Survey: Most Kids Pick Up Smoking at Home
Patricia Guthrie, Atlanta Journal-6/20/2002

The majority of kids who smoke cigarettes in Georgia may pick up the habit at home, reveals the first statewide detailed survey of youth tobacco use. Asked if they lived with a smoker, 70 percent of middle school students and 57 percent of high school students who are smokers said yes. Released Wednesday, the Georgia Youth Tobacco Survey found 9 percent of middle school students and about one-quarter of high schoolers use cigarettes. Nearly half said they would like to quit.
    Compared with the rest of the country, Georgia gets better marks for kids who light up than for those using spit tobacco. Nationally, 35 percent of high school students use cigarettes while 15 of middle schoolers smoke. But the rate of smokeless tobacco use is higher in Georgia: 10 percent of students are users compared with 7 percent nationally.
    The survey asked about students' attitudes, social influences, knowledge, access to tobacco products and media and advertising influence. Answers will help guide the state's new plan of attack on reducing teen smoking, said Kristen Copes, director of the tobacco use prevention office of the Department of Human Resources. This year, about $2 million of the state's tobacco settlement funds will be aimed at youth smoking cessation, she said. Approximately 80 percent of adult smokers started before the age of 18, studies show. The survey, taken in the fall of 2001, involved about 5,700 students across the state who answered hundreds of questions.
    Among other findings:
* 18 percent of middle schoolers and 47 percent of high school students reported buying their cigarettes at gas stations.
* 28 percent of high school teens thought that cigarette smokers have more friends.
* About one-third of students who do not smoke live with someone who does.
* Black students significantly less likely to smoke cigarettes than white and Hispanic students.
* Metropolitan Atlanta recorded the fewest number of middle-school smokers (4 percent) while the LaGrange area in middle Georgia showed the most (13 percent.) High-schoolers had no significant regional variation.

Stepmoms Must Re-Shape Maternal Instincts
Anne Pleshette Murphy, ABC News- 6/20/2002

The six stepmoms who met for the first time in person already had one thing in common: their Brady Bunch fantasy of combining two families easily into one bigger one had gone bust. After meeting each other online, the small group of women decided to get together for three days in Indianapolis for a stepmom support session to share war stories and advice. Good Morning America joined them as part of its three-part parenting series looking at parents, stepparents, and stepchildren. Since 65 percent of remarriages in the United States involve stepchildren, similar groups are becoming more popular — fueled by confusion about what a stepparent's role should be.
    "No book I could have read, or anyone I would have talked to would have helped to prepare me for being a stepmom," said Ginger P'pool. Another stepmom said that it doesn't help that the image of stepmoms is a negative one. "I think that just in general, stepmoms are looked at as evil people," said Lisa Mueller. "And they don't know what they're doing and they're trying to take the place of somebody else."

A Child’s Cutting Words
Carolyn Hittle said that TV portrayals of stepparents are off the mark. "When you blend your two families, you immediately think that everything's going to be like The Brady Bunch, and that's definitely not so," Hittle said. One of the most hurtful sentences her stepdaughter said is something that other stepparents have surely heard as well. "You know, 'you're not [my] mom.' I've heard that before," she said. "I've only heard it once and it cut me to the bone. But she's right. I'm not her mom."
    At one time or another, all of the women said they felt like they couldn't deal with the situation. "The process of becoming a stepfamily is kind of like a liver transplant," said Teresa Crafton. "It doesn't always take, but it will take lots and lots of medication in order to get everything accepted there. And the medication, in this instance, is education."
    Christina Shepard, newly married, has acquired a teenage stepdaughter. For stepmoms, bonding with a stepdaughter is usually harder than a stepson — especially during the teen years, experts say. "I came to learn parenting skills. I'm dealing with a stepdaughter," Shepard said. "I recognized the second we got in the door and within the first week, that it was going to be different than our previous relationship had been. And I just realized that I was going to need to get skills to learn how to deal with her."

Trying Not to Be a Mom
Each day is a tightrope walk, with emotions running high. One minute, it's love, the next, it's hate. The biggest pitfall of all is the role that a stepmom plays: Are you the mom or are you a friend? A great deal of literature says that stepmoms should not try to be a mother to the stepchild. But stepmoms say that is easier said than done. "They're with you and you love them and it's just an instinct to want to be their mother," P'pool said. "There's something inside us, just being females, that we mother," Crafton said. "In a stepfamily it just makes it doubly difficult because again, these are not your children. But you're still kind of expected to assume that role."
    How do you make that role work? These stepmoms were unanimous: the key is the dad. "My husband and I are both working really hard to figure out how to be able to say something to the other one's children or about the other one's children without the respective parent taking it personally," Mueller said. "It's a big adjustment." "Yes, it's gonna be hard," Hittle said. "It's going to be extremely hard at times. And there's going to be times that you want to leave. But if you fight for it and persevere in what your goal is, and our goal is to make it and grow old together."

Right of Second Opinion for HMO Patients Upheld
Charles Lane, Washington Post- 6/21/2002

The Supreme Court yesterday upheld an Illinois law that guarantees many patients an independent second opinion when an HMO denies them medical benefits, a decision that preserves similar laws approved by 42 states and the District in response to the national patients' rights movement. By a vote of 5 to 4, the court ruled that HMOs regulated by these state laws are a form of insurance as well as an employee benefit plan. As such, the states' authority to regulate them is not preempted by a 1974 federal statute that makes regulation of employee benefit plans the exclusive province of Congress, the court said.
    "An HMO is both: it provides health care, and it does so as an insurer," Justice David H. Souter wrote for a majority that also included Justices John Paul Stevens, Sandra Day O'Connor, Ruth Bader Ginsburg and Stephen G. Breyer. "Nothing in the 1974 law requires an either-or choice between health care and insurance in deciding a preemption question, and as long as providing insurance, fairly accounts for the application of state law," federal law permits it, he wrote.
    Supporters of limiting managed-care companies' latitude to decide issues of medical necessity hailed the court's ruling as a vindication of the states' approach. The ruling "represents a victory for America's patients and their physicians," Dr. Donald J. Palmisano, president-elect of the American Medical Association, said in a statement. "As the AMA has said all along, patients are entitled to an independent review when a health plan overrules the treatment recommended by the patient's physician."
    The case, Rush Prudential HMO v. Moran, No. 00-1021, has been closely watched for its possible impact on the stalemated debate in Congress over a patients' bill of rights. If the court had struck down the state independent review laws, most of which were enacted in the last five years, pressure could well have grown for Congress to fill the gap, health care analysts said. Yesterday's decision, however, leaves the status quo in the states unchanged.
    Both the House and Senate versions of patient rights legislation provide for an independent review process; that issue is not the main source of the deadlock over the bill. But Republicans and Democrats have been unable to compromise over the separate issue of how much liability HMOs should have to consumer lawsuits. Republicans want to limit liability, and Democrats favor expanding it.
    Still, the court's ruling is a major setback for the health insurance industry. It had hoped that the justices would relieve it of what it regards as a costly and burdensome patchwork of state laws that provide for independent review of HMO decisions. Donald Young, president of the Health Insurance Association of America, said in a statement that the court's decision "will add greater cost and complexity to health insurance coverage. . . . Having 50 different state standards governing how external review is practiced will mean people covered under a multi-state plan will not have the same benefits." "With costs already skyrocketing, employers navigating varying state laws may be forced to reconsider whether they will offer health insurance for their employees," Young added.
    In dissent, Justice Clarence Thomas, joined by Chief Justice William H. Rehnquist and Justices Antonin Scalia and Anthony M. Kennedy, expressed similar concerns. Thomas wrote that the ruling "eviscerates the uniformity of the 1974 law's remedies Congress deemed integral to" balancing fairness to employees who claim benefits with the need to encourage employers to provide benefits at all.
    While cheering the ruling, supporters of a federal patients' bill of rights emphasized that the state laws the court upheld yesterday are relatively limited in their impact. They apply only to the 53 percent of health plans considered "fully insured." In these, employers pay a separate insurance company to supply the health coverage, as opposed to "self-insured" plans, which are common at large companies and under which employers negotiate directly with health care providers.
    Maryland Insurance Commissioner Steven B. Larsen said yesterday's ruling does not eliminate the need for Congress to act, because most state review boards cannot punish HMOs if they defy a board's order to provide more care. Since the first independent review law was passed in Michigan in 1978, only 3,957 cases have gone through the process. About half resulted in a reversal or modification of the plan's decision, according to a study sponsored by the Kaiser Family Foundation. The study found that many people do not even seek independent review after losing in health plans' own internal review processes. The patients' bills of rights being considered in Congress would not only create independent review, but also streamline those internal review procedures. "Any assumption that a patients' bill of rights is unneeded is totally unwarranted," said Ron Pollack, executive director of Families USA, a nonprofit organization that supports stronger health insurance regulation. The pending legislation would extend the right of independent review to all 50 states and include self-insured plans, Pollack noted.
    The case decided yesterday began in 1996, when Debra Moran went to a primary care physician within Rush Prudential's network to seek treatment for severe shoulder pain. Eventually Moran, with the doctor's support, underwent complex surgery by another physician outside the HMO network. The HMO refused to pay the $95,000 cost of the operation, saying she could have been treated by a cheaper procedure.
    An independent doctor sided with Moran, but the HMO still refused to reimburse her and Moran sued. Rush Prudential won in a federal district court, which agreed with the firm that the Illinois law was preempted by the 1974 Employee Retirement Income Security Act (ERISA), the federal law that covers the regulation of pensions and other employee benefit plans. The Chicago-based U.S. Court of Appeals for the 7th Circuit sided with Moran, a ruling that clashed with a decision by the New Orleans-based U.S. Court of Appeals for the 5th Circuit, which had struck down a Texas statute in 2000. The Supreme Court accepted Rush Prudential's request to settle the conflict. ERISA says it supersedes "any and all state laws insofar as they may now or hereafter relate to any employee benefit plan." But in another clause, ERISA allows states to regulate the insurance business.

Former Student Found Insane in Pedestrian Killings
San Francisco Chronicle- 6/21/2002

A former college student was insane when he drove through a crowded street and killed four pedestrians in a student housing area serving the University of California, Santa Barbara, a jury found Thursday. David Attias, 20, hugged his attorney and smiled when the verdict was read. The verdict drew tears from Attias' family and relatives and friends of victims who crowded the courtroom. "This was a horrible, horrible tragedy," said the defendant's father, Emmy-nominated director Daniel Attias. "There are no victors today. The losses that were incurred Feb. 23 are permanent, and we are very, very shaken. We continue to be very shaken. But we're grateful that, in our view, that tragedy was not compounded today by an unjust ruling." Tony Bourdakis, who lost a son that night, said the verdict let Attias "get away with murder." "In our opinion David Attias will not serve the appropriate time for killing four young people and for horribly injuring a fifth," Bourdakis said.
    Attias was found guilty last week of second-degree murder. A jury then began hearing testimony June 13 to determine if he was insane at the time. Killed were Nicholas Bourdakis, 20; Christopher Divis, 20; Ruth Levy, 20; and Elie Israel, 27. Levy's 27-year-old brother, Albert Levy, was injured. Attias had pleaded innocent by reason of insanity. The insanity ruling could send him to a mental hospital for an indefinite period of time.
    Witnesses testified that after Attias struck the pedestrians with his speeding car on a crowded street on Feb. 23, 2001, he shouted, "I am the angel of death." Attias has a history of mental illness. Drug tests showed he had the dental painkiller, lidocaine, in his bloodstream after the crash. A video shown to jurors showed him fighting with onlookers shortly after his car struck the pedestrians.
    In Tuesday's closing arguments in the sanity phase of the trial, Attias' attorney urged the jury to find that his client was insane on that night in February. "We have a place in our system for justice for everyone," defense attorney Jack Earley told the jurors. "The proper, the just, the decent thing to do is to find Mr. Attias was insane at the time." Earley repeatedly pointed to the conclusion of two court-appointed psychiatrists who said Attias was insane at the time of the crime.
    Assistant District Attorney Patrick McKinley countered with a laundry list of the defendant's actions before and after the accident that he said proved Attias was sane. "There is nothing that the defense can point to that points to insanity," the prosecutor said during his 50-minute closing argument. "He put the key in the ignition, not in a toaster. He wasn't out of it."

Company Gets FDA OK for Fast Ecstasy Test
Reuters News Service, 6/21/2002

WASHINGTON—Worldwide Medical Corp. announced Tuesday that the US Food and Drug Administration (FDA) has approved the company's over-the-counter First Check Ecstasy test for marketing. The urine test can provide results within minutes, according to the company, and is being marketed for both home and workplace use. Ecstasy, or MDMA, is an illegal drug akin to methamphetamine.
    Worldwide Medical CEO Daniel G. McGuire estimated the company would sell more than $1.4 million worth of the tests over the next year. He told Reuters Health that the firm has already begun a marketing campaign for the product and has entered distribution deals with the grocery chain Kroger and the wholesale distributors Cardinal Health and AmeriSource. The test will be offered at a retail price ranging from $10.99 to $12.99 and a wholesale price of about $8, he added. Worldwide Medical said the Ecstasy test is its fifth drugs-of-abuse test to receive FDA clearance.

Eating Disorders May Be Rising Among College Men
Reuters News Service, 6/21/2002

NEW YORK— If new study findings are any indication, eating and exercise disorders may be gaining a foothold among college-aged men. As many as one in five male college students worry about their weight and body shape, follow rules about what they can and cannot eat, and limit their food intake, researchers report.
    While eating disorders like anorexia and bulimia have been extensively studied in young woman, there are few studies about eating disorders in men, according to lead author Dr. Jennifer A. O'Dea of the University of Sydney in New South Wales, Australia. However, O'Dea and her co-author Suzanne Abraham point out that one recent study found men with eating disorders tended to develop them later in life than women--at an average age of about 21, versus 17 for women. And during the 1980s and 1990s, "men constituted an increasing percentage of eating disorder admissions," they note. This suggests eating problems may be on the rise among young men, the authors report in a recent issue of the Journal of American College Health.
    To investigate, O'Dea and Abraham interviewed 93 male college students about their eating and exercise habits, as well as issues pertaining to self-image. "The respondents met clinical diagnoses for objective binge eating (3%), self-induced vomiting (3%), bulimia nervosa (2%), and exercise disorders (8%)," the researchers write. "Although 9% reported disordered eating, none had sought treatment."
    In other findings, "between 9% and 12% were unhappy with their body shape, felt fat and seriously wanted to lose weight." Nearly half said exercise was important for their self-esteem and 34% said that they were "distressed when they could not exercise as much as they wanted," according to the report. And 14% of the men reported that they were "worried" about the amount of exercise they were doing, the report indicates.
    "Among the findings of greatest concern in our current study were the reports from some of the young men that although they believed they had a problem with disordered eating, weight control and binge eating, not one had ever sought any treatment for his problems," the authors write. "Health professionals should be aware that eating and exercise disorders may be present in college men and that screening may help in the early identification of these problems," O'Dea and Abraham conclude. O'Dea is currently a visiting scholar at the Center for Weight & Health at the University of California, Berkeley.
    SOURCE: Journal of American College Health 2002;50:273-278.

Young Victims Struggle to Heal From Sexual Abuse
Claudia Feldman, Houston Chronicle- 6/23/2002

She's 10, way too young to know anything about gynecological exams. But there she is, covered modestly with a sheet, naked from her waist to her white socks. Pediatric nurse-practitioner Deborah Parks lifts the sheet, already knowing what she will find. In the child's short life, she's had two sexually transmitted diseases: chlamydia, which is curable, and herpes, which is not. Even worse than infections or the open sores, the child says, are the flashbacks. She says her dad molested her. She says she was 4 the first time, She says she cried and pulled a blanket over her head when he took off her clothes and touched her bare skin. "I tried to push him off me. I couldn't." A year or two passed. The abuse, she says, became habitual. One night, she asked her dad, "Is this right?" She watched Oprah, so she knew it wasn't. This is an ugly story about an ugly subject that is ripping many families apart.
    Thirty years ago, child sex abuse was not a subject discussed publicly. Today it's hashed and re-hashed on the front pages of newspapers, on TV and radio talk shows, in every kitchen and coffee shop in America. Partly because of the priest scandal in the Catholic church, partly because of sex offenders prowling the Internet for prey, citizen outrage finally has reached critical mass. One woman, furious at the young man who raped her 8-year-old grandson, summed up the mood of the country: "I don't care that he's in prison. He can go to hell."
    For 20 years there have been whispers of pedophile priests abusing young parishioners. Finally the whispers are roars. Americans are disgusted that the church has taken all these years to address the issue and is refusing to take that final step. They're enraged that the church has moved offending priests from parish to parish rather than confront and stop them. Non-Catholics are frightened, too. They know sex offenders are prowling the Internet to lure away their children. They're frustrated that perpetrators are hard to identify and harder to catch -- they are every color, every nationality, in every income and education bracket.
    In May a Connecticut 13-year-old was slain during a sexual encounter with a 24-year-old Brazilian national she met on the Internet. Christina Long was a cheerleader, a good student, an altar girl, and, according to an FBI affidavit, an Internet surfer. Apparently she had agreed to meet the 24-year-old at least once before. Saul Dos Reis faces a federal charge of using an interstate facility -- the Internet -- to entice a minor for sexual activity and multiple state charges, including manslaughter and sexual assault of a child. Tuesday another Connecticut man was charged with raping a 16-year-old he met on the 'Net.
    "I deal with child sex abuse all the time," says state District Judge Mark Kent Ellis, who in May presided over the high-profile trial of rapper Carlos Coy. "People think it doesn't happen in their neighborhood, or it doesn't happen to people they know. "It happens frequently, unfortunately." Jurors convicted Coy of aggravated sexual assault of a child, sentenced him to 45 years in prison and ordered him to pay a $10,000 fine. Coy and his many supporters in the courtroom denied the accusations until the last few minutes of the sentencing. Then, when the judge asked him if he had any comments, he was wordless. His victim was 9. Ellis filled the silence. "After 17 years in the courthouse, I've seen more sex offenders than I wish to remember. All were liars. And you are no exception. You're a liar, too."

A few facts:
*Most perpetrators, about 90 percent, are family members or, like Coy, trusted acquaintances. They are mostly but not exclusively male.
*Figures that quantify the problem vary widely. Spokesmen from the National Children's Alliance say one in four girls and one in six boys are at risk of sexual abuse before the age of 18. Individual charges, however, are difficult to prove. Amanda Wellman Peterson with the alliance says confirmed cases of child abuse and neglect were up in 2000 after a marked decline in the 1990s, according to the U.S. Department of Health and Human Services. "We have 900,000 confirmed cases of child maltreatment, and about 10 percent of that, 90,000, is child sex abuse. But many, many children who are abused don't get reported. The Catholic Church is a perfect example."
*Harris County judges say they are seeing more child sex abuse cases in their courts than ever before and stiff sentences for defendants who are found guilty. Says state District Judge Ted Poe, "Juries now are in the punishment business as opposed to the rehab business, and it doesn't matter who the convicted person is. Very, very few excuses for that conduct are working with juries."
*The veil of secrecy is being ripped away. Child sex abuse allegations investigated by Children's Protective Services have risen from 10.2 percent in fiscal year 2000 to 18 percent in December, January and February, the latest reporting period. Spokeswoman Judy Hay speculates the rising numbers reflect more child outcry and better reporting, not an increase in cases.
*In Harris County, parents worry that sex offenders may be lurking in their neighborhoods, and they feel justified in their fears. Roughly 22 percent of the convicted sex offenders supervised by the parole division of the Texas Department of Criminal Justice live here. That compares to about 13 percent who live in Dallas County, about 8 percent who live in Bexar County and about 5 percent in Travis County. Those numbers do not include offenders on probation or those awaiting trial, like the 10-year-old's dad.
    The child waited four years to cry for help. She says the days were agonizing. She says she watched as he bought, sold and ingested drugs. When he was hungry, she says, he made her cook. When there was no money for food, she says, he inhaled the pizza or groceries she wheedled from neighbors. The nights were worse, she says. In the apartment, she says, he kept sex toys and skimpy outfits he insisted she wear. When she finally was rescued by her mom, who had moved out years earlier, the child had the forethought to take the paraphernalia with her as evidence. She says she won't forget what he used to tell her while she wore the outfits, which were tight on her round figure. He said she'd look better if she weren't so fat.
    When the couple first met, it felt like love. By the time the young woman realized she'd made a terrible mistake, it seemed too late. She had a baby kicking in her womb. The young woman says she tried to make the marriage work. When she finally gave up that fantasy, she tried to take her daughter and split. Her husband, the 10-year-old's dad, wouldn't hear of it. Leave the kid, he said, or there will be bloodshed. The mom, who felt emotionally if not physically abused, wasn't sure whose blood would spill. For a while she was like a yo-yo. She'd leave and come back. Finally she handed her 4-year-old daughter her new phone number, told her to hold on to it, and left for good. The child didn't call. She didn't tell anybody about the alleged abuse until Thanksgiving 2001. Finally, she says, she couldn't take it any longer. "I had to get out. I didn't want this happening the rest of my life." She was close to one of her dad's girlfriends. That's who she told.
    When a child cries for help as the 10-year-old did, a lot of things happen at once. In this case, the girlfriend called the mom. The mom called police, then raced over to the apartment and grabbed her child with the help of a young neighbor. The dad ran into the woods. Police caught him a few days later, interrogated him and placed him in the Harris County Jail. Prosecutors charged him with three counts of aggravated sexual assault of a child. Attempts to interview him have been rejected by his attorney, Jim Medley. In the next few months, the dad has to decide whether to plead guilty and accept a 25-year prison sentence or maintain his innocence and go to trial Sept. 9. If convicted, the maximum punishment is life behind bars. He would have to serve 30 years before his first opportunity for parole. After the mom recovered her child from the ramshackle apartment complex, they drove straight to Memorial Hermann Hospital. The staff alerted Children's Protective Services, the agency responsible for abused and neglected children in Harris County, examined her, and referred her to the Children's Assessment Center.
    The CAC, fueled by public and private funds, is a three-story building in Rice Village that looks like a cousin of the Children's Museum. Everywhere kids turn, there are bright colors, toys and furniture their size, and adults who are experts in child sex abuse. Fifteen agencies that offer services to young victims have offices under the CAC roof. The idea is one-stop service. In theory, kids tell their stories to authorities just once, on videotape, and receive a wide range of services that are affordable or free. "There's no psychobabble here -- we just love working with kids," says Dr. Margaret McNeese, the pediatrician in charge of the clinic. "I enjoyed my childhood. Every time I walk into one of the examining rooms, I return to that. ... Little children are ridiculous in the most gentle and wonderful way."
    Still, some days leave the staff despairing. Nurse-practitioner Deb Parks remembers when a 10-month-old baby was brought in bleeding from the vagina, in need of surgery. Parks and Dr. Sheela Lahoti had to bathe the dirty baby and her two toddler brothers before it was possible to examine them. Afterward, Parks remembers rocking one of the little boys -- she doesn't think he had ever been rocked before. When clients have cases that go to trial, the medical professionals often testify. Sometimes they can show jurors pictures of tears, swelling and bruising in the genital area. Sometimes they can cite sexually transmitted diseases present in the child that also were found in the defendant. Sometimes the kids on the stand look innocent and vulnerable and easily win jurors' hearts.
    Don McKusker, who served as a juror on a child sex abuse case in March, remembers listening to the testimony and wondering sympathetically, "How is that child going to be able to hold up? But she did. She dressed real well and stood up great on the stand." McKusker also remembers how the testimony affected him. "It just tore me up," he says. "I couldn't believe what I was seeing and being told." The mother's boyfriend was found guilty and sentenced to 40 years in prison.
    Other times the clinicians and their patients aren't as lucky. In most sex-abuse cases, there is no physical evidence of sexual contact or intercourse because the body heals so quickly. Without evidence or witnesses, it becomes the child's word against the adult's. Sometimes the kids are older and streetwise and do not impress jurors. Sometimes it's the defendants who are or appear to be favorite sons or family clergymen or popular coaches. On rare occasions, the clinicians say, they do see patients who make up stories to frame innocent adults. They say those girls and boys eventually reveal themselves and need other types of help.
    Julia Wolf, director of therapy services at CAC, says average citizens don't understand nearly as clearly the fate of children who have been sexually abused. Adults often rationalize or minimize or deny, Wolf says. It sounds something like this: The kid seems to be OK. Maybe Uncle Johnny or Grandpa or Pete shouldn't go to prison for 35 years for that. Partly to help the children express themselves, partly to help adults better understand the damage done, Wolf proposed a T-shirt project some months ago. Kids in therapy at CAC were given T-shirts, paint, glitter and glue and were asked to show how the abuse had affected them. The results shocked even Wolf. A few T-shirts were wordless masses of black and purple and red, like wounds. One was drawn quickly in red. It read, "I don't like sex." Another said "triste," Spanish for "sad." Below the word was a drawing of a little girl crying. On the T-shirts, there were many pictures of children crying. Most had words, all painful. "Moms don't always protect you." "After all the trust you gave me, you hurt me." "I feel heartbroken." "Dads shouldn't do that to their sons." "No one believes me."
    That's an abused child's worst fear, Wolf says, that no one believes them. Or that the criminals won't be punished but they, the innocents, will. It's difficult even for socially aware parents to understand that their close relatives or trusted friends could hurt children, Wolf says. "It creates a lot of fear and guilt. We have to help parents understand that they got tricked just like their child did. But that doesn't make them feel any better. They wonder, `How could I have been so wrong?' They question their ability to make judgments about people. They wonder if they should trust anybody."
    Over the years, Wolf has treated hundreds of children and dealt with that many parents. She and fellow therapists have experimented with art therapy, music therapy, play therapy, dance therapy and the old standby, talk therapy, to help clients heal. Children react in fairly predictable ways, Wolf says. The 10-year-old who says she was abused by her dad, for example, has nightmares. When she walks around her mother's house after her bath in the evening, she covers herself head to toe to avoid revealing any body part. She is a beautiful child, but she describes herself as ugly. She believes her dad belongs in jail, but she says she feels sorry and guilty that he is there. Sometimes she cries. Sometimes she is silent and withdrawn.
    There are other responses, too. Wolf tells about a 6-year-old girl who was sexually abused by a neighbor. The child, not understanding what happened to her or that the behavior was wrong, gathered her little friends in the neighborhood and began teaching them what she had learned. One of the friends brought her baby sister into what seemed to be strange but interesting games. The older children took off the baby's diaper and touched her vagina. Nothing else happened. The child who was abused moved away, the baby and her older sister moved away, and whatever had been learned was forgotten. When the older sister hit puberty, however, she remembered what she had done to her sibling, and she felt so much shame, guilt and sadness that her grades dropped, she went in and out of therapy, and she started experimenting with drugs. It wasn't until she finally disclosed the source of her misery that social workers could explain that she was a victim just like her friend and her sister. She wasn't a horrible person, and none of it was her fault. It was the adult neighbor's fault.
    "The trauma of child sex abuse comes in lots of different forms," Wolf says. "It's subtle, and it spreads like poison." And it's a pain that keeps hurting. It comes back at different stages of victims' lives, and it's not uncommon for them to have to return, even if briefly, to therapy. Victims need to know that's normal, Wolf says. "They're not going crazy. And offenders need to know that it's a lifelong thing that they've done to a child."
    Wolf remembers a little girl who was abused by her dad. After intercourse, he led his daughter in prayer. He told God he and his child should stop doing what they knew was wrong. "That kid's spirituality was shot," Wolf says. "It's these sick, kind of subtle things that are perpetrated on kids. It's not just the sex, it's this twisted, distorted thinking that gets dumped on them. For some, sex isn't even the issue. It's the sense of culpability that they get for somehow going along with it."
    Wolf sees some children who have been abused by three, four, five people -- every relative in the family. "They don't trust anybody," she says. Some have become hypersexualized. They think about sex all the time and become small perpetrators, Wolf says. "We have to teach them socially acceptable behaviors and to stop offending behaviors," Wolf says. The children may expose themselves, insert foreign objects into body cavities -- theirs or another child's -- and attempt intercourse. "We try to put the brakes on the behavior," Wolf says. "But the children don't even understand that what they are doing is wrong."
    Sex offenders often target 9- to 12-year-old girls, those who are just starting to dabble with independence but are still painfully naive. But the story plays out in so many other ways. Last year, an 8-year-old boy was assaulted by his 16-year-old half-brother here. The 8-year-old was secure, well-cared for, well-loved by his mother. The teen led a more difficult life. For a week last July, the older boy baby-sat for the 8-year-old while his mom went out of town on business. The boys' father was present, but he frequently left them alone. He told his wife the boys were fine, and her fears were groundless. Late one night, the big brother raped the little one. It took the child just a few hours to tell his mom once she arrived home. "His little bottom was swollen with red and bluish blood stains," the mom says. "I immediately took him to the bathtub and ran some warm water. It looked like he was in pain. The first thing he said to me was, `Mommy, am I going to die?' He thought he had done an evil act. He thought he was in trouble."
    The mom cried hysterically. She confronted her husband. She confronted her stepson. Nothing she could say, however, was as painful to the teen-ager as his father's fury. He dragged the teen to the car. He said, "If you did this, you're going to jail, or I'm going to kill you, one." The little boy went to the hospital, where the medical staff found evidence of abuse, despite the bath. His brother, tried as an adult, was sentenced to five years in prison for aggravated sexual assault. The mom focuses on her child and his recovery. He worries that he might be gay. He worries that his half-brother is going to get out of prison and try to hurt him again. He expresses anger at his mom, his dad and God for failing to protect him. The mom still cries when she tells the story. She has so many worries now, but the main one is raising her son to be a well-adjusted adult with more good memories than bad.
    That's what most nonoffending parents want. They feel guilty and ashamed that they failed to protect their children. Another mom talks about her then-6-year-old daughter who was repeatedly abused by her stepgrandfather. It's a cautionary tale, she says, for those who think sex offenders are strangers. This perpetrator was a pillar in his community, so comfortable financially that he and his wife took three cruises a year. When he was home with his stepgranddaughter, he was showing her pornographic movies, taking showers with her and ejaculating on her. The child's mother had no clue until she was straightening some of her daughter's papers, and the line "I have sex with ------" stopped her cold. She asked her child a few questions, enough to prove that the words on the paper meant exactly what they said. "By then I was crying uncontrollably. I couldn't stop."
    Within a few days, the mom had contacted Children's Protective Services and the police and sought help from the Children's Assessment Center. Today, the mom says, the child is in therapy. Lately she's been drawing pictures of herself in her underwear. At the end of the school year, her grades were poor. Her teachers said she couldn't concentrate. The mom struggles, too. She won't let her daughter spend the night with friends. The mom wonders whom she can trust, if anyone. She despises the man who stole her daughter's innocence and her peace of mind. She tries not to dwell on the crime, but she can't stop.
    The CAC offers group therapy for nonoffending parents struggling with the aftereffects of abuse, and both moms are thinking about attending. For parents trying desperately to prevent rather than repair, Julie Anderson, a Houston Police Department investigator based at the CAC, has simple advice. "Talk to children in language they understand. When they're little, teach them the difference between bad touches and good touches. The parts covered by a bathing suit are not to be touched. That's private. If someone does something that makes them uncomfortable, it's always OK to tell. No matter what anybody says." As the children get older, Anderson says, keep talking. "Know your children. Be available. Go places with them. Give each child a little one-on-one. You can't be too paranoid with your child. Set ground rules at an early age. Don't take your eyes off your child."
    When rapper Carlos Coy was called to testify in the sentencing phase of his trial, he tried to give jurors an idea of who he was. He grew up in a single-parent home. He dropped out of school when he was 17 and still in the ninth grade. He briefly worked at a construction job, but, he said, he couldn't keep up with the work. "I was blistering my hands," he said. "I have sensitive skin." For a short while Coy sold perfume, hoping to make $75,000 a year as an entrepreneur. When that didn't pan out, he said, he started selling drugs. When that didn't pan out, he turned to rap. He was so successful and made so much money in the music business, he said, that many people, including young women and their families, tried to take advantage of him.
    The bulk of the trial involved one charge of aggravated sexual assault. During the sentencing phase, however, prosecutors discussed seven other child sex abuse charges pending against Coy. Most of those stories were trumped up or distorted, the rapper said. Why did all those girls go to so much trouble to lie about him, defense attorney Chip Lewis asked. "Because I was the star of the neighborhood," Coy said. "Throw me the football, I'll catch it. Give me the basketball, I'll make a basket. I am a star." Shortly after the jurors settled on the lengthy prison sentence, one juror said the panel might have been more lenient had Coy admitted his mistakes and said he was sorry. She also said she had been abused as a child. In her case, the perpetrators were women.
    Child molesters, whoever they are, wherever they are, worry Judge Ellis. To date, he says, the only reliable way to keep sex offenders from abusing children is to keep them apart. In prison, Ellis says, that's a relatively easy task. Offenders living in the community on probation or parole, however, are extremely difficult to supervise. The goal, Ellis says, is to watch sex offenders so closely that it's virtually impossible for them to offend again. "But you wouldn't believe what we find. They're doing everything from farm animals to multiple, multiple offenses (against children)."
    Jennifer Welch, a psychologist at the CAC and an expert on sex offenders, says offenders tend to be narcissistic, egocentric and self-centered. They think no one will ever catch up with them. Welch divides them into two groups, though they are not mutually exclusive. Pedophiles suffer from mental illness. They are sexually attracted to children, but not all act on their impulses. If they do, they are criminals. If they don't, they are sick but law-abiding citizens. Child molesters, Welch says, may not be pedophiles -- that is, they may not be primarily attracted to children -- but they do act out in deviant, sexual ways with children.
    Denise Oncken, chief of the child-abuse division in the district attorney's office, says the least severe child sex abuse charge is indecency, usually a man exposing himself. The range of punishment is two to 10 years behind bars and a fine. Most severe is aggravated sexual assault, which means some type of genital contact with a child who is 13 or younger. The range of punishment in those cases is five to 99 years or life in prison and up to a $10,000 fine. "These are the most difficult of any cases I've ever tried," Oncken says, "but when I'm successful, I really feel like I'm helping. The kids who come through the system need somebody to do a little bit to help them heal. "It's almost devastating to a child when they hear a not-guilty verdict from a jury. They think they're thought of as liars."
    It's also tough on the children when they feel they're responsible for sending a family member to prison. "I don't want them to carry that weight," Oncken says. "We carry the weight as the state of Texas." The child who says she was assaulted by her dad hopes he will plead guilty and spare her the agony of a trial. If she has to testify, however, she says she can handle the pressure. Some days it feels like a 50-pound weight around her neck and shoulders. Other days she can imagine the pleasure of telling the judge, the jury, the entire courtroom the pure, simple truth.
    Life at her mom's house is not problem-free, but it's slowly feeling like normal. She loves to curl up and read. She loves to do hair and pretend to model with her older sister. She loves to go to the movies, and she loves to sing. Once in a while the image of her father's face sticks in her mind. Sometimes more graphic sexual images stick in her mind. Sometimes she checks the door locks to make sure her dad can't come to get her. But she's learning to cope. She's learning that if she talks about her fears, they seem to disappear. She smiles a thoughtful smile. "I'm still kind of working on it." She has plenty of time. She's 10.

Mentally Ill Find More Doors Shut
William Branigin, Washington Post- 6/24/2002

Few thought Robert Matthew Pomeroy posed an "imminent danger," even though he showed suicidal tendencies. For much of his life, Robert Matthew Pomeroy struggled with bipolar disorder, depression and drug abuse. He was in and out of Northern Virginia mental health facilities, rehabilitation programs and jail. He seemed to deteriorate even more after his mother was struck and killed by a bus in late January.
    Sometime over the weekend of June 1, after having been turned away from a mental health center and a homeless shelter in Reston, Pomeroy ended his ordeal. In a small, wooded area where he had been sleeping in a tent, police said, he put a yellow plastic bag over his head and tied a gray strip of cloth around his neck. His body was found by another homeless man who went out to look for him, in a patch of trees within a few hundred yards of the mental health center, the homeless shelter and the Reston police station. He was 27.
    Pomeroy's death, which police ruled a suicide, was not made public, and Fairfax County social services officials have refused to discuss it, citing confidentiality rules. But the case has outraged social workers and mental health advocates. "We hear about preventable tragedies all the time, and this sounds like another one," said Ron Honberg, director of legal affairs at the National Alliance for the Mentally Ill. "This sort of shell game, where nobody is willing to take responsibility, is all too common."
    It was not the first time that a mentally ill person, unable to obtain help locally, has committed suicide. In November, Kevin McElhone, 46, doused himself with gas and set himself on fire in front of the Arlington County Department of Human Services four days after being discharged from a homeless shelter. Friends said he was frustrated over his inability to obtain a refill from the county for anti-depression medication.
    Nationwide each year, about 29,000 people commit suicide, more than two-thirds of them suffering from a depressive illness or bipolar disorder, according to the American Foundation for Suicide Prevention. Virginia's suicide rate, 11.5 per 100,000 population, is slightly above the national level of 10.7. Maryland's rate is 8.4 per 100,000; the District's is 5.8.
    McElhone, an accomplished carpenter, is survived by his parents, two siblings and, eerily, a personal Web page that still displays his résumé and photo and a picture of the Grateful Dead rock group. "For all the people I have loved and who loved me," reads a dedication on the site. McElhone and Pomeroy are among thousands of people with severe mental illness who advocates say have been failed by the nation's mental health systems. Unable to receive adequate treatment from cash-strapped community programs, many wind up homeless or in jail, often for relatively minor offenses related to their illness. Their plight is the subject of a 430-page report issued this month by the Council of State Governments and presented to the Senate Judiciary Committee. "People with mental illness are falling through the cracks of this country's social safety net and are landing in the criminal justice system at an alarming rate," says the report, the result of a two-year study. Called the Criminal Justice/Mental Health Consensus Project, the report is aimed at improving the criminal justice system's treatment of the mentally ill and reducing what it calls "unnecessary arrests and incarcerations." Among its recommendations: "Conduct suicide screening for all people with mental illness who are detained for a short time in a police lock-up or jail."
    As a model of a successful program, the study cites the Montgomery County Detention Center, where inmates with mental health problems undergo three screenings for suicidal tendencies. But with jails returning an estimated 1.4 million mentally ill people to their communities every year, local mental health programs need help, too, advocates say. "Building internal jail mental health programs at the expense of community-based treatment just doesn't make sense," said Arthur Wallenstein, director of the Montgomery County Department of Corrections and a participant in the Consensus Project.
    Although voluminous, the study stops short of addressing one of the most controversial aspects of mental health care: what to do when people with severe mental illness refuse treatment, as Pomeroy apparently did. In Virginia and many other states, mentally ill people can be committed involuntarily to a treatment center only if they pose an imminent danger to themselves or others. Similar statutes apply in Maryland and the District. Social workers and relatives say that although Pomeroy posed such a danger, he was shunted aside.
    Pomeroy, who grew up in Falls Church, began abusing drugs at a young age and never graduated from high school, a friend said. At some point, he was diagnosed with bipolar disorder and depression, according to his sister, Lisa Matthews. In 1999, he was charged with assault and destruction of property in Fairfax County, but those charges were later dropped. A police report noted "self-inflicted cuts" on Pomeroy's arms and said he sometimes stayed at the Northern Virginia Mental Health Institute. In February, about a week after his mother's death, Pomeroy was arrested after he was accused of stealing a bottle of Benadryl from a Reston store. A bench warrant was issued after he failed to appear in court in April but was never served.
    Last month, according to social workers familiar with the case, Pomeroy expressed suicidal thoughts and tried to overdose on Benadryl. The Embry Rucker Community Shelter in Reston, where he was staying, sent him to a hospital, which medically cleared him and sent him back. When he began mutilating himself with a razor, the shelter referred him to nearby Northwest Community Mental Health Center. But the center determined that Pomeroy did not meet the "imminent danger" standard and sent him back to the shelter, which then refused to readmit him because officials believed he was suicidal and might traumatize other residents, social workers said. He spent the next few days in the nearby woods before killing himself.
    "This is just one of several examples of tragic deaths of mentally ill homeless people," said a social worker who did not want to be named because of the confidentiality rules. He lamented that "it took another homeless person to go and look for him to see if he was okay, rather than professionals who are being paid to provide that kind of service." Another social worker who also did not want to be identified summed up the central contradiction in Pomeroy's case: "If he was dangerous enough to create a liability, then he was sick enough to need help."
    Valerie Marsh, director of Virginia chapter of the National Alliance for the Mentally Ill, said that "too many emergency services around the state . . . are trained to 'just say no.' It is exceedingly hard to get into the hospital in Virginia." Aneata Bonic, director of the Embry Rucker shelter, said she could not talk about Pomeroy but, speaking generally, said: "We're a homeless facility; we're not a mental health facility. We have children in this facility. We can't have unstable clients . . . who can cause trauma to other people living here." Homeless people who are turned away are given a list of other shelters and left to decide "whether they want to access services," Bonic said. Citing limited resources, she added: "It's unfortunate that some people may fall through the cracks. But we have no way of predicting if someone is about to hurt themselves."
    Did the system fail Matt Pomeroy? Gary Axelson, director of clinical operations for the Fairfax County mental health system, would not comment on the Pomeroy case but noted that because of past abuses, the law "sets a very high bar" for compelling someone into treatment involuntarily. "My brother wouldn't commit himself, and I knew this was going to happen," said Matthews, Pomeroy's sister. "I have no faith in the system." McElhone's sister, Noreen, said she, too, felt betrayed, especially when Arlington authorities met with her after his suicide. They seemed more intent on covering themselves, insisting that "they were very limited in what they could do," she said.
    Shortly before his death, McElhone, who had battled alcoholism for years and withdrawn from his family, told a friend that he was going to buy gasoline and immolate himself in front of the county's Department of Human Services, Noreen McElhone said. The friend called 911. Arlington police responded immediately, sending a patrol car to look for McElhone and alerting a DHS supervisor, said Matt Martin, a police spokesman. But Noreen McElhone said her brother loitered in front of the DHS building, even getting shooed away by a security guard at one point for urinating on the sidewalk. "He was killing time, desperate to have somebody stop him," she said. Nobody did.

Can the Placebo Treat Depression? That Depends
Richard A. Friedman, New York Times- 6/25/2002

A patient of mine who had been depressed gleefully announced that he was going to stop his antidepressant because he had just read in the news that placebos were as effective as antidepressants. A provocative simple claim, but is it true? Suddenly, the placebo effect has made a comeback after having been supposedly debunked last year by a group of Danish researchers. In a study published in The New England Journal of Medicine, Dr. Asbjorn Hrobjartsson reported that placebos were no more effective than doing nothing in a variety of medical illnesses like hypertension, asthma and obesity. As a result, many researchers pronounced the placebo effect a myth. Perhaps this is true for the medical disorders in this study, but what about the placebo response in depression, which was unexamined in this meta-analysis?
    In a soon to be published study, Dr. Arif Khan, a psychiatrist at the Northwest Clinical Research Center in Washington, analyzed the Food and Drug Administration's database of 52 clinical trials in depression, involving nine new antidepressants, conducted from 1985 to 2000. Since the agency requires drug companies to report all data from all studies for drugs under development, the database can give a more accurate picture of a new drug's efficacy than the medical journals, where positive findings are far more likely to be reported than negative ones.
    Dr. Khan found that in only 48 percent of the 52 clinical trials was the antidepressant superior to the placebo. Does this really mean that antidepressants are on average no better than placebos for depression? In a word, no. It all depends on how depression is defined and what kind of depressed patients are included in the clinical trials. Unlike a disease like HIV, which can be diagnosed by a simple blood test, the cause of depression is unknown; it is a syndrome that is diagnosed based on a cluster of symptoms like sad mood, low self-esteem, suicidal ideation and insomnia. So two depressed patients who appear the same in terms of their symptoms may be biologically very different.
    To get into a study, a subject needs both to meet diagnostic criteria for depression and to have the requisite symptom severity, which varies from study to study. But depressed people who enroll in antidepressant clinical trials are a very select group who are not representative of depressed patients in general. For example, they tend be only mildly or moderately depressed and are never actively suicidal. And they also are usually free of other psychiatric or medical illness that are common in the general population.
    It turns out that the more severely depressed people are, the less likely they are to respond to a placebo. And people with more mild depressions get better with just about all treatments, including placebos. Since most clinical trials enroll less severely depressed patients, the observed difference between the response to an antidepressant and a placebo can be misleadingly small. So placebo response rates vary a lot depending on the characteristics of the study subjects; it is easy to pick a group of mildly depressed patients and show that a placebo is equivalent to an antidepressant.
    There are other reasons that researchers may mistakenly conclude that placebos are as effective as antidepressants. For example, at least nine clinical trials included in Dr. Khan's meta-analysis lasted only four to five weeks. Yet we know that it can take up to six weeks and more for someone with depression to respond to an antidepressant. For example, studies have shown that about half of patients who had not improved after four weeks of antidepressant treatment responded by Week 6. So studies of short duration can exaggerate the efficacy of placebos. But why does it matter whether a depressed patient gets better on a placebo or an antidepressant? Isn't the mere f act of improvement proof of efficacy? Well, the problem is that the placebo effect is only short-lived, while depression tends to be a chronic illness with a variable rate of recurrence. Patients who continue on placebos have more than double the risk of relapse to depression than those who stay on antidepressant medication.
    But the real problem with the so-called placebo effect in depression is that no one really knows what it is. The reason is that when people are given placebos, there are two reasons why they may get better. One is suggestibility or enthusiasm on the part of the patient who wishes to get better. The other is spontaneous change: they might have gotten better if nothing was done.
    Spontaneous remission occurs naturally in many diseases, like the common cold, ulcers and asthma, as well as depression. Without comparing a group of depressed patients followed on neither drug nor placebo with a group taking a placebo, it is impossible to tell how much of the placebo response rate is due to suggestibility and how much is due to spontaneous change. And this is not done in clinical trials for depression. So when it comes to depression, no one knows if placebos are really better than doing nothing. At best, a placebo may give the patient a temporary boost if he is mildly depressed, but in a seriously depressed patient, it is right in more ways than one to call it a dummy pill.

Spanking Study Draws on 60 Years of Data
Associated Press, 6/25/2002

NEW YORK -- After analyzing six decades of expert research on corporal punishment, a psychologist says parents who spank their children risk causing long-term harm that outweighs the short-term benefit of instant obedience. The psychologist, Elizabeth Gershoff, found links between spanking and 10 negative behaviors or experiences, including aggression, antisocial behavior and mental health problems. The one positive result of spanking that she identified was quick compliance with parental demands.
    "Americans need to re-evaluate why we believe it is reasonable to hit young, vulnerable children, when it is against the law to hit other adults, prisoners, and even animals," Gershoff writes in the new edition of the American Psychological Association's bimonthly journal. Her analysis, one of the most comprehensive ever on the topic of spanking, was accompanied in the Psychological Bulletin by a critique from three other psychologists. They defend mild to moderate spanking as a viable disciplinary option, especially for children 2 to 6, but advise parents with abusive tendencies to avoid spanking altogether.

CDC: More Teenagers Using Cocaine
Associated Press, 6/26/2002

A T L A N T A— More teenagers are using cocaine and regularly smoking and drinking, but an increasing number are also wearing seat belts and refusing to ride with a driver who's been drinking, according to a survey released Thursday. The annual survey, conducted by the Centers for Disease Control and Prevention in schools across the country, examined the behavior of 13,600 high school students.
    The survey found injury and violence-related behaviors have fallen, but kids still regularly smoke and drink nearly half said they'd consumed more than one alcoholic beverage more than once in the month before the survey. The number of teenagers who said they had tried cocaine within the past 30 days rose to 9.4 percent, up from 5.9 percent in 1991. About 4.2 percent of students said they had used cocaine in the past 30 days, a 59 percent increase from 1991. "We still have plenty of work to do," said Laura Kann, a researcher with the CDC's National Center for Chronic Disease Prevention and Health Promotion.
    About 46 percent of teenagers said they'd had sex, down from 54 percent in the 1991 survey. The percentage of sexually active teenagers who had used a condom increased from 46 percent to 58 percent from 1991 to 1999, but then remained there through 2001. That points to a failure of "abstinence-only" sex-education programs favored by the White House, said James Wagoner, president of Advocates for Youth, a Washington nonprofit that supports both abstinence and birth-control education for teenagers. "The implication is clear and yet, the current administration ignores it. If you give young people information about how to protect themselves, they use it," Wagoner said in a statement.
    Other findings from the CDC survey:
*The number of teenagers who said they never or rarely wore a seat belt fell from 25.9 percent to 14.1 percent.
*The number of teenagers who said they rode with a driver who had been drinking fell from 39.9 percent to 30.7 percent.
*The percentage of teenagers in daily physical education class fell from 41.6 percent in 1991 to 32.2 percent a decade later.
*The percentage of students who carried a weapon decreased from 26.1 percent in 1991 to 17.4 percent in 2001.
    On the Net: CDC Morbidity/Mortality weekly report, http://www.cdc.gov/mmwr

Swedish Clinic Unveils Anorexia Treatment Success
Reuters News Service, 6/27/2002

STOCKHOLM — A Swedish clinic says it has developed a highly effective treatment for anorexia and bulimia, eating disorders affecting many thousands of people, especially teenaged girls. The treatment involves training patients in normal eating habits then making them sit down to rest in rooms with a temperature as high as 104 Fahrenheit.
    "Treating anorexic patients with warm temperatures is an old method which was long forgotten in the medical world," Per Sodersten, a professor at the Anorexia Center at Stockholm's Huddinge Hospital, told Reuters on Thursday. "Experiments have shown that animals (with eating disorders) have calmed down in warmer temperatures and have begun to eat more," Sodersten added. Since the seven-year study started, 75 percent of the 168 treated patients have regained normal weight, with an average recovery time of 14 months. For 12 percent the condition improved and only seven percent had a relapse.The study was published earlier this week in the American journal PNAS (Proceedings of the National Academy of Sciences).
    Both patients with anorexia nervosa, which involves self-starvation, and bulimia, binge-eating followed by self-induced vomiting, were successfully treated. With the new method, patients are trained to eat bigger and bigger portions of food, helped by a special computer program. Plates of food are put on scales linked to a computer and patients can track their eating speed on a graph, trying to match it with the speed of a normal eater. Patients are then taken to rest in a warm room and are only allowed to move in a wheelchair in order to conserve energy. "Anorexic patients have low body temperatures and often try to get warm by moving a lot. There is also a genetic explanation, when we eat too little our genes tell us to be more active in order to find food," Sodersten said. Patients are also trained in resuming normal social activities such as working or going out to a cafe. Sufferers often shun human contact or are too weak to go out. One percent of all girls in Western countries are estimated to develop anorexia between 14-19 years of age. Only five percent of all patients with eating disorders are male.

3,000 Domestic Abusers Bought Guns, Report Says
Dan Eggen, Washington Post, 6/27/2002

WASHINGTON - Because the FBI was unable to complete criminal background checks before gun sales went through, nearly 3,000 domestic abusers bought firearms between 1998 and 2001, despite laws designed to prevent such purchases, a congressional study has found. The General Accounting Office found that federal authorities have had to retrieve guns from the convicted domestic abusers and from more than 8,000 other felons because they had been wrongly allowed to buy weapons. A draft of the report was obtained by The Washington Post. While most of the purchasers were felons, more than a quarter of the cases involved people convicted of misdemeanor domestic violence offenses whose criminal pasts were difficult for authorities to assess in determining whether to approve gun purchases. Usually this occurred because of haphazard record-keeping and other problems, the study found.
    The large number of domestic abusers who were able to buy weapons underscores a chronic problem with the background check system implemented under the Brady Handgun Violence Prevention Act, one that increases the risk that violent spouses might take advantage of the loophole, according to the GAO study and victim advocacy groups. ''The weapon can be used in a homicide or to terrorize battered women and their children,'' said Lynn Rosenthal, executive director of the National Network to End Domestic Violence. Nearly 10 percent of the nation's 15,000 annual homicides involve the killing of a spouse or partner. Almost all victims are women, and most are killed with a firearm, according to US statistics.
    The study, which was requested by Representative John Conyers Jr., Democrat of Michigan, is likely to play a role in the debate on Capitol Hill over proposals to conduct background checks at gun shows, an issue that hinges in part on how much time the FBI should be given to complete the task. The GAO study argues that federal authorities, who are now limited to a three-day check before a purchase goes through, should be allowed as much as 30 days to research questionable cases before a sale is approved, noting that a relatively small number of buyers would be affected. Some members of Congress have recommended shrinking the background check time to 24 hours in some cases.

Officials Release Zantop Papers
Maeve Reston, Boston Globe- 6/29/2002

CONCORD, N.H. - Newly released letters and school essays written by Robert Tulloch, who helped carry out the grisly murders of Dartmouth professors Susanne and Half Zantop last year, reveal a confident and calculating young man with little remorse for the pain he caused others. The thousands of pages of documents released by the New Hampshire attorney general's office yesterday were described by prosecutors as virtually their entire case file. The records offer new clues about the transformation of Tulloch, now 19, from an intelligent student to a killer who fantasized from his jail cell about how he could make millions by writing about the murders he committed with his friend James Parker in January 2001.
    Months before Tulloch and Parker armed themselves with military-style assault knives and entered the Zantops' secluded home in Etna while posing as students doing an environmental study, Tulloch described the evolution of his personality in a school essay. His discontent with his life, he wrote, had built up years before when his family lived briefly in Florida. By the time he moved back to Vermont in the fifth grade, the feeling had solidified. ''By this time, I had developed into an incredibly smart, witty, and scheming individual,'' Tulloch wrote in the essay, which he handed in during the fall of his senior year at a public school in Chelsea, Vt. ''So now, after defying school for the last five years, having regular conflicts with the teachers, enjoying myself by doing exactly what I want, I am ready to depart. School is not for me and now I can leave.'' By the time the essay was written, prosecutors say, Tulloch and Parker, now 18, had already begun training themselves as killers so they could steal $10,000 and move to Australia.
    New Hampshire Assistant Attorney General Kelly Ayotte, the lead prosecutor in the case, said yesterday that Tulloch's writings were helpful to prosecutors because they gave credence to Parker's descriptions of his friend and the pair's elaborate murder plot. Ayotte added that the interviews with Parker, who agreed to share details of the murder with police for a reduced sentence, were a critical part of the investigation. She said Tulloch's writings gave prosecutors another window into the mind of the tight-lipped teenager. ''It's difficult to extrapolate from them,'' Ayotte said, ''but they demonstrate the level of intelligence that Tulloch had. Tulloch's writings also demonstrated what we had gleaned from police interviews with Parker -- that he had this attitude that he was superior to other people.''
    Some of Tulloch's writings also seem to affirm his apparent lack of remorse for his crime. The teenager, who wore a smirk during his sentencing and scarcely showed emotion during the trial earlier this year, in contrast to his sobbing accomplice, wrote letters from jail about how he and an inmate friend identified as ''Chief'' could profit from Tulloch's crime. ''Chief and I were going to write a book, and make millions since two Dartmouth professors died,'' Tulloch wrote to Chief's wife. ''Everyone who knew them or lived in New Hampshire or who likes this kind of thing will buy it. I believe you could end up with some $30 million.'' ''Boy, this idea makes me jumpy,'' he wrote.
    Tulloch had planned to use an insanity defense at his trial, but abruptly changed his mind before the proceeding began in April. He pleaded guilty to first-degree murder and got the mandatory sentence of life without parole. Parker cut a deal with prosecutors that enabled him to get a sentence of 25 years to life in exchange for his testimony against Tulloch.

Wayne County Mental Health Appoints New Director
Wendy Wendland-Bowyer, Detroit Free Press- 6/29/2002

The Detroit-Wayne County Community Mental Health Agency has appointed Patricia Kukula interim director, making her the third director the troubled agency has had in the past six months. Kukula, the former deputy director of Wayne County's Health and Community Services Department, said Friday she'll provide the stability needed to turn things around. "I'm the right person at the right time," said Kukula, an occupational therapist from Grosse Pointe Woods who has worked in Wayne County government for 17 years. Kukula's 1-year appointment started June 19. The Detroit-Wayne board has a $540-million budget and provides care for 45,000 people.
    Kukula was brought in after the previous interim director, Karen Schrock, left in April. Schrock had started Jan. 1 after Dr. Altha Stewart, a psychiatrist hired in 1999 after a national search, decided not to renew her contract that expired in January. Schrock, who worked in state government for years, was asked to leave because she had taken a 1-year leave of absence from her employer, an agency that contracts with the board, instead of resigning her post, Kukula said.
    This isn't the only recent difficulty the board has faced. Last year, the board was millions of dollars behind in payments for psychiatric care to some hospitals. Those payments are now caught up, Kukula said. Then, earlier this month, the agency's bid to continue providing mental health services for fiscal year 2003, beginning in October, was rejected by the Michigan Department of Community Health. The state is re-bidding contracts for mental health services and boards that fail to meet certain standards could lose their contracts. The Wayne County board will present its case again in August.
    Despite the challenges, Kukula said she did not hesitate to take the job. She has managed care experience, directing the county's PlusCare, a health care program for indigent residents, and HealthChoice, a program for small businesses. She said she is excited about the plan the board is developing. Mental health consumers, for instance, could chose which agency they go to for treatment. Now, consumers are assigned a provider based on where they live. The competition, Kukula said, would encourage better services. Kukula is a resident of Grosse Point Woods. She is married to James Chylinski, a Wayne County Circuit Court judge, and has two daughters.

Antidepressants Lose 'Miracle Drug' Label
Erica Goode, New York Times- 6/30/2002

Fourteen years after Eli Lilly introduced a small green and white capsule called Prozac, antidepressants have mushroomed from a modest market into a $12 billion industry. And Americans, little by little, are coming to think of depression as an illness like any other, a topic discussed on dates and at dinner parties. But the euphoria that greeted the arrival of the generation of drugs that Prozac heralded has faded.
    Millions are helped by antidepressants, with some studies indicating that 35 to 45 percent of those who take them experience complete relief from their symptoms. But millions more, 55 to 85 percent, are not helped nearly enough. Some people experience no side effects, but for others, sexual dysfunction, emotional numbing, insomnia, weight gain, restlessness and memory lapses make the drugs unusable -- or simply not worth the trouble. Many patients end up on a merry-go-round of medication trials, switching repeatedly from one drug to another or combining drugs to maximize their effects. "There is no question that the drugs work," said Dr. Steven Hyman, the director of the National Institute of Mental Health before becoming the provost at Harvard, "but they leave a lot to be desired."
    At the same time, the approaching expiration of the exclusive patents on many best selling drugs of the 1990's has given pharmaceutical companies other worries. Eli Lilly's patent on Prozac ran out last August, opening the field to a crowd of generic equivalents and resulting in a drop of more than 80 percent in sales of the brand-name drug. The market for antidepressants, which in 1998 grew by 24 percent, is expected to expand by only 5 percent this year, said Richard T. Evans, an analyst at Sanford C. Bernstein & Company.
    Scrambling to regain their competitive edge, the drug manufacturers are searching for new molecules that are more effective and have fewer side effects. They are tweaking the chemical structures of existing drugs and re-harnessing old standbys for new uses, marketing them for everything from social phobia to generalized anxiety and severe premenstrual distress. Psychiatrists argue that such conditions are real illnesses that cause real suffering. But others say the impression often conveyed by commercials for the drugs is clear: almost anyone could benefit from them. "The symptomatology is so broad and vague that almost any one of us could say, yeah, that is me," said Arthur A. Levin, director of the Center for Medical Consumers.
    Yet even the most aggressive advertising is unlikely to be enough to solve the industry's problems, analysts say. What is really needed is a new class of drugs, one that will have as much impact -- clinically and financially -- as Prozac did 14 years ago. "The field is waiting for the next breakthrough in terms of new treatments, through new mechanisms," said Dr. Alan Schatzberg, the chairman of psychiatry at Stanford University School of Medicine. "That's what people are hungering for."
    Several new antidepressants will reach the market soon. Lexapro, from Forest Laboratories, maker of Celexa, is expected to reach drugstores as early as next month, and Eli Lilly's drug Cymbalta should arrive late this year or early next. But no breakthrough product is in sight. The very complexity of depression as an illness, experts say, makes it unlikely that the next Prozac will arrive soon.

The Promise In a Pill
The earliest antidepressants were discovered by accident. Iproniazid, a drug first used for depression in the 1950's, was a treatment for tuberculosis before doctors noticed its mood-elevating effects. Prozac, in its way, was also a product of serendipity. It arrived at a time when scientists were first exploring in earnest the biological underpinnings of depression, and when organizations like the National Alliance for the Mentally Ill and the National Depressive and Manic-Depressive Association were working to convince Americans that depression and other serious mental disorders were illnesses like diabetes or heart disease, not weaknesses or failures of character. At the same time, surveys indicated that depression was far more common than researchers once thought. One of the most exhaustive surveys found that in any given year, 9.5 percent of Americans met the diagnostic criteria for a mood disorder.
    Yet even as awareness increased, few drugs were available for depression. Only two classes of antidepressants were on the market, tricyclics like Elavil and monamine oxidase inhibitors like Parnate. Both had been in use for decades. Both had problems that limited their use. Tricyclics caused side effects like constipation, weight gain and, in some cases, heart irregularities. Worse, even a small overdose could be lethal. The monoamine oxidase inhibitors required patients to avoid cheese, red wine and other foods that interacted with the drugs and could cause severe headaches or even strokes. For pharmaceutical companies, devoting much energy to marketing either class of drugs, their patents long expired, seemed hardly worth the effort.
    Prozac and the other drugs in its class -- selective serotonin reuptake inhibitors, or S.S.R.I.'s -- offered several advantages over their predecessors. They had standard dosages, making them easy to prescribe. People had taken huge overdoses and survived. Also, their side effects appeared minimal. Still, even Eli Lilly was surprised when its new drug attained the status of a cultural icon, making the cover of newsmagazines and inspiring books like "Listening to Prozac" and "Prozac Nation." Executives at Lilly have said that during development, they envisioned sales of $70 million a year. Instead, at Prozac's peak, sales approached $3 billion a year. "We underestimated the number of patients that could benefit from a drug like Prozac," said Dr. Steven Paul, vