Maine Methadone Clinics Limit Take-Home Prescriptions
Associated Press, 6/6/2002

PORTLAND, Maine -- Southern Maine's methadone clinics have agreed to limit patients' take-home prescriptions at the request of state officials. Following the Portland area's 17th overdose death of the year, the Maine Office of Substance Abuse asked that the clinics open on Sundays and revoke patients' biweekly and monthly take-home privileges. The request came Wednesday, a day after the state released a report that said Discovery House in South Portland and CAP Quality Care in Westbrook were in compliance with all state and federal regulations and a day after a 20-year-old woman died of an apparent overdose of cocaine and methadone obtained from a clinic patient.
    ''What we're doing is asking (the clinics) again to be more vigilant for their sake, their clients' sake and the general public's sake,'' said Bill Lowenstein, associate director of the Office of Substance Abuse. ''We're not requiring them to do this, but it was strongly suggested.'' Lowenstein said no one is disputing the usefulness of methadone in treating addiction to heroin and other opiates, but he said that the synthetic narcotic is increasingly ending up in the hands of the wrong people. Police and public health officials had asked the state to review the clinics' operations because they feared patients had been selling or giving away their take-home doses of methadone.
    Since January, 17 people in greater Portland have died from drug overdoses three times as many as during the same period last year. Methadone was a factor in several cases. Neither Steve Cotreau, program director at CAP Quality Care, nor Steve Gumbley, the project director at Discovery House, could be reached for comment. Lowenstein said both clinics were ''more than eager'' to comply with the state's request to open on Sunday to eliminate the need for weekly take-home doses and to stop allowing patients to take home two- and four-week supplies.
    The number of overdoses has prompted the state Emergency Medical Services Board to consider allowing rescue workers other than paramedics to administer Narcan. Currently, only paramedics are allowed to administer the drug, which can reverse the effects of a narcotics overdose. Rescue workers with basic- or intermediate-level training cannnot administer Narcan. In Portland, the change would allow some firefighters to treat overdose victims. In Portland alone, rescue personnel have responded to approximately 175 overdose calls since January.

Massachusetts Town to Drop Methadone Clinic Fight
Jenn Abelson, Boston Globe- 6/7/2002

Calling off a six-year legal feud with Spectrum Health Systems, the Framingham Board of Selectmen voted to withdraw its opposition to a proposed downtown methadone clinic and avoid the possibility of a court judgment that could be financially devastating to the town. Spectrum is seeking more than $1.5 million in a lawsuit filed against Framingham that accuses the town of discriminating against drug addicts - a case the company is willing to drop as part of the settlement approved by the selectmen last night.
    According to the terms of the agreement, Spectrum would abandon the discrimination suit. In return, Framingham would withdraw its appeal of a state Land Court decision that ordered the town to issue the company a building permit, and would stop fighting Spectrum's application for a license to dispense methadone at the 214 Howard St. site. Each side would bear its own costs and legal fees.
    Although the town counsel, Christopher Petrini, said he believes Framingham would have prevailed in the discrimination case, he recommended that the board seek a settlement because of the significant financial risk. Last night, Petrini repeated concerns he expressed to Town Meeting in April, among them that courts have sided with methadone clinics in similar cases, and that a judge, not a jury, would decide the suit. ''It's in the town's best interest to try to achieve a constructive relationship so there will be mutual cooperation,'' Selectman John Kahn said.
    While derailing the possibility of a financially ruinous ruling, the board's decision to settle sparked vociferous criticism at the meeting from many residents who spent nearly an hour heaping scorn on the selectmen. ''You people are turning this town into another Lawrence,'' said Sandy Norton, owner of Framingham Typewriter Sales, which is next door to the proposed clinic. ''You are doing a disservice to Framingham; you're dumping on it.''
    Numerous town officials spoke out against what they called a complete disregard for Town Meeting. In November, Town Meeting passed a resolution calling on the selectmen to do everything in their power to prevent a methadone clinic from opening at 214 Howard St. Town Meeting renewed its request in April when it asked that Framingham's legislative delegation fight the facility. ''It doesn't matter what we do. You chose what you wanted to do,'' said Daniel Gittelsohn, a Town Meeting member. ''You're ruining our town.''
    The legal bickering between the town and Spectrum erupted six years ago, after the company tried to find a new spot in town for its methadone clinic. Spectrum had operated clinics in three locations on Waverly Street and Union Avenue from 1989 to 1995. Community opposition mounted when the company tried to find a new site in 1996. Framingham initially rejected a building permit request and the Zoning Board of Appeals denied a variance exemption from parking regulations. Spectrum then took Framingham to court, and that part of the case ended last June when state Land Court ordered the town to issue a building permit. Town officials appealed that decision and Spectrum filed its discrimination lawsuit in Middlesex Superior Court.
    Petrini said Spectrum and the town would drop their respective court cases Monday. The town is sending a letter today to the state Department of Public Health that withdraws Framingham's opposition to Spectrum's application to dispense methadone. Spectrum, meanwhile, has not completed the community siting process of its state application for a license to distribute methadone.
    Several Town Meeting members hope to garner unified community opposition and the intervention of state officials to prevent the clinic from securing a license, although officials from the Public Health department have said opposition alone is not enough to block the granting of a license. Petitions have been circulating through the town, and Francis X. Reilly, a leader of the civic group FIMBY, or Framingham is My Backyard, said he wants to call a Special Town Meeting to discuss the Board of Selectmen's decision.
    According to Petrini, the selectmen have the authority to make settlements under $25,000. Selectmen Ginger Esty, who has been a vocal critic of the proposed clinic, refused to sign the agreement. ''I cannot be silenced,'' Esty said at the meeting. ''The selectmen have no business going forward with this settlement,'' she said in an interview. ''Not once, but twice the selectmen were told by Town Meeting to keep fighting.'' Although the terms of the settlement prohibit the board or any town body from suing Spectrum to block its opening, the agreement does not prevent individuals from filing private lawsuits against the company. ''The town has not subverted the power of private citizens who want to carry the battle forward,'' Kahn said.

Michigan Courts to Implement Drug Courts
Associated Press, 6/7/2002

DETROIT -- The U.S. Department of Justice is giving two Michigan courts nearly $700,000 to implement drug courts. The Livingston County Circuit Court in Howell will receive $159,211, and the Family Division of the Monroe Circuit Court will get $500,000, the Justice Department said Thursday. Michigan's awards are among 94 Justice Department grants totaling nearly $3.2 million to plan, establish or improve drug courts. Thirty-one states and two territories will receive funds.
    Drug court participants must take frequent drug tests and meet regularly with judges, who monitor offenders' treatment. Participants are expected to stay in treatment and may be ordered to take part in educational, vocational or community service activities. Successful participants may get reduced sentences or have their charges dismissed.

Lawsuit: Foster Care System Imperils Georgia Kids
Margaret Newkirk, Atlanta Journal- 6/7/2002

Two child advocacy groups sued Georgia Gov. Roy Barnes, the state and Atlanta foster care officials Thursday, saying that the area's child protection system is out of control, overburdened and putting thousands of children at risk. The lawsuit, filed by the New York-based Children's Rights organization and Keenan's Kids Law Center of Atlanta, is meant to force state action on what law center lawyer Jane Okrasinski called "terrible systemic problems" with Atlanta's child welfare programs. The suit names the county child welfare agencies in Fulton and DeKalb, in addition to the governor and state child welfare officials.
    The class-action suit on behalf of more than 3,000 Atlanta area children, cites specific histories of nine children who were allegedly harmed in state care. They include a 2-year-old boy who the complaint said is poised for a third foster home and a 14-year-old girl molested at her most recent foster care placement -- her 15th in 11 years. They also include a 16-year-old former honor student who the complaint said is living in fear in an emergency foster care shelter -- a student the DeKalb County Department of Child and Family Services allegedly neglected to enroll in school. Some of the children have been denied mental health services and at least three were sexually abused, the lawsuit claims.
    The children exemplify the overriding problems in Georgia's child welfare system, according to both Okrasinski and Marcia Robinson Lowry, executive director of Children's Rights. Children spend too much time in foster care, get bounced from home to home, suffer emotional damage and abuse that goes undetected by overburdened caseworkers and languish in crowded emergency foster care shelters, they say. A handful of high-profile tragedies have focused public attention on the system's inadequacies over the past few years. What has been missing is action, according to both Okraskinski and her partner, lawyer Don Keenan. "We've had 25 years of words," said Keenan, who sued the state three years ago after 5-year-old Terrell Peterson died despite repeated warnings to child welfare officials that he was being abused.
    Thursday's lawsuit comes as Georgia is, according to state officials, making unprecedented progress in improving its child welfare system. "No one would deny that Georgia's child protective service system has had some problems in the past, and there are no acceptable excuses," Barnes said in a statement. But he and state Department of Human Resources Commissioner Jim Martin said the state increased funding for child welfare by $44 million in the past two years. The state is also closing the controversial emergency foster care shelters -- criticized sharply in the lawsuit -- in about 18 months. Martin said he could not discuss the specific allegations in Thursday's lawsuit. Lowry said Children's Rights has been investigating Georgia child welfare for a year, at the invitation of local advocates. "Our staff made dozens of trips to the state," Lowry said. "Georgia has serious, serious problems."
    In addition to closing the shelters, the advocates want Georgia and the metro area child welfare agencies to spend more money supporting foster families and hiring caseworkers. Child protection caseworkers in the Atlanta area handle caseloads at least twice as large as recommended by the federal government, they say. And Atlanta area foster parents are paid $2,000 per year less than the amount federal officials say is needed to raise a child in the urban South, Lowry said. The result is a dearth of foster parents and overreliance on shelters, she said. "There are few places that I'm aware of that have shelters that are as bad as Atlanta's," Lowry said.
    The lawsuit also accuses area child welfare agencies of obstructing the adoption of black children, in an attempt to place them with parents of their own race. "They're not allowing trans-racial adoptions," Lowry said. "That's a specific violation of federal law." Thursday's lawsuit is part of a national campaign to reform child welfare agencies, coordinated by Children's Rights. The Georgia suit is the organization's 10th.

Hundreds Of Priests Removed Since '60s
Alan Cooperman & Lena Sun, Washington Post- 6/9/2002

The Roman Catholic Church has removed 218 priests from their positions this year because of allegations of child sexual abuse, but at least 34 known offenders remain in church jobs, according to a survey of Catholic dioceses across the United States by The Washington Post. The survey also found that at least 850 U.S. priests have been accused of sexual misconduct with minors since the early 1960s, and that more than 350 of them were removed from ministry before this year.
    The numbers, which are considerably higher than previously disclosed, not only suggest the scope of the scandal rocking the Catholic Church in the United States but also underscore the continuing shortage of reliable statistics on the church's sex abuse problem. Catholic officials have said that, as a decentralized institution of autonomous dioceses, the church has no way of compiling those figures.
    The Post conducted its survey by contacting each of the nation's 178 mainstream Roman Catholic dioceses. Ninety-six dioceses responded and 82 did not, despite repeated phone calls and e-mail messages. Of those that did answer The Post's questions, only a few provided information on financial settlements. Many diocesan spokesmen said they did not know whether the victims of local priests were boys or girls, teenagers or small children. Supplementary data were then gathered from local newspapers, church newsletters and diocesan Web sites.
    David Clohessy, national director of the Survivors Network of Those Abused by Priests (SNAP), an 11-year-old support group that says it has 4,000 members, speculated that the lack of information may reflect a deliberate strategy to shield the church from liability. "It's ludicrous that you can't get very, very basic data such as the number of priests who've been defrocked or the number of criminal or civil abuse cases filed against priests," Clohessy said. "I think any prudent person would assume the church has more data than it's sharing. But I also think that the church is smart enough not to have collected data, which could be discoverable" by plaintiffs' lawyers in lawsuits.
    As the nearly 300 active U.S. bishops head for Dallas this week to debate and vote on a mandatory policy toward priests accused of sexual misconduct, they themselves don't know the extent of the problem and have made no real effort to figure it out. The bishops' Ad Hoc Committee on Sexual Abuse has proposed, for example, to allow some offenders to remain in the Catholic ministry if they have committed only a single known act of abuse in the distant past, have undergone psychological treatment and have not been diagnosed as pedophiles. But the committee's chairman, Archbishop Harry J. Flynn of St. Paul and Minneapolis, said no one knows how many priests fit that description.
    The president of the bishops' conference, Bishop Wilton D. Gregory of Belleville, Ill., said that he is committed to greater transparency, but that many of his fellow bishops are reluctant to provide statistical data, fearing they would only lead to more bad publicity. "In my diocese, two weeks ago, I gave a complete financial accounting for what this has cost us -- legal fees, settlements, counseling for victims, everything going back 10 years -- and I did that because people have a right to know. It's their money," Gregory said. "But not every bishop is there." (Belleville, a relatively small diocese with 105,000 Catholics and 180 priests, has spent $3.1 million on lawsuits and counseling.)
    Among the proposals on the agenda for the Dallas meeting is the setting up of a commission to research the church's response to sex abuse. Flynn's committee has recommended that the bishops require every diocese to "develop a communications policy that reflects a commitment to transparency and openness." At present, however, the U.S. Conference of Catholic Bishops does not keep any nationwide statistics on sexual abuse cases, and individual dioceses vary greatly in their openness.
    The archdiocese of New Orleans, for example, responded to the survey by saying that, over the past 50 years, 18 of its priests have been accused of sexual misconduct with minors. An independent board of lay people reviewed those records this year and decided that the allegations in eight cases were credible, in six cases were not credible and in four cases required further investigation. Archbishop Alfred C. Hughes removed 11 priests from their positions this year because of sexual abuse allegations, and the archdiocese reported payments of $455,000 for legal settlements and $420,000 for psychological counseling in abuse cases since 1980.
    The archdiocese of Indianapolis, in contrast, said it had conducted an "internal review" of past allegations and would not make public any of its findings. "We've made a decision not to release names or numbers. We believe that one case is one too many, that child abuse is wrong and that it's not helpful for people to have numbers," said Susan Borcherts, spokeswoman for Archbishop Daniel M. Buechlein. Officials in several dioceses said they have a policy of not responding to surveys. Some said they would answer questions only from local media, not the national press.
    Monsignor Gerald Calovini, spokesman for the diocese of Steubenville, Ohio, said no abuse allegations are "now pending" there, but he declined to discuss how many Steubenville priests have been accused or how those allegations were resolved. "We're not talking about cases in the past. That's confidential information," he said.
    Generally, church officials were even less willing to talk about legal settlements. The Post survey found only $106 million in acknowledged payments. Plaintiffs' lawyers say that the true figure is in the range of $1 billion, but that most of the settlements have been made under confidentiality agreements. The survey found that 866 priests have been accused of child sexual abuse over the past four decades, less than 1.5 percent of the estimated 60,000 or more men who have served in the Catholic clergy over that period. The actual number accused, however, may be considerably higher. Sylvia Demarest, a plaintiff's lawyer in Texas, said that she compiled a database in the mid-1990s of about 1,200 priests who were accused of sexual misconduct with minors, and that she believes the current figure is higher than 1,500.
    A.W. Richard Sipe, a former priest turned psychotherapist who has counseled hundreds of clergymen and victims of abuse, estimates that 6 percent of all U.S. priests have committed child sexual abuse. Some church officials, including Cardinal Theodore McCarrick of Washington, have cited figures between 1 percent and 2 percent, based on a study several years ago of personnel records in the archdiocese of Chicago.
    The scandal that erupted in January with the revelations that Boston's Cardinal Bernard Law and other prelates had transferred known sex offenders from parish to parish may have created an impression that, in the past, problematic priests were usually shuffled around and seldom removed from ministry altogether. But The Post's survey found that, even before this year, 355 priests had been removed from ministry because of sex abuse allegations. Of those, however, only a small percentage were defrocked or "laicized," the church's term for removal from the organized priesthood. The survey turned up just 20 laicizations in abuse cases. Most of the other offenders apparently were forced to retire or had their priestly "faculties" lifted -- meaning that they were not allowed to say Masses publicly or to engage in any ministry -- but they remained priests. This year, 218 priests have been removed from their jobs and not reassigned. Most have been placed on administrative leave pending the outcome of investigations by the church into the allegations against them.
    Catholic leaders have said that they expect a heated debate at the Dallas meeting on the question of whether past offenders can, under certain conditions, remain in ministry. Some bishops, led by Cardinal Roger Mahony of Los Angeles, favor a strict "one strike you're out" policy. Others, including Cardinal Francis George of Chicago, want to allow exceptions for priests who have undergone therapy and have been vetted by lay review boards before being returned to ministry under continuing supervision. The Post survey found nearly three dozen such priests across the country, including a few who have served prison time. In most cases, the past offenders are in some form of restricted ministry, working in convents, hospitals or administrative jobs in which they are not supposed to have any regular contact with minors. Many dioceses have disclosed the priests' names and positions to the public, but a few have not.
    The Rev. Harlan Clapsaddle of Rockford, Ill., is an example of an acknowledged offender who has remained in ministry under supervision. Rockford Bishop Thomas G. Doran publicly discussed the case last month, announcing that the diocese had paid $80,000 to settle sexual abuse claims against the priest. Doran said that when the charges were made against Clapsaddle about five years ago, he was removed from his parish and underwent evaluation and treatment for several months. He was allowed to return to the diocese, but his work was restricted to a home for the elderly and to the local administrative offices of Catholic Charities, Doran said.
    In Grand Rapids, Mich., the Rev. Don Heydens is also in a restricted ministry, running the diocese's program for deacons, because of an abuse incident in the 1970s. In Springfield, Mass., the Rev. Richard Meehan is working as an archivist eight years after being removed from his post because of an allegation of abuse. In Columbus, Ohio, Bishop James A. Griffin this year transferred Monsignor Joseph Fete from a parish to the position of director of ecumenical and interfaith affairs because Fete acknowledged having a sexual relationship with an adolescent boy from 1976 to 1979.
    The archdiocese of Chicago has four past offenders in some form of ministry. Milwaukee has six whose names and positions have not been made public, but whose status is under review by a lay panel. The diocese of Covington, Ky., disclosed in March that three of its 110 priests remain in restricted assignments "after allegations of misconduct with teenagers." Their names and jobs have not been made public.
    How many other offenders hold church positions with the quiet knowledge of Catholic leaders is unclear because some bishops still treat such cases with the utmost secrecy. The Rev. Gerald Calhoun, the vicar general, or second-ranking official, in the diocese of Owensboro, Ky., said he suspects that there are two priests in restricted ministry there. "But I don't know," he said. "Only the bishop would know."

Brain Scans Cited in Treating Depression
Maggie Fox, Reuters- 6/10/2002

WASHINGTON - A simple one-hour brain scan may be able to predict who will be helped by antidepressants and who will not, scientists said today. Weeks before patients showed any visible benefits from taking antidepressants, their brain waves started changing, the researchers said. The method can save patients from wasting time taking drugs that are both expensive and have potential side effects, said the researchers, led by Dr. Ian Cook at the University of California/Los Angeles. ''This is the first study to detect specific changes in brain wave activity that precede the clinical changes in a way that can usefully predict response,'' said Cook, a psychiatrist, in a statement.
    ''Up to 40 percent of depressed patients do not respond to the first medication they try. Since it takes several weeks for an effective treatment to produce clear improvement, doctors often wait six to 12 weeks to decide that a particular medication just isn't right for that patient and move on to another treatment,'' he added. Recent studies have also shown that patients may respond to placebos - dummy pills - in much the same way they respond to antidepressants. And research suggests that cognitive therapy, which means talking with a psychotherapist instead of taking pills, may work as well as or better than drugs in treating depression.
    Cook said his team's methods, using electroencephalograms, might shed light on these issues. Different people may have different forms of depression that respond to different treatments, he said. ''We were looking at the prefrontal cortex - the part right behind the forehead,'' Cook said in a telephone interview. ''It's an area involved in judgment, motivation - many of the things that make us human.''
    Electroencephalograms, or EEGs, measure electrical activity of the brain, using electrodes applied to the patient's head. These tests showed changes soon after patients took medications. ''We were seeing EEG changes at 48 hours to one week and people didn't show clear clinical differences until about four weeks into the study,'' said Cook, whose team reported its findings in the journal Neuropsychopharmacology. ''We are continuing to follow them and see what the changes are like at three months, six months, a year.''
    His team studied 51 volunteers, divided into groups that got either fluoxetine, made by Eli Lilly and Co. as Prozac, venlafaxine, made by Wyeth as Effexor, or a placebo. Overall, 52 percent of the volunteers, who had acute depression, responded to one of the two drugs, while 38 percent responded to the placebo, they reported. The rest did not show significant improvement. But there was a clear pattern early on in the EEGs of those who later showed clinical responses - meaning they felt measurably better.
    In January, the same team reported they used EEGs to show, in the same patients, that brain function changes when a patient responds to a placebo. But the researchers found it took two weeks for any changes to be seen in the brains of people who responded to placebos, and when the change did come, it was characterized by an increase of activity in the prefrontal cortex, not the decrease seen with the drugs. Testing first to see who will respond to medications may save money. A 16-week course of treatment with antidepressants can cost $2,500. An estimated 20 million Americans suffer from depression.

Meth Use Among Women Growing
Miranda Leitsinger, Associated Press- 6/10/2002

DES MOINES, Iowa --To outsiders, Debra Breuklander appeared to be a tireless single mother of three. She had an immaculate home in a middle-class suburb, perfect credit and was a homeroom mom at her children's schools. She also was taking methamphetamine and selling the drug to make ends meet. ''I thought I was 'Super Mom' and I was doing everything right,'' said Breuklander, 43, now serving a 35-year prison sentence. ''In actuality, my thinking was so twisted. I was doing everything wrong.''
    Breuklander is among a growing number of women who have abused meth, a highly addictive stimulant that produces a euphoria similar to cocaine, but lasts longer and is made from common household ingredients. Experts and users say meth appeals to women because it's relatively inexpensive and easy to obtain, and it gives them energy to take care of their children or feel more efficient in everything they do. ''There's no comparable drug that we've ever seen as long as I've been in substance abuse that appeals to women as much as meth does,'' said B.J. VanRoosendaal, spokeswoman for the Utah State Division of Substance Abuse.
    Nationally, women made up 47 percent of patients in substance abuse treatment centers who identified meth as their primary drug of use in 1999, according to data from the U.S. Department of Health and Human Services. In Iowa, 43 percent of women entering prison in the first quarter of fiscal 2002 said meth was their drug of choice, compared with 29 percent of men. In fiscal 2000, it was 25 percent of women and 19 percent of men. More than 40 percent of women arrested in the counties surrounding Honolulu and San Jose, Calif., in 2000 tested positive for meth use, a National Institute of Justice program found, and the figure was more than 20 percent in several other areas studied.
    Miranda Charbonneau, like Breuklander an inmate at Iowa Correctional Institution in Mitchellville, said she turned to meth after previously using marijuana. It soon became an obsession for the then 16-year-old who had left school and was working. Every day, the focus was, ''where I could get it, who I could get it from, how much was it going to cost me ... and what was I going to have to give up to get it,'' said Charbonneau, 23, who is serving 10 years for child endangerment. ''I gave up personal items with sentimental value. I sold a lot of my belongings ... I lost my car, I almost lost my job. I ended up losing part of my relationships with my family,'' she said. ''I began to steal to find ways of getting methamphetamine.'' Breuklander, a former nurse who was on disability for a degenerative back disease, said her relationship with meth began with financial troubles. Her boyfriend at the time was selling meth and she joined in, selling it to a group of friends. ''It all looked glamorous and wonderful and there was such a demand for it,'' she said. ''I think for a lot of women, especially single mothers, it gives you the energy that you think you need to keep the house, the kids, the yard, the cars, the groceries, the laundry, everything going,'' she said. ''At least, that's how it took me over.''
    Sheigla Murphy, director of the Center for Substance Abuse Studies at The Institute for Scientific Analysis in San Francisco, said she started seeing women fitting Breuklander's profile in the early 1990s. ''There seemed to be a little proliferation when people started to realize that cocaine was trouble and that's when we started seeing more middle-class women drinking 'biker coffee,''' Murphy said. That drink is made by adding meth to coffee. ''A lot of women use it for performance things or weight control,'' Murphy said. Women ''get into this for a lot of what many could consider to be good reasons,'' she said.
    Women's meth use may initially be more concealed than that of men because of different reactions when they take it, said Arthur Schut, president and chief executive officer of the Mid-Eastern Council on Chemical Abuse based in Iowa City. Men abusing meth get police attention because they are more likely to be involved in assaults or to drive drunk. Women are less likely to do those things, Schut said.
    Breuklander said everyone thought she was fine because she didn't look like a drug user. ''I did not look like an addict, I did not function like an addict, but I was an addict and that's a scary thing,'' Breuklander said. Meth ''can cause you to look like you're highly efficient, highly effective in your daily living when in fact, you're going downhill fast,'' she said.
    Charbonneau and Breuklander have been treated at a substance abuse program at Mitchellville and now are mentors there. Nearly 100 women are either in the inpatient care program or in after care, which helps prepare inmates for their return to the outside world. Women spend their day in classes, therapy groups and live in a communal environment all in one room. The treatment is peer led: they give each other push ups congratulating each other for good behavior and pull ups telling each other when they do something wrong. Breuklander is grateful to the program, but has regrets. ''I have three children. I have missed two of their high school graduations. I've missed their birthdays, I've missed important things in their life,'' she said. ''It ruined my life.''
    On the Net: Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/

 D.C. Domestic Partner Plan Apporved
Avram Goldstein, Washington Post- 6/10/2002

The District government is preparing to launch one of the nation's broadest domestic partnership programs next month, a move that was delayed for 10 years by Congress and nearly watered down recently by Mayor Anthony A. Williams (D). But after Williams upset some gay activists last week by fretting about the unknown cost of extending partnership benefits to a wide range of couples, including unmarried relatives, he let it go forward in the form passed by the D.C. Council in 1992. Until September, Congress had consistently blocked the legislation from taking effect.
    The program is often associated with gay couples, but the majority of people expected to sign up are heterosexual, officials say. The law will immediately make thousands of unmarried people who live with District government workers eligible to purchase membership in a city health plan and provide coverage to their own children. The health care benefit has no effect on any private employer. Those with domestic partner certificates will have the right to visit a partner in a nursing home or hospital despite objections from relatives, and they will have authority over the remains of partners after death.
    The law authorizes the city to register adults as domestic partners if they present evidence that they are unmarried, living together in the same domicile, over 18 years of age and mentally competent. There is no residency requirement, but the rights of partners are enforceable only within the District, said Ronald Lewis, deputy director of the D.C. Health Department. If the partnership ends, either partner can terminate the registration after a six-month wait.
    The department's vital-records office plans to issue certificates beginning July 8, Lewis said, and they will be suitable for framing. "It is a way for people to get insurance coverage," Lewis said. "It fits well with the goal of getting people access to health care." City officials expect to issue 5,000 to 8,000 certificates in the first year. Each will cost $45. "I think the gay community is excited," said Wanda Alston, special assistant to the mayor for gay, lesbian, bisexual and transgendered affairs. "We believe it's long overdue."
    Still, the administration remains wary about the financial impact, even though domestic partners of city employees will pay the entire cost of joining the city's health plans. For a city employee who belongs to the Aetna health maintenance organization, taxpayers pay about $150 a month and the worker has about $50 a month deducted from his or her paycheck. A domestic partner who joins the same plan would pay the full $200 a month, deducted from the worker's paycheck. Three of the city's four health plans -- Cigna PPO, Aetna HMO and Kaiser Permanente HMO -- have agreed to enroll additional employees this year without a rate increase.
    But Williams and Milou Carolan, the District's personnel director, say actuaries predicted that domestic partnership could drive up premiums for everyone next year. As a result, the administration had considered limiting the program to partners unrelated by blood to keep the system's cost in check. Bob Summersgill, president of the Gay and Lesbian Activists Alliance, said that when Williams testified before Congress on Wednesday, the mayor said it was not the intention of the D.C. Council to have the broad eligibility. "I don't want to say what his motives were," Summersgill said. "He was certainly incorrect. [Council Chairman] Linda Cropp corrected him in front of Congress."
    Alston said the discussion focused on fears that high medical costs among domestic partners could push health plan premiums up sharply for all employees, not just the domestic partners who would pay 100 percent of their premiums. "We want a benefit, not a penalty," she said. But council member Vincent B. Orange Sr. (D-Ward 5) rejected the idea and the administration backed off, she said. "Orange liked that the law was more inclusive," Alston said.

 Case Raises Questions About Keeping Teen Therapy Confidential
Associated Press, 6/10/2002

DETROIT -- The case of a 14-year-old girl who said she told a therapist and school social worker about numerous sexual encounters has raised questions about confidentiality and adolescent therapy sessions. Troubled teens may talk about experimenting with drugs, alcohol or sex. Psychologists must then decide what to keep in confidence and what to report to parents.
    "It's very tough to be a therapist and figure this out," Dr. Robert Erard told the Detroit Free Press for a Monday story. "Children who feel as though all you're going to do is tell their parents are never going to tell you anything that's worth working on," the Franklin psychologist said. But Erard said he tells teen-age clients that he will report harmful situations to parents. "There's a legal dimension, there's a therapeutic dimension and there's a commonsense dimension," he said.
    Andover High School officials said that the school's social worker did not know about the 14-year-old Bloomfield Township girl's sexual activities. Officials said district policy requires counselors to report information about underage sex. The girl said she told the social worker and a private therapist that she sneaked out of her family's home at night to meet 22 partners who ranged in age from 14 to 20. "They normalized it and made it sound like they've heard it a number of times," the girl told the newspaper. She said the therapist told her to tell her parents, but she chose not to. The girl's father said he was disappointed that the therapist did not reveal the information. Five men have been charged with statutory rape in the case.
    State confidentiality laws protect discussions with therapists, who generally cannot release information without a client's permission. There are exceptions. If a client threatens to harm someone, the therapist is obligated to tell the intended victim and information about the abuse of a minor must be turned over to a protective agency.
    Malpractice lawyers said breaking confidentiality can be problematic. "It's not something that is like an equation, where you can say you have X plus Y and therefore Z," Bloomfield Hills attorney Maureen Adkins said. "But I would say that if there's a question about whether or not you should report, then you should report, because it's a crime not to."
    School social workers said they are bound by a district's rules. Brenda Bentley, a social worker at Sashabaw Middle School in Clarkston, said if a teen told her about having a drink at a party, she would call the teen's parents. "If a 14-year-old says to me, "I'm having sex with a 19-year-old,' I'm going to tell," said Bentley, president of the Oakland County region of the Michigan Association of School Social Workers.
    Private therapists must weigh the patient's treatment against his or her safety. Stephen Behnke, director of the Ethics Office at the American Psychological Association, said therapists should set ground rules with teen-age clients and their parents ahead of time. "The parents absolutely can ask the therapist, "I want to know if my child is having sex,' but then the child must be part of that conversation" and know what the rules are, Behnke said.

One of Unsung Millions Who Quelled Manias
Rob Morse, San Francisco Chronicle- 6/10/2002

This was Electroboy. This was the art dealer, forger, jailbird, stripper, sex maniac and prodigious consumer of drugs and alcohol -- and all he was having was a ginger ale, while quietly expressing sorrow for those with troubles greater than his own. Andrew Behrman had written a memoir of manic-depression, called "Electroboy, " a nickname he got while undergoing electroshock. He has been through false heavens and real hells, but he's alive, even if sometimes drowsy from his nine medications. Those we were talking about hadn't done so well. They were dead, in jail or crazy in the streets.
    Behrman, a New Yorker, said he was startled to see how many pathetic people were wandering San Francisco. Then he spoke of health care and pharmaceuticals. "Do you know how much one Depakote tablet costs?" Behrman said, referring to one of his meds. "They're $4 each. What happened to the issue of cost of prescription drugs? People ought to be jumping up and down shouting about it. The only people shouting are shouting to themselves." So many are dead, from one of my college roommates to Abbie Hoffman. "The suicide rate for manic-depressives is amazingly high," said Behrman.
    Experts say that 20 percent of manic-depressives die by their own hand, and perhaps more because of deaths caused by risky behavior in manic phases. Behrman used to run out at 3 in the morning for drugs and sex with strangers of any gender or number. In her memoir of manic-depression, Kay Redfield Jamison, the psychologist who's done more for the understanding of the disease than anyone else, recalls driving fast at all hours of night. Last year, Idriss Stelley suffered a breakdown and waved a small knife in the Metreon. San Francisco cops shot 20 holes in him. Behrman looked stricken when I told him the story. It could have happened to anyone in a manic state. This month the SFPD agreed to teach officers how to deal with the mentally ill, and that's a step in the right direction. They might use the Electroboy Web site, www.electroboy.com.
    The descriptions of the alternating euphoria and hopelessness of manic- depression (or "bipolar disorder") are useful and personal. Behrman admits he enjoyed his "out-of-control lifestyle." This was a man very resistant to treatment, a man who finally had to undergo 19 electroshock treatments to break the manic cycle. As Behrman points out, electroshock is a more exact treatment than it was in the days of "One Flew Over the Cuckoo's Nest," a movie that discredited electroshock and mental institutions, whose passing we now lament. "Cuckoo's Nest" also romanticized mental illness. "Electroboy" gives the real feel of mania's sensory ride and its raunchy comicalness. But there's no romance.
    "Pure mania is as close to death as I think I have ever come," wrote Behrman in his book. He hadn't heard of the case of David Attias, who drove his car into a crowd of students at UC Santa Barbara and is pleading insanity because of bipolar disorder. "Was anyone killed?" asked Behrman, with real worry in his voice. When I told him that four young people had died, Behrman just stared into his ginger ale. What can you say?
    Someone failed to take responsibility -- to own Attias' long-standing disorder. His parents sent him off to college and knew he wasn't taking his meds. They threatened to take away his Saab Turbo but, sadly, they didn't. Maybe the parents were in denial. I can't guess what was in the kid's head. Manic-depression is treatable, but first you have to own your disease -- really own it, and take responsibility for it. And that's hard for anyone to do.
    How do you get all the crazy people on the streets to take their meds, even if we can provide them? Good luck. For now, let's give credit to those you'll never see in police reports or hear babbling on the sidewalk -- the millions who continue the courageous struggle against mental illness. It's a measure of stigma that you'll see the phrase "courageous struggle" when it comes to cancer, but not mental illness. The success stories are walking among us. Off the top of my head, I can name three local celebrities who have beaten manic-depression, but I won't. Then there's Andrew Behrman, who came out of the closet of madness and wrote a great book. And he's alive.

When Picky Becomes a Problem
Christopher Walton, Detroit Free Press- 6/11/2002

To look at him, you wouldn't guess that eating poses any problems for 5-year-old Nolan Waters. Standing 4-foot-1, weighing almost 60 pounds, he's in the 90th percentile in height and weight for children his age -- a strapping pre-schooler by all appearances. But ever since he was born six weeks early his mom, Kimberly Waters, suspected that Nolan's extreme reaction to certain foods was something more than just picky eating.
    "There were all these quirky things," says Waters, who lives in Wolverine Lake. "The smell of oatmeal made him so upset he'd run out of the kitchen. He would hold gumballs in his hand but wouldn't put them in his mouth. If he was forced to put the gum in his mouth, he would hold it in his teeth and not chew. He refused to even touch cotton candy and he would spit out chicken, saying 'I like the taste, but I don't like the chicken.' "
    Though Nolan was growing normally, Waters feared he wasn't getting adequate nutrition from the limited foods he would eat. Pediatricians repeatedly told Waters not to worry, that her son's height and weight were in the normal range. It wasn't until a specialist discovered that Nolan's brain has difficulty processing information received from his five senses that the pre-schooler's unusual eating behaviors began to make sense.  Because he has what's known as sensory integration disorder, Nolan can't tolerate certain textures in his mouth or smells in his environment. He runs from the smell of oatmeal because it hurts his nose, and he, therefore, believes that eating oatmeal will hurt his mouth. His mom's instincts were right. Nolan's not merely a picky eater -- he's a problem feeder.

Malnutrition is a risk
Problem feeder is a term commonly used to describe children between the ages of birth and 10 years old who, due to some underlying combination of physical and behavioral issues, won't eat, or will eat only a few select foods. It's estimated that about one of every 20 children under 10 has a feeding difficulty which, if left untreated, may result in malnutrition or a failure to gain weight. Because of myths that surround children and eating, and the inadequacy of traditional medical approaches in diagnosing and treating the often multi-layered problem, many parents spend years shuttling from one specialist to another while their child continues to not eat, or eat very little. There are several feeding clinics around the country, though none in Michigan, that treat problem feeders through an interdisciplinary approach consisting of a team of pediatric specialists working in unison.
    Dr. Kay Toomey of Colorado, one of the nation's leading specialists in treating problem feeders, is a pediatric psychologist who specializes in assessing and treating children with feeding difficulties. She is cofounder of Children's Hospital Oral Feeding Clinic in Denver and is director of Colorado Pediatric Therapy and Feeding Specialists, Inc. She is best known for developing the multidisciplined Sequential, Oral, Sensory (SOS) Approach to Feeding and presents seminars once a month around the country to meet the growing demand from parents and health care providers for more information. "Many people believe that eating is completely instinctual and that no matter what, a child will eventually eat," Toomey says. "This is a myth. Instincts only start the process, and only then if they're not interfered with by premature birth or a physical disorder. Eating is, in reality, a learned behavior. Just as children learn to eat, so children can be taught to not eat by the circumstances of their lives."
    In the SOS approach, the first step is figuring out how a child learned not to eat. "Did they have pain every time they ate?" asks Toomey. "Were they always congested so that they could never breathe while they were eating? Did they have motor problems so that it was hard to coordinate eating and they were always frustrated? Do they have a sensory integration disorder so that it's hard for them to understand all the different pieces to eating?"
    The SOS approach uses several behavioral strategies to reinforce normal, healthy eating patterns, but also incorporates treatment of physical problems. For instance, Nolan attends therapy sessions at the Abilities Center each week under the supervision of occupational therapist Kathy Dovey. The Abilities Center, 5600 West Maple Road in West Bloomfield, MI, is a provider of occupational therapy, physical therapy and speech services for children with special needs.
    In addition to working with Nolan and his relationship to food, Dovey tries to develop the 5-year-old's motor skills through a variety of physical activities, including obstacle courses, handwriting and using tools and utensils. "These activities help Nolan figure out 'How do I go about doing it,' " says Dovey. "It's practice for his brain to talk to his muscles, to get around the roadblocks that come up for him because of his sensory integration disorder." "We use a lot of Dr. Toomey's approach," says Dovey. "But we're hoping to learn more and become experts. Dr. Toomey will be coming here to teach us while she's in town. We want her approach to be available in Michigan and we want to be a part of it."
    Toomey says 94 percent of the problem feeders she sees have a combination of physical and behavioral issues. Premature babies, she says, are prime candidates for developing feeding difficulties -- they account for half of the patients she sees -- because the normal progression of learning to eat can easily be thrown out of whack. Other conditions that can interfere with feeding include cystic fibrosis, cerebral palsy, autism, low muscle tone and allergies, as well as sensory, oral-motor, gastro, cardiac, metabolic and genetic disorders. "Feeding is one of the most difficult things humans do," Toomey says. "It requires use of all the organ systems, the brain, cranial nerves, the heart and vascular system, the respiratory system, the entire gastrointestinal tract, the endocrine system, and the metabolic system, to name a few. For instance, to coordinate a single swallowing involves 26 muscles and six cranial nerves."
    Because there are so many activities involved in feeding, problems can arise in a number of often overlapping ways. Which is why, according to Toomey, a transdisciplinary approach is necessary for assessing and treating problem feeders. "We have a team of specialists from several disciplines look at the whole child and all the issues, not just their own area of specialization," Toomey says. Her team includes a pediatrician, a pediatric psychologist, an occupational therapist, a speech pathologist, dieticians and a physical therapist.

Fulfilling a Need
Dr. Patricia T. Siegel, a pediatric psychologist at Children's Hospital in Detroit who has attended a workshop of Toomey's, says Michigan needs a feeding clinic like the one Toomey operates in Denver, where several specialists under one roof can assess problem feeders and offer combined treatments. "There's no formal feeding program in our area," says Siegel, "and it's a tragedy. The parents of these kids have nowhere to go for help. Efforts need to be made within the community to provide these services to children."
    Dr. Souheil Gebara, a pediatric gastroenterologist at Beaumont Hospital in Royal Oak, agrees. "Definitely, our area does need a comprehensive program," he says. "The closest place to Detroit is the University of Cincinnati's feeding program. These kids require a multidisciplinary approach, because every child's feeding problem is unique. As it is now, they might come to me, I do my part, then I refer them to say, a pediatric psychologist, then three weeks later they get in to see an occupational therapist. All of a sudden, two months have gone by and there's been a lot of wasted time and the patient has gotten worse. The communication is not as efficient as if all the specialists were in the same room."

Getting help
When children can't or won't eat, many parents are at a loss as to where to turn. Health care professionals and families are invited to the "Picky Eaters vs. Problem Feeders," conference, 9-5 Friday and Saturday in the auditorium at Beaumont Hospital, 3601 W. Thirteen Mile, Royal Oak. Representatives of the Colorado Pediatric Therapy and Feeding Specialists, Inc. team will discuss feeding difficulties in children from birth to 10 years old. Admission for both days is $52 for parents, $145 for professionals. Meals are not included. To reserve a spot or for more information, call the Abilities Center, 248-855-0030, 9-5 weekdays or visit www.abilitiescenter.com/PickyEaters.htm

Mealtime myths:
**Eating is instinctive. Eating is only instinctive for the first month of life. After that, we have a set of primitive motor reflexes (rooting, sucking, swallowing) that take over and keep us eating while we lay down a pathway in the brain for voluntary motor control over eating. Between the end of the fifth or sixth month of life, these primitive motor reflexes drop out and eating is essentially a learned motor behavior.
**Eating is easy. Eating is the most complex physical task humans engage in. It is the only human task that utilizes every one of your organ systems, and requires that those systems work correctly. In addition, every muscle in the body is involved (one swallow for example, takes 26 muscles and 6 cranial nerves to coordinate). Eating is the only task children do which requires simultaneous coordination of all sensory systems.
**It is not appropriate to touch or play with your food. Wearing your food is part of the normal development process of learning to eat it. You can learn a great deal about foods before they ever get into your mouth, by touching them first. It is play with a purpose.
**If a child is hungry enough, he/she will eat. They will not starve themselves. This is true for about 96 percent of the pediatric population. For the other 4 percent who have feeding problems, they are capable of inadvertently starving themselves. For the majority of these children, feeding hurts and no amount of hunger is going to overcome that fact. Children are organized simply; if it hurts, don't do it. For children who have skill or medical problems with eating, their appetite often becomes suppressed over time, such that they no longer respond correctly to appetite as a cue to eat.
**Children only need to eat 3 times a day. To meet their daily calorie requirements, children would have to eat adult-sized meals if they only eat 3 times a day. Given their small stomachs and short attention spans, it takes most children 5-6 meals a day to get enough calories for proper growth.
**Certain foods are only to be eaten at certain times of the day and only certain foods are healthy for you. Food is just food. It is not breakfast food, or dinner food, or snack food, or junk food. Food is either a protein, a carbohydrate or a fat. While some foods have more nutritional value than others, labeling foods as "good" or "bad" or "only to be eaten at X meal" is not helpful in teaching children to eat or to have a healthy relationship with food.
**Mealtimes are a solemn occasion. Children are to be seen and not heard. Feeding is supposed to be fun. Children eat so much better when their food is engaging, interesting and attractive. They also eat better when mealtime conversations are focused on talking about the food.

Red flags for eating disorders
Here are some warning signs that suggest a child is a candidate for feeding therapy.
* Ongoing poor weight gain or frequent, prolonged weight loss.
* Ongoing choking, gagging or coughing during meals.
* Ongoing problems with vomiting.
* More than one incident of nasal reflux.
* History of eating and breathing coordination problems, with ongoing respiratory infections.
* Inability to transition to baby food purees by 10 months of age.
* Inability to accept any table food solids by 12 months of age.
* Inability to transition from breast/bottle to a cup by 16 months of age.
* Inability to be weaned off baby foods by 16 months of age.
* Crying and/or arching the back and neck at most meals.
* Parent repeatedly reports that the child is difficult for everyone to feed.
* Parental history of an eating disorder, with a child not meeting weight goals.

Which one is your child?
There are differences in the habits and behavior of picky eaters versus those of problem feeders as identified by feeding specialists.
PICKY EATERS
* Limited range or variety of foods that they'll eat -- 30 foods or more.
* After two weeks, will return to foods that were once binge favorites, but fell out of favor because of burnout.
* Able to tolerate new foods on plate and usually can touch or taste a new food (even if reluctantly).
* Eats at least one food from most food texture groups, such as leafy vegetables or hard fruit.
PROBLEM FEEDERS
* Restricted range or variety of foods, usually fewer than 20 different foods.
* Does not return to favorite binge foods lost to burnout
* Cries and acts out when presented with new foods.
* Refuses entire categories of food textures like soft cheeses or cereals.

 Exercise May Treat Depression
Cecilia Capuzzi Simon, Washington Post- 6/11/2002

Could the path to emotional health be as simple as a 30-minute weekend walk in the park? Alen Salerian, medical director of the Washington Psychiatric Center, thinks so. Salerian says he is helping his depressed patients recover not only by administering antidepressant drugs and therapy, but also prescribing a moderate regimen of weekly exercise. And he is now on a mission to spread the message and persuade other doctors to include an exercise program in their treatment of depression. Salerian describes his approach as "simple," "totally radical" and so obvious that it's "stupid."
    While other mental health practitioners concede that Salerian's weekly workout recommendation may be simple (no comments on the stupid part), few are reaching for their prescription pads. Many say it's fine to recommend physical activity to amenable patients. Few think of exercise as a bona fide treatment for mental illness. "I have never prescribed exercise, nor would I," says Wayne Blackmon, a Washington psychiatrist who treats many patients for depression. "The general nostrum is, 'Being more active is better.' But as a specific treatment modality, there's a lot I'd need to know before I prescribed it to a patient." Helen Mayberg, a professor of psychiatry and neurology at the University of Toronto, worries that encouraging expectations that exercise can help cure depression "trivializes" a serious illness. "Exercise sounds good," she says, "but where's the data?"

A Modest Proposal
What Salerian proposes seems benign: a once-a-week regimen that gradually increases in duration. He asks his patients to choose a day and a time to exercise, and to assign a backup day in case that one falls through. They start with 30 minutes of moderate exercise. (He usually recommends brisk walking.) Over 12 weeks they gradually build to 2 1/2 hours of activity in a single outing. Salerian can't prove that this regimen works, but he believes it can not only help recovery from depression and anxiety but also lead to physical fitness. "Over the years, we have heard you must exercise four times, five times a week to get into shape," says Salerian. "I think the average American would be totally surprised to learn that once-a-week exercise might help him."
    So would those at the American Heart Association and the American College of Sports Medicine. Both organizations recommend 30 minutes of exercise at least three times per week to achieve some measure of physical fitness. "A single bout of exercise [weekly] is unlikely to drive any real physiological or psychological benefits," says Steven W. Edwards, a sports psychologist and professor at the School of Applied Health and Educational Psychology at Oklahoma State University.
    Still, admit Edwards and others, Salerian could be on to something. Depressed people often lead a depressed lifestyle, prone to lethargy, apathy and feelings of isolation, says Robert Carney, a professor of psychiatry at Washington University in St. Louis, who studies the links between exercise, depression and heart disease. Two-thirds of all adults in the United States lead a sedentary lifestyle, according to Paul Salitsky, a professor of exercise science at the University of California, Davis. If Salerian's low-dose exercise prescription helps a depressed person become more active, that could be a "baby step" toward a healthier lifestyle, Edwards says.
    Salerian is not suggesting that exercise alone can lift depression. Even someone mildly depressed, he says, would probably find his regimen very difficult absent other steps to recovery. Underlying mental ills have to be treated first, or simultaneously, for an individual to take on an exercise routine as part of a recovery plan. "My short message for the majority of people is that if you are not exercising, there's always a reason, and that reason is fixable," he says. Not exercising, Salerian believes, is the equivalent of "self-abuse."
    Language like that may not win him many friends. But then Salerian, an assistant clinical professor at George Washington University School of Medicine who worked as the medical director of the FBI's Mobile Psychiatric Emergency Response Team (he debriefed agents during the 1993 siege at the Branch Davidian complex in Waco, Tex.), is used to controversy and prides himself on being a risk-taker. At last month's American Psychiatric Association convention, Salerian presented a paper on the use of Marinol (the marijuana derivative used to treat nausea in cancer patients) as an aphrodisiac. He's already prescribing the drug to patients suffering sexual dysfunction as a side effect of antidepressants.Last year, Salerian found himself in a flap involving Robert Hanssen, the former FBI agent who was sentenced last month to life in prison for years of spying. Salerian treated Hanssen when the spy was first brought into custody. He was fired from the defense team after talking to the press about Hanssen's mental state. Salerian has said Hanssen asked him to go public with some information.

Personal Experience
Salerian's unconventional approach to exercise and its uses grew from his personal life and from observing patients in his practice. About seven years ago, he says, he had a chance encounter with a 60-year-old runner who claimed to jog just once a week for 15 miles. Salerian considered his own exercise habits -- about seven times a week -- coupled with his 80-hour workweek, and decided the jogger's path to fitness was more efficient. He adopted the schedule himself and about two years ago began to include the regimen in his practice. The 54-year-old Salerian trained for this year's D.C. Marathon -- which he says he completed in five hours and 10 minutes -- by running just once a week for 12 weeks. He started with 30 minutes and gradually increased his time, peaking at just over three hours the week before the race -- not exactly what the marathon books recommend.
    Like many doctors, Salerian often recommended that patients exercise three times per week for 30 minutes. Many patients, he says, tried to take his advice, started a routine . . . and quickly gave up. Many felt worse than before they had started. Some said they didn't have the time. Many found the regimen too high a hurdle. "They would get really disgusted with themselves and feel guilty," Salerian says. "That stayed with me." His once-a-week regimen, he says, is ideal for therapeutic purposes because it lowers expectations for his patients and works on the reward system. "Each week, it gets easier for them." The protocol eliminates guilt and the excuse of time, he says, and patients report that it makes them feel good.
    He was so encouraged by his patients' response that he introduced the concept to 12 women who come to his clinic for group therapy. The women, who suffer severe psychiatric and medical problems including high blood pressure, high cholesterol, obesity and diabetes, responded well to 15 minutes of light exercise at the beginning of each group meeting, he says. Last month, Salerian developed a formal protocol that will work them up to 2 1/2 hours of exercise once a week while closely tracking their blood pressure, heart rate and improvements in mental health. "Does it work?" Salerian asks. "That's the question."

An Exercise in Research
That is the question, especially for many in the field who would consider using exercise as an adjunct to traditional therapies if there were solid research showing its value. Salerian has only anecdotal information from his patients on the mental health impact; he uses his own marathon experience as evidence of the physiological benefits. Psychological journals are loaded with studies done since the 1970s documenting a relationship between exercise and reduced depression, but meta-analyses have concluded that much of that research is flawed. "No one would doubt that exercise could be helpful" in managing depression, says Michael Blumenfield, professor of psychiatry at New York Medical College. "But psychiatry is an evidence-based specialty. Whether we prescribe exercise will come down to the research, and not fads."
    A study that drew much attention when it was released in 1999 came close to establishing the link that Salerian has suggested. But the study also pointed up the complications of connecting exercise and depression relief. In that study, adults diagnosed with mild to severe depression were randomly assigned to groups in which they received the antidepressant Zoloft; exercise only, three times a week; or both. After four months, people in the exercise-only group improved just as much as those who took Zoloft. In a six-month follow-up, the exercise-only group had the lowest relapse rate -- one-third that of the other two groups.
    Despite the positive findings, the study's lead author, James Blumenthal, a professor of medical psychology at Duke University in Durham, N.C., is not ready to trade in the Zoloft for a trip to the gym. Participants in his study, he concedes, were receptive to the idea that exercise might help them. They were also encouraged and reminded to exercise, and they developed a social support network that grew from exercising with others. These factors, he says, may have influenced their depression as much as the activity itself.
    Why does exercise generally make people feel better? Most likely it's a constellation of reasons, including increased levels of serotonin and other chemicals in the brain, along with lifestyle changes that can result when a person becomes physically active and engaged in the world. No one knows for sure. As Blumenthal says, "If exercise needed FDA approval, it probably wouldn't get it."
    Prescribing exercise as an adjunct to traditional psychiatric or psychological therapies is not yet widespread, but that is not necessarily a bad thing, adds Blumenthal. "People are nervous about doing it. Depression is a serious condition with a high mortality rate." But it's hard to argue with Salerian's minimalist supplement to conventional treatment: Knowing all we know about the benefits of exercise, once a week is probably better than nothing. "What are we talking about?" he asks. "Thirty minutes. What excuse can you have not to do it?"

Group Seeks Solutions for Imprisoned Mentally Ill
Bryan Robinson, ABC News- 6/11/2002

Years before becoming an advocate for the mentally ill, a suicidal Tom Lane was surrounded by armed police, contemplating whether he should force the officers to kill him — and none of the law enforcement officials seemed to know it. In July 1997, Lane, a cabinetmaker who was a recovering alcoholic and substance abuser, was suffering from severe depression. A head injury from a construction accident left him suffering from seizures and unable to work. Despondent, he called a suicide hotline from his trailer home in Northern California. When he could not guarantee the hotline operator that he would not harm himself, police were dispatched to his residence and he found himself surrounded. "I had hidden my .357 [Magnum] inside my travel trailer. They asked me to come out and show my hands. I could see the laser from one of the officers tracing me from 15 feet away," Lane said. "I really contemplated doing something to make these officers do something to me, a suicide-by-cop kind of thing."
    Police did not kill Lane, but he did not receive immediate counseling for his depression, either. Lane, who is considered legally blind, recalled being thrown and dragged on the gravel outside his home to a police car. His glasses were broken and he was thrown in jail, where police refused to let him take his anti-seizure medication. Lane was hospitalized after he began suffering two seizures a day. Upon release from the hospital, he still suffered from depression and did not receive the any recommendation for treatment for mental illness. He soon began sleeping in the bushes outside the hospital. Lane was able to call his mother collect from a pay phone and his family found him and brought him to New Mexico. Once he was receiving treatment and was back on his feet, Lane became an advocate for the mentally ill.
    Now living in Fort Lauderdale, Fla., Lane, 42, has been instrumental in forming peer counseling groups for people suffering from mental illness. He has focused on their problems in dealing with law enforcement. And he helped contribute ideas to the Criminal Justice-Mental Health Consensus Project, a two-year bipartisan collaboration by the Council of State Governments with law enforcement officials, criminal justice officials and mental health advocates and consumers that will present a report at hearing before the Senate Judiciary Committee today.

The Mentally Ill’s Revolving Crime Door
The report is designed to help state and local government officials who are dealing with the significant number of people with mental illness in prison or jail. The Justice Department estimates that 16 percent of the people incarcerated in America suffer from mental illness. "When on any given day there are more people with mental illness in the Los Angeles County Jail than in any state hospital or private facility in the United States, it's time to agree we have a major problem," said Ron Honberg, director of legal affairs for the National Alliance for the Mentally Ill.
    The report makes 46 recommendations, from training officers better to handle initial encounters with the mentally ill, to ensuring that the mentally ill receive the treatment and counseling they need upon release to prevent their return to jail. "Every day, police officers encounter individuals and situations in which untreated mental illness has resulted in behaviors that generate a citizen complaint or disorderly behavior," said Robert K. Olson, president of Police Executive Research Forum and chief of the Minneapolis Police Department. "My officers know we can better serve individuals with mental illnesses without risking public safety." he said. "This report shows police how to work with all stakeholders using models and principles they can tailor to their own community — approaches that will minimize the costs in human lives, dignity and police resources."

Avoiding Deadly Decisions
Olson said he became involved in the Consensus Project because in the course of his 37-year career, he found that hundreds of people with mental illnesses were killed by police who he said were not trained to handle special situations properly. To save lives, Olson said, his department developed methods to better prepare his officers for encounters with disturbed people.
    In Minneapolis, Olson said, some police are specially trained to assess situations involving people suspected of suffering from mental illness. Olson said his officers are also being trained to use less-than-lethal methods when dealing with the mentally ill, such as stun guns. Olson and the Consensus Project also recommend the use of mobile crisis intervention teams to assess and defuse explosive situations, and police protocols for handling people with mental illness. "Before [the reforms], we were not trained normally to deal with people with mental illness," Olson said. "We're not psychiatrists; we're cops. … There were a lot of people — hundreds — with some kind of mental illness we later learned about who were getting killed or wounded needlessly. And I thought that there must be a better way for us to serve the community and not make deadly decisions with the mentally ill. My hope is that other state and local governments could perhaps adapt our model, what we're doing here and conform it to fit the particular needs of their community."
    Olson also favors — and the Consensus Project recommends — a database that documents incidents between the mentally ill and police to keep law enforcement officials accountable, track repeat offenders and to help prevent mentally ill people from returning to prison.

Hopeful for New Legislation and Collaboration
Lane realizes he was lucky that police did not grant his suicide wish. Many people who suffer from mental illness are undiagnosed, refuse treatment or don't have relatives to look after them or are unable to help them. And often, as in Lane's case, they are refused medical treatment or mishandled by officials. That makes them more likely to have repeated encounters with police. "Mentally ill people are more likely to have encounters with law enforcement," Lane said. "They attract attention when they act out and they're more likely to return to prison because they and police don't know they have an illness or they refuse treatment. When they're released, they're still undiagnosed and poor and more likely to return to prison. We've got to have more innovative solutions and better collaborations between law enforcement and mental health experts after the mentally ill are discharged. I just hope the report is a tool, an instrument of change."
    Based on the findings of the report, the Consensus Project hopes congressional leaders will introduce legislation that will enable communities to adapt some of the recommendations of the report and perpetuate better understanding of the mentally ill in the criminal justice system, a problem some believe has been long overlooked. "This is a complex problem that Congress should examine," said Sen. Patrick Leahy, D-Vt. "If we are going to help our law enforcement officers reduce crime, we need to stop the revolving door of arrest, release, and re-arrest that is so common for mentally ill offenders."

Drawing Inspiration
A better understanding of the mentally ill is a good beginning, law enforcement officials say. But recognizing a need for collaboration between police and mental health professionals is the key. "Awareness is always a good thing," Olson said. "There have been literally hundreds of deaths when a system that was supposed to protect them [the mentally ill] failed them. There has to be coordination and collaboration that involves law enforcement, mental health professionals, and the courts."
    Meanwhile, Lane is dealing with his mental illness and seems to be winning. As late as 1999, he said almost killed himself during a bout with severe depression when he overdosed on prescribed medication. Today, as a survivor of a suicide attempt and an encounter with police who did not fully understand his condition, Lane hopes that some of his peers will learn and be empowered by his story. In July, he said he will begin a new job as director of consumer affairs for the National Alliance for the Mentally Ill. "I'm managing to manage the illness instead of having the illness mismanage me," Lane said. "I just want to get the word out and if people draw some kind of inspiration from my story, then I'm happy."

Anorexia Strategy: Family As Doctor
Erica Goode, New York Times- 6/11/2002

When a teenage girl develops anorexia, a team of experts usually takes charge of bringing her back to a normal weight, while her parents stand on the sidelines. But a promising and controversial new therapy gives parents the primary responsibility for an anorexic child's recovery. The goal of the therapy is to mobilize the family as a whole in a fight against the eating disorder, said Dr. James Lock, an associate professor of psychiatry at Stanford School of Medicine and the lead author of an extensive treatment manual for the technique, published last year by Guilford Press.
    The parents are told that no one knows what causes anorexia -- a problem that affects boys but is far more common in girls -- and that the illness is no one's fault. They are encouraged to think of the disorder as an outside force that has taken over their daughter's life. And they are exhorted to .be unwavering in finding ways to feed their child. The message, Dr. Lock said, "is that food is medicine and medicine must be delivered." "If not," he said, "this child is at severe risk." The technique, developed at the Maudsley Hospital in London, is now being tested in the United States. Preliminary studies suggest it is strikingly effective in helping many adolescents to recover from anorexia, an illness that carries the highest mortality rate of any psychiatric condition and is notoriously difficult to treat.
    But it is not without critics. Traditional theory holds that the self-starvation of anorexia represents an adolescent's desperate attempt to assert independence in the face of overbearing or intrusive parents. Some therapists worry that the Maudsley approach will exacerbate a teenager's feelings of helplessness and make the illness worse. Other experts argue that the method may be impractical in many families where two parents work.
    Dr. Lock and other experts who use the therapy agree that the therapy is not suited to every family, and that it is impossible to use in a minority of families, those with parents who are abusive or have other major psychiatric problems. But the experts say that in many cases, the parents are in the best position to help an adolescent get better, especially in a world of managed care, where hospital stays are short and therapy sessions are limited. Helping an adolescent in trouble is "normally what we would expect a family to do," Dr. Lock said. But, he added, parents "often get thrown off by being told they are at fault, that they can't do anything about it or that they need someone else to do it."
    The principles underlying the approach, he said, are similar to those used in residential eating disorder programs. In those programs, Dr. Lock said, "One of the first things you notice is that the children, when you take the responsibility for food and eating away from them, can actually eat. They're not torn and conflicted and they usually can gain weight." And once a safe weight is restored, he and other experts contend, the child can move, unencumbered, to the other developmental tasks of normal adolescence -- the focus in the second part of the therapy, when responsibility for eating is gradually shifted back to the child.
    Dr. Katherine L. Loeb, a research scientist at the New York State Psychiatric Institute in Manhattan who is directing a pilot study of the therapy, said many parents expressed perplexity about ways to induce a resistant teenager to eat. "I tell them: `The same way you got her to take a distasteful medicine when she was younger. It wasn't a matter of taking the antibiotic or not, but of how it was going to happen,' " she said. Dr. Loeb said the parents might say to their daughter, "Don't think that it's an option not to eat because we are not going to let you starve." In some cases, they may tell an adolescent she cannot leave the table until she has eaten a certain amount. Or they emphasize the rewards that come with weight gain -- and the gains in health and physical strength that accompany it. For example, Elizabeth H., a 15-year-old from Westchester County who participated in the study, said it was the promise of a bicycle trip to Cape Cod -- a trip she would be physically capable of only at a higher weight -- that made the difference. "All I could think of was a tunnel vision of my trip," she said. "So I gained 20 pounds in two months."
    Whatever approach the parents adopt, they must be "at the same place on the same page" in their efforts, Dr. Loeb and other experts said. The therapist monitors the process, offering suggestions and making sure parents do not use the treatment as an excuse to indulge in emotional tyranny. "This is not a green light for parents to be aggressive, controlling or hostile" toward their children, said Dr. Daniel le Grange, director of the eating disorders program at the University of Chicago and an author of the treatment manual.
    The evidence that the Maudsley approach works is increasing, but still limited. An early study by Dr. Gerald Russell and his colleagues at the Maudsley Hospital reported the method to be more helpful than individual therapy for adolescents who had been ill for three years or less. Later studies by Dr. le Grange and other researchers also found the therapy successful in preventing hospitalization and helping adolescents recover their normal weights. And Dr. le Grange said that in a follow-up study, as yet unpublished, at least 75 percent of patients maintained their recovery at five years.
    Dr. Lock is now conducting the largest controlled study of the therapy -- indeed, of any treatment for adolescents with anorexia -- comparing 6 months and 12 months of treatment in about 88 patients, about 9 percent of them boys. Still, making parents the prime agents of therapy is at odds with more traditional views of anorexia. Many researchers now believe that a predisposition to the illness, which tends to run in families, may be genetic. But older theories in part blamed parents for the development of the eating disorder and regarded self starvation as part of a larger battle over control and independence. And even today, many therapists distrust parents' becoming too involved in their child's treatment, echoing a view expressed more than a century ago by Sir William Gull, the English physician who coined the term anorexia nervosa. "Relations and friends," Sir William wrote, were "generally the worst attendants" for anorexic patients.
    Other experts do not dispute the value of parental involvement, but they question how broadly the Maudsley approach can be applied, a question they say will be answered only by more studies. Dr. David Herzog, a professor of psychiatry at Harvard Medical School, noted that every treatment for anorexia must balance the child's need for autonomy with the medical necessity of getting her to eat. But different families may require different types of treatment, he said. And while some teenagers may be responsive to parents' taking charge, "there are others who need to be separated from their families, at least for some period of time," he said.
    Anorexia is a lethal illness. In a long-term follow-up of women with anorexia, Dr. Katherine Halmi, director of the eating disorders program at the Westchester division of New York Presbyterian Hospital, and her colleagues found that 7 percent of them had died after 10 years. In a Swedish study that followed patients for 30 years, 18 to 20 percent of the women died. Even when anorexia does not kill, patients often suffer long-lasting medical complications. Bones become fragile. Heart muscle is damaged. Hair thins. Skin bruises easily. In adolescents, Dr. Loeb noted, anorexia can develop so Insidiously that parents sometimes do not realize that something is wrong until their child becomes drastically underweight. Making detection more difficult, many normal teenage girls diet or indulge in odd eating habits. And adolescence is a time of changing bodies, rapid spurts of growth and baggy clothing. "All the kids were shooting up and getting thinner," said Elizabeth H.'s mother. "If you looked at her in clothes, you really couldn't tell."
    Teenagers with anorexia, many experts said, often become young tyrants, demanding that parents provide minuscule portions or buy only fat-free foods, taking hours to finish a meal or lying about how much they have eaten during the day. But bargaining, Dr. Lock said, only plays into the illness. "With anorexia, you never win, you always lose," he said. "If you start with broccoli, soon it's going to be half a serving of broccoli."
    For parents, participating in the therapy often means rearranging their work schedules or taking leaves of absence so that they can be present to supervise every meal. In one family, said Dr. le Grange, the parents would sit with their daughter at breakfast, and then send an e-mail message to her school counselor, listing what was in her lunchbox. The counselor then supervised her lunchtime meal.
    Early in the therapy, he and other experts said, the therapist underscores the dangerous nature of the illness and tries to instill in the parents a sense of urgency. Siblings, too, are urged to do their part. One small boy, recalled Dr. le Grange, decided his job would be to give his older sister a hug once a day. The family is also directed to bring in a picnic meal representing the kinds of foods they think are appropriate to restoring their child's weight. Some families in the pilot study,. Dr. Loeb said, bring fettucine alfredo, a dish good for starved bodies that need calorie-dense food in order to gain weight. Others arrive with carrot sticks and fat-free yogurt, believing It is what their daughters will agree to eat. "It's not because they don't care," she said, "but because there was a big battle and they let the child be involved in picking the food."
    Over the course of treatment, Dr. Loeb added, parents begin to realize that with a combination of determination and creativity, they can get their child to eat. But at least initially, the child herself may not be so enthusiastic. A 16-year-old girl participating in the pilot study, for example; said she disliked the whole approach. "I have a great deal of concern that right now I'm trying to separate from my parents and become my own person," she said, "and I'm scared that the goal of the treatment is to give the parents total control." Her mother, on the other hand, said she felt the Maudsley therapy "put the power back in the family." "It gives me a parental mandate," she said. "I'm there, and I'm going to be more dedicated to getting rid of this problem than anyone because it's my child." For now, the whole family -- mother, father and daughter -- has agreed to give the Maudsley therapy a chance. The process, Dr. Loeb said, is likely to test their strengths as a family and challenge their patience. "But parents do it anyway," She said, "because they need to save their daughter's life."

Experiment Offers Look Through Eyes of Autism
John O'Neil, New York Times- 6/11/2002

Enlisting Richard Burton and Elizabeth Taylor and a high-tech eye-tracking device developed for the military, researchers at Yale ran experiments that came closer than anything yet to offering a look at the world as seen through the eyes of people with autism. In one experiment, described in the current issue of The American Journal of Psychiatry, the researchers compared the eye movements of a highly intelligent autistic adult and a control subject of the same age, sex and I.Q. as they watched the relentless emotional conflicts of "Who's Afraid of Virginia Woolf?"
    What the experiment showed was that the two subjects were seeing the movie in starkly different ways. When Mr. Burton and Ms. Taylor, playing an alcoholic professor and his shrewish wife, confronted each other face to face, the gaze of the nonautistic adult swung intently between their eyes, while the autistic subjects looked back and forth, as well, but focused on the actors' mouths. When Ms. Taylor flirted with George Segal, playing a young professor, as her husband lurked in the background, the gaze of the nonautistic adult described a triangle as he followed the expressions of all three. The autistic man never looked at Mr. Burton or anyone's eyes.
    Dr. Ami Klin, a psychologist at the Yale Child Study Center who was the lead author of the study, said his team chose the movie because it presented complex social situations that involved just four characters and had few distracting inanimate objects: To track eye movements, the researchers used a device made by Iscan of Burlington, Mass., said Warren Jones, a research associate who worked on the technical end of the experiment. He said eye-tracking technology had originally been developed largely with military funds to create a look-and-load system for fighter pilots.
    The system in the Yale experiment looked like a baseball cap with two cameras attached. One camera, at cheek level, faces forward and records the field of view. An infrared camera on the bill points down to a piece of glass that hangs in front of the eyes and acts as a mirror; letting the cameras capture eye position changes without blocking the subject's view. Dr. Klin said the device offered a tool to deal with one of the most frustrating research problems in studying autism, a little-understood brain disorder whose diagnosis has become increasingly common.
    Although autism affects a broad range of skills, the Yale researchers consider its central feature to be "a profound social disability," in Dr. Klin's words. But when social tasks are broken down into discrete components suitable for research, autistic children can perform far better than in the hurly-burly of real social challenges like recess, he said. The eye-tracking device allows researchers "to see what they see" while engaged in a more natural task, said Dr. Klin. "But we're less interested in what they understood than in how they searched for meaning," he said.
    What the researchers saw in the "Virginia Woolf" study and in a larger follow-up trial -- that autistic people tend to look at mouths or extraneous objects when nonautistic people look at eyes -- fits in with other classic signs of autism like limited eye contact and difficulty in remembering faces. Dr. Kiln called it especially intriguing because normally developing infants learn, often as early as 3 months, to look at people's eyes instead of their mouths when searching for information about feelings and intentions.
    Although autism is thought to affect brain development even before birth, in most children it is not diagnosed until age 3 or 4 or even later, when symptoms like language deficiencies or repetitive behaviors become evident. The Yale group has begun experiments to see whether eye-tracking tests could lead to earlier diagnoses because the best results come from intensive treatments that begin as soon as possible. Dr. Klin said eye-tracking fitted into a developing theory about the delay in symptoms. The problem is not just abnormal brain structure, but a stunting of brain development because of the limited social input that comes from a focus on objects rather than people. "We are," he said, "the sum of all our experiences."