Study Challenges Earlier Estimates of U.S. Mental Illness
Tammy Webber, Associated Press, 2/14/2002

CHICAGO -- A new study suggests that mental disorders may be less prevalent among adults in the United States than previously thought. Two large surveys that for years have been used to determine the need for mental health treatment may have overestimated the prevalence of mental and addictive disorders, according to the study published in February's Archives of General Psychiatry.
    The older surveys suggest that in a given year almost 30 percent of U.S. adults experience mental and addictive disorders, with nearly 50 percent needing mental health services in their lifetime. That data comes from the National Institute of Mental Health Epidemiologic Catchment Area Program (1980-85), and the National Comorbidity Survey (1990-92). ''When people look at numbers that say close to 30 percent of the American public has a mental disorder and therefore needs treatment, most would say that is implausibly too high,'' said the study's lead author, Dr. William E. Narrow, director of the psychopathology program at the American Psychiatric Institute for Research and Education.
    Researchers in Narrow's study re-evaluated both surveys' data to determine if respondents had talked to a professional, taken medication for their symptoms or their symptoms interfered substantially with their life. The previous surveys assumed that if a person had symptoms, treatment was needed, the researchers said. Using the new method, researchers said, the one-year prevalence of adult disorders fell to 18.5 percent, a decrease of about 19.2 million people.
    The new estimates should help organizations including public health departments and insurers more accurately project how to fund and deliver mental health services, Narrow said. But in an accompanying editorial, Jerome C. Wakefield of the Institute for Health, Health Care Policy and Aging Research at Rutgers University, challenged the new estimates. While agreeing that previous estimates were probably too high, Wakefield said the new analysis addresses who needs treatment, not how many people have disorders.

Free Clinic That Serves Addicts Closed by New Jersey
Geoff Mulvihill, Associated Press, 2/14/2002

VINELAND, N.J. -- Friday morning, patients, many of them drug addicts, may still congregate in Dr. Eddie's Free Clinic/La Clinica Gratis de Andujar. But they'll only be sipping coffee and watching television. A two-member committee of the state Board of Medical Examiners ruled in Newark on Thursday that Andujar cannot practice medicine without approval of the board. The entire 20-member board will consider ratifying the decision in Trenton on March. 13.
    With his lawyer out of the country Thursday, Andujar showed up alone at his hearing. He said he'll have busloads of supporters next month. A spokeswoman for the Attorney General's office said it would be up to the board to decide whether to take any testimony there. ''They're supposed to be protecting the public,'' Andujar said after the decision was announced. ''They have no answer for me when it comes to what will these patients will do as of tomorrow.'' The board found Andujar's office which was also cited this week for dozens of local fire, health, zoning and license and inspection violations unsanitary.
    For the past three years, Andujar, a 46-year-old graduate of Harvard Medical School, has run a free clinic in his hometown. The staff of eight consists mostly of Andujar's relatives, who sometimes work without pay. The clinic is open 9 a.m. until 9 p.m. and homeless or otherwise wayward patients can often be found in the waiting area watching television. Andujar's sister-in-law Wendy Viruet, runs the business affairs of the office, which is funded with Medicaid and Medicare payments along with donations. Viruet said as many as 37 patients come three times a day for IV treatments of pain drugs or vitamins. The total number of patients is around 100 a day.
    Patients like Tanya Walker, who was a heroin addict when she first came to his office four months ago seeking treatment for abscesses, said they don't know what they would do without Andujar. ''Oh God. We're going to be devastated, devastated because not many people will touch us people without insurance,'' she said as she awaited her 4 p.m. physical therapy appointment Thursday. Walker, 43, said she has been clean for the past three months.
    Hers isn't the only success story at the clinic in Vineland, a sprawling town of 56,000 deep in southern New Jersey.  But it was the story of one patient who didn't make it who attracted the attention of local and state officials to the clinic earlier this month. Terrence Conroy, a homeless man, had been living in a small room in the back of Andujar's rambling building when he was found dead there Feb. 3. Authorities believe it was a drug overdose.  Officials spent most of the day Monday inspecting the office where the clinic has been set up since December.  They found code violations, mostly in the unfinished back of the building, which Andujar said he used only as a spillover area for patients and said he would shut down until work could be finished.
    The Board of Medical Examiners is also considering a list of charges that could not be so easily remedied. A hearing has not been scheduled for those matters. The state Attorney General's office, in a seven-count complaint, said Andujar gave a patient methadone as a heroin treatment. Only specially designated clinics are allowed to distribute the potent drug. He's also accused of giving patients buprenorphine, which the state said violates federal law. Andujar said he only gave out methadone briefly before he knew doctors could not simply prescribe it like they can other drugs. He said the buprenorphine is legal.
    Andujar is familiar with the medical examiners board. On Aug. 12, 1999, when Andujar ran the Mays Landing-based chain of Medistop clinics, it barred him for two years from treating Lyme disease, required him not to be majority owner of a clinic and to work only with another physician as medical director. He's charged with violating those three provisions as well. Andujar's wife, Nancy, a nurse, said the couple spent 1986 traveling in South America treating poor patients. They saw a similar need here, too. ''It is so much easier to help in a Third World nation just to go in and help people who need help,'' Nancy Andujar said. ''You can't do it here.''

Connecticut Attorney General Blasts HMO's Mental Health Coverage
Christopher Zurcher, Associated Press, 2/14/2002

HARTFORD, Conn. -- A company set up to handle mental health services for Anthem Blue Cross and Blue Shield in Connecticut was instead used to enrich its founder while patients were improperly denied care, state Attorney General Richard Blumenthal said Thursday. Blumenthal said he will file a lawsuit against Psych Management Inc. and Dr. Peter Benet, a psychiatrist practicing in Hartford.
    Blumenthal said Benet founded the company as a nonprofit called PsychCare Inc., then converted it to a for-profit company called Psych Management Inc. and pressured employees to keep coverage expenses to bare minimums.  Doctors were left unpaid and patients were left suffering from their illnesses while Benet collected hundreds of thousands of dollars in dividends and other profits, Blumenthal said. ''It points out the failure of managed care organizations to meet the needs of those they are there to serve,'' Blumenthal said. Like most state employees, Blumenthal is covered by Anthem. Benet has been removed from his position at PMI. Neither he nor PMI officials returned telephone calls seeking comment Thursday.
    Melissa Fahey was 19 when she sought treatment for post-traumatic stress disorder. She is one of 2,500 patients covered under the plan in Connecticut who sought mental health treatment, Blumenthal said. Fahey remained untreated for months at a time while she was shuffled from hospital to hospital by doctors seeking to limit PMI's expenses, the attorney general's report alleged. ''She has a lot of talents and gifts and we're doing everything we can to help her continue to receive the right treatment,'' said Fahey's mother, Leslie Fahey. ''She is an excellent student and we're trying our best to get her life back to normal.''
    Blumenthal said the company, under Benet's direction, established caps and coverage guidelines that were unrelated to medical necessity but helped enrich PMI executives. While ordering the limits on coverage, Blumenthal said, Benet spent money on luxury office space, automobiles, parties and new executives. Later, when financial pressures continued to mount, the company allegedly made a practice of ''holding'' checks to doctors. The checks would be written but not mailed, while PMI sought reimbursement from Anthem.
    Blumenthal said Anthem had failed to exercise proper oversight of PMI. Anthem said it was cooperating with Blumenthal's office. ''We are unaware of any current complaints from physicians over the quality and access to care of any PMI patients,'' Anthem said. ''(Anthem) will take all necessary steps to address the issues raised in the attorney general's report.'' Blumenthal said he had not decided whether to refer the matter to either the Securities and Exchange Commission or the chief state's attorney for possible criminal investigation. Blumenthal said his office became involved because it regulates nonprofit companies and the assets of PsychCare may have been misappropriated when PMI was created; because state employees are covered by Anthem; and because the PsychCare-PMI transaction may have violated the state Unfair Trade Practices Act.

Yates Relative Says Publicity Saps Family's Energy
Carol Christian, Houston Chronicle- 2/16/2002

Eight months after Andrea Pia Yates confessed to drowning her five children in the bathtub, her family has had little opportunity to grieve, a family member said Friday. Family members' emotional energy has been spent coping with continuous publicity and capital murder charges against their loved one, the Rev. Fairy Caroland said.
    An ordained Presbyterian minister in Savannah, Ga., Caroland, 48, is the great-aunt of the deceased children -- Noah, 7; John 5; Paul, 3; Luke, 2; and Mary, 6 months. Her sister, Dora Yates, is the mother of Russell Yates, Andrea's husband. "We have started the grief process, and yet we haven't," said Caroland, in town to attend Yates' trial, which begins with opening statements Monday. "Once this happened, it was like, boom, so many things happened so fast legally and so much publicity happened so fast," said Caroland, who has made three trips to Houston since the children died. "I don't think any of us have had the full opportunity to take a good breath. That's part of the problem. That means we're all still in shock in some ways. "And we're all still saying to some degree, `How could this happen, especially with someone like Andrea?' To all of us, she was the epitome of a good mother, just a wonderful girl. We thought she was wonderful with Rusty. They were just a real sweet couple."
    To deal with her grief, Caroland went through her many photo albums and put all the pictures of the children and their parents into a separate book. "It helped me walk through the years of watching them," she said. The last pictures were taken in April, when Caroland was in Houston for a church conference. In those pictures, Andrea Yates looks like a different person, Caroland said. "I said to Dora later, `When I looked in Andrea's face, the human being was gone, she wasn't there.' "
    Caroland also turned to her church, Montgomery Presbyterian in Savannah, where she was head pastor until October. "My church reacted the way a lot of people did to what happened -- everybody was shocked," she recalled.   "Once it happened, I got in the pulpit the very next Sunday morning and said something to the effect of, `You've heard something in the news that was very horrific and I need to explain to you how I'm connected to the family.' I could watch everybody's mouth just kind of drop to the floor when I told them." Caroland, who started at the church in November 1999, said she asked the congregation to allow her to process her grief.
    In October, in keeping with plans she had made before the children died, she decided to leave the church to devote more time to studying counseling at Georgia Southern University in Statesboro. Months earlier, she had decided she wanted to do counseling on a more formal basis and is working toward becoming a licensed professional counselor.  She said the family is going through the ordeal together, but much of it has to be confronted alone. "We have all cried our own separate tears behind closed doors, and there are times when we have cried together," she said.
    Much of the family was together for Christmas at Caroland's home in Savannah, Ga. Caroland is married and has two grown stepchildren. "It was a good reminder of how fragile life is, how precious life is," she said. "We were all very conscious of the kids not being there, of Andrea not being there. We're used to the kids running around." Now, as the legal proceeding against Andrea Yates is entering its final phase, Caroland said she hoped people would let the family deal with their unspeakable grief. The loss is not just the children and Andrea Yates' mental stability, she said. "There's also the loss of what won't be, of what the kids would have been like as teen-agers and adults. That's one of the toughest things for Rusty. He misses them desperately."

