First Man Selected to Yates Jury
Lisa Teachey, Houston Chronicle- 1/11/2002

A local engineer was selected Friday as the first male juror in the Andrea Pia Yates capital murder trial, bringing to five the number of people chosen in the first week of jury selection. The man said he has been married for 15 years and has no children. His name, along with those of the four women picked earlier this week, is not being made public.
    Jury selection began Monday when a pool of 60 people was summoned to state District Judge Belinda Hill's courtroom. After questioning by the judge, prosecutors and defense attorneys, only three members of the original pool remain. They will be questioned Monday, when court officials also will summon another pool of 60 potential jurors. Court officials will continue calling and questioning prospective jurors until 12 jurors and two alternates are selected. The jury will then be sworn before hearing testimony to determine whether Yates -- the Clear Lake woman who confessed to drowning her five young children in her bathtub last year -- was legally insane at the time of the killings.
    Because of international media attention surrounding the case, Hill has said the jury may be sequestered during the trial. Testimony is scheduled to begin a week after the last alternate is chosen. So far, the process has moved more quickly than expected. Texas law requires that -- before being selected -- potential jurors must be questioned individually to allow prosecutors, defense lawyers and the judge to determine whether they can follow the law, even if it means sending the defendant to death row.
    Most of the questioning in the Yates case has focused on how jury candidates have been affected by publicity about the case, whether they understand the legal definition of insanity and whether they would refuse to consider the death penalty as a potential sentence. Jurors can find Yates insane only if they believe she had a severe mental disease or defect and did not know her actions were wrong. The defense has the burden to prove both factors. Prospective jurors have said they have heard or read news accounts of the case, but those selected said the accounts would not affect their judgments during the trial.
    In addition to the man selected Friday, the jurors so far are:
· A mother of a 3-year-old daughter who works at a state-funded private foundation that places foster children. She is married and has a degree in psychology.
· A married woman with no children. She also has a psychology degree, but works as an office administrator at the Baker Botts law firm.
· A divorced mother of two adult children who works as a director of plant operations. Before her divorce, she and her husband had undergone marriage counseling.
· A 22-year-old student who lives with her parents and younger brother. She works as a receptionist while attending classes on computer networking.

Teen Suicide Pilot: A Life Filled with Contradictions
Vickie Chachere, Associated Press- 1/12/2002

TAMPA, Fla. --Gawky and shy, Charles Bishop ambled through life the way a million other 15-year-old boys do a square peg, a kid with a bad complexion and big dreams. So when he crashed a stolen Cessna into a skyscraper and left a handwritten note showing sympathy for Osama bin Laden, Bishop again seemed to fit a familiar profile: copycat teen grasping for attention.
    But as investigators probed deeper into the boy's life, they began to see a jumble of contradictions. Why would he target a skyscraper after telling friends that he abhorred the World Trade Center attacks and wanted to go to Afghanistan and ''get the SOBs''? Why would an honor student who knew patriotic songs by heart and aspired to join the Air Force sympathize with bin Laden, the nation's No. 1 enemy? Why would he tell his grandmother that if anything happened to him he didn't want his ''enemies'' coming to his funeral, a request similar to one made in the last will and testament of suicide pilot Mohamed Atta? Bishop had warned a friend in an e-mail just hours before his Jan. 5 flight that he was ''going to be on the news.'' But few imagined anything like this.
    With the images of the crash still fresh, investigators are working on a ''psychological autopsy.'' But they acknowledge that they may never know what motivated Bishop, and that the answers may have vanished with him into the hole he left in the skyscraper's 28th floor. Always eager to fly, Bishop arrived 10 minutes early for his 5 p.m. flight lesson at National Aviation Academy at St. Petersburg-Clearwater International Airport on that Saturday. ''He seemed happiest when he was involved with anything related to aviation,'' relatives would write later in a ''family remembrance.''
    His grandmother, Karen Johnson, dropped him off for what was to be his first night flight. Earlier that day, he had told her that if something happened to him, he didn't want his ''enemies'' coming to his funeral and not to tell his father, from whom he was estranged. A dispatcher handed the boy the paperwork for that day's lesson ''touch-and-go'' landings and a key to the airplane, loaded with 40 gallons of fuel. Then Bishop was buzzed out to the ramp where the planes are parked. He was supposed to wait for the flight instructor to finish another lesson. Before anyone noticed, however, the boy hopped in the plane and took off. He easily could have crashed on the runway, flight school owner Robert Cooper said. The plane's brakes were not on, meaning it could have lurched forward when he started it or hit someone or another plane. ''By the time we realized it, he was rolling,'' Cooper said. ''You can't tackle an airplane.''
    Flight school officials alerted the Clearwater control tower as the red-striped airplane buzzed over Tampa Bay, hooking eastward over the restricted airspace of U.S. Central Command headquarters, which directs the military's actions in Afghanistan. The plane flew 1,000 feet over Southwest Flight 2229, which had just taken off from nearby Tampa International Airport with 114 passengers and five crew members aboard, causing the jet to make a shallower climb on its path to New Orleans. The North American Aerospace Defense Command scrambled two F-15s from Homestead Air Reserve Base in South Florida as a precaution. The pilot of an orange-and-white Coast Guard helicopter used hand signals to try to get Bishop to land, but the teen never responded. Cooper said the plane's radio was likely turned off. Twelve minutes after he took off, Bishop's plane struck the 28th floor of the 42-story office tower, scattering office furniture and a black leather chair in a law office. Just an hour earlier, an attorney had been at his desk in the corner office.
    Friends and teachers say Charles Bishop was shy but friendly. An honors student who loved classical music and shunned rock and rap. A student councilman who had three mixed-breed dogs. He had bounced from school to school in his home state of Massachusetts, Atlanta and the Tampa area. He rarely spoke of his father, Charles Bishara, whom investigators have so far been unable to locate. Shy when he arrived at Dunedin Academy for the eighth grade, Bishop quickly became popular in his class of 20. Dressed in their red, white and blue uniforms, students gathered every morning to sing patriotic songs after a flag-raising ceremony. Bishop volunteered to hold the gold-fringed flag and would belt out ''The Battle Hymn of the Republic,'' ''America the Beautiful'' and ''My Country 'Tis of Thee.'' ''When we sang it you would hear his voice the loudest,'' said Danielle Parker, his computer science teacher.
    Last year, Bishop helped publish a book of essays about Christmas, which he called ''my favorite holiday.'' ''People who celebrate the holiday of Christmas should not be selfish. Rejoice! Be thankful!'' he wrote in his essay, titled ''True Christmas Spirit.'' ''Some people have nothing to be thankful for and are severely depressed.''  The boy's mother pre-registered him for high school last February but then changed her mind, headmaster Dale Porter said. In a May 14 letter, she said a ''sudden, critical illness in the family'' would prevent her son from attending his eighth grade graduation and continuing at the school. ''Thank you for providing Charles with a safe and happy school year,'' she wrote. By August, Bishop was among more than 2,000 students at East Lake High School, where he was remembered for wearing sunglasses in class and silently gazing out the school bus window.
    Following the attack on the World Trade Center, 15-year-old Emerson Favreau recalled that Bishop ''hated bin Laden.'' Cooper, at the flight school, said Bishop wanted to ''just go over there and get the SOBs.'' The flight school's operations manager, Doug Cunningham, said his pupil was angry that private planes were grounded after the attacks. In an e-mail, Bishop said student pilots should be required to wear identification badges to increase safety.
    In the days before the Christmas holidays, Bishop's honors-level English class was reading ''Romeo and Juliet'' but Shakespeare's tale of teen suicide never seemed to bring out a response in him, said teacher Andrea Panarelli. ''We didn't get to Act V. Everyone was still alive when we left on the 21st'' of December, Panarelli said.  Before his fateful flight lesson, Favreau said Bishop sent him an e-mail saying he was going to be on the news.  ''When I heard a Cessna hit the building, what he said popped into my head. I knew that's what he flew,'' Favreau said. ''And when they said it was a 15-year-old East Lake High School student, I knew it had to be him. But I kept hoping.''
    Grim-faced investigators from state and federal agencies gathered at Tampa Police headquarters the day after the crash. Tampa Police Chief Bennie Holder said the case will likely be ruled a deliberate crash caused by a suicidal teen. Still, the Hillsborough County Medical Examiner's Office is conducting a ''psychological autopsy.'' James Sewell, regional director of the Florida Department of Law Enforcement, has asked his agents to find out ''what makes this kid tick.''
    The theories of his death abound. ''I think he wrote the note to get publicity so people would know who he was when he died,'' classmate Favreau said. ''And they do.'' Investigators learned that Bishop had been prescribed Accutane, a powerful acne medication which has been under federal investigation for its links to suicide and depression.  Detectives also took note of his parents' own brush with suicide, though a family lawyer said the boy knew nothing of it. In 1984, his mother and father joined in a suicide pact when they were denied a marriage license because of insufficient documentation. The pact ended when Bishop's mother, then 17 and known as Julia Detore, was arrested for stabbing Charles Bishara, 19, with a 12-inch butcher knife. Charges were dropped when Bishara refused to cooperate with prosecutors. The couple married after their son was born in 1986 but divorced when he was a baby. Julia Bishara later changed her name and her son's to Bishop. ''It was a very depressing time for her,'' said family attorney Pamela Campbell on Friday. ''Through that tragedy hope was born.''
    The lawyer said Bishop's distraught mother still has no insight into the crash and remains unsure whether it was a suicide or an accident. ''At this point in time, she really doesn't know what to believe,'' Campbell said. If investigators ever determine what prompted Charles Bishop's dramatic act, the next step is to find ways to prevent it from happening again. Some investigators including the National Transportation Safety Board's lead investigator Butch Wilson doubt that's even possible. ''You can't protect people from someone who is bound and determined to do themselves in,'' he said.

HMO Arbitration Case Heads to Supreme Court
Judy Peres, Chicago Tribune- 1/13/2002

The U.S. Supreme Court this week will take up a patients' rights case that could determine whether disputed medical decisions are arbitrated by doctors or by managed- care administrators. At stake is the Illinois HMO Act and similar laws in three dozen other states that call for binding review by an outside physician when the patient's doctor and the health maintenance organization disagree on whether a procedure is medically necessary.
    Debra Moran of west suburban Winfield sued under the little-known law when her HMO refused to cover treatment recommended by her doctor. "Who should decide whether something is medically necessary--a doctor who has no [financial] interest in the outcome, or an insurance company?" said Moran's attorney, Daniel Albers of Chicago. "The Illinois legislature has decided to protect citizens by saying the doctor will decide." Albers is scheduled to argue his case before the justices Wednesday.
    He will be opposed by John G. Roberts Jr. of Washington, representing Rush Prudential HMO. Roberts says those state laws are superseded by a federal law and therefore are not enforceable. As he sees it, the Moran case will help determine whether employer-sponsored medical plans are governed by uniform federal rules or by the laws in different states. "If there are 50 different sets of rules that makes it more expensive for companies. And the more expensive the plans are, the less likely companies will be to offer them," Roberts said.

No relief from rare condition
Moran, 31, a speech therapist, was insured by Rush (now Unicare) in 1996, when she was diagnosed with a rare condition that caused debilitating pain in her right shoulder. Conservative treatments by doctors in Rush's network failed to provide relief. "I went to orthopedists, rehab doctors and physical therapists but the pain would always come back," Moran said. She says she was getting worse when she heard about Julia Terzis, a surgeon in Norfolk, Va., who had excellent results with patients like her but did not belong to the Rush network. Moran's primary-care physician agreed that treatment by Terzis was Moran's best bet. But Rush refused to cover the specialized microneurological surgery Terzis recommended, proposing instead a less expensive operation by a Rush-affiliated thoracic surgeon. That surgeon gave Moran a one-third chance of getting better and an equal chance of serious adverse consequences, including possible paralysis.
    Moran didn't like those odds. After several appeals failed to change the HMO's decision, Moran went to court to force Rush to submit to an independent review, as required by the Illinois law. But even after the outside specialist decreed the microsurgery medically necessary, Rush denied coverage. Moran eventually went to Norfolk and had the operation at her own expense. The procedure and post-surgical care cost nearly $95,000, for which Moran then sued the HMO.
    Rush's defense is that the Illinois HMO Act is pre-empted by the federal Employment Retirement Income Security Act, known as ERISA, which governs employee benefit programs. Though Rush won at the trial level, the U.S. court of appeals in Chicago ruled last year that ERISA does not bar enforcement of the state law and that Rush should have paid for the surgery. Last summer the Supreme Court agreed to hear Rush's appeal.
    Lined up in support of Moran are the U.S. government, the State of Illinois and the American Medical Association, among others. Dr. Donald Palmisano, secretary-treasurer of the AMA, said: "When Congress passed ERISA in 1974, they did not mean states wouldn't be able to regulate the practice of medicine." Rush Prudential HMO has the support of the health insurance industry.

`Tidal wave' of suits feared
Miguel Estrada, counsel for the American Association of Health Plans, said that if Moran wins, "it could expose the industry to a tidal wave of litigation." The Illinois HMO Act says managed-care organizations must submit to an independent physician review when the patient's primary-care physician recommends treatment the HMO declines to cover. The decision of the independent consultant is then binding on the HMO.
    According to the language of the federal statute, ERISA supersedes "state laws . . . [that] relate to any [covered] employee benefit plan." But the law also says state laws that "regulate insurance" are generally exempt from that pre-emption. The federal district court in Chicago ruled that Rush was justified in not paying for Moran's surgery because her suit was essentially a claim for benefits and, as such, was pre-empted by ERISA. The U.S. Court of Appeals for the 7th Circuit reversed that decision, saying there was no conflict between the Illinois law and the federal law. Another federal appeals court, however, reached the opposite conclusion in a similar case from Texas.
    About 57 percent of private sector workers--some 58 million people--get their health insurance through employee benefit plans covered by ERISA, according to the U.S. Department of Labor. "ERISA is one of the most important health-care policy issues," said Peter Hammer, law professor at the University of Michigan. "And the scope of ERISA pre-emption is about as big of an issue as you can get."

Suicide Crash Revives Accutane Questions
Shankar Vedantam, Washington Post- 1/13/2002

Accutane, the acne medicine that was prescribed to a Florida youth who crashed a plane into a skyscraper on Saturday, has long been controversial, with critics and proponents debating whether the drug can cause depression and suicidal behavior. While no definite link has been demonstrated, the Food and Drug Administration was concerned enough about the possibility to require the drug carry a warning: "Accutane may cause depression, psychosis and, rarely, suicidal ideation, suicide attempts and suicide," states the medicine's warning label, which was agreed to jointly by the agency and the manufacturer, Hoffmann-La Roche.
    Steven Galson, acting director of the FDA's Center for Drug Evaluation and Research, said one small study had showed that "when people took Accutane [they] became depressed and when they had the Accutane taken away, the depression went away." "That's the evidence that there could be a causal link," he said. Because the study was so small, a prospective trial is being designed with the company to study the matter. It is just as likely to find a link as not, he said.
    Attention has focused again on Accutane after investigators found that a prescription for the drug had been written for Charles Bishop, 15, who crashed a small airplane into a Tampa building last week. Police said a note found in the wreckage professed solidarity with Osama bin Laden. After teachers described him as a bright and patriotic youth, his behavior seemed all the more incomprehensible.
    Accutane has been on the market since 1982 and has been used by hundreds of thousands of people. A half-million prescriptions were written in the United States last year, the manufacturer said. It is reserved for intractable cases of acne and is sold under an increased security prescription system, mostly because pregnant women taking the medicine are liable to have babies with birth defects. The medicine is not given to pregnant women, and doctors strongly urge women not to become pregnant while taking the medicine.
    While the FDA has about 140 reports of suicide after people took Accutane, the rate of suicide remains extremely low, making it difficult to pin down which cases might have occurred anyway and whether cases were caused by the medicine. Carolyn Glynn, vice president for public affairs at Hoffmann-La Roche, said the rate of suicide in the group of 15- to 24-year-olds taking Accutane was lower than the rate of the general population. "Acne is closely related to depression -- there are strong psychological scars that go with the condition," she said, explaining why Accutane could reduce depression.
    Douglas Jacobs, a Harvard Medical School psychiatrist who conducted a review of the drug for Hoffman-La Roche, said "the overwhelming evidence is there is no causal link." "My worry is it is going to be legislated out of existence, and then you will have many more suicidal kids because they can't get their acne cleared up," said Lawrence Green, a Rockville dermatologist.  Experts agreed that no conclusions could be drawn in Bishop's case without knowing whether he was taking the drug, whether he had a history of psychiatric illness and whether his behavior changed after he took the medicine. James O'Donnell, a pharmacologist at Rush Medical College in Chicago, has testified against Hoffman-La Roche in court cases. He said that while he did not want the medicine banned, "we need to make sure there is no over-promotion by the company suggesting either in advertising or by their sales force that this is not a significant side effect."

Numbers Don’t Support Accutane, Suicide Link
John Allen Paulos, ABC News- 1/13/2002

Reports have surfaced that Charles Bishop, the 15-year-old who flew a small plane into a Florida skyscraper last week, may have been taking the acne medication Accutane and that this might have accounted for his suicide. Such speculation stems from the 37 suicides and 110 suicide attempts among users of the medication since its introduction in 1982. Whatever plausibility such a conjecture might have, however, is diminished by other numbers.
    It's estimated that 500,000 Americans, mostly teenagers, take Accutane annually so something on the order of 10 million have taken it since its debut. The number of different people who have taken the medication is no doubt considerably lower since some take it for more than a year and are thus counted among the 500,000 in more than one year. So let's cut the 10 million figure by more than two-thirds and estimate that 3 million different people have taken Accutane since 1982. If roughly 150 of them either committed or attempted suicide, we determine that approximately one in 20,000 committed or attempted suicide.
    But the overall suicide rate (successes, not just attempts) for teenagers is approximately 10 per 100,000 or one in 10,000. This is much higher than the rate among Accutane users! If we were to draw any top-of-our-head inference from the figures, it would be that Accutane has a prophylactic effect and lessens the risk of suicide, not that it causes it.  If Accutane is associated with a reduced risk of suicide, it may be because untreated acne itself sometimes leads to suicide. Or it may be because teenagers who care about their appearance are less likely to attempt suicide.   In any case, even a superficial look at the numbers involved strongly suggests that Charles Bishop's demons came from elsewhere and were more than skin deep.

Freed Colorado Sex Offender Arrested
Denver Post, 1/14/2002

GREELEY - A man who was among dozens of imprisoned sex offenders released by a Colorado Supreme Court decision last year has been arrested again on suspicion of sexual assault on a child. Joshua Daniel Trujillo, 26, of Greeley, was arrested Dec. 28 on accusations he forced a 14-year-old boy to perform a sexual act. He was being held in lieu of $10,000 bond.
    Faced with conflicting state laws, the state Supreme Court last summer determined that some sex offenders were wrongly sentenced to lengthy parole terms by the wrong statute. The decision affected roughly 1,500 sex offenders, some of whom were serving prison terms for violating parole that they should not have served.
    In 1994, Trujillo was accused of attempting to force himself on a 5-year-old girl and 10-year-old boy, according to court records. In a plea bargain, Trujillo pleaded guilty to third-degree sexual assault. He served three months in jail and was sentenced to six years of probation. He was later sentenced to three years in prison for violating terms of his probation. He had failed to attend sexual-offender classes or report to his probation officer. Trujillo is the second sex offender released by the Supreme Court to be accused of new charges in Weld County. Vance Martin, 35, of Fort Lupton, was arrested in early December for investigation of charges including sexual assault on a 14-year-old victim.

Therapists Becoming Life Coaches
Eils Lotozo, Knight Ridder Newspapers- 1/14/2002

PHILADELPHIA -- After 20 years as a psychologist, helping to mend frayed psyches, Ralph Jaffe needed a break.  "This is very wearing work," said Jaffe. "We are dealing all the time with human pain." Two years ago, he added a sunnier sideline to his work. He became a personal coach, counseling achievers in their quest for more.
    Pummeled by managed care and weary of a steady diet of depressed patients, mental-health practitioners are finding a satisfying and lucrative new source of clients in personal coaching -- acting as paid cheerleaders for generally high-functioning people. "With coaching, you can come to see me when your life is going well and you just want it to go better," said Jaffe, whose practice is now one-quarter coaching.
    Matt Dansker, a stockbroker from Cherry Hill, N.J., hired Jaffe to help him retool his approach to his job after a market downturn. "I thought it was the perfect time to get a partner, maybe someone who could guide me and get me to think a little bit differently," Dansker said. "I guess I needed some support that even a family member or friend couldn't give." Dansker said Jaffe has helped him with structure and discipline and has worked with him on nutrition and establishing an exercise program. "I expected he would help me at work, but it really crossed over, because life isn't 9-to-5," Dansker said.
    Personal or life coaching was pioneered in the 1980s by Salt Lake City financial planner Thomas Leonard, who found his clients seeking broader life advice. Mentors can be hired, over the phone, for about $100 a half-hour.  Mental-health practitioners are flocking to the booming field. According to a survey published in October 2000 by the newsletter Psychotherapy Finances, 20 percent of therapists now offer coaching. And coach-training programs designed specifically for mental-health professionals are burgeoning.
    Many practitioners are fleeing managed care and its severe limits on therapist visits, said Ben Dean, founder of a training program in Bethesda, Md., called MentorCoach. "You find yourself arguing with a clerk, begging for two more visits for a patient you really know needs six months to make progress," he said.
    Many therapists say the freedom to coach over the phone is a big attraction. "I can be anywhere and do a coaching session," Jaffe said. But therapists say the real draw is the chance to offer their skills to a new world of clients: can-do types chasing their dreams, people who would never seek the counsel of a therapist. "The word coaching has no stigma," said Diana Adile Kerschner, a coach and therapist. "It doesn't indicate in any way that they have personal problems. It indicates they want to achieve and create their future."
    MentorCoach graduate Jeffrey Kaplan has shifted his psychotherapy practice to nearly half coaching. A recent morning found Kaplan pacing his home office, phone pressed to his ear in an introductory coaching session with Sarah Funt, a real estate agent from Bethesda, Md. Her reason for seeking Kaplan's help? "Work tends to consume me," said Funt, who confessed she routinely worked 14-hour days. Over the half-hour, Kaplan listened and probed, finally pushing Funt to focus on change. "If you were to move one little notch forward to honor a little more personal time, what might you do?" he asked. The two came up with a goal: One morning a week, Funt would make no appointments and not answer her phone until 10:30. "That's great," said Kaplan. "If you try to change too quickly, often the gremlins of resistance come up."
    While more therapists may be embracing coaching, they still have qualms about the unlicensed and unregulated nature of the field. There are voluntary industry certification programs, but anyone, trained or not, can advertise as a coach and solicit clients. "Some people are just intuitively natural coaches," said Melinda Vilas, spokeswoman for Coach U, founded by the coaching pioneer Leonard. Most therapists-turned-coaches don't buy that, insisting that they are the best-qualified. "People get more when they come to a coach who is a clinician," said Dean, the MentorCoach founder. "We've got thousands of hours of working with people, and a century of social-science research and practice behind us."

John Walker's Restless Quest Is Strange Odyssey
Rene Sanchez, Washington Post- 1/14/2002

MILL VALLEY, Calif. -- Before he became known on battlefields in Afghanistan as the holy warrior Abdul Hamid, or had shocked his doting parents by adopting the Muslim name Suleyman, John Walker Lindh walked into a mosque in this foggy hillside town near the Golden Gate Bridge five years ago eager to learn about a religion that would soon dominate his life.
    He was shy and studious, a lanky 16-year-old who had a basketball hoop in his driveway but showed little interest in predictable teenage pastimes. And his strange odyssey was about to begin. "He was a good person, a quiet person," said Abdullah Nana, 23, who often prayed with Walker on the red carpet of the Islamic Center of Mill Valley and gave him rides home because he did not have a driver's license. "He was accepted and respected for his dedication. No one like him had ever come here before."
    As his devotion grew, Walker would get rid of his coarse collection of more than 200 hip-hop and rap CDs and begin wearing an ankle-length white robe. He would forsake an easy path to college to travel alone to remote villages in Yemen and Pakistan. He would try to memorize the Koran. And he would scorn the peace-and-love precepts of his parents to take up arms with the harshly conservative Taliban. "When he left, he just said that he wanted to learn Arabic and follow Islam full time," Nana said. "We thought it would be beneficial for our community, because no one else here had gone to study overseas the way he wanted to. We thought he would be a pioneer."
    Instead, Walker has become a puzzling prisoner of war, the lone American caught with enemy forces in the aftermath of the Sept. 11 terrorist attacks, dragged filthy and wounded from a medieval fort with other defiant al Qaeda fighters last month. U.S. military officials have Walker in custody, and President Bush is preparing to decide his fate. He could be prosecuted for treason or aiding terrorists, charges that could bring the death penalty or many years in jail.
    But much of Walker's journey is still a mystery. Was he just an innocent abroad, an impressionable young scholar swept up in a movement he did not fully understand -- "brainwashed," as his mother, Marilyn Walker, has suggested? Or was he a teenage rebel with a cause, renouncing the have-it-all, progressive suburban culture from which he came and duping his parents into believing they were supporting, and financing, a purely spiritual quest?
    His father, Frank Lindh, has said he was astonished to discover that his son had even gone to Afghanistan, much less to help the Taliban. "He never came to his papa to ask for permission," he said. But Frank Lindh's son did not sound clueless or contrite while lying on a hospital bed shortly after his capture. As a doctor tended to his wounds, a CNN correspondent asked him whether he thought he had been fighting on the right side. "Definitely," Walker replied. He seemed dazed. But was he?

'A Birkenstock Family'
Frank Lindh had just received a master's degree in social work when he and Marilyn Walker had their second child in February 1981. They decided to name him John, partly in homage to Beatle John Lennon, who had been murdered by a deranged fan two months earlier. The couple were renting a house in Takoma Park, settling into new roles as middle-class parents after coming of age in the counterculture of the 1960s. Neighbors say they were Sunday regulars at St. Camillus Catholic Church, took an interest in natural foods and medicines, and embraced the People's Republic politics of the community. Both parents declined to be interviewed for this story, but answered a few questions through their lawyer. They also spoke to reporters briefly after their son's capture. "They were kind of a Birkenstock family," said Chris Madison, who lived near them. "Very earnest, very nice, very intellectual." "They were liberal in the classic sense," said Dan Parr, another neighbor. "They said they really wanted to let their children develop by giving them different experiences."
    John showed promise. By fourth grade, he was among a select group of students in the "gifted and talented" program at Kensington Parkwood Elementary School. His parents appeared to be deeply involved in his life. "They seemed like such a happy family," said Judy Colwell, who had a child attending the same school and became friends with Marilyn Walker. Lindh had decided to pursue a career in law, working as a clerk in the solicitor general's office of the Justice Department by day, attending Georgetown law school at night. But he was the rare father who also found time to attend PTA meetings.
    Walker, a stay-at-home mom, chaperoned school field trips and earned a little money by taking jobs at retail stores during the holiday season. She was busy raising John and two other children, a boy a few years older than him and a baby girl. She also had become something of a local activist. Neighbors recall her waging a zealous campaign to have a metal slide at a local playground removed, saying it was too dangerous for children. But some old friends of the couple remember thinking that they might be pampering the children a bit too much -- like the time, one neighbor recalled, that John told classmates that his parents had taken him to a therapist to cope with the death of a pet.
    The first big change in John's life came when he was 10. Frank Lindh, who had graduated from Georgetown with honors and was working at a Washington law firm, decided to move his family west. He had accepted a job at the firm's San Francisco office and bought a multi-floor modern home on a narrow, leafy street amid the lush hills and redwood groves of Marin County, another place with a tolerant, liberal creed. "I figured they would fit right in," Dan Parr said.

Home in a California Cliché
The joke about Marin is that it is a California cliché, a hot-tub haven that values nothing as much as self-discovery. It is a community where the local Center for Massage Therapy is celebrating its 25th anniversary and graying lefties in fleece vests walk the streets sipping chai tea. But it also is one of the wealthiest counties in California, a land of $300 strollers, crowded SAT prep classes, and chic cafes crackling with chatter about high-speed modems and ski trips to Tahoe.
    It is also a place willing to dabble in novel educational trends. So, too, were Frank Lindh and Marilyn Walker. They decided to send John to a small, new public high school that had a rare teaching philosophy: It held no classes. Tamiscal High School, which opened in 1991, was designed for academically elite and creative students, a select group of highly motivated self-starters. John Walker made the cut. He had to take the same courses as any other high school student in California, but the curriculum was more rigorous and far-flung. And he had to show up only once or twice a week for one-on-one meetings with teachers. "The kids here are not flaky or wacky, they're very serious," said Bill Levinson, superintendent of the local school district. "It's not easy. The biggest challenge is that you don't depend on teachers telling you what to do." John had to study world cultures and try his hand at poetry and read "The Autobiography of Malcolm X," the story of an aimless petty criminal whose life is transformed by his conversion to Islam. Lindh has said that the epic tale seemed to captivate his son.
    The teenager began spending his unscripted days asking questions about Islam in Internet chat rooms and expressing moral doubts about some of the rap musicians he had liked. On one Internet posting under his name, he questioned why one rapper whom someone else in the chat room apparently had called a "god" deserved such adoration. "If this is so," Walker wrote, "then why does he smoke blunts, drink Moet, fornicate and make dukey music? That's a rather pathetic 'god,' if you ask me."
    His family was changing, too. Frank Lindh had taken a job as a staff attorney for corporate giant Pacific Gas and Electric Co., and Marilyn Walker, once an avid Catholic, began practicing Buddhism. But Jay Murphy, who lived next door, said the family seemed content. "They were kind people, very intelligent," he said. "They were all doing their own thing."
    In 1997, at 16, John Walker dropped out of Tamiscal. His family says it was because he had an intestinal illness. He took and passed a state proficiency exam to earn a high school diploma. Then he announced that he was changing his name and converting to Islam. Family friends say that both of his parents struggled at first with the decision, then were struck by how committed he seemed to be. Lindh has said that his son reminded him of a "Catholic seminarian." Marilyn Walker worried about some Islamic views on the rights of women but believed local mosques were not militant. "They were very supportive," said Bill Jones, a friend of Frank Lindh. "It was all very spiritual. He wasn't angry, and it had nothing do with politics."
    The family was not apolitical, however. About that time, Marilyn Walker took their 9-year-old daughter, Naomi, to a small local demonstration denouncing U.S. bombing raids over Iraq. The Marin Independent Journal ran a photo of the girl standing amid a few dozen protesters waving signs at passing traffic that read, "Don't Kill Iraqi Kids."
    Not long after John Walker converted to Islam, he told his family that he wanted to live and study in Yemen, at a school where he could learn a dialect of Arabic that would allow him to read the Koran in its original language. Again, his parents obliged. But it was no longer a happy household. Frank Lindh and Marilyn Walker separated. She moved into a nearby apartment. He rented a room from Jones. John left home for the first time. He would not return for nearly a year.

First Sign of Trouble
In hindsight, the first sign of trouble may have been an e-mail Frank Lindh has said he received from his son in the fall of 2000, after the USS Cole was bombed while it idled in a port in Yemen. The terrorist attack, which U.S. officials blamed on Osama bin Laden, killed 17 U.S. sailors. Lindh told John how upset he was by the incident. From overseas, the son sent back a surprising message. Lindh has told reporters that his son wrote that the U.S. ship should not have been docked in an Islamic country.
    By then, the teenager had embarked on his second extended stay in the Middle East. After his first trip to Yemen, he had returned home to Marin for about eight months in 1999. But Nana, his friend at the Mill Valley mosque, remembers that he was restless and said that he no longer felt comfortable in a place where Islam was not a way of life. Walker spent much of his time visiting other mosques in the San Francisco Bay area. Family friends say his parents were not worried. He was talking about going to medical school, then returning to Pakistan to aid the poor -- "on a mission of mercy," Jones said.
    Not long after the Cole bombing, John Walker told his parents he was traveling to Pakistan, to attend another religious school. Accounts from the time that he spent there are sketchy, but a school official has told reporters that Walker was an intense, solitary student. After his capture, Walker told CNN that during his studies his "heart became attached" to the Taliban because the movement had strong support in the region. "I started to read some of the literature of the scholars, the history of the movement," Walker said. "I wanted to help them one way or another."
    Last April, Walker told his parents in an e-mail that he was still studying the Koran and might travel "someplace cooler" for the summer. Lindh has said that his son did not mention Afghanistan, or hint that he had any other plans but to study. He had not been home in more than a year. But he asked his father for money. Lindh wired $1,200. He did not hear from his son again for eight months.

'I Am in Safe Hands'
"Dear Mama and Papa," Walker, a bedraggled new captive of the U.S. military, began in a brief letter to his parents a few weeks ago. "I apologize for not contacting you in such a long time. I realize this must have caused you a lot of grief. I am currently alive and well in Afghanistan and I am in safe hands. I cannot give you many details about my situation but it would be good to hear from you all." He had just survived a bloody uprising of captured al Qaeda fighters in the northern Afghan city of Mazar-e Sharif. Johnny "Mike" Spann, a CIA officer who had been questioning prisoners, including Walker, was killed when the riot erupted.
    From a hospital bed, Walker told CNN that he did not see or take part in the uprising because he was hiding in a basement of the fort with dozens of other captured Taliban fighters. They did not surrender until Afghan and U.S. forces bombed the compound, then dumped burning oil into the basement, then flooded it with cold water. In a groggy interview, which CNN broadcast last month, he also said that he had been in Afghanistan for six months, had been assigned to a branch of Arab fighters in the Taliban army, and had trained at several camps in the country. With only a faint American accent, a world away from the comforts of his former life and the mild-mannered mosque where his spiritual search began, Walker said that he had volunteered for the fighting. "It's exactly what I thought it would be," he said, softly.

The Therapy Generation
Leslie Berger, New York Times- 1/14/2002

Thousands of college students seeking mental health services at university counseling centers are forcing campus mental health services to reevaluate their mission and expand. This fall, partly in response to highly publicized suicides and partly because of growing recognition of mental health needs, Columbia, the Massachusetts Institute of Technology and the University of Michigan began new research projects and programs aimed at improving their services. Concerns remain, however, over waiting times for appointments and frequent referrals off campus, especially at suburban and rural colleges with long commutes to medical centers and limited public transportation.
    Columbia's counseling service reports a 40 percent increase in use since the 1994-95 academic year. Illustrating experts' views that the Ivy League is not alone in increasing demand, the State University of New York at Purchase has seen a 48 percent increase over the last three years. The events of Sept. 11 and since have further strained resources. On the Purchase campus, for example, counselors saw almost as many students during the fall semester as the entire 1997-98 school year. "We are drowning here," says Robin Kaufman, director of the SUNY-Purchase counseling center. "Right now, if it's not an emergency, it's two to two and a half weeks to get an appointment. Plus, students seen on a regular basis are getting bumped."
    The classic concerns of students--leaving home, fitting in, forming relationships, doing well, finding the right career--have been complicated by more split families, more lifestyle choices, the alienating effects of technology, constant bombardment of information, a shrinking economy and mounting academic pressure. "College does not exist independently of society," says Vivian Boyd, director of the counseling center at the College Park campus of the University of Maryland. "The whole notion of the divorce rate among parents, the economic shifts that are occurring, the disappearing of whole classes of jobs that people used to count on going into, the fact that the degrees of freedom of making choices in your life are growing shorter and shorter because the cost of being wrong comes at a higher price--there are societal pressures that exist independent of the college environment to which young people are responding." "People are being exposed to all kinds of things at a much earlier age, including pressure to compete," Dr. Boyd adds. "How many people do you know who don't have a 3-year-old in some sort of preschool program?"
    Though upperclassmen are hardly exempt and comprise a proportionate share of campus counseling patients, separation from home and old friends and the double-edged sword of freedom can make freshman year especially disorienting. Martin E. Seligman, a widely published author and research psychologist at the University of Pennsylvania, tries to prevent depression in freshmen by teaching those at greatest risk how to defend themselves against pessimistic thoughts. A modern-day proponent of old-fashioned optimism, he offers training sessions for 8 to 10 students aimed at disputing negative thinking. The idea is to catch yourself in self-defeating thoughts like, "This is going really badly." "I've really lost my touch," Dr. Seligman says, and then to build up a mental argument for why that isn't so. For the last 11 years, in a program replicated elsewhere, Dr. Seligman has been sending a questionnaire about pessimism and optimism to all students admitted to the University of Pennsylvania. Those who rank among the most pessimistic (viewed as more susceptible to depression) are urged to participate in the workshops.
    Researchers at the University of Michigan in Ann Arbor also hope to catch depression early through detection and intervention. A new Comprehensive Depression Center, announced in November, will also treat students as part of the university's mental health system, according to John F. Greden, its director and chairman of the department of psychiatry. "These disorders are treatable," he says. "The progression is generally preventable." Eventually, the program is supposed to be consolidated within a proposed $32 million building.
   M.I.T., criticized for having the highest student suicide rate in the country, similarly announced plans in the fall for a major overhaul of its mental health services. Changes include extended appointment hours, 100 percent insurance coverage for off-campus services, and an education and outreach program aimed at making students more comfortable seeking help. In its mental health task force report in November, M.I.T. showed a 50 percent increase in the use of its mental health services between 1995 and 2000. It also showed an increase of about 69 percent in student psychiatric hospitalizations, "reflecting a growing number of students with serious mental health concerns."
    Though the reaction to the 9/11 disaster has been felt more keenly closer to New York City, marked increases in traffic at counseling centers, an estimated 17 to 22 percent, have been seen across the country, according to Dr. Matthew Boyd of the International Association of Counseling Services. Counseling centers traditionally see an increase during late fall because visits home and the approach of final exams tend to stir strong emotions. But Dr. Boyd and others suspect the sharp rise reflected a response to the terrorist attacks, although a direct link is hard to pin down because many first-time patients describe classic symptoms of distress without specifically mentioning hijackings, war or bioterrorism.
    "They can't concentrate, and they can't understand why," says Dr. Kaufman at SUNY-Purchase, a suburban campus about 45 minutes north of New York City. "They have lots of anxiety, they can't get out of bed. Basically, it feels like a very unsafe world." But the apparent reaction to 9/11 only underscores issues that campus mental health workers were already seeing. To begin with, Dr. Kaufman and others note, the college years are when depression and other mental illness tend to first manifest themselves. College itself does not cause depression, but its stresses, including sleep deprivation and substance abuse, can trigger depression in those already vulnerable, as some 15 percent of the general population is believed to be. Moreover, some research shows that depression among young people has been steadily increasing, Dr. Seligman says. "It's gone from being a housewife's disorder to a student's," he says.
    Dr. Seligman blames cultural factors for building an emotionally fragile generation, including a self-centered society and victimology, or "the belief that when bad things happen, you played no role, it was done to you." "It's learned helplessness," he says, "and when you feel helpless, that's a recipe for depression." The self-esteem movement has also backfired, Dr. Seligman says, by causing children to become addicted to constant praise.
    Anti-depressants and Ritalin may also account for a greater number of students going off to college with psychiatric histories. For the last several years, 85 percent of those polled by the National Survey of Counseling Center Directors reported seeing more college students with severe problems, including learning disabilities, clinical depression and bipolar disorder. "Many who wouldn't have made it to college in the past now do so because of medication," says Robert P. Gallagher, the author of the annual survey and former director of the University of Pittsburgh's counseling center.
    "Anybody capable of doing the work ought to have a crack at it," Dr. Gallagher says. "But it's putting more pressure on the people providing the services. It's a bit of a struggle because many centers have gone to briefer-term interventions in the last 10 years or so. Those with more serious problems obviously need more time, and many have gone to 8- or 10- or 12-session limits. And it's harder to find places to refer students because community mental health places are also overwhelmed."
    Several of these concerns played a role in the suicide last year of Candy R. Wei, a 20-year-old sophomore at the University of Michigan, according to her mother, Jing Wang, a professor of Chinese cultural studies at M.I.T. Ms. Wei suffocated herself with a plastic bag in her dormitory room on Jan. 16, 2001, apparently after learning that her appointment with a new, off-campus psychiatrist had been switched to another patient. Ms. Wei, an art and design major who had a five-year history of psychiatric treatment, had just returned to the campus from home after a breakdown during the fall semester. She and her mother had been anxious for her to quickly establish a rapport with a local therapist. But Dr. Wang says she had called three off-campus psychiatrists before finding one who could schedule a meeting with her daughter.
    Dr. Wang says that before her daughter came home, she had sought help at Michigan's campus counseling center but was told she had to wait a week and a half to see someone. "She felt so discouraged, she didn't want to go back," Dr. Wang says. Ms. Wei had also been to the university hospital's emergency rooms twice: the first time, she was told about its psychiatric emergency services, but she was not admitted; two days later, she went to psychiatric services with her mother, who had sensed her daughter was in crisis and had flown in to help her. A doctor recommended hospitalization. But Dr. Wang says that by then, after all the delays, she was not comfortable with the campus services and had just wanted to get her daughter home.
    "We consider Candy Wei's case a real tragedy," says a University of Michigan spokesman, Michael Harrison. "Although I can't comment on the specifics, I will say that we very carefully assess each patient and determine their care, under the guidelines of the American Psychiatric Association and our own experts, to develop treatment protocols. We hope that their family or their support system will take advantage of these treatment recommendations."
    Dr. Greden of the University of Michigan says that "mental health services in general, not just at the University of Michigan, are filled with gaps in providers and in coverage--our society has yet to step up to that." Is too much expected of universities? It seems, Dr. Greden responds, that they are being held to a different standard. "When corporations don't provide coverage for mental health, when insurance companies provide limits for coverage for mental health, it's puzzling that universities should have different standards," he says. "I wish all of us had a higher bar."

John Walker Lindh Bumbled His Way Through the Mideast
Margie Mason, Associated Press- 1/15/2002

SAN FRANCISCO -- John Walker Lindh bumbled his way through his first trip to the Middle East, unwittingly insulting other Muslims and repeatedly getting into trouble with authorities, say those who encountered the California teen-ager in Yemen. Ultimately, he came to feel that the brand of Islam he encountered in Yemen's capital was not fervent enough he even objected to having women in his classes, according to students and administrators at the school where he studied Arabic.
    Lindh, the 20-year-old American who was captured in November fighting with the Taliban in Afghanistan, traveled alone to Yemen at 17 in the summer of 1998. A recent Muslim convert, he stepped off the plane full of zeal. He donned white robes and sandals, wore a full beard, and even pretended to speak broken English with an Arabic accent before abandoning the school where his parents had paid thousands of dollars for a year's stay. Lindh instead sought more fundamentalist teachings in the country's dangerous northern mountains, but was repeatedly turned back by Yemen's military, said Steven Hyland, who taught English and studied Arabic at the Yemen Language Center. ''This is an individual whose idealism led to ideology and he lost all ability for pragmatic thought,'' Hyland said by telephone from Texas.
    It was not the first time he embarrassed the school, situated in the capital of San`a. That came the morning after his arrival, after he exchanged several hundred dollars a substantial sum in a country where the average civil servant earns about $75 a month. On his way back from the money market, Lindh saw beggars and decided to pay alms to the poor, one of the five pillars of Islam. ''When you give money to beggars in the street, you give them about 10 rials,'' Hyland said. ''He starts passing out 200 rial notes, which is way, way, way too much.'' Lindh was mobbed. A woman who worked at the school had to break up the crowd to protect the young American. ''John is in the middle of this whirlwind of people,'' Hyland recalled. ''He's much taller than the average Yemeni, with a fist full of cash just raised in the air with his left hand and with his right hand just duking the Yemenis away.''
    After that incident, Lindh told other students he was disenchanted with aspects of Yemeni culture and began skipping classes at the school, where about 15 language teachers instruct four or five students each in several elegant buildings near the city's center. ''From that point on, Yemenis weren't Muslims and that was the argument that he tried to make,'' Hyland said. Josh Mortensen, another student, said from Cairo that Lindh asked peers to call him Suleiman, affected a ''bogus'' Arabic accent and wore traditional Muslim garb unlike that of most Yemenis. Other foreign students at the school mockingly nicknamed him ''Yusuf Islam,'' the name pop singer Cat Stevens took when he became a Muslim and rejected his music career. ''That whole convert thing just doesn't compute for lifelong Muslims. It's almost like they're being made fun of in a way,'' Mortensen said. ''He was so clueless and so rigid, and it was almost patronizing. He adopts all these ridiculous stereotypes.''
    Lindh slipped up again by approaching another student, Rizwan Mawani, who happens to be a Shia Muslim, and asking for directions to a Sunni mosque. Lindh was adamant about not wanting to pray with Shiites, who are part of the other main branch of Islam. ''I wasn't insulted. I found it quite humorous,'' Mawani recalled in a telephone interview from London. In Yemen, Mawani said, Shia and Sunni Muslims typically pray side by side. Lindh was frustrated when he saw some Yemeni Muslims ignoring the calls to prayer, students said. He was particularly bothered when Mawani told Lindh he was more interested in taking a nap, Mawani recalled. Mawani said Lindh considered himself a Salafi, part of a movement whose members believe they are promulgating the true Islamic faith as taught by the prophet Muhammad in seventh-century Arabia. ''Yemenis speak one of the purist forms of Arabic, but it's not a fanatical country,'' said Barbara Bodine, U.S. ambassador at the time. ''Somebody looking for that fire-and-brimstone approach would get to Yemen and be very unhappy. It's simply not there.''
    The language center's owner, Sabri Saleem, said Lindh disappeared after complaining that his classes included women and that the secular school did not offer the Islamic studies he craved. Lindh's goal, other students said, was to reach the mountains of northern Yemen, a risky venture for an American teen-ager. Militants there have kidnapped or killed numerous Western tourists. ''John was problematic for the center because he kept trying to steal away to the northern part of the country because there was an Islamic theologian there that he wanted to study under,'' Hyland said. Saleem, interviewed by telephone recently while visiting the United States, said Lindh did not surface until police caught him at the airport months later. He had overstayed his visa and failed to get an exit visa.
    Lindh came home to Marin County, north of San Francisco, in the spring of 1999. Eight months later, he returned to Yemen, then went to Pakistan and then Afghanistan, where he fought with the Taliban. Now he is being held by the U.S. military as the Bush administration decides how to deal with him. Lindh's parents referred all questions to their lawyer, James Brosnahan. His spokeswoman had no comment on Lindh's stay in Yemen. Islamic experts said that in his naivete, Lindh, a baptized Roman Catholic who converted to Islam at 16, fell into a trap so common that Muhammad himself predicted it. ''A person who might have been living a typical happy-go-lucky life and then he really gets very much attracted to the teaching of Islam and its ideal, but then he wants to change overnight that's what the prophet actually was teaching against,'' said Jamal Badawi of the Islamic Information Foundation in Halifax, Nova Scotia. ''He said, `Go gently.''' On the Net: http://www.ylcint.com

Head Injury Linked with Depression
Lindsey Tanner, Associated Press- 1/15/2002

CHICAGO -- Concussions and other head injuries in early adulthood may significantly raise the risk of depression decades later, a study of World War II veterans found. The study has disturbing implications for football and hockey players, motorcyclists and others who have taken blows to the head. Other research has shown that head trauma patients may be prone to depression shortly after suffering their injuries. But the new findings suggest that the risk persists even 50 years later.
    The study involved 1,718 veterans hospitalized for various ailments during the war and questioned 50 years later. About 11 percent who had had head injuries said they currently had major depression, compared with 8.5 percent of those hospitalized during the war for other reasons. Overall, the lifetime prevalence of major depression was 18.5 percent in the head-injury group and 13.4 percent among the other veterans, Drs. Tracey Holsinger and Brenda Plassman of Duke University and colleagues reported in January's Archives of General Psychiatry. The researchers found similar depression rates in veterans who had received their head injuries in combat and in those whose injuries occurred elsewhere. Thus it is unlikely that post-traumatic stress syndrome, which can include symptoms of depression, would explain the findings, the researchers said.
    Plassman said the findings could mean that people who suffer head injuries today for example, football players or motorcyclists will have a greater risk of depression. A sizable portion of the veterans who suffered head injuries did so in non-combat situations such as motor vehicle accidents and sports, she said. The findings underscore the importance of recognizing the potential long-term risks of head injuries so that patients can get early treatment, according to an accompanying editorial. ''The lifelong nature of these disorders argues strongly for their identification and treatment to improve quality of life, and perhaps long-term survival,'' Drs. Robert G. Robinson and Ricardo Jorge of the University of Iowa psychiatry department wrote. Men with the most severe head injuries loss of consciousness or amnesia for a day or more faced a higher risk of developing depression than men with the most mild injuries those who blacked out or had amnesia for less than 30 minutes, the study found.
    While it is unclear how head injury is related to depression, Holsinger and colleagues offer some theories. Depression has been linked with dysfunction in the brain's frontal region, and research has suggested a strong link between depression and head trauma resulting in lesions in the frontal region, the researchers said. In addition, head trauma causes an inflammatory response that includes increased production of an immune system protein called interleukin 6, and increased levels of interleukin 6 also have been found in depression.
    The authors said the study is limited by a lack of information on when depression began. They said it is possible that some of the men with head injuries had a pre-existing psychiatric disorder that could make them prone to depression as well as head injury. But that is unlikely, they said, because that kind of ailment probably would have kept the men out of the military. On the Net: Archives: http://archpsyc.ama-assn.org National Depressive and Manic-Depressive Association: http://www.ndmda.org

High Court to Examine HMO Dispute Reviews
David G. Savage & Charles Ornstein, Los Angeles Times- 1/15/2002

WASHINGTON -- The Supreme Court on Wednesday will take up the health insurance industry's challenge to what many experts laud as the most promising legal reform in health care: independent medical review of HMO disputes. In recent years, California and 41 other states have adopted laws that give patients a right to a second opinion if their HMO refuses to pay for a medical treatment. These measures grew out of complaints from angry consumers and doctors, who alleged that medical decisions were being made by managed care firms that were determined to save money, even at the cost of their patients' health. Under these laws, an outside medical expert, or a panel of doctors, can review the patient's case and the HMO's decision. If it's concluded that the desired medical treatment was needed, the state can force the HMO to pay for it.
    If the high court strikes down state-mandated independent medical reviews, "it's like taking the metal detectors out of an airport on Sept. 12," said Daniel Zingale, director of the California Department of Managed Health Care. California would lose the power to require HMOs to provide such reviews to patients in employer-sponsored health plans. "It would cut the heart out of California's patients' bill of rights," Zingale said.
    Because the laws are new, experts say it is too early to evaluate their true effect. But researchers who have studied them are convinced they are a step in the right direction. "This responds directly to the backlash over managed care," said Karen Pollitz, a health policy researcher at Georgetown University who led a study of the independent review laws for the Kaiser Family Foundation. "If you are a consumer, you get to take your claim before an expert. . . . And you can get a fast answer to your question: 'If you were my doctor, would you have ordered this treatment for me?' "We found that about half the time, the independent review overturns the HMO's decision," she said.
    In California, HMOs have fared slightly better. Since last January, when independent reviews began in California, HMO regulators have handled 651 patient appeals. Of those completed, experts have upheld HMO decisions in 58% of cases and overturned 34%. In the other cases, health plans reversed themselves during the course of the appeal.

Insurance Industry Fights 2nd Opinions
During the 2000 presidential campaign, George W. Bush said independent review was the right solution to the managed care dilemma, saying it avoided costly and drawn-out lawsuits. Most in Congress agreed in the early debates over the proposed patients' bill of rights. While the legislation foundered over whether patients should be allowed to sue their HMOs for damages in state court, all sides portrayed independent review as a reasonable reform.
    Meanwhile, the health insurance industry began challenging state independent review laws in federal court, and its lawyers have won some key victories. Shortly after Bush praised the Texas system of independent review, the U.S. Court of Appeals struck it down as conflicting with federal law. The judges pointed to the Employee Retirement Income Security Act of 1974, which Congress passed to secure the pensions of American workers. The law set rules for retirement funds and other "employee benefits," national standards that would "supersede any and all state laws." This rule was intended to shield large national corporations, such as AT&T and IBM, from different state rules.
    By the mid-1990s, most American workers and their families were receiving health care as an "employee benefit." Typically, insured people sue for damages in state courts. But when disgruntled patients tried to sue their HMOs, the Supreme Court said these "employee benefit plans" were governed "exclusively" by ERISA and, therefore, were off limits to suits brought under state law. These decisions shielded HMOs from being sued over their benefit decisions.
    In the Texas case, the appeals court extended that shield to protect an HMO from the state's independent review law. If a state seeks to force an employee benefit plan to pay for an extra medical treatment, that demand "conflicts with ERISA's exclusive [federal] remedy," wrote Judge Patrick Higginbotham of the U.S. 5th Circuit Court of Appeals. Last year, lawyers for Texas and 24 other states, along with the Bush administration and the American Medical Assn., urged the Supreme Court to reconsider that ruling. Instead, the justices voted to hear an Illinois case in which independent review had been upheld.
    It began when Debra Moran, a suburban Chicago woman, complained about recurrent nerve pain in her right shoulder. She was offered physical therapy by the HMO used by her husband's employer. When the pain and numbness worsened, Moran sought out a specialist who recommended a type of nerve surgery. While her primary care doctor approved, Rush Prudential HMO said the surgery was not "medically necessary" and refused to pay for it. Moran had the operation, paid $95,000 and later sought an independent review of her claim. A specialist from Johns Hopkins Medical Center in Baltimore concluded the surgery was medically necessary.
    Undaunted, the HMO went to federal court, arguing that the Illinois independent review law conflicted with ERISA. A divided U.S. Court of Appeals sided with Moran and upheld the state law. Its judges pointed to a little-noticed clause in ERISA that preserved standard state laws that "regulate insurance." Because the Illinois system of independent review was a means to regulate health insurers, it did not conflict with the federal pension law, said the U.S. 7th Circuit Court of Appeals. But the Supreme Court voted in June to hear the insurance industry's appeal in Rush Prudential HMO vs. Moran, 00-1021. In their legal briefs, the competing lawyers argue over whether independent review laws regulate "employee benefit plans" or insurance companies. The fate of all state independent review laws might turn on the answer to that question.
    Regardless of how the high court rules, Congress could impose such a system by passing a federal patients' bill of rights law. HMO industry representatives say they fully support the concept of independent review. Nearly all health plans offer the option, even for members in states without such laws. But the American Assn. of Health Plans objects to different state laws, which could pose uneven requirements for a company that has employees in many states. Only some states require medical reviewers to use nationally accepted scientific standards, for example. States also have different licensing requirements for reviewers, timelines for reviews and rules on who pays the cost of appeals. "We can be for the concept of external review but also feel very strongly that there is a value of uniformity across the states," said Karen Ignagni, the HMO group's president.

Treatments OK'd After Independent Reviews
But some Californians say the new system has proved its worth. Angie Birdwell, 41, used the state's external review process last year after her physician group and then her HMO denied her 17-year-old son a referral to a specialist who could treat his heart condition. "I had been frustrated for so long and felt that I had no options," said Birdwell, director of marketing for Wells Fargo bank in the Bay Area. The review process overruled the HMO, and on Friday her son will undergo a procedure to correct his rapid and painful heartbeat. It will be covered by the HMO.
    Sheila Ghen, 36, of Oxnard, credits independent medical review for saving the life of her 2-year-old son, Caden. She won a referral to take her son to a pediatric surgeon to repair a life-threatening hernia in his abdominal wall. Her HMO wanted to send the boy to a general surgeon who did not treat patients younger than 12. "My only choice would have been to take my son to a doctor that doesn't treat children under 12 or pay thousands and thousands of dollars for this myself," Ghen said. "It's unfortunate that the health plan could not have figured it out for themselves, and it took the state to intervene to get it resolved."

Drunk Driving Warnings Heeded, Statistics Indicate
Bettina Boxall & Caitlin Liu, Los Angeles Times- 1/15/2002

Drunk driving arrests by the California Highway Patrol continued their long-term decline last year, pushing levels to half of what they were in 1990. CHP officers arrested 79,460 people for driving under the influence in 2001. The previous year they made 81,383 arrests. The number has fallen annually since 1990, reflecting an overall drop in drunk driving resulting from a multi-pronged national offensive, officials say. Laws have been toughened. Public education campaigns about the dangers of drinking and driving have become commonplace. And society's tolerance of drunk driving has been decreasing. "There's an entirely different attitude about people consuming alcohol and how they're going to get home that you didn't see before," said Tina Pasco, executive director of the Los Angeles chapter of Mothers Against Drunk Driving.
    Studies have shown that license suspension or revocation, alcohol treatment and education programs, and impoundment of drivers' cars to be effective, said Steve Haskins, spokesman for the Department of Motor Vehicles. Intoxicated drivers who kill also face increasingly stiff penalties that keep repeat offenders incarcerated longer. A law enacted in 1997, called Courtney's Law, allows judges to sentence repeat drunk drivers to 15 years to life in prison. "The Legislature has been steadily tightening up the laws," said CHP Commissioner Spike Helmick. "And I think society as a whole has finally gotten the message that it's not acceptable."
    But Helmick also cited another factor--one he is not happy about. There are more drivers, and there is more for CHP officers to do, but agency staffing is essentially the same. "Our people are stretched," Helmick said. "Fewer people patrolling means fewer people are arrested." The number of drivers in California has increased with the state's population. In 1990, the state had about 30 million people and 19.9 million licensed drivers, according to the CHP. In 1999, the population was 34 million, with about 21 million licensed drivers. Over the same period, Californians also drove more, from 259 billion miles in 1990 to more than 300 billion miles in 1999.
    Statewide, the total number of drunk driving arrests declined from 193,250 in 1997 to 183,955 in 2000, according to the DMV. In Los Angeles, drunk driving arrests declined from 3,744 in 1993 to 2,758 in 2000, the most recent year for which statistics are available. "DUI enforcement is one of our highest priorities because drunk drivers cause a lot of grief," said Sgt. John Pasquariello, a spokesman for the Los Angeles Police Department.
    Other cities where such arrests have dropped include Oakland, where they fell from 658 in 1998 to 552 last year. In San Jose, however, arrests rose, from 2,427 in 1998 to 3,349 last year. Sgt. Steve Dixon, spokesman for the San Jose Police Department, said he couldn't explain the increase but believed that the region's growing population during the high technology boom was a factor. "This is the Silicon Valley. We have a lot of drivers up here," Dixon said.
    Although the problem of drunk driving has hardly disappeared, the long-term drop in CHP arrests has been dramatic. The agency cited twice as many people for driving under the influence in 1990 as it did last year. Statistics compiled by the state Department of Motor Vehicles similarly show a plunge in DUI arrests by all law enforcement agencies from 1990 to 1999, the last year for which the agency has figures.
    Nationally, a 1999 U.S. Justice Department study found that the number of drunk driving arrests fell nearly 20% from 1986 to 1997. Alcohol-related fatalities are also down significantly nationwide, falling 25% from 1990 to 2000. However, the 2000 figures were higher than the previous year.
    In California, alcohol-related traffic deaths and injuries followed the same pattern, declining generally but creeping up in 2000 for the first time in more than a decade. Figures for such deaths in 2001 will not be available until spring. Statewide, 1,233 people died in alcohol-related traffic accidents in 2000, 21 fewer than in 1996, but 5% more than in 1999. Though the increase was not especially significant statistically, it caused concern. "It is a wake-up note to pay attention," said Carol Thorp of the Automobile Club of Southern California.

Washington D.C. Mentally Ill's Options Vanishing
Dana Hedgpeth, Washington Post- 1/15/2002

Three struggling mental health clinics in Montgomery County are about to close, caught in a state funding crisis that has put 3,400 county patients at risk. Four clinics closed last year, when CPC Health Inc., by far the largest provider, declared bankruptcy and ceased all operations in the county. Montgomery General Hospital will shut its Silver Spring clinic Jan. 31, forcing its mostly schizophrenic and bipolar clients to find their way to the hospital in Olney, 12 miles away. And Threshold Services, a nonprofit founded in 1981 to "help people with mental illness lead fulfilling lives," has told patients at its two clinics to start looking for other doctors because it will close April 8 -- or sooner. All of the remaining eight providers in Montgomery County, one of the wealthiest counties in the nation, are struggling, unable to cover their expenses because the state grossly underestimated the need for mental health care.
    A shutdown could be catastrophic for some of Threshold's patients, who fear they will regress without the support system the clinic has provided. Steve Cohen, for example, a 39-year-old schizophrenic, doubts whether any private psychiatrist will take on the cost of treating him. Cohen has been one of Threshold's success stories. After being diagnosed with schizophrenia just after graduating from Walter Johnson High School in Bethesda, he spent seven years at the state mental hospital in Sykesville. With an intense drug regimen and therapy, the voices in his head were stilled, his doctor said, and he was able to leave the hospital in 1994. At 39, he lives by himself in an efficiency apartment and holds part-time jobs as a greeter at a Rockville Safeway and a courier for Threshold. "People thought Steve would never come out of the hospital," Pauline Rabin, Cohen's psychiatrist, said.
    Recently, a Threshold staff worker handed Cohen a list of private doctors and told him to start calling them. But the possibilities are few. "We've tried the psychiatrists, and we pretty much know there is no one who will take him," said Indrani Mookerjee, clinic director at Threshold. "We've called at least 15 in the area. They don't want to take these patients because they can't pay their co-pay, and you don't get enough reimbursement for serving them."
    The situation reflects a national crisis in the mental health field, according to providers and advocates. In Maryland, an estimated 74,000 patients are imperiled as outpatient clinics close or refuse service because they are losing money. At least one, St. Luke's House, which has clinics in Bethesda and Silver Spring, has said it will no longer accept new Medicare patients." We are at our Medicare capacity," said Pam Cudahy, president of St. Luke's House. "We're not planning to expand the capacity at this point. The financing is so impossible to make it on, and we can't afford to do it."
    The crisis in the clinics "is a state responsibility," Montgomery County Executive Douglas M. Duncan (D) said. "Clearly, the state needs to meet its financial obligation to provide mental health services. They've under-funded that dramatically. If that continues, we're going to see more and more mental health services shut down." Oscar Morgan, director of Maryland's Mental Hygiene Administration, said he would have a plan within the week. "We're taking a hard look at this. We have some things on the table to enable a strategic plan," he said, declining to elaborate.
    Maryland's mental health patients are covered by a patchwork of state and federal programs. Those whose conditions are so serious they are considered disabled are eligible for the federal Medicare program, but that does not cover drugs and reimburses only 50 percent of their psychiatrist bills (as opposed to 80 percent of bills for physical ailments). Patients who are impoverished are eligible for the state's Medicaid program, which covers all medical care and drugs. The rest have private coverage or are uninsured, according to providers and mental health advocates.
    The problem has been building since 1996, when Maryland dropped its policy of paying the remaining 50 percent of bills for Medicare patients who also qualified for Medicaid. Without that state help, most patients were unable to pay their part. In 1997, the state began an ambitious program to cover more people at lower cost, but officials greatly underestimated the number of people needing mental health care. Instead of the expected 40,000 patients, 80,000 have sought treatment, including many who fall in the "gray zone" -- those who earn too much to receive Medicaid but have no health insurance. "The demand was greater than our resources," Morgan said. Providers complain that the state's reimbursement rates for Medicaid patients fall at least 15 percent below their costs, which a state study has confirmed. They also say that the state delays payment and that Medicare patients are often incapable of paying their part of the bills.
    "Medicaid rates are too low. Medicare rates are too low. And you just can't survive those two things," said Lori Doyle, vice president and chief operating officer for ReVisions Behavioral Health, which is closing its two clinics in Catonsville and Savage on Feb. 1, cutting off 400 people. Doyle estimates that the clinics are losing $40,000 a month. "We can't afford to keep absorbing that." Executives at ReVisions yesterday turned down a $21,000 bailout offer from the state, calling it "too little, too late." Doyle, who said that the state owes her nonprofit more than $1 million for services rendered, asked for $130,000 -- the amount she said she would need to offset half of the clinics' losses for the next six months. "A one-month reprieve will only fuel panic and uncertainty for both staff and clients," she wrote in a letter to Morgan.
    Affiliated Santé Group, which runs clinics in Montgomery, Anne Arundel and Prince George's counties, has taken about 800 patients from clinics that have closed. "We're the second-largest provider in the state, and we're not able to make it work," said Jeff Carswell, vice president of corporate development. His clinics are losing about $50,000 a month, he said. "We're the only provider left in Montgomery County who continues to take clients who have Medicare and who are uninsured. The doors have been closed everywhere else." One problem is that "the state is taking a private-sector approach to a public-sector population." For example, he said, clinics like his have three times the no-show rate as do private doctors' offices.  Advocates fear that the closings will force the clinics' clients into emergency rooms, homeless shelters or jails.
    "If people don't get treatment, they get worse," said Herbert S. Cromwell, executive director of the Community Behavioral Health Association of Maryland, in Catonsville. "They end up going to the ER, then they get sent to a state hospital where treatment runs $180,000 a year. We are regressing if we allow people to lose access to community services that keep people living and participating in society."
    Officials of Threshold said they have stretched their assets to the limit. The nonprofit's other programs -- a group home for the mentally ill, oversight programs for patients who live independently, rehabilitation for substance abusers and work placement -- break even because of higher reimbursement rates. But the two outpatient clinics in Silver Spring and Rockville, which serve 500 people, have been money losers and have run up a $650,000 deficit for the 20-year-old agency. "I'm taking money out of our rehabilitation program to pay for the clinics," Executive Director Craig Knoll said. "The bank has now told us they won't give us overdraft protection anymore. We've used everything we have to keep treating patients at the clinics. We're tapped out." Friday afternoon, for example, he was on the phone with state officials trying to get a $53,000 check wired to Threshold's account to cover the payroll the bank had paid Thursday. "The bank took me at my word that we were getting the money," he said. It still hadn't arrived by 4:40 p.m. yesterday, when he last checked.
    Keeping the clinics afloat has forced Threshold to make sacrifices in its residential treatment centers. At the center in White Oak, for example, therapists said they can no longer afford to give the 25 patients free tickets to the movies or bus tokens. At its group home in Silver Spring, burned-out fluorescent lights aren't being replaced. Patients in Threshold's residential programs turn over their disability checks to Threshold, which manages their money for them, paying their rent and doling out funds for living expenses. "The rent gets paid, but not on time," said Jennifer Johnson, a counselor at Threshold. "We try to just go for the big things, like getting them checks for their groceries." The penny-pinching is creating anxiety for Threshold's clients. "We're talking about people who already live with high levels of anxiety from their illnesses," Johnson said. "Stress is not something they need."
    Knoll is trying to scrape together enough money to pay the 17 therapists, secretaries and psychiatrists at the clinics. He narrowly escaped having to put patients out Jan. 1 after getting $160,000 from an $870,000 package of emergency funding for the county's clinics from the Montgomery County Council and about $50,000 from a walk-a-thon for the homeless. "We're going to have to say April 8 -- when the Maryland legislature ends -- that's it," Knoll said. But his staff isn't sure it can cover the costs until then. One of his clinical directors said the clinics can probably make it only until March. Staff psychiatrists' cell phones were cut off last week, even though that makes it harder to reach them in an emergency. The bills for the cleaning service have gone unpaid. Threshold hasn't paid the county the nominal monthly rental for the buildings in months. And there's no money left in the petty cash fund for the occasional cab fare for patients in crisis.
    Doctors at Threshold said they've started to pressure patients to hand over their co-payments but that many are unable. "We're talking about people who have low-wage jobs and are barely making it by bus to get here," Rabin said. "I can't ask someone for $15 a week to see me when I know they are barely able to eat." Other clinics said they are switching from individual to group therapy to reduce costs, but most clients request, and often require, individualized sessions. Many families and mental health advocates criticize the switch. "These are not the kind of patients you can skimp on," said Evelyn Burton, of the Montgomery County chapter of the National Alliance for the Mentally Ill.
    Jay Lavelle, a patient at Threshold, said he is worried about finding a new psychiatrist. "I have no idea what I'm going to do," he said. "On the one hand, I'm hopeful that there will be an alternative, but I like it here. They're very knowledgeable, and I've made it 52 days without abusing a substance. We were just getting into tackling my weight gain from my medicines." Steve Cohen has started to call the doctors on the list he was given but has gotten no positive response. Once Threshold closes its clinics, Cohen said he will have to turn to his father -- who already helps him out financially -- for help in paying a private psychiatrist. Although his doctors say that Cohen should be getting individual or group therapy, he only has 15-minute medication consultations every other week. With his monthly income of $1,200, he is ineligible for the state's Medicaid program. A handful of psychiatrists at Threshold have said they will donate their time so people like Cohen won't be abandoned. "Some of our patients have come really far," Rabin said. "I'd hate to see them fall."