million overhaul ''sends a pretty strong signal.'' ''They do work for him,'' he said.

Sex-Offender Paroles Challenged
Kirk Mitchell, Denver Post- 1/3/2001

Colorado sex offenders who are freed early can't be kept on parole for longer than they would have been held behind bars under their original sentences, according to a lawyer for the prisoners. The argument from state Public Defender David Kaplan is the latest volley in the debate over a 1996 law that could free as many as 1,600 sex offenders from parole or prison. "The legislature intended the periods of parole . . . be served in lieu of the prison sentence, not in addition to it," Kaplan wrote in a December brief to the Colorado Supreme Court.
    The state Court of Appeals and the state Supreme Court ruled last year that the 1996 law made parole discretionary and not mandatory. Because of flawed language in the law, the courts found that a sex offender's parole term could not exceed the remainder of his prison sentence. That allowed for paroles to be cut short or offenders who had returned to prison after parole violations to be freed. More than 160 people were freed from parole or prison last year but then rounded up. Attorney General Ken Salazar asked the Supreme Court to overturn the rulings in part because legislators who passed laws in 1993, 1996 and 1998 were trying to make sentences tougher for sex offenders, not shorten them.
    The brief filed by Kaplan's office on behalf of sex offender David Cooper said Salazar's argument is "wrong, unreasonable, and unconstitutional" because it relies upon the 1993 statute, not on the more recent 1996 law. It said the 1996 law could actually result in lengthy parole terms for sex offenders if they are released from prison with many years left on their terms. For example, if a sex offender is sentenced to 80 years and paroled after 40 years, the parole could be 40 years. But an offender who serves four years of a five-year sentence could only be on parole for one year, according to the brief.

Before You Get on the Virtual Couch
Benedict Carey, Los Angeles Times, 1/3/2001

Metanoia.org
Background: Martha Ainsworth, a Web designer, mental health advocate and former counselor, founded Metanoia after searching for information about online therapy back in 1995. Once a novelty, e-therapy is now a staple of Web activity that is largely unregulated and uncharted. Ainsworth's site attempts to give consumers some navigational help, while also acting as a watchdog.
What Works: This is the place to go to learn how e-therapy is conducted (by e-mail, mostly) and when it's appropriate. The site explains, for example, that online therapy is not a substitute for face-to-face psychotherapy nor a solution to any serious crisis, such as suicidal feelings or major depression. Ainsworth answers fundamental questions--Is this therapy? Is it effective? Is it confidential?--head on, and identifies people for whom e-therapy makes sense, such as those living in remote areas, or simply too embarrassed to come clean with a therapist in person. Best of all, Metanoia reviews specific e-therapists' sites, giving them one- to four-star ratings, listing prices and checking credentials.
What Doesn't: Ainsworth is a believer in online therapy; she has benefited from it herself, and her site seems slightly more promotional than critical. According to Metanoia, for instance, 90% of those who try online therapy say they are satisfied with the experience. But what happened with the other 10%? Were they merely unimpressed with the e-mailed advice they got--or were there serious breaches of confidentiality, trust or ethics? You won't find good answers here. And for all the helpful ratings and encouragement the site gives, it offers no examples of exactly what an e-therapy exchange looks like. Metanoia could use an Ask the Therapist feature, with sample questions and answers. An online consultation can cost $35 or more. Let's see what we'd be paying for.

Psychcentral.com
Background: A psychology researcher, John Grohol has been listing and tracking mental health sites since 1995. Psychcentral is meant to give consumers an overview of what's out there, a guide to "the most useful Web sites, newsgroups, and mailing lists online today in mental health, psychology, social work and psychiatry."
What Works: The best feature on Psych Central is Mental Health and Psychology Resources Online. This page lists hundreds of mental health Web sites, grouping them in useful categories such as "anxiety and panic," "parents and children," and "alcohol and substance abuse." Within each category, Grohol lists not only general information sites but support groups, books and frequently asked question (FAQ) pages. He adds a sentence below each link letting you know something about what's to be found there. Psych Central also includes an "articles and essays" section with editorials about controversial subjects, such as electroshock therapy and the risks of online therapy.
What Doesn't: Grohol's site is as much a vehicle for self-promotion as it is a consumer guide. He advertises his book, he devotes considerable space to what he calls his "editorial ramblings," and he lists live chats--hosted by himself. He spends less energy doing evaluations of outside resources. About the mailing list called "controlled drinking," for example, he tells you how to sign up, but nothing about the content or philosophy of the online source. He describes the support group alt.recovery as a "newsgroup on general topics in recovery." Such as? You'll have to spend some time in the online group to find out.

Pasadena Therapist Accused of Having Sex With Patients
Richard Winton, Los Angeles Times- 1/4/2001

A Pasadena therapist has been arrested on two felony counts of sexually exploiting female patients who came to him for marriage counseling. Sami Hickey Alexander, 45, a licensed marriage and family therapist, was arrested at his Pasadena home Tuesday and released on $40,000 bail. Alexander faces as much as three years in prison if he is convicted on charges of engaging in sex with a patient or former patient while practicing therapy. "The victims were women in their 40s," said Pasadena Police Lt. Rick Aversano. "Essentially he gained their confidence during their therapy sessions and eventually he used it to manipulate them into a sexual relationship." Aversano alleged that Alexander had sex on numerous occasions with clients, beginning in the early 1990s.
    The therapist, Aversano said, was arrested after two victims met each other and agreed to go together to authorities. Police say that at least one other woman has also contacted them about Alexander's conduct. Under state law, a therapist cannot have sex with a client or former client, even with consent. Alexander, who has been a licensed therapist since 1988, could not be reached for comment. Sandi Gibbons, a spokeswoman for the district attorney's office, said prosecutors filed the charges Dec. 27 and a warrant was issued for Alexander's arrest. He is scheduled to be arraigned Feb. 2. The criminal charges came after state officials began proceedings to revoke Alexander's therapy license because of allegations of misconduct reported by two female clients.
    Last Aug. 23, the state Board of Behavioral Sciences and the attorney general's office accused Alexander of gross negligence, intentionally causing emotional harm to clients and sexual abuse, misconduct and relations with patients. In October 1989, he began counseling a married couple but after a while only the wife continued the sessions. According to the allegations, Alexander "engaged her in sexual contact and on numerous occasions for least 3 1/2 years at almost every session, including one which she attended just after receiving chemotherapy for breast cancer." Alexander allegedly gave the woman an expensive vase and a key to his office, went shopping with her and sent her a catalog of sex toys, according to the state accusation.
    State officials alleged that he also began a sexual relationship with another woman after she and her husband came to see him in 1991. Alexander allegedly engaged in a sexual relationship with the woman patient, causing emotional stress for her husband, according to a state accusation. At one point, state officials allege, Alexander offered the husband "free therapy sessions for his wife . . . in exchange for nude photographs of her." The state accusation called this "an extreme departure from standard practice." Kim Hunter, a state Department of Consumer Affairs spokeswoman, said a hearing before the state board on Alexander's license is scheduled for Jan. 22.
Licenses of a dozen marriage and family therapists in California were revoked for sexual misconduct in the 1999-2000 fiscal year, state records show. So far in the 2000-2001 fiscal year, four have lost their licenses for the same violations.

Report: Ecstasy and Steroid Use Rising Among Teens
Sonya Ross, Associated Press- 1/4/2001

W A S H I N G T O N, Jan. 4 — President Clinton praised recent signs of progress in curbing drug use today but bemoaned the fact that "drugs continue to exact a tremendous toll" on young people dabbling in steroids and club drugs such as ecstasy. In receiving the final report from his drug policy adviser, Clinton said he was glad that the report showed drug-related murders are at their lowest level in 10 years and that drug use by young people aged 12-17 is down 21 percent since 1997. But, he said, studies also are providing disturbing evidence of increased use of steroids, ecstasy and other drugs. "Too many young people are still using alcohol, tobacco and illegal substances," Clinton said. "We must never give up on making our children’s futures safe and drug-free," he said. "Despite our progress, drugs continue to exact a tremendous toll on our nation."
    Barry McCaffrey, director of the Office of National Drug Control Policy, noted that drug education and prevention efforts have not kept up with the onslaught of new drugs such as ecstasy, known chemically as methylenedioxymenthylamphetamine, or MDMA.
Those who use ecstasy normally experience feelings of euphoria and an increased desire for social interaction. They also experience dramatic increases in blood pressure, heart rate and body temperature. Use of MDMA, once mainly an East Coast drug, has spread rapidly across the country, McCaffrey said, with an "explosive increase in exposure among our children." "They think it’s a hug drug, it’s a dance-all-night, feel-good drug," McCaffrey said. But ecstasy also may permanently impair the brain’s neurochemical functions, McCaffrey said, "never mind the possibility of dropping dead the first time you use it."
    McCaffrey also noted that steroid use is up, particularly among youths who want "to get that slightly ripped look … to improve their chance of getting selected for Little League baseball, or high school diving, or track." And he said treatment remains a goal of the National Drug Control Strategy, pointing out that chronic drug users in the United States tend to be employed and stable, but view treatment as a stigma. "We’ve got 5 million chronically addicted Americans. If we don’t have them in effective drug treatment programs we can’t ever break the cycle of crime, violence, accidents, health costs that come from drug abuse," McCaffrey said in an interview today on CBS’ The Early Show. McCaffrey, who is stepping down Friday, said he is confident the incoming Bush administration is aware of the importance of treatment.
    Ethan Nadelmann, director of the New York-based Lindesmith Center Drug Policy Foundation, said in choosing McCaffrey’s successor, President-elect George W. Bush should focus on "a new bottom line" for drug policy that emphasizes reducing the consequences of drug use — death, disease, crime and overall suffering — rather than focusing on cutting the total number of drug users. "The war on drugs persists because most politicians dare not admit that the strategy itself is fundamentally flawed," Nadelmann said. McCaffrey’s report said curtailing illegal drug use requires an approach much like the fight against cancer — prevention coupled with treatment accompanied by research. "The moment we believe ourselves victorious and drop our guard, drug abuse will resurface in the next generation. To reduce the demand for drugs, prevention must be ongoing," the report said.

Parents Say Defendant in Wakefield Slayings Was Hospitalized Repeatedly
Andrea Estes, Boston Globe- 1/5/2001

MARSHFIELD, Mass.--The parents of Michael McDermott, a Haverhill man accused of one of the worst workplace killings in state history, said yesterday their son suffered a mental breakdown while working at a Maine nuclear power plant during the 1980s and was hospitalized repeatedly for mental illness during the next decade. In an emotional interview yesterday, Richard and Rosemary Martinez said they think their son's mental problems are to blame for his arrest in the shootings of seven employees at Edgewater Technology Inc. in Wakefield. But they said he seemed fine in the days leading up the shooting - and laughed and joked with his mother in a phone call an hour before the gunfire began. ''Everyone is looking for me to say something that is dramatic to explain why he did this,'' said Richard Martinez, 72, a retired schoolteacher. ''But I cannot. I cannot comprehend that my son did this. I think of the seven families who have been so horribly destroyed. We're devastated for these seven families.''
    ''Those horrible pictures of him - the face of evil,'' said his mother, Rosemary Martinez, referring to a newspaper headline just after McDermott was arrested last week. ''He's not a fiend. It's the face of mental illness, not evil.'' During a three-hour interview in their century-old farmhouse, Martinez and his wife said they were still distraught over the shootings and talking about their son was extremely difficult. Though seemingly inconsolable, they agreed to speak to a reporter hoping to explain that McDermott's alleged rampage was spurred by mental illness, not rage. ''It's just awful,'' Richard Martinez said. ''It just can't be. We're going to wake up and this is not going to be.''
    Poring through scrapbooks in their living room cluttered with antiques, Richard and Rosemary Martinez recalled their son's happy years: his bravura performance in a production of ''The Music Man'' at Marshfield High School, his decorated career as a Navy submariner, his wedding to a hometown girl. The walls of their home are lined with happy family photos and portraits.  The couple, retired teachers married 45 years, described their middle child as outgoing and friendly - the antithesis of the man authorities describe as a cold, methodical killer. ''He was never violent. That's why this is incomprehensible,'' said Rosemary Martinez, 71. In fact, they said, their son seemed content.
    The day before the Wakefield shooting, McDermott invited a girlfriend to his family's house to celebrate Christmas, his parents said. He gave books as gifts to his relatives, including ''Merriam-Webster's Book of Quotations'' for his mother and a book on antiques for his father. ''We had the most wonderful Christmas with him,'' his mother said. ''I don't know a time when he was in better spirits. From start to finish it was a great day.'' The next day - 45 minutes before the shooting began - Rosemary Martinez called her son at work. She reminded him to bring some Christmas gift certificates he'd left at home the day before. ''He said he wished [Christmas day] hadn't ended,'' she said. ''I talked with him and laughed with him at 10.'' She sighed. ''That was an hour before all this broke loose.''
   Police say McDermott stalked and killed a targeted group of co-workers in the Edgewater Technology headquarters the morning after Christmas. Authorities say he may have been upset that the company had agreed to seize part of his wages to pay off an IRS debt of less than $5,000. When the shooting ended, State Police SWAT officers found McDermott sitting calmly in the lobby, holding an AK-47-style assault rifle, a shotgun, and a pistol. Yesterday, as mourners in New Jersey paid their respects to Craig Wood, 29, the last of the seven to be buried, a private memorial service was held for the victims in North Reading.  Richard and Rosemary Martinez said they grieve, too, for the victims as they struggle to cope with what their son may have wrought.
    ''Everyone keeps asking us to go on TV and discuss the case,'' Richard Martinez said. ''All we know is we have a very seriously ill son, and that seven people have died.'' Looking back, they said, there were no signs of turmoil in the early years of their son, a ''brilliant'' child with a penchant for science and math. As he grew, they said, McDermott became a self-taught computer whiz and a mechanical expert who could fix anything. He still did odd jobs for his parents - including rewiring the house - and had promised to fix the back porch light. In high school, he excelled in math and science. He had a beautiful voice, his parents said, and loved performing in the theater. His new job at Edgewater, which paid about $55,000 a year, was the latest in a string of technical positions McDermott held since high school. Though his college entrance exam scores were ''spectacular,'' his father said, his son's grades weren't good enough to enroll in a four-year school, so he signed up for a six-year hitch in the Navy. There, he joined the submarine corps and was trained as a nuclear technician. Court records indicate McDermott filed for a legal name change in 1982 to identify with his Irish heritage, but Richard Martinez said his son simply wanted to honor his ancesters from Gibraltar - and avoid confusion with another shipmate on the USS Narwhal named Martinez.
    After leaving the Navy, his parents said, McDermott wanted to go to college but liked having a regular paycheck. He took a job at Maine Yankee nuclear power plant in Wiscasset, Maine, and took a few college courses while working full time. While working in Maine in the late 1980s, however, McDermott suffered the first of several mental breakdowns - triggered, his parents believe, by a breakup with his girlfriend at the time. ''He was suicidal,'' said his father. ''I drove all night and I got him home [to Marshfield] between 4 and 5 a.m.'' McDermott returned to Massachusetts, where a psychiatrist sent him to Pembroke Hospital for a month, being treated for severe depression, his parents said. ''We have a very bad genetic family history of depression,'' he said.
    With therapy and antidepressants, McDermott eventually returned to Maine and worked for a time in the company's Augusta office. But the depression returned, so McDermott came back to Massachusetts and moved to Rockland. Another bout of depression sent him back to Pembroke for another month, his parents said. He moved to Quincy and was hospitalized for another month. Around this time, his parents said, McDermott met Monica Sheehan - a high school acquaintance who graduated a year after he did - his mental state improved. They had a lot in common: a taste for movies, books and Trivial Pursuit, where they formed an unbeatable team.  ''She was a very vivacious girl. They'd spend hours watching movies,'' Rosemary Martinez said. But the depression returned and his marriage failed, his father said.
    Though he'd been a tall, handsome child, his mother said, McDermott had gained more than 150 pounds by the 1990s, around the time he took a job with Duracell testing battery components. When the company moved to Connecticut, McDermott didn't want to leave. He wanted to stay close to his family. After his marriage dissolved, McDermott indulged his love of computers, spending more and more time on line, his father said. That expertise, he added, led a friend to recommend McDermott for a job at Edgewater Technology.  Though interviews and documents suggest that McDermott's life was slowly unraveling by this point - he owed around $5,000 in back taxes, his car was near repossession, and he had developed a taste for weapons and explosives - his parents saw no warning signs: he was on medication and was seeing a psychiatrist once a week.
    ''They gave him a clean bill of health,'' Richard Martinez said. ''They said with medication he'd be fine.'' McDermott had hobbies as well, his parents said. He loved books and was a member of a group dedicated to the fantasy role-playing game Dungeons and Dragons, where he met his new girlfriend. Though they knew their son kept guns, his father insisted ''there was nothing sinister about it.'' ''All but one were licensed. He'd go and do target shooting,'' Richard Martinez said. ''He learned it in the Navy ... In Maine and New Hampshire, you can buy guns legitimately. They were from catalogs and what have you.'' If their son had financial problems, he kept it to himself. He was generous to a fault and indulged his friends and family. ''I read in the papers that he owed something like $5,000 in all'' in back taxes, he said. ''That's chicken feed. You don't go out and kill someone for $5,000.''
    When news of the shooting broke - and they found out their son was the suspected gunman - ''I don't think you could put into words how we felt,'' Rosemary Martinez said, reaching for her husband's hand. They've seen their son once in jail. They didn't discuss the shooting during the interview. ''We just wanted to let him know how much we loved him. We knew that he knew that we had been through hell,'' Richard Martinez said. ''We knew he had been through hell.'' ''You hear about this and other people,'' Richard Martinez said. ''It can't happen to you, but it does. We have tremendous faith, strength in our God, and we will soldier on.''

Massachusetts Psychiatric Hospital Closing Feared
Larry Tye, Boston Globe- 1/5/2001

State officials say another Massachusetts medical facility may be on its deathbed, this one in Malden, and they warn that its closure would exacerbate the critical shortage of psychiatric beds and emergency services in Boston and its suburbs. Malden Medical Center already is a shadow of the full-service hospital it was two years ago, with only urgent care and psychiatric units, dialysis and sleep clinics, and a family health center. Now Hallmark Health, the not-for-profit chain that runs the center, is weighing a shutdown of the psychiatric unit and perhaps even the urgent care and the clinics to help curb what its board chairman says is a flood of red ink.
    While a final decision is unlikely for a week or two, state officials already are weighing in with their concerns. The loss of Malden's 42 psychiatric beds ''would mean that people who are in imminent need of inpatient psychiatric services could potentially be waiting for a very long time in emergency rooms,'' warns Marylou Sudders, the commissioner of mental health. ''And that would be compounding what already is a crisis for ERs.'' The Department of Public Health also made clear yesterday that it will hold hearings and otherwise scrutinize any move to shutter facilities at Malden the same as it would at the Whidden Memorial Hospital in Everett, another Hallmark facility threatened with closure.  Even as they await word on what will happen in Malden, officials expect confirmation within the next few weeks that Beth Israel Deaconess Medical Center will keep open at least 25 of the 43 psychiatric beds it planned to close. ''Our department remains hopeful on that,'' says Sudders, who along with Boston Mayor Thomas M. Menino has been pushing hard to keep those beds open.
    The crunch at the Hallmark facilities could not come at a worse time. Emergency rooms in and around Boston have been backed up to the point where they regularly turn away all but the sickest ambulance patients, a crisis that was pushed to the top of the agenda at a meeting yesterday of top state health officials. Two-thirds of the state's hospitals are operating at a loss and 35 have had to shut since 1978. The bed shortage is especially acute for psychiatric patients, many of whom cannot afford to wait until a bed opens up.  The latter problem was spotlighted last year when Beth Israel Deaconess said its money woes would force it to close another 43 psychiatric beds. While that decision probably will be partially reversed, new worries have been raised by Hallmark's consideration of closing its 42 psychiatric beds in Malden, which represent a quarter of those in the area along I-93 north of Boston.
    The same situation exists in the contemplated shutdown of Malden's urgent care center, which is open 12 hours a day to walk-in patients and is especially critical for the poor and elderly who would find it difficult to travel to another city for services. Shutting it also would add to the burden at already overburdened emergency rooms at nearby hospitals. Hallmark officials say they realize how damaging such cuts could be, and know the state will make it hard for them if they try to close the psychiatric unit or other services on the old Malden Hospital campus. Still, they say they have few options. ''We're losing money and we're very badly in debt ... All I know is there's going to be drastic cutbacks,'' Edward Cameron, chairman of the Hallmark board, said last night. Just where those cuts will come, he adds, depends on what the board hears from consultants, accounting firms, and Hallmark staff members, all of whom have been meeting in recent weeks to come up with plans.
    One option would be to close Whidden, but that notion ran into stiff opposition from officials in Everett and from state Senate President Thomas Birmingham, who lives down the hill from the hospital and has been working with Hallmark to keep it open.  Another that seems likely, with or without the Whidden closure, would be to shut everything at the Malden facility except the family health center, with many of those services being folded in to Hallmark's more profitable hospitals in Medford and Melrose.   ''I'd put the odds at 50-50'' of the Malden campus being mothballed, Malden Mayor Richard Howard says.

Washington State Court Upholds Sex-Offender Registration
Scott Sunde, Seattle Post-Intellingencer- 1/5/2001

The Washington Supreme Court has upheld a state law that requires registration of sex offenders and allows local law enforcement to tell the public how likely offenders are to commit another crime. The court ruled 6-3 yesterday that the process state and local law enforcement use to classify the risk posed by released rapists and child molesters is constitutional. "The sex-offender registration and disclosure statutes are essentially procedural statutes; no liberty interest arises from them," wrote Justice Philip Talmadge in the majority opinion. He was joined by Justices Richard Guy, Charles Smith, Barbara Madsen, Faith Ireland and Bobbe Bridge. "The point of the court is that the current process is constitutional and is valid under state and federal law," said John Samson, an assistant attorney general.
    Justices Gerry Alexander, Charles Johnson and Richard Sanders dissented. Alexander maintained that a fundamental liberty interest is interwoven throughout the process. "It is an interest in knowing when the government is moving against you and why it has singled you out for special attention. . . . It is an interest in avoiding the social ostracism, loss of employment opportunities and significant likelihood of verbal and perhaps even physical harassment likely to follow from designation," he wrote.
    The Supreme Court upheld the constitutionality of the 1990 law once before. But in that 1994 decision, the court focused on whether the state could force sex offenders to register and whether notifying the public they were about to be released from prison amounted to punishment. Sex offenders don't get to see the reports used to determine their classification, and they aren't entitled to a hearing to challenge the label. Often they learn of their classification the same time the public does -- when a law enforcement agency lists the offender's name and other information and assesses his risk of reoffending.
    More than a thousand sex offenders are released from prison each year in Washington. The law requires offenders to register with local law enforcement -- giving his name, age, address, place of employment and other personal details. The Department of Corrections, meanwhile, assesses how likely the sex offender is to commit a crime after being released. Corrections passes that recommendation on to local law enforcement, which has the final say on the classification. Offenders can be classified as either Level I (low risk of reoffending), Level II (moderate risk) or Level III (high risk). The higher the risk, the more widely information about the offender is disseminated.
    Law enforcement, for example, can alert the entire community about a Level III offender. "We believe an informed community is a safe community," said Jan Jorgensen, spokeswoman for the Snohomish County Sheriff's Office. Jorgensen said her office holds community meetings before Level III offenders are released. The purpose is to provide important public-safety information, not scare people unnecessarily, she said.
    One of the three sex offenders who challenged the classification process was convicted in Snohomish County. Eric Erickson pleaded guilty in 1993 to child molestation and was sentenced to more than eight years in prison. The other two offenders are Douglas Meyer, convicted of rape in Grant County in 1992, and Bradley Sundstrom, who pleaded guilty to child molestation in Clark County in 1997. Corrections has released all three from prison, labeling Meyer as Level I offender, and Erickson and Sundstrom as Level III offenders.  Corrections officials take into account such factors as previous criminal record, behavior in prison, willingness to undergo treatment and the facts of the latest crime to determine the classification.
    Seattle attorney Pat Arthur, who represented Erickson and Sundstrom, said the process used to classify them and other sex offenders is unfair. "It's really not fair not to allow them to see information used that labels them as a continuing risk," she said. Offenders can challenge the classification in court. But Alexander noted that challenge is a "hollow remedy" since it occurs after the classification is already out. The information can be erroneous. Information used to classify one of her clients, Arthur said, included a previous criminal conviction that was wrong. Even the justices who upheld the law admitted yesterday that they have "a certain discomfort with the seeming unfairness of a process of classification in which the offenders have little involvement." They suggested that the Department of Corrections notify offenders and let them comment to avoid any errors.

Report: 200,000 Children Between 2 & 4 Years Old on Ritalin
Jennifer Huget, Washington Post- 1/5/2001

Under pressure from parents and schools looking to control attention deficit/hyperactivity disorder (ADHD), doctors commonly prescribe methylphenidate (MPH), best known by the brand name Ritalin, as a treatment for children as young as 2 -- even though the drug has been tested and approved only for children ages 6 and up. A report published early last year in the Journal of the American Medical Association by Julie Zito, an epidemiologist at the University of Maryland School of Medicine in Baltimore, estimates that some 150,000 to 200,000 children between the ages of 2 and 4 in the United States are currently receiving prescriptions for MPH. Steven Hyman, director of the National Institute of Mental Health (NIMH) in Rockville, asks, "How can we tolerate a situation in which drugs are prescribed to an increasing number of preschoolers without safety and efficacy data?"
    Laurence Greenhill, of the New York State Psychiatric Institute at Columbia Presbyterian Medical Center, thinks we can't. Greenhill organized a consortium of six institutions to apply for a grant to study the effects of Ritalin on a group of children ranging in age from 3 to 8. About two-thirds of the 312 children to be enrolled in the $6 million Preschool ADHD Treatment Study (PATS) will be younger than 6 years old. Greenhill's plan has raised ethical questions of its own, including whether children this young should be subjected to clinical trials of any drug, much less one with Ritalin's ability to alter the way the brain works. In addition to concerns about possible effects on a young child's developing brain, many question whether little children can adequately understand their participation and articulate their willingness to take part in any clinical trial. Hyman says all of this has been thoroughly examined and planned for, both by the research team and through the NIMH's and local institutional review processes. "We were tied up in knots by this," he says, acknowledging the vetting to which the NIMH subjected Greenhill's plan.
    The study is designed to include children with moderate to serious symptoms who have never been medicated for ADHD. Before any child joins the study, his parents receive training intended to help them improve the child's behavior without drugs. Children who respond positively to these efforts will be dropped from the study. Only those whose symptoms remain moderate to severe will continue. After the correct dose for each child is established, he or she will be monitored for 40 weeks to ascertain the drug's longer-term effects. "The consent process is active and ongoing," says Greenhill. "Parents are re-consented at each of five stages." Children accepted into the study must be fluent enough to object to what's going on; each will be offered an age-appropriate explanation and will be asked to either assent or say no to further testing.
    Psychiatrist Peter Breggin, the Bethesda-based author of the 1998 book "Talking Back to Ritalin," has been one of the most outspoken of the drug's -- and the study's -- detractors. "We shouldn't be giving addictive drugs to kids because we're not willing to give time to them," says Breggin, who advocates non-pharmaceutical treatments such as parental training for the set of symptoms known as ADHD. "All ADHD is, is a list of symptoms that irritate teachers," Breggin says. "To call it a disease is ridiculous, and to say it's hard to treat is meaningless. What we're doing is drugging our kids instead of improving family life and schools. "If the NIMH were being responsible, they'd call for a moratorium on drugging little children," Breggin says. "There is no scientific way to rule out that we're ruining their brains."
    Greenhill counters: "The naysayers may say this isn't needed, but we have to try to collect information because it's been shown that more and more children in this age group are receiving this medication, and we don't have any idea about safe dose range or how it works over time." "Of course there are some children who are over-medicated, but also some who are horrendously impaired," adds Hyman. "We worry about the impact of treatment on the developing brain, but also the impact of no treatment on the developing brain." "Without a controlled trial," Hyman says, "in essence every kid is an uncontrolled experiment -- but we never learn anything." The trials are due to begin this month at six sites, including Johns Hopkins University in Baltimore.

Mentally Ill Not Ripe for Violence, Psychiatrists Say
Anne Barnard, Boston Globe- 1/6/2001

A day after Michael McDermott's parents disclosed that their son had been hospitalized for depression and was being treated for it when he allegedly gunned down seven co-workers, psychiatrists said that people suffering from the disorder are no more prone to violence than the general population. Some mental illnesses, such as schizophrenia and bipolar disorder, may be associated with a slightly increased risk of violence, which grows significantly if the sufferer also abuses drugs or alcohol, the psychiatrists said. But even those risks are greatly exaggerated by popular culture, the specialists said.
    Depression is one of the mental disorders least often associated with violence toward others, though sufferers are at increased risk of harming themselves, psychiatrists said. People who suffer depression at some point in their lives make up between 6 and 20 percent of the population. ''I would hate to think that now people in the workplace were looking over their shoulder worrying that if someone had sought psychiatric treatment they were now at greater risk for violence,'' said Dr. Scott Ewing, a psychiatrist who heads the depression and anxiety disorders clinic at McLean Hospital in Belmont. ''That would only have the effect of discouraging people from getting appropriate treatment, and there's no credible evidence that such people would pose a greater risk to their co-workers,'' said Ewing, who also teaches at Harvard Medical School.
    McDermott's parents, Rosemary and Richard Martinez, told the Globe Thursday that their son became suicidal after a breakup with a girlfriend, while he worked at the Maine Yankee nuclear power plant in the late 1980s, and that he was hospitalized for depression. They said he was seeing a psychiatrist and taking medication at the time of the killings. He has pleaded not guilty. While stressing that they could not comment on McDermott directly without examining him,
    Ewing and others cast doubt on one defense theory proposed by McDermott's lawyer: that Prozac or another antidepressant medication helped trigger the Dec. 26 killings in Wakefield.  Dr. Emil Coccaro, a psychiatry professor at the University of Chicago, said his research showed that drugs such as Prozac, which raise the brain's level of a chemical called serotonin, dampen aggressive impulses in people prone to anger attacks.  Psychiatrists said that in some cases, Prozac or similar drugs could worsen a person's condition, if the patient were misdiagnosed with depression but actually had bipolar disorder, also known as manic depression. Because the first signs of manic depression are often hard to distinguish from ordinary depression, it is sometimes misdiagnosed. But even then, the specialists said, a mistakenly prescribed antidepressant would likely trigger agitation or aggression, rather than outright violence.
    Some researchers have accused Prozac's manufacturer, Eli Lilly, of downplaying side effects, including agitation and suicide. The company has denied any link between Prozac and increased risks of violence or suicide.  Coccaro also questioned whether authorities' descriptions of McDermott's actions suggest a biological or pharmaceutical cause. ''These are complex behaviors,'' he said, referring to allegations that McDermott smuggled guns into the office and stalked specific victims.  But McDermott could use depression as part of a ''diminished capacity'' defense, in which a defendant would still be responsible for his actions but to a lesser degree, said Dr. Ron Schouten, director of the law and psychiatry service at Massachusetts General Hospital.
    According to the National Mental Health Association in Alexandria, Va., the vast majority of mentally ill people are not violent and are more likely to be victims than perpetrators of violence.  A study published in the Archives of General Psychiatry in 1998 found that patients discharged from mental hospitals who did not abuse drugs or alcohol were no more likely to commit violence than their well neighbors. Schouten said mentally ill employees are among the most loyal and punctual. Rather than screening them out, he said, employers should make sure all employees have access to good mental health services. And, he said, they should be willing to intervene if workers display threatening behavior or start having problems taking care of themselves.

Defense Lawyers Say First Expert Witness in Malpractice Isn't Expert
Linda A. Johnson, Associated Press, 1/8/2001

HAMILTON SQUARE, N.J.--As their malpractice trial grinds on, two addiction specialists accused of negligence in the deaths of seven heroin addicts after rapid detoxification said Monday they don't plan to do the controversial procedure again. Drs. Lance L. Gooberman and David Bradway have not performed rapid opiate detoxification for 18 months under an interim agreement with the state Board of Medical Examiners, which regulates doctors. The agreement prohibits the doctors from again performing rapid detox as an outpatient procedure, but not from performing it in a hospital with an overnight stay, as most doctors do.
    The procedure, performed under general anesthesia, involves using medications to ease withdrawal symptoms and flush heroin or other narcotic drugs from addicts' bodies in hours, rather than days, sparing them the worst of the ordeal. ''I'm not interested in doing this again,'' Gooberman, who has already spent more than $400,000 on his defense, said during a break in Monday's testimony. ''They'll keep coming after me,'' he said of state regulators, adding that long-idle medical equipment in his clinic, for performing the procedure and handling any complications, is for sale. Bradway, Gooberman's former employee, likewise said he won't resume the procedure. Gooberman indicated they recently made that decision, after considering it for 18 months.
    The doctors, who say they successfully detoxified about 2,350 heroin addicts in Gooberman's Merchantville office from 1994 through June 1999, insist they followed appropriate medical standards and were not responsible for any deaths. The state is trying to strip Gooberman and Bradway of their medical licenses. Both are charged with malpractice, negligence and incompetence.
    After presenting testimony last week from relatives or friends of patients who died or needed emergency care, Deputy Attorney General Douglas J. Harper on Monday presented his first expert witness, Dr. Herbert D. Kleber. A psychiatrist and medical director of the National Center on Addiction and Substance Abuse at Columbia University in New York, Kleber has spent 35 years treating addicts, doing research and training new doctors in addiction medicine. But attorneys for Bradway and Gooberman argued Kleber has only observed rapid detox procedures five times and likewise is not an expert in anesthesia use, issues at the crux of the trial. Administrative Law Judge Jeff Masin, who is presiding over the civil trial, ruled Kleber is an expert on addiction medicine in general and can testify. The judge could later discount some of Kleber's testimony if it appeared the psychiatrist did not have proper expertise in that area, however.
    Kleber then summarized findings of three medical journal articles on rapid detoxification, one of which noted several serious complications but included only a dozen patients. But Masin agreed with the doctors' attorneys that two of the articles, published after the doctors had performed most of the procedures, appeared irrelevant. Harper also tried to have Kleber discuss a 1996 report on rapid detox, issued by the National Institute on Drug Abuse and written by several consultants, including Kleber. ''The report is highly critical,'' Harper told the judge. Harper said the report suggested standards of care for patients undergoing rapid detox, and Kleber said some news media and the Journal of the American Medical Association had reported on it. But after more than an hour's discussion, it was unclear whether Gooberman and Bradway knew about the report or whether it applied to their work. Masin was to decide whether to admit the report into evidence Tuesday morning, when testimony resumes. It is scheduled to run through Thursday, then break until Feb. 8.
    Gooberman's attorney, John Sitzler, has noted the clinic's mortality rate was only 0.3 percent. Meanwhile, heroin abuse kills an estimated 5 percent of U.S. addicts each year, and addicts have also died from traditional, slow detoxification and initiation of maintenance therapy on methadone, a slower-acting, legal narcotic. By doing rapid detox in his clinic, then sending the patients home with a relative and detailed care instructions, Gooberman says he was able to hold the cost to about $3,000. That made it affordable for more patients, given few had insurance that would pay for it. Most doctors performing rapid detox in a hospital charge about $7,000.

Tragic 'Transfer' to Montana: Mass. Sex Offender Charged in Boy's Death
Elizabeth Mehren, Los Angeles Times- 1/8/2001

BOSTON--It is known in some circles as the geographical cure. Pack up your child molester and ship him far away. Montana maintains--and Massachusetts does not deny--that this is what happened in the case of 43-year-old Nathaniel Bar-Jonah. The hulking Massachusetts native now is charged with kidnapping and murdering 10-year-old Zachary Ramsay. The child lived in Great Falls, Mont., where Bar-Jonah was sent by the state of Massachusetts after spending 12 years in a treatment center for sexual offenders.
"Obviously, we're pretty irate about" his transfer to Montana, Cascade County's attorney, Brant Light, said Monday. "The way it was done was pretty remarkable." Bar-Jonah is to be arraigned Thursday in Great Falls on charges of murder, kidnapping and child molestation.
    Along with explicit photographs and other evidence found in Bar-Jonah's residence, Great Falls police discovered a list that officials say links him to at least 54 cases of child abduction and molestation in several states. The handwritten document, with names and dates, prompted police in Bar-Jonah's former hometown of Webster, Mass., to pursue at least eight possible incidents. Bar-Jonah already had been convicted of assaulting four boys in Massachusetts. Investigating the new leads, Webster Police Officer Michaela Kelley said it was "embarrassing" that a known child sex abuser had been sent to another state. "That's just unbelievable to me," Kelley said. "It's just an awful, awful thing." Connie Isaac, executive director of the Assn. for the Treatment of Sexual Abusers in Beaverton, Ore., said moving a convicted sex offender from state to state "has absolutely nothing to do with the treatment of the offender and has nothing to do with public safety. It's a good way for one jurisdiction to wash their hands of the problem and say it won't be my kid and I don't know anyone in Montana."
    Montana authorities said they became suspicious of Bar-Jonah when residents reported him lurking around a Great Falls elementary school. Police said they found him carrying a fake police badge and dressed to resemble an officer. Then known by his birth name, David P. Brown, Bar-Jonah had used that approach as early as 1975, when he picked up an 8-year-old Webster boy on the way to school. Two years later, he employed the same disguise when he kidnapped two boys in another town in Massachusetts. After pleading guilty in both cases, Bar-Jonah was given an indefinite sentence at a Massachusetts treatment center for the sexually dangerous. A report from a therapist who treated him at the facility said his "bizarre" sexual fantasies "outline methods of torture extending to dissection and cannibalism." While at the treatment center, Brown changed his name.
    Although several evaluations had deemed Bar-Jonah a risk to society, two psychologists testified in 1991 that he was no longer a threat. One month after he was released from the treatment center, Bar-Jonah was arrested in the attempted kidnapping of a 7-year-old.  Bar-Jonah avoided jail by agreeing to two years of probation--and promising to move to Montana with his mother. That decision by Massachusetts officials was "a bad move," said Rob Freeman-Longo, an expert in sexual abuse prevention education in Summerville, S.C. "Treatment's great, but to throw someone into a brand new environment, with no . . . follow-up--that's a real problem," Freeman-Longo said. Repeated, escalated behavior on the part of sex offenders often is typical, but it is "less likely with treatment," Freeman-Longo stressed.
    Months after arriving in Great Falls, Bar-Jonah was charged with molesting an 8-year-old boy whom he was baby-sitting. The charges were dropped when the boy's mother refused to let him testify. Bar-Jonah's former probation officer in Great Falls said Massachusetts "set up" Montana by exporting a multiple sex offender. "Those prosecutors, defense attorneys and judges ought to be ashamed," Mike Redpath said. In 1996, Zachary Ramsay disappeared on his way to school. Three weeks ago, Bar-Jonah was charged with his kidnapping and murder. After Bar-Jonah's arrest, authorities revealed their belief that he ate the boy's remains and fed them to unsuspecting friends and family. Light said bones of a child from 8 to 13 years old were found in Bar-Jonah's garage. After DNA tests failed to link them to Zachary, Light said, many agencies from other states contacted his office to see whether the bones match the DNA of other missing youths. The lack of a body makes prosecution difficult, Light said. He added that because of intense publicity, the trial will likely be moved out of Great Falls.