Alabama Judge Calls Being Lesbian 'Detestable'
Associated Press, 2/16/2002

MONTGOMERY, Ala. -- In awarding custody of three teenagers to their father over their lesbian mother, the chief justice of the Alabama Supreme Court wrote Friday that homosexuality is "an inherent evil" and shouldn't be tolerated. The nine-judge panel ruled unanimously in favor of a Birmingham man and against his ex-wife, who now lives with her partner in Southern California. The parents weren't named in court documents to protect the identity of the children, ages 15, 17 and 18. Chief Justice Roy Moore wrote that the mother's relationship made her an unfit parent and that homosexuality is "abhorrent, immoral, detestable, a crime against nature, and a violation of the laws of nature."
    Moore also quoted Scripture, historical documents and previous state court rulings that he said back his view. Moore is known for his decision to place washing machine-sized monuments of the Ten Commandments in the state judicial building after he became chief justice last year. He also fought to keep a Ten Commandments plaque in his courtroom when he was a district judge.
    David White, state coordinator for the Gay and Lesbian Alliance of Alabama, said Moore's opinion reflects outdated thinking. "It's unfortunate Alabama is going to be embarrassed once again by a religious fanatic in a position of power in Alabama," White said. "It's obvious he cannot judge a gay person fairly and he should be removed from office."
    John Giles, state president of the Christian Coalition, said Moore's decision protects the institution of marriage and strengthens the traditional family. The father had held custody since 1996, but the mother petitioned for custody in June 2000, contending the father had been abusive. John Durward, the father's attorney, said his client "is very relieved." The mother's attorney, Wendy Crew, had no immediate comment.

Yates Court Phase to Begin
Carol Christian, Houston Chronicle- 2/17/2002

Eight months after a stay-at-home mom in Clear Lake shocked the nation by drowning her five children in the family bathtub, a Houston jury today begins the task of figuring out whether she belongs in prison, on death row or in a mental hospital. If Andrea Yates, 37, is convicted of capital murder, Harris County prosecutors plan to ask for her execution. But defense attorneys, citing a history of mental illness that includes two suicide attempts, will ask to have her declared not guilty by reason of insanity. The two sides start work today trying to sway the jury of eight women and four men, plus three women alternates. The opening statements begin at 10:30 a.m.
    "What the prosecution wants to do is keep the jury focused on what happened that morning," Dallas-area trial consultant Robert Hirschhorn said. "I call that looking at the last chapter of the book." Trial experts say prosecutors will paint a graphic picture of Yates' actions June 20, over which there is little dispute. By her own statement, she waited for her husband, Russell Yates, to leave for work at NASA and then proceeded to half-fill the bathtub with water and drown the children one at a time.
    The jury will hear a tape recording of Yates' 911 call that morning, in which she stated repeatedly that she needed police to come to her house but would not say why. The prosecution also reportedly has a videotape of the crime scene that shows the four youngest children in bed, as if tucked in for the night, and the oldest facedown in the bathtub. "The prosecution will put on evidence about the scene right away," said prominent Houston defense attorney Dick DeGuerin, who is not participating in the case and is not covered by a judge's order not to talk about it. "They will drag out pictures of the dead babies and come on real strong about that," he said. "Their strongest point is five dead babies. They want that to be an indelible impression jurors get from the very beginning."
    For Yates to win -- capital murder carries only two punishment options: death or life in prison -- her lawyers must convince the jury that when she drowned the children, she did not understand that her conduct was wrong. They will work aggressively to shift the jury's attention away from June 20 and to look at the events in Yates' life that led up to that tragic morning. "Each side will go for the jugular," said Robert Gordon, founder and director of the Wilmington Institute of Trial Sciences, which has offices in Houston and Dallas. He has written books on strategies for winning jury trials.
    It took 3 1/2 weeks to select the jury, and the trial is expected to last two to four weeks. To shield jurors from the enormous media coverage, state District Judge Belinda Hill has said there is a strong possibility she will order them confined to the courthouse and a hotel for the duration. Hill will allow only the opening statements, final arguments and verdict to be filmed for television broadcast.
    The jury and a packed courtroom of spectators can expect to see a parade of prosecution witnesses who will recite grim details of what happened at 942 Beachcomber between 9 a.m. and 10 a.m. June 20. Veteran prosecutors Joe Owmby and Kaylynn Williford are likely to call a representative of the Harris County medical examiner's office to testify that bruises on the bodies of the four boys indicate they struggled, probably hitting the sides and bottom of the bathtub as their mother held them facedown. Jurors can also expect to hear testimony about how a person drowns. Although the prosecution is not required to address the issue of mental health to prove its case that Yates killed her children, trial experts say Owmby and Williford probably will do so, knowing that the defense's goal is to show she was, by legal definition, insane at the time.
    Once the prosecutors finish, defense lawyers George Parnham and Wendell Odom will have the burden of proving that Yates' mental illness prevented her from knowing her conduct was wrong. If the insanity defense succeeds, Yates will be sent to a maximum-security mental institution, where she will be evaluated by doctors periodically. If she is ever declared sane, a judge would still have to approve her release. By Texas law, the jury cannot be told that during the trial, however.
    At a seminar on trial techniques last month at South Texas College of Law, Parnham gave a talk titled "Insanity: Helping the Jury Comprehend the Inconceivable." Though couched in general terms, his talk could be interpreted as outlining the defense strategy in the Yates trial. In 1994, Parnham successfully defended Calvin Bell, who was found not guilty by reason of insanity in a 1992 shooting rampage. Two police officers were wounded in the incident at Houston's Piney Point Elementary School.
    Because jurors have an automatic bias that lawyers resort to the insanity defense when they cannot come up with anything better, Parnham said it is critical to establish that the defendant has a history of mental illness. Based on Parnham's lecture, he and Odom are likely to show the jury a timeline of Yates' hospitalizations, suicide attempts and other major events that chronicle the deterioration of her mind. They may present a videotape of Yates being interviewed shortly after her arrest, to show the contrast between her demeanor then and how she will appear in the courtroom, after treatment. Information about medications Yates has been prescribed at various times and their effects on behavior will be presented, judging by Parnham's talk.
    Each side has hired a high-profile forensic psychiatrist. The defense's expert is Dr. Philip Resnick, professor of psychiatry and director of the Division of Forensic Psychiatry at Case Western Reserve University School of Medicine in Cleveland. He is also a lecturer in law and psychiatry at Case Western's School of Law and has studied mothers who kill their children. The prosecution's expert is Dr. Park Dietz, professor of psychiatry at the University of California at Los Angeles School of Medicine and the forensic psychiatrist for both the FBI's Profiling and Behavioral Assessment Unit and the New York State Police Forensic Sciences Unit.  Dietz, who usually testifies for the prosecution, and did so successfully in the trial of serial killer Jeffrey Dahmer, is well known for making an extremely detailed study of the defendant's actions surrounding the crime.
    The prosecutors may not call Dietz until after the defense team has finished and they are allowed to present rebuttal witnesses, Hirschhorn said. "He's a heavy hitter," Hirschhorn said of Dietz. "You want to have something in your pocket that's strong for rebuttal. Unless they have some smoking-gun witness, he's as good as they get in terms of a strong rebuttal witness." And given the intense news coverage that is expected, the trial testimony may help educate the public about mental illness, said Gerald Treece, dean of South Texas College of Law. "Every once in a while, you have a trial that has to do with something so unknown that it becomes educational, and I think that's going to happen here," he said. "We're going to explore mental illness better than we ever have in any Texas case I've ever heard of."

Mom's Mental Illness on Trial
Flynn McRoberts, Chicago Tribune- 2/18/2002

CLEAR LAKE, Texas -- Five hearses, that's what the neighbors remember. One for each of the children Andrea Yates drowned in the bathtub at the family's yellow-brick home in this Houston suburb. The youngest victim and only girl, Mary, was 6 months old. The oldest, 7-year-old Noah, had to be chased through the house before Yates overpowered and drowned him, leaving him in the tub. The other four siblings she tucked into her bed. On Monday, in a dimly lit Houston courthouse with a soaring ceiling, opening statements are scheduled to begin in Yates' murder trial. As with Marilyn Lemak of Naperville, Ill., who recently was convicted of killing her three children, no one disputes that Yates' kids died at their mother's hand. After calling police on June 20, 2001, Yates phoned her husband, a computer engineer at NASA's facility in Houston. "It's time. I finally did it," she told him. "It's the kids." Which of the five, he wanted to know. "All of them," she replied.
    Yates, 37, a postoperative nurse before quitting to raise and home-school her children, has pleaded not guilty by reason of insanity. So under Texas law, jurors will weigh a deceptively simple question: "As a result of severe mental disease or defect," did Yates "not know that [her] conduct was wrong"? She could face execution if convicted, though the lead prosecutor said last month that he might recommend life in prison if she were to "accept criminal responsibility." Jurors in cases of mothers who have killed their children and claimed insanity often say they looked for an established history of serious mental problems before the crime. In Yates' case, such a history seems extensive.

Medical files detail illness
Long before the killings, Yates told doctors she twice tried to commit suicide because postpartum voices and visions urged her to hurt someone with a knife, according to medical records filed in court by defense attorneys last summer. Her illness was severe enough that one doctor put her on Haldol--an anti-psychotic medication--after one of her four hospitalizations since 1999. Two months before the killings, Yates' husband, Rusty, checked her in to a local mental hospital after she filled their tub with water and would not explain why.
    Now the explanations will be left to the lawyers and their witnesses. Why, for instance, did one doctor stop giving her anti-psychotic drugs and send her home after only slight improvement? Why did her husband--well intentioned but controlling and apparently lacking empathy, according to mental health personnel who treated his wife--not fully appreciate the gravity of her illness?
    Neighbors on Beachcomber Lane in Clear Lake have answered some of those questions in their minds in the eight months since the world media descended on their tidy community. "Something happened to that woman, and her husband should have known--he did know," said Larry McBeth, a construction worker whose mind cannot purge the image of those five hearses pulling out of the parking lot for Clear Lake Church of Christ. "My wife thinks she should get the death penalty. Why? Because she's a mother, I guess," he said. "But I don't think so. Not because she doesn't deserve it, [but] I think she should spend the rest of her life thinking about it. Put the pictures of her children right there in her cell."

Defense has a `good' chance
Some of Houston's top criminal defense lawyers believe that Yates has a good chance of winning on her insanity plea--not an easy task, especially in Harris County, which leads all Texas counties and most states in the number of prisoners executed since 1982. "If you're ever going to win an insanity case, this looks like a good one to me because you have a sympathetic defendant and a well-documented history of mental illness," said Robert Morrow, a Houston criminal defense attorney. "That's important for jurors, to know this isn't something invented by the lawyers."
    Some even hold out the hope that Yates' trial will have the power to enlighten the nation about mental illness. "People can suffer greatly, even though they don't have any physical scar," said T. Gerald Treece, professor and associate dean at South Texas College of Law in Houston. "People suffer from serious mental problems in this country and do unspeakable things when they're not in their right mind. "I'm not saying that she'll be exonerated through the insanity defense. This tragedy is of Shakespearean proportions, the fact that you would take your children's lives," Treece added. "But there's some explaining to do."
    Specifically, Treece pointed to the medication Yates was on but suddenly stopped taking. In the past, she had sometimes been reluctant to take it. But at least once she was released from treatment due to "insurance reasons" while still depressed, according to medical records. "The question is, why? Was it because there was no insurance for this?" Treece asked. "I want to see if the care of the mentally ill is a function of HMOs or other medical insurance providers not meeting the needs of the people."
    Regardless of this trial's outcome, prosecutors have left themselves another option allowed by Texas law. Yates is standing trial Monday on an indictment for the deaths of just three of her children; a second, still-pending indictment charges her with the deaths of the other two. "They've given themselves some room in case the first case doesn't go the way they like," Morrow said, explaining that it is not considered double jeopardy because the state can argue that each victim deserves his or her own trial. But Treece said another trial for Yates is unlikely "because I think the D.A. would settle for life in prison tomorrow. If she is exonerated here, it will be because the defense expert won the day."

Lemak's expert is involved
For Yates that person will be Dr. Phillip Resnick, who also was Lemak's mental-health expert. Watching it all unfold will be more than 50 reporters who reserved credentials weeks ago. The predictable frenzy has drawn dozens of media organizations, but not as many as another high-profile Harris County murder case: that of Yolanda Saldivar, who was sentenced to life in prison in 1995 for the shooting death of Tejano singer Selena. Also sitting in Judge Belinda Hill's fifth-floor courtroom will be Yates' relatives. For months after the killings, her family members defended Rusty Yates for doing the best he could. But fissures emerged when jury selection began last month; privately, some are angry with him for not doing more.
    Though a gag order issued by Hill bars Rusty Yates and other potential witnesses from speaking publicly, Yates' husband granted Time magazine 40 hours of interviews for a recent story. He also has created a Web site that features links to the gag order and an appeal for donations to his wife's legal defense.

Use of Antibuse Brings Suit
Jim Hughes, Denver Post- 2/18/2002

BOULDER - The drug was supposed to make them sick - if they drank alcohol. But Mitzi Kay Morris-Beeman, 48, and Melissa Lake, 25, say that a court-ordered regimen of Antabuse, which causes violent illness when mixed with alcohol and is often given to alcoholics and convicted drunken drivers, made them sick by itself. In a lawsuit filed this month against Boulder County and others, the two convicted drunken drivers say they suffer from toxin-induced hepatitis, liver damage and other physical and psychological maladies after being put on Antabuse without seeing a doctor.
    Chuck Stout, Boulder County's director of public health, said the county's policy has always been to administer Antabuse only with a doctor's approval. "Attorneys are going to have to deal with the lawsuit," Stout said. "But we've been doing this for 25 years. I've been here for better than a decade, and it's never been an issue." Neither he nor Andrew Macdonald, an assistant county attorney, would comment on the specifics of the case. Lake also couldn't be reached for comment.
    Experts say doctors are supposed to perform thorough exams - including liver-function tests - before prescribing Antabuse, but that sometimes doesn't happen. Morris-Beeman was put on Antabuse after her second drunken driving conviction in January 2001. Her sentence required her to report to Boulder County's Addiction Recovery Center, where she was then told to report to Dr. Richard Wills, who was working under a county contract, to receive her Antabuse prescription, she says. When she got there, "They said: "Oh, the doctor's already been here. Here's your prescription,' " Morris-Beeman said. Wills couldn't be reached for comment. She didn't see another doctor until she got sick and sought help on her own, she says. She said the doctor she saw at Boulder's People's Clinic told her that if she had stayed on Antabuse much longer, she would have died.
    The suit isn't the first of its kind, said Andrew Popper, a law professor at American University in Washington. "While there haven't been many (such cases), several courts have talked about the need for monitoring, the need to track adverse reaction and the need for follow-up," he said. The reason is that Antabuse can kill - especially if people have weakened livers, said Anne Hatcher, co-director of the Center for Addiction Studies at Metropolitan State College of Denver. But because Antabuse isn't considered addictive, federal regulations don't require a medical checkup for prescriptions. Industry standards call for an evaluation before a prescription is given, Hatcher said. "What is supposed to happen is that, before somebody is put on (Antabuse), they're supposed to have a thorough medical exam, including a liver-function test," she said. "The tests then should be repeated two weeks after the first use, and then again every six months, to check for any signs of liver damage."
    But that never happened, said the women's lawyer, Steve Shapiro. "Just because a court orders you to do something doesn't mean that you give up your rights to appropriate medical treatment," he said. In addition to Boulder County, the suit names as defendants Wills and Correctional Management Inc., a private company that oversaw part of Morris-Beeman's Antabuse regimen. Scott Wood, president of Correctional Management, which also runs addiction-recovery programs in Denver and in Arapahoe County, said it was not his company's responsibility to ensure that Morris-Beeman received adequate medical care. "Our primary role is to monitor that they show up and that they don't appear to be under the influence, and to make sure they take their Antabuse per their prescription," he said. "We don't dispense it or anything else." He said he was surprised by the suit's allegations - that two Boulder women, one of them a client of his, had been put on Antabuse without the benefit of a medical exam. "We wouldn't have allowed her to take Antabuse without a prescription in her name," he said. "And (a doctor) wouldn't have prescribed it for her without giving her a physical. I hope doctors aren't doing that. I don't believe they are."
    The incident highlights the tension that's inherent in the use of drugs to deter drinking and driving, Hatcher said.  "We want to help clients, and that's our ideal," she said. "But the reality is, what society and our politicians are concerned about is controlling their behavior so they don't hurt people, because that's what the public is so upset about." As someone who teaches addiction recovery protocols, she doesn't like to hear about the kind of laxity alleged in the Boulder County lawsuit, but she's heard similar stories before, she said. "It comes down to, well, is it safer to put someone on something like this to get some kind of control over their alcohol use, or do you risk them killing somebody?"

Prosecution, Defense Debate Houston Mother's State of Mind
ABC News, 2/18/2002

Andrea Yates was mentally ill and suffered from delusions when she methodically drowned her five young children in a bathtub last summer, her defense attorney told a jury today at the start of her capital murder trial. Prosecutors argued today that the Houston mother, while mentally ill, knew what she was doing when she killed her children.   Throughout today's opening arguments, Yates stared straight ahead and did not glance at the jury of eight women and four men. She showed no emotion but clenched her jaw as the prosecutor described how she killed her children one by one. "She knew this was an illegal thing," Harris County Assistant District Attorney Joe Owmby said during opening statements. "It was a sin. She knew it was wrong."   Prosecutors say Yates confessed to the killings and admitted they were premeditated. She allegedly told police she planned the slayings the night before she carried them out. Police have also said that the last child killed, 7-year-old Noah, walked in on his mother while she was drowning his baby sister and tried to flee. Yates allegedly confessed to chasing the boy and then drowning him.

Knowing Right From Wrong
Yates' attorney, George Parnham, said that Yates' mental illness kept her from knowing right from wrong. He said that at the time of the killings, Yates was suffering from postpartum depression and severe psychosis, which he said "takes the very nature and essence of motherhood — to nurture, to protect and to love — and changes the reality."
    Jurors heard testimony from police officer David Knapp, who described the scene he found at the Yates home that day. Yates' hair and clothing were wet, Knapp said, and when asked why she called the police, Yates allegedly told him she had killed her kids. Yates was stone-faced and cooperative, Knapp said, and led him into her house where he saw wet footprints on the tile floor in the entrance, kitchen and living areas, the officer said. He told jurors how Yates directed him into the master bedroom where he saw a small arm sticking out from under a sheet on the bed. Owmby told jurors in his opening statement that the burden was on the defense to prove insanity. "She is presumed to be sane, to know right from wrong," Owmby said. "The state bears no burden of proof to prove she was sane."

An Uphill Battle
Experts say Yates' defense attorneys may have a difficult time proving insanity. Juries tend to be skeptical of the insanity defense to begin with, and the images of five beautiful smiling children that flashed across newscasts following the slayings may be too much for the defense to overcome. "Some [judges and jurors] believe mental illness should not be a defense at all," said Christopher Slobogin, professor of law and affiliate professor of psychiatry at the University of Florida. "Others might be sympathetic to an insanity defense but are suspicious of mental illness claims and the doctors who support them. Still others may believe a person's claim that he or she was disordered at the time of the offense, but just not think there was enough of a disorder." Slobogin also said jurors generally are not confident that mental institutions will keep defendants who successfully use the insanity defense off the streets. Defendants found not guilty by reason of insanity, he said, are kept in institutions at least as long as the time they would spend in prison if convicted.   Another challenge facing Yates' defense is the high standard for proving insanity in Texas. Parnham must prove that Yates not only felt an uncontrollable urge to kill, but that she didn't know right from wrong at that moment.
    Speaking on Good Morning America today, Reverend Fairy Caroland, an aunt of Russell Yates, said Andrea Yates seemed unstable when she last saw her in January. "She's still not quite all here. In the same question she will ask a question or make a statement about a family member, about something totally removed from all this and in less than two minutes repeat the same thing." She said Yates "doesn't have much of a short term memory right now," but is aware that she faces the death penalty. She said the family was very concerned about how she will react in court, especially to an expected prosecution videotape of a re-enactment of what happened.

Potentially Damning Confessions
Prosecutors concede Yates was mentally ill, but say she was not insane. During a competency hearing, a state psychologist who evaluated Yates said the woman admitted she had planned the killings. That testimony is expected at the trial. In addition, jurors will hear the tape of the 911 call Yates made to police after the slayings and police officers' account of her alleged confession.
    Since the killings, Yates has had steadfast support from her husband, who unsuccessfully urged prosecutors not to seek the death penalty against his wife. Russell Yates has publicly said his wife had a history of postpartum depression. He said she attempted suicide after the birth of their fourth child in 1999 and suffered from postpartum depression after their fifth child, Mary, was born. The depression, he said, was further aggravated by the death of his wife's father in March, three months before the drownings.  Andrea Yates had been on anti-psychotic medication in the months before the slayings. However, Russell Yates has said that a doctor refused his plea to put her back on medication two days before the children were killed.
    Yates could have been indicted in all her children's deaths, but prosecutors have said it is not necessary to seek indictments for all of them. One capital murder charge covers the deaths of Noah and John, qualifying for capital punishment because two victims were killed during the commission of the same crime. The second charge lists the death of Mary as a child under the age of 6, which is also a capital offense. Russell Yates is expected to take the stand in approximately two weeks and will likely plead for his wife's life.  If Yates is acquitted, she still could be prosecuted again for the other two deaths.

Police Testify at Start of Yates Trial
Associated Press, 2/19/2002

HOUSTON -- When Andrea Yates said she had just killed her children, the police officer stood at the door in disbelief. Officer David Knapp followed her into the house, and in the bedroom he saw a child's arm protruding from under a wet sheet. Knapp lifted it and saw the lifeless bodies of Mary, 6 months, Luke, 2, Paul, 3, and John, 5. Noah, 7, was floating face down in the bathtub. "She was standing behind me ... and I didn't hear her cry" or show any emotion, Knapp said Monday as Yates' capital murder trial started.
    Defense attorney George Parnham told jurors that Yates had a history of suicide attempts and was so psychotic that her delusions drove her to drown her children. "Postpartum depression with psychotic features, as will be testified to from the stand, is the cruelest and most severe of mental illnesses," Parnham said. "It takes the very nature and essence of motherhood to nurture, to protect and to love and changes the reality.
    Jurors on Monday also heard Yates' 911 call. During the call, Yates paused frequently and breathed heavily. When asked if she was alone, Yates first said "yes." But the second time, she responded "no, my kids are here" and then told the dispatcher their ages. Knapp said Yates answered his questions in a monotone voice and followed his instructions to sit down and show identification. "Her eyes were wider that what I'd consider normal," Knapp said.
    Frank Stumpo, the second Houston police officer who arrived at the house, testified that he found the oldest boy dead in the bathtub, then went into the living room and asked Yates if she realized what she had done. "Yes, I do," was Yates' response, the officer testified. Stumpo said Yates did not appear to be upset or distraught and that she would answer his questions without prompting when he spoke aloud to himself.
    Owmby said Yates, during questioning by police, told an officer that she should go to hell for what she had done. She told the officer she waited to drown the children until her husband, Russell, left for work because he would have stopped her, the prosecutor said. Yates' extensive medical records detail her bouts with depression and two suicide attempts. They also show her fear that she might hurt someone and a doctor's caution that the couple stop having children to avoid future psychosis after Luke was born in 1999.
    ''When you have a crime like this that is so heinous, I think the jurors' inclinations are likely going to be somewhat disinclined to find insanity,'' said Brian Serr, a Baylor University law professor. ''The fact that she was feeling psychological or mental pressure to kill them does not mean she was in some sort of psychotic state or that she, in a twisted fashion, perceived it to be right.'' ''Given the nature of this crime, it might be a worse punishment for this woman to be locked up forever and to have to think day after day after day that she killed her children and they were perfectly aware of who had become their enemy.''

Discovery of Children's Bodies Described
Carol Christian, Houston Chronicle- 2/19/2002

A tiny arm was sticking out from under a sheet on a mattress at Andrea Pia Yates' home when police responded to her 911 call last summer, an officer testified Monday. "I saw what looked like four lumps in the bed," officer David Knapp said Monday during the first day of testimony in Yates' capital murder trial in the deaths of three of her five children, all of whom were drowned in the family bathtub. Knapp was the first Houston police officer to arrive at Yates' home about 9:55 a.m. June 20. "The bed was soaking wet," he said. During his testimony, Knapp said he later learned that Luke was the child whose arm was sticking out from the sheet.
    The defendant appeared in the courtroom wearing a long, gray knit dress that she wore several times during the three weeks of jury selection last month. She showed little emotion. At the end of the day, she joined the attorneys before state District Judge Belinda Hill for a discussion on evidence to be entered. Although the five-minute conversation was inaudible to the rest of the courtroom, Yates could be seen listening intently to the judge and nodding occasionally. Her husband, Russell; mother, Jutta Kennedy, and mother-in-law, Dora Yates, were not in the courtroom because they are scheduled to be called as witnesses.
    Prosecutor Joe Owmby acknowledged in his opening statement that Yates was mentally ill when she drowned the children. But he told the jury that her defense lawyers will be unable to show that she was legally insane. Under Texas law, her lawyers must prove that at the time of the deaths she did not understand that her conduct was wrong.
    Yates' attorney George Parnham told the jury that she was not only suffering from postpartum depression with psychotic features, she was one of the sickest patients ever seen by psychiatrists who interviewed her. Parnham said that on June 20 she had no antipsychotic medication in her system, whereas now she takes 15 mg daily of Haldol, a strong antipsychotic.
    After attorneys' statements, Knapp testified that when he arrived at Yates' home, she told him, "I killed my kids" and then led him to the master bedroom. He said he pulled back the sheet and found the youngest four children, looking as if they had been tucked into bed. The officer said he knew that three of them were dead because they had a frothy substance coming from their noses and mouths. Knapp said he checked for a pulse on the other child but found none. The child was cold and clammy, he said. Two sets of wet footprints -- one set adult size following another half as big -- were visible on the tile floor of the living room, Knapp said. Yates, who said nothing to him, had no problem following instructions, Knapp said. She made eye contact but did not ask him questions. Frank Stumpo, the second officer on the scene, testified he found the oldest child face down in the bathtub.

Insanity vs. Awareness in Texas Child Murder Case
Paul Duggan, Washington Post- 2/19/2002

HOUSTON, Feb. 18 -- The defendant, in a gray sweater-dress, was ushered to her seat in the crowded courtroom at 10:30 a.m., a pale, slender, expressionless woman, going on trial for her life. In the spectator gallery, her husband and mother craned to see her. "Not guilty," were the only words Andrea Pia Yates spoke in court today, almost in a whisper, after a prosecutor read aloud each count of the indictment.
    A topic of debate on talk radio and around office water coolers, the issue of Yates's legal culpability for a homicidal rampage that stunned the nation will be decided in state Judge Belinda Hill's courtroom. A jury of eight women and four men, plus three female alternates, was sworn in this morning to hear the case. In televised opening statements, the prosecution and defense cast the killings differently, one side focusing on the horror of the drownings, the other emphasizing Yates's history of mental illness.
    Assistant District Attorney Joseph Owmby went first, in a calm voice, without flourish. "Luke, John, Paul, Mary, Noah: These were the Yates children," he began. The oldest, Noah, was 7; the youngest was 6-month-old Mary. "The breath was taken out of them by their mother," Owmby said. He told jurors they would see a police videotape of the grisly scene, including the bodies of four children on a bed, covered by a sheet. Ownby said Yates told investigators in an audiotaped statement that she placed the youngsters there after drowning them, then dialed 911. The videotape also shows Noah's body, floating face down in nine inches of cold water in the bathtub, Owmby said. The tape "shows the cereal bowls on the table where the children had eaten that morning," he said.
    Owmby acknowledged Yates was emotionally unstable at the time of the killings. "She was more than a little depressed," he told the jury, noting the array of psychiatric medication that had been prescribed for her, starting three years ago. "There's no question Andrea Yates had some form of mental illness." But under Texas law, for Yates to be acquitted by reason of insanity, the defense must prove "by a preponderance of the evidence" that she was so deranged on June 20, the day of the drownings, that she could not distinguish right from wrong. The facts of the case contradict that argument, Owmby said. In her audiotaped statement, for example, Yates, 37, told police she began thinking about drowning her children two years ago. "She killed them because [she thought] they weren't developing properly, and she was a bad mother," Owmby told jurors, referring to Yates's mental illness. But "you'll also hear testimony that she knew it was an illegal act, a sin." A big obstacle for the defense is this question: If Yates could not appreciate the wrongfulness of her actions, why did she summon police after the drownings?
    Yates said in her statement that she waited to drown the children until after her husband, Russell, a computer engineer, left home for work at NASA's Johnson Space Center, not far from the couple's three-bedroom, brick-front ranch house on Beachcomber Lane in a middle-class Houston neighborhood. Owmby today played a tape recording of her 911 call, letting the jury hear her emotionless voice.
    Yates's lead attorney, George Parnham, told jurors in his opening statement that psychiatric experts called to testify by the defense would explain "what the mind's eye of Andrea Pia Yates saw and caused her to do on June the 20th, 2001." He said the testimony "will support the proposition that . . . [she] suffered from a severe case of psychosis -- postpartum depression with psychotic features." He said the defense would present a videotape of its own: images of Yates playing happily with her children at times when her mental illness was under control. "Andrea Pia Yates is the most loving of mothers," Parnham said. Saying his client's psychiatric problems included "hallucinations, delusions and disorganized thought," Parnham told the panel that Yates suffered "from the cruelest, most severe of mental illnesses. It takes the very nature and essence of motherhood -- to nurture and protect -- and changes the reality."
    Mental health experts say postpartum depression afflicts about one in five women after they give birth. Most cases involve relatively mild symptoms. Postpartum psychosis is far more unusual, occurring in two or three new mothers out of 1,000, researchers say. In those cases, women often become delusional and sometimes hear voices urging them to commit suicide or harm their children.
    Parnham today recounted Yates's struggles with postpartum mental illness, which included two suicide attempts and four hospitalizations, beginning in 1999. At times during her treatment, she appeared catatonic, unwilling or unable to cooperate with psychiatrists, who prescribed several different medication regimes, Parnham said. He said one mental health professional who evaluated her found that "on a scale of one to 10, with 10 being the most severe psychosis, Andrea Yates was off the charts." In early June, he said, she stopped taking antipsychotic drugs. "And on June the 20th, the inevitable happens," Parnham said. At the time of the drownings, "she had zero antipsychotic drugs in her system." He pointed to Yates in the courtroom, where she sat motionless. She is being held in the psychiatric unit of the Harris County jail in Houston. "As she sits here today," Parnham told the jury, "she takes daily doses of 15 milligrams of [the antipsychotic drug] Haldol . . . to prevent her from slipping back into psychosis."
    The jurors were chosen from among scores of prospective panel members in a selection process that lasted nearly a month. Six of the eight women have children, and two of the women have college degrees in psychology, though neither is a practicing psychologist. One of the men said he is a recovering alcoholic and another said his wife had been treated for depression. Each of the three alternates is a mother. If the jury acquits Yates on the basis of insanity, she would be confined indefinitely to a secure mental hospital. If found guilty of capital murder, she would be sentenced either to death or to life in prison with eligibility for parole in 40 years. The jury would make that decision in a penalty phase of the trial.
    Although the National Organization for Women and other groups have criticized District Attorney Chuck Rosenthal for seeking the death penalty in Yates's case, Rosenthal has said that he was guided by his conscience. In responding to one of the dozens of e-mails and letters sent to his office by people commenting on the case, Rosenthal said the pro-death-penalty views of the conservative voters who helped elect him in November 2000 had nothing to do with his decision. "I do all this after seeking wisdom from God," Rosenthal wrote. "My oath of office requires me to follow the law without considering public opinion."

Scientists Examine How 'Social Rewards' Hijack the Brain
Sandra Blakeslee, New York Times- 2/19/2002

Compulsive gambling, attendance at sporting events, vulnerability to telephone scams and exuberant investing in the stock market may not seem to have much in common. But neuroscientists have uncovered a common thread. Such behaviors, they say, rely on brain circuits that evolved to help animals assess rewards important to their survival, like food and sex. Researchers have found that those same circuits are used by the human brain to assess social rewards as diverse as investment income and surprise home runs at the bottom of the ninth. And, in a finding that astonishes many people, they found that the brain systems that detect and evaluate such rewards generally operate outside of conscious awareness. In navigating the world and deciding what is rewarding, humans are closer to zombies than sentient beings much of the time.
    The findings, which are gaining wide adherence among neuroscientists, challenge the notion that people always make conscious choices about what they want and how to obtain it. In fact, the neuroscientists say, much of what happens in the brain goes on outside of conscious awareness. The idea has been around since Freud, said Dr. Gregory Barns, a psychiatrist at Emory University School of Medicine In Atlanta. Psychologists have studied unconscious processing of information in terms of subliminal effects, memory and learning, he said, and they have started to map out what parts of the brain are involved in. such processing. But only now are they learning how these different circuits interact, he said. "My hunch is that most decisions are made subconsciously with many gradations of awareness," Dr. Berns said. "For example, I'm vaguely aware of how I got to work this morning. But consciousness seems reserved for more important things."
    Dr. P. Read Montague, a neuroscientist at Baylor College of Medicine in Houston, says the idea that people can get themselves to work on automatic pilot raises two questions: how does the brain know what it must pay conscious attention to? And how did evolution create a brain that could make such distinctions? The answer emerging from experiments on animals and people is that the brain has evolved to shape itself, starting in infancy, according to what it encounters in the external world. As Dr. Montague explained it, much of the world is predictable: buildings usually stay in one place, gravity makes objects fall, light falling at an oblique angle makes long shadows and so forth. As children grow, their brains build internal models of everything they encounter, gradually learning to identify objects and to predict how they move through space and time.
    As new information flows into it from the outside world, the brain automatically compares it to what it already knows. If things match up -- as when people drive to work every day along the same route -- events, objects and the passage of time may not reach conscious awareness. But if there is a surprise -- a car suddenly runs a red light -- the mismatch between what is expected and what is happening instantly shifts the brain into a new state. A brain circuit involved in decision making is activated, again out of conscious awareness. Drawing on past experience held in memory banks, a decision is made: hit the brake, swerve the wheel or keep going. Only a second or so later, after hands and feet have initiated the chosen action, does the sense of having made a conscious decision arise.
    Dr. Montague estimates that 90 percent of what people do every day is carried out by this kind of automatic, unconscious system that evolved to help creatures survive. Animals use these circuits to know what to attend to, what to ignore and what is worth learning about. People use them for the same purposes which, as a result of their bigger brains and culture, include listening to music, eating chocolate, assessing beauty, gambling, investing in stocks and experimenting with drugs -- all topics that have been studied this past year with brain imaging machines that directly measure the activity of human brain circuits.
    The two circuits that have been studied most extensively involve how animals and people assess rewards. Both involve a chemical called dopamine. The first circuit, which is in a middle region of the brain, helps animals and people instantly assess rewards or lack of rewards. The circuit was described in greater detail several years ago by Dr. Wolfram Schultz, a neuroscientist at Cambridge University in England, who tracked dopamine production in a monkey's midbrain and experimented with various types of rewards, usually squirts of apple juice that the animal liked. Dr. Schultz found that when the monkey got more juice than it expected, dopamine neurons fired vigorously. When the monkey got an amount of juice that it expected to get, based on previous squirts, dopamine neurons did nothing. And when the monkey expected to get juice but got none, the dopamine neurons decreased their firing rate, as if to signal a lack of reward.
    Scientists believe that this midbrain dopamine system is constantly making predictions about what to expect in terms of rewards. Learning takes place only when something unexpected happens and dopamine firing rates increase or decrease. When nothing unexpected happens, as when the same amount of delicious apple juice keeps coming, the dopamine system is quiet. In animals, Dr. Montague said, these midbrain dopamine signals are sent directly to brain areas that initiate movements and behavior. These brain areas figure out how to get more apple juice or sit back and do nothing. In humans, though, the dopamine signal is also sent to a higher brain region called the frontal cortex for more elaborate processing.
    Dr. Jonathan Cohen, a neuroscientist at Princeton, studies a part of the frontal cortex called the anterior cingulate, located in back of the forehead. This part of the brain has several functions, Dr. Cohen said, including the task of detecting errors and conflict in the flow of information being processed automatically.
    Brain imaging experiments are beginning to show that when a person gets an unexpected reward -- the equivalent of a huge shot of delicious apple juice -- more dopamine reaches the anterior cingulate. When a person expects a reward and does not get it, less dopamine reaches the region. And when a person expects a reward and gets it, the anterior cingulate is silent. When people expect a reward and do not receive it, their brains need a way to register the fact that something is amiss so it can recalibrate expectations for future events, Dr. Cohen said. As in monkeys, human dopamine neurons project to areas that plan and control movements, he said. Fluctuating levels of dopamine make people get up and do things outside their conscious awareness. The number of things people do to increase their dopamine firing rates is unlimited, neuroscientists are discovering. Several studies were published last year looking at monetary rewards and dopamine. Money is abstract but to the brain It looks like cocaine, food, sex or anything a person expects is rewarding, said Dr. Hans Breiter, a neuroscientist at Harvard. People crave it.
    Some people seem to be born with vulnerable dopamine systems that get hijacked by social rewards. The same neural circuitry involved in the highs and lows of abusing drugs is activated by winning or losing money, anticipating a good meal or seeking beautiful faces to look at, Dr. Breiter said. For example, dopamine circuits are activated by cocaine; people become addicted when their reward circuits have been hijacked by the drug, Dr. Montague said.
    Winning in gambling can also hijack the dopamine system, Dr. Berns said. Many people visit a casino, lose money and are not tempted to go back. But compulsive gamblers seem to have vulnerable dopamine systems, he said. The first time they win, they get a huge dopamine rush that gets embedded in their memory. They keep gambling and the occasional dopamine rush of winning overrides their conscious knowledge that they will lose in the long run.
    Other experiments show that reward circuits are activated when young men look at photos of beautiful women and that these circuits are defective in women with eating disorders like bulimia. Bulimics say they are addicted to vomiting because it gives them a warm, positive feeling. Music activates neural systems of reward and emotion. Older people with age-related impairments to the frontal cortex do poorly on gambling tasks and, experiments show, are prone to believe misleading advertising. Neuroscientists say that part of the appeal of live sporting events is their inherent unpredictability. When a baseball player with two outs at the bottom of the ninth inning hits a home run to win the game, thousands of spectators simultaneously experience a huge surge of dopamine. People keep coming back, as if addicted to the euphoria of experiencing unexpected rewards.
    One of the most promising areas for looking at unconscious reward circuits in human behavior concerns the stock market, Dr. Montague said. Economists do not study people, they study collective neural systems in people who form mass expectations. For example, when the Federal Reserve unexpectedly lowered interest rates twice last year, the market went up, he said. When it lowered interest rates on other occasions and investors knew the move was coming, markets did not respond. Economists and neuroscientists use the same mathematical equations for modeling market behavior and dopamine behavior, Dr. Montague said. Neuroscience may provide an entirely new set of constructs for understanding economic decision making.

A Growing List of Drugs to Help Smokers Quit
Sally Squires, Washington Post- 2/19/2002

About 40 percent of America's 50 million smokers will try to kick the habit at least once this year, according to the federal Centers for Disease Control and Prevention (CDC). On each attempt, fewer than one in 10 will succeed. As discouraging as those numbers may seem, nicotine addiction researchers offer the offsetting news that those very failures pave the road for breaking dependence on tobacco – something that about half of smokers ultimately achieve, according to federal treatment guidelines. "Most people have to try to quit probably five to seven times before they succeed," said John Hughes, professor of psychiatry at the University of Vermont. "It's just like swimming – it's important to keep jumping in the water to learn."
    And as experts like to note, there has never been a better time to quit – or so many different scientifically validated options to help smokers reduce the pangs of nicotine withdrawal and the craving for cigarettes, both of which make quitting smoking harder than making most other behavioral changes. (To help prompt smokers to make the effort and to limit exposure of non-smokers to cigarette smoke, 82 percent of work sites in Washington, D.C. are smoke-free, 43 states restrict smoking in government offices and 21 restrict smoking in private work places, according to the CDC.)
    Ten years ago, "all we had to offer was going cold turkey or nicotine gum," says Michael C. Fiore, chairman of a federal panel that issued treatment guidelines two years ago calling for nearly every smoker who wanted to quit to use medications to support their efforts. Today, there are seven drug treatment choices, as well as many organized smoking cessation programs and individual counseling services that also boost chances that smokers will manage to quit.
    Four safe and proven nicotine replacement methods – gum, a patch that delivers nicotine through the skin, an inhaler that mimics the effect of smoking and a spray that provides a quick burst of nicotine to nasal passages – can deliver gradually declining doses to take the edge off cravings and withdrawal. They have only minimal side effects, a very low risk of addiction and are free of the nearly 4,000 harmful substances that cigarette smoke delivers.
    The treatments don't end there. An antidepressant medication – bupropion, marketed for depression under the brand name Wellbutrin and for smoking cessation as Zyban – can also help break cigarette addiction, though the scientific process by which this occurs is still not understood. There have been many reports of serious adverse effects, including some deaths, from Zyban in Europe. Next week, several professional societies will review the data. But for now, "it's unclear if the events are related to the medication," says Hughes.
    Two other options for especially difficult cases of smoking addiction are the blood pressure medication clonidine and the antidepressant nortriptyline. While the evidence of their value is not as extensive as that for nicotine replacement drugs, a government panel advised recently that these medications be tried if other drugs have failed. (Neither, however, is approved for this use by the Food and Drug Administration). "The good news for smokers," Fiore says, "is that people now have a choice. There's never been a better time to quit."
    Trouble is, a lot of smokers do it the wrong way and increase their odds of failure. Since smoking is often viewed as a weakness or character flaw, many smokers tend to tough it out themselves and go cold turkey. Or they mistakenly use minimal amounts of the nicotine replacement drugs and other medications that are proven scientifically to help assuage the strong physiological symptoms of withdrawal. "That is why there is such a high relapse rate," explains David Sachs, clinical associate professor of pulmonary and critical care medicine at Stanford University School of Medicine in California. "It's like killing all four engines on a Boeing 747 where you're 2,000 feet above the runway. You crash and burn and then people start beating up on themselves. They say, 'I am a failure,' when they are really dealing with something that has a striking rationale as far as pharmacology and physiology are concerned."
    No one suggests that quitting is easy, even with nicotine replacement medications. Adult smokers go through an average of a pack of cigarettes each day. At 20 cigarettes per pack and 10 puffs per cigarette, that's 200 nicotine hits a day right to the brain, making smoking "one of the world's most intense habits," says the University of Vermont's Hughes. The cigarette is one of the fastest and most powerful drug delivery systems ever known. "It takes just a few heartbeats to get nicotine from the tip of your finger to the brain," says Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic in Rochester, Minn. Once there, nicotine produces significant changes in brain cells. Chemically similar to naturally occurring neurotransmitters or chemical messengers, nicotine displaces some brain chemicals. Just 10 days of smoking triples the number of entry points – receptors – that allow nicotine to get inside brain cells, says Stanford's Sachs. There, nicotine acts on the pleasure-reward pathway by raising levels of four key neurochemicals that affect alertness, energy and mood – dopamine, norepinephrine, beta endorphins and serotonin. (Newer antidepressant medications target levels of these same brain chemicals.) "The bottom line is that nicotine has a lot of very beneficial effects on how we feel and think," Sachs says.
    That's why the development of effective nicotine replacement drugs has finally given an edge to smokers who want to quit. Using one or more of these medications boosts success rates to about 25 percent, the federal treatment guidelines issued in 2000 by the Agency for Healthcare Research and Quality (AHRQ) found. Evidence suggests they could go higher if more intensive treatment and greater support were applied. Close monitoring of withdrawal symptoms and tailoring nicotine replacement therapy to the individual has produced success rates of up to 50 percent at some of the best smoking cessation programs.
    At Mayo's Nicotine Dependence Center, for instance, smokers pay $3,300 each to check into an intensive, weeklong residential smoking cessation program. They undergo blood testing for cotinine, a marker of nicotine byproducts; the tests are used to help adjust treatment individually for withdrawal symptoms and cravings. The program includes daily group and individual therapy, stress reduction, nutrition and diet information, supervised exercise and a 12-step program similar to Alcoholics Anonymous. About 700 smokers have gone through the decade-old program, which attracts long-term older smokers – average age 53 compared with early forties for other programs – who have tried to quit on numerous occasions. Eighty percent of the participants are already experiencing tobacco-related illnesses such as emphysema or heart disease. Yet, one year after treatment – the longest follow-up data available – about 45 percent of participants remain smoke-free, according to Hurt. At Stanford, Sachs and his colleagues have also found that an individualized outpatient approach can be effective, boosting quitting success rates to 50 percent. Both programs, Hurt says, show the kind of results that could be expected "if the federal guidelines were fully implemented with more intensive treatment for smokers."
    In the community at large, however, research suggests that both smokers and some physicians are confused about what approach to use. "While we are blessed with a variety of treatment strategies, the challenge is finding the right combination for each individual," says Neil Grunberg, professor of psychology and neuroscience at the Uniformed Services University of the Health Sciences in Bethesda. Science still can't say with certainty which smoker will benefit most from which treatment, but there are tantalizing hints. "Men seem to do better [than women] with nicotine gum and the patches," Grunberg says. Studies suggest that bupropion works equally well in men and women and is especially helpful for smokers with a past history of depression, according to Fiore. The 2000 treatment guidelines, which were written after an extensive review of the scientific literature, note that gum and bupropion seem to help prevent weight gain. Those who have experienced severe withdrawal symptoms in previous attempts to quit may do better on the patch; studies suggest that smokers who suffer severe cravings seem to be helped by the high-speed nicotine delivery of the gum, the inhaler or the nasal spray.
    Yet all too often, tobacco addiction experts find that smokers go cold turkey and don't take advantage of these aids – an almost-certain program for failure. Or they don't follow directions and use too little of the medications to help them succeed, perhaps because the treatment can cost $4 to $18 a day – compared with $3.50 for a pack-a-day habit. "Most people are way under-dosed," Hurt says. "If they're getting more than 300 milligrams a day from cigarettes – that's about two packs a day – then we will use two [nicotine replacement] patches."
    Not using enough nicotine replacement medication can sabotage the most dedicated attempts to give up smoking. At Stanford, Sachs and his colleagues monitored the blood levels of nicotine as smokers quit and compared them with the eventual rates of success. When nicotine levels dropped too precipitously to 50 percent or less of what they had been while participants were smoking, success rates were no better than the 5 to 8 percent seen with a placebo, about equivalent to going cold turkey. Smokers need to take a cue from other over-the-counter medications. "They say: If your symptoms persist for a few days, go see your doctor," Sachs notes. "What nicotine replacement products should say is: If craving for cigarettes continues or you experience increased irritability or difficulty concentrating, contact your doctor. As a physician, that would tell me that you're probably not getting an effective dose."
    Another mistake smokers make is thinking of nicotine replacement as a magic bullet that will help them sail through the difficult days of withdrawal and ease their cravings without any additional effort. Those who ignore the importance of behavior change or social support undermine their efforts. The federal treatment guidelines found that only the combination approach – proper doses of medication along with professional and/or social support can consistently push the success rates to about 30 percent. "You should not approach taking a smoking cessation medication the way you would approach taking an antibiotic or a painkiller," Grunberg says. "These medications do not work on their own."
    For those trying to quit, there's no safe way to light up a single cigarette – which is why the current treatment guidelines advise abstinence. Some nicotine replacement medications, such as the patch, could contribute to toxic levels of nicotine if they are combined with smoking and lead to nausea, blood pressure problems and other health effects. But worse, even one cigarette can send a smoker down a slippery slope toward re-addiction.
    "There's never a point where there is an absolute guarantee that someone has quit smoking," says Harry Lando, professor of epidemiology at the University of Minnesota's School of Public Health and a member of the federal committee that drafted the treatment guidelines. It is true, however, that the longer abstinence is achieved, the better the chance that it will be permanent. Large population studies show that smokers who quit for a year have an 85 percent chance of maintaining their abstinence, Lando says. Those who make it five years have a 97 percent chance of continued success. "But it's important that someone not feel too safe and let down their guard," Lando says. "I have a colleague, a professional in the health area, who had not smoked for 16 years. He ran into marital difficulties and a serious health issue with a child and went back to smoking and has not yet been able to quit."
    However difficult it may be to quit, smoking researchers are convinced that nearly everyone can achieve independence from smoking – given the right help. A new generation of drugs now in the research pipeline – such as a tobacco vaccine currently under development at Nabi in Rockville – is expected to attack tobacco dependence in bold new ways. The $206 billion settlement by state attorneys general with the tobacco companies established the American Legacy Foundation in 1999. The foundation is pumping dollars into prevention programs and into practical strategies, including $7.5 million for the establishment of a toll-free telephone hot line for pregnant smokers trying to kick the habit (1-866-66-START).
    "We know that quit lines can be an effective way to help people quit smoking," says Scott Leischow, chief of the National Cancer Institute's tobacco control branch. But these help lines are still only available in 28 states. The District, Maryland and Virginia are among the jurisdictions that don't yet offer quit lines. There's also a growing recognition that smoking is not a character flaw or a weakness, but an addiction and a serious chronic disease that warrants treatment. "We wouldn't tell someone with a blood sugar of 500 to just work on their willpower," Fiore says. "We don't tell someone who has a systolic blood pressure of 250 that if they really had character they could control it on their own. Why hold back treatments from smokers that we know could help?"
    And yet that is essentially what happens every year. Medicare doesn't pay for smoking cessation medications, and only about half of private insurers cover such treatment, although health maintenance organizations often do. "It's important that smokers, doctors, insurers and the U.S. Congress hear what a paradox it is that our health system spends tens of billions of dollars to provide care for heart attacks or strokes or lung cancer or emphysema, but it does not pay for medicine that could help people quit smoking," Fiore says. "Not too many PPOs [preferred provider organizations] cover it and I don't know why," says Walter Cherniak, Mid-Atlantic public relations manager for Aetna, whose PPOs do not cover cessation but whose HMOs do. "But prevention and health promotion are the biggest advantages of belonging to an HMO."
    The bottom line that tobacco experts are delivering is this: Smokers should keep trying to quit no matter what the cost. Giving up cigarettes at age 50 cuts the risk of dying in half from smoking related illnesses during the next 15 years, Fiore says. Even long-term smokers who have been diagnosed with smoking-related health effects – chronic obstructive pulmonary disease or lung cancer – can buy time and improve breathing capacity by as much as 5 percent by quitting. "In someone who is oxygen-impaired, that really makes a difference," Fiore says.
    Continuing to try to cut the dependence on smoking can help save lives and health care dollars, according to a 1997 report by the agency now known as AHRQ. Providing smoking interventions to 75 percent of U.S. smokers 18 and older would cost $6.3 billion for the first year, but would produce 1.7 million new quitters, the report said. Even so-called "failures" – people who quit for days or weeks but go back to smoking – stand a good chance of succeeding ultimately. Studies show that being able to stay off cigarettes for a week is strongly linked – eventually – to long-term quitting. "The message is: Keep trying," says the University of Vermont's Hughes. "A lot of people give up too soon. The number one message is that there is a lot of help out there now."

Pulling Back the Curtain of Smoke
Hubert B. Herring, New York Times- 2/19/2002

It is always interesting to talk to smokers about their habits. Young ones say they will quit soon (most of them won't); older ones, resigned to being hooked come up with a variety of rationales. One woman told me she did not care if she died 10 years earlier -- the important thing was enjoying her life, and that meant smoking. What she seemed to believe was that at some point she would have a peaceful, easy death, but that if she kept smoking, it would simply come a decade sooner. No big deal.
    But smokers' deaths can be anything but easy. Yes, we hear statistics - more than 400,000 Americans a year killed by smoking, more than 1,000 a day, but those are sterile numbers. They give no sense of how long, how painful, some of those deaths can be. That is because we do not see them. We see healthy-looking people puffing away in office doorways, we see movie stars smoking on screen, but those deaths are invisible except to those near and dear. So let's pull back the curtain, past the cloud of smoke, and look at one such death closely.
    Imagine being slowly, slowly, slowly asphyxiated -- breath by ever-harder breath -- for a decade. That will give you an idea. When I met my future father-in-law 20 years ago, he was a healthy, vigorous 59. Yes, he was a heavy smoker, but that did not stop him from whipping me at tennis. Within five years came the first mention of emphysema. His shortness of breath steadily got worse. The warning signs were crystal clear, but still he would not quit. Then, about 12 years ago, his doctor told him not to waste his time anymore: get out and come back when you have quit. That scared him enough to quit. But it was too late. His breathing got more and more difficult. Tennis had already gone by the wayside, and golf soon did, too.
    About six years ago, he heard about a surgery that involved cutting away the diseased part of the lung, allowing the smaller, remaining lung more room to expand. Desperate for relief, he had that surgery -- an ordeal for him, a huge expense (at least for Medicare), a disruption to the lives of many family members who had to ferry him to doctors, to care for him during the recuperation. For six months, he seemed to improve ever so slightly, but then the decline resumed. Bit by bit, his life narrowed. The winter month in Florida, treasured by his wife, had to go -- getting on a plane was too much of an ordeal. Traveling anywhere, even by car, got more difficult. In his last few visits, he would pull into our driveway, get his strength up while hooked to a portable oxygen tank, then dash in and collapse, taking a few more minutes before he could talk.
    Those visits stopped. By a year ago, his world was limited to a sad little triangle -- his bed, his bathroom and the dining table. For a while, on a good day, he could sit comfortably at the table, reading or carrying on a normal conversation. Gradually there was more time in bed, less at the table, and the conversations grew shorter. He would say one sentence, someone would answer, and, struggling for a breath, he would sputter, "I can't talk right now."
    In his last month or so, he mostly lay in bed -- at 112 pounds, just over half his former weight -- struggling nearly every minute just to breathe. One daughter, my wife, asked him if he wasn't terribly bored, having to just lie there. No, he said -- the never-ending fight to breathe kept him fully occupied. He was able to stay at home only because another daughter devoted much of her time to caring for him.
    The end, considering the glacial progress of the disease, came with whirlwind speed. One day he could not get out of bed, looking almost as if he was in a coma. The ambulance came, and when the family's attention was briefly distracted in the hospital, he was hooked up to a respirator, even though he had a living will that forbade such measures. Two days later, the doctor asked him if he wanted it removed, making clear that he would then surely die; he nodded a definite yes. It was removed, and in a day and a half he was dead.
    This was not a life that happened to end in one decade rather than the next. It was a grueling, sad, costly ordeal -- excruciating for him, as he was slowly choked to death by his rotting lungs, and endlessly disruptive for family members, who spent hundreds of hours caring for him -- that stretched for years, stealing his entire retirement. If you poked around, you could probably find many equally excruciating stories just for that single day he died -- Jan. 20, 2002. But those stories are invisible.

Connecticut Psychiatric Care In Crisis
Hilary Waldman, Hartford Courant- 2/19/2002

WATERBURY -- With regular psychotherapy and medication, Sue Gelinas has managed to control her chronic mental illness, work part time and keep up her own apartment. So when her psychotherapist moved her office away from Gelinas' hometown last month, the 53-year-old Waterbury woman had to find somebody else. Last week she called six therapists in the city, hoping for an appointment. Four turned her away, saying they did not accept her state-paid health insurance. Two did not return her calls. She's still looking. "If I get really bad, I guess I can [check in] to Waterbury Hospital," said Gelinas, who has struggled with mental illness for more than 20 years.
    Outpatient psychiatric care always has been scarce. But in the past year, even more people have been shut out as general hospitals, long the providers of last resort, have buckled under the burden of high demand and low payment and simply stopped taking more patients into their psychiatric clinics. After losing $4 million from its psychiatry department alone last year, Waterbury Hospital has stopped taking any new mental health patients, said John Tobin, the hospital's chief executive officer. "In Waterbury, unless you show up in the emergency room in crisis, you have to wait six to eight weeks for a community provider," Tobin said.
    Hospitals in Connecticut must seek state approval to eliminate any service, such as psychiatric care, but they can just go ahead and cut their clinical staffs and strictly limit the number of patients they see. And that's exactly what has occurred, Tobin said. "What's happening is the hospitals have quietly wound down mental health services. You don't have to go to the state for permission. You just kind of drift away."
    Clinic waiting lists have exacerbated gridlock throughout the mental health system, especially for people who don't have private insurance. For example, if Gelinas is lucky enough to find a mental health clinic that is taking new patients, she can expect to wait three months for an appointment, maybe longer. About the only thing that might speed things up is if she becomes psychotic and starts hearing voices. "We routinely hear from patients [in the emergency room] who have an appointment five or six weeks out, but they can't wait," said Dr. Thomas Rheinhardt, medical director of crisis and consultation at Waterbury Hospital. "People have killed themselves," said Tony Leonardi, a psychologist who manages the Waterbury Hospital's crisis intervention team. "I'm aware of people looking for care and unable to get care who have harmed others." More often, they are admitted and stabilized in hospital psychiatric units. Then they face another outpatient crunch at discharge time, because again there can be a six-week wait to see a community psychiatrist for a follow-up visit.
    While the problem is particularly acute in Waterbury, a city of 107,200 where few psychiatrists are in private practice and there are not enough community mental health centers, the outpatient crisis has touched all corners of the state. Connecticut's 31 general hospitals have noted a 20 percent to 40 percent increase in emergency room visits for psychiatric care. "Has there been an increase in mental health problems?" asked Stephen W. Larcen, chief executive officer of Natchaug Hospital, a 54-bed psychiatric facility in eastern Connecticut. "Probably not."
    Money is at the core of the crisis. Because of the debilitating nature of chronic mental illness, many people who suffer from it cannot work full time. Thus, many are poor and supported by government programs, such as Medicare and Medicaid. The government programs pay so little to mental health providers that many private clinicians refuse to treat patients with government coverage. That leaves hospitals and charity organizations. But they too are squeezed by the government's payments, which don't begin to cover the cost of care. For example, the state pays $42 to United Services Inc., a large provider of mental health care in eastern Connecticut, for a routine adult counseling session. That same session costs the nonprofit organization $89, which covers the therapist's salary and benefits, licensing and overhead costs.
    "The reimbursement rates are so phenomenally low that you can't afford to hire people to provide services," said Diane Manning, United Services' president and chief executive officer. Her clinic treats 850 to 900 people at any given time. Even people being discharged from psychiatric hospitals must wait at least two weeks for a follow-up appointment with a social worker. The wait to see a psychiatrist after a hospital discharge is up to two months. Manning said she came face to face with the backlog about a year ago when she dropped her clothes at a dry cleaner near the clinic in Danielson. "I told the clerk where I worked so she could call me when the cleaning was ready and she started crying," Manning recalled. The clerk explained that her husband was suffering from obsessive compulsive disorder. He had lost three jobs because he constantly thought he was sick. Instead of taking his children to school and going to work, he'd rush himself to the emergency room. The Department of Children and Families was warning it might take the children out of the home because of truancy. The clerk was on the verge of quitting her job and going on welfare so she could stay home and keep the family together. Manning said the woman's husband was on waiting lists for counseling at United Services and Day Kimball Hospital, the general hospital in Putnam. "Here was an anxiety disorder that's relatively easy to treat on an outpatient basis and instead a whole family was falling apart," Manning said. With Manning's intervention, the husband got an appointment at United Services, and his wife is still working at the dry cleaner. "She happened to hit the right person and cry," Manning said.
    The shortage of outpatient care has only worsened since July 2000 when Gov. John G. Rowland's Blue Ribbon Commission on Mental Health presented a scathing assessment of mental health care in Connecticut. The commission documented long waits for hospital and outpatient care. Last year, Rowland and the legislature promised about $26 million to improve care for mentally ill children and adults. But on Wednesday, Rowland proposed cutting that sum to about $17 million as he tries to balance the state budget.
    Meanwhile, financially strapped general hospitals continue to pare services at their outpatient mental health clinics as they seek ways to keep up with their primary mission - caring for physical illnesses. "On the outpatient side you're seeing more and more that you can't afford to see all the patients who arrive at your door," said Laurence A. Tanner, president and chief executive officer of New Britain General Hospital. "We have not shut down yet, but without more money from the state we will continue to reduce, rather than expand."
    Almost two years ago, when several hospitals applied to the state for permission to shut down their psychiatric services, Raymond J. Gorman, commissioner of the Office of Health Care Access, intervened. Gorman, whose approval is necessary to hospitals planning to cut or expand services, asked for a voluntary moratorium on any reductions in mental health services.  But the moratorium lapsed in January 2001, and Gorman said that without any more formal applications to reduce psychiatric services, there's not much he can do. Gorman, whose office faces elimination under Rowland's new budget proposal, said he has no plans to call for another moratorium.  So people continue to wait and suffer. And only people with the most serious mental illnesses, or those with good private insurance, get mental health care. "If someone calls our intake this week very depressed, not sleeping with two kids at home, [they have to wait] 12 weeks," said Doreen Buttner, director of behavioral health at Family Services of Greater Waterbury, where 10 master's-level counselors see patients. Even people diagnosed with serious illnesses don't always get the care they need.
    Annette Bombaci, 24, has been in and out of psychiatric hospitals since she was 11. She is manic-depressive. When she takes her medication, she can work part time and be an active leader at the Mental Health Association of Connecticut's Independence Center, a Waterbury social club for people with psychiatric disabilities. "If I don't take my meds," Bombaci says, "I can get to the point where I'll go to a car dealer and try to buy a car with no money in the bank, or I'll want to hide in my house crying all the time." The only consistent access to care that Bombaci and her friends at the club have are 15-minute medication checks once a month or once every two months. A psychiatrist at Waterbury Hospital generally asks how they're doing, writes a new prescription and sends them for blood work, club members said.
    "All the doctors do is give us medications; they don't have time to talk," said Sue Gelinas, who also is active at the Independence Center. That may be adequate until there's a problem - and the nature of mental illness almost guarantees there will be problems. Psychiatric medications that can stabilize patients also cause awful side effects. Inner voices or a misconception of being cured can also prompt people to stop taking their medicine.
    Bombaci and Wendy Wheeler, another Independence Center member, said they deteriorate quickly when they stop taking their pills. And without a therapist who knows them, it often takes too long before a friend or staff member at the Independence Center notices or gets up the nerve to call the hospital. Bombaci said she recently felt like she needed somebody to talk to and called two clinics in Waterbury. "I got frustrated and hung up," she said. "I can't wait six months for therapy."

Mental Health Coverage Faulted
Hilary Waldman, Hartford Courant- 2/19/2002

Attorney General Richard Blumenthal Thursday said the case of a penny-pinching managed care company and a young woman harmed by bargain-basement care points up problems in the way all HMOs pay for mental health care. Blumenthal released a report documenting the case of Melissa Fahey, a 22-year-old woman, who like 600,000 other Connecticut residents, has health insurance through Anthem Blue Cross-Blue Shield.
    Like other HMOs, Anthem subcontracts with another firm to manage mental health care. Anthem's behavioral health subcontractor is Psych Management Inc. Blumenthal charged Thursday that Anthem's low payments to Psych Management, also known as PMI, combined with financial misdeeds by the subcontractor's medical director, caused harm to Fahey when she needed psychiatric care. Blumenthal said the case is an extreme example of why managed care firms must be forced to stop skimping when providing psychiatric care. He said an untold number of state residents may be harmed each year because HMOs treat mental health as a sub-class of medicine, allowing subcontractors to strictly limit hospital stays, counseling visits and access to medication.
    Blumenthal said he is preparing to sue Anthem in the Fahey case, but the ultimate solution rests in the legislature. HMOs, he said, should be prohibited from using subcontractors and paying less for mental health care than they do for physical care. Attempts to equalize mental and physical health care coverage have long been on the legislative agendas in Hartford and Washington, but have languished because they threaten to increase health care costs. In the Fahey case, Blumenthal said greed exacerbated the problem. But Anthem must be held accountable, he said. He is suing Anthem, he said, because the company is responsible for the actions of its subcontractor - PMI.
    In a prepared statement, Anthem officials acknowledged that there had been complaints in 2000 about PMI's apparent inability to process claims and pay mental health providers in a timely fashion. But the statement said those problems have been resolved and Anthem is unaware of any ongoing complaints. Blumenthal's report traces the case back to 1999, when Anthem agreed to pay PMI a flat monthly rate of about $4.30 per member to provide mental health care for any Anthem client who needed it. The contract was worth $20 million a year, which was not nearly enough to cover the actual cost of care, Blumenthal said. Although the contract did not specifically restrict care, PMI started limiting outpatient visits and sending members to the cheapest hospitals to save money. At the same time, PMI's medical director, Dr. Peter Benet, was using company funds to support a lavish lifestyle, Blumenthal said.
    When Melissa Fahey showed up in the emergency room at Manchester Memorial Hospital in October 2000 suffering from severe psychiatric distress, he said she became trapped in the web. Blumenthal and Melissa's mother, Leslie Fahey, of Suffield, said Melissa's condition deteriorated after PMI refused to pay for her care at a specialized hospital in Vermont and shuttled her between inappropriate psychiatric units in local general hospitals. Melissa Fahey ultimately got the care she needed in Connecticut and Benet has been fired from PMI. Attempts to reach Benet or PMI were unsuccessful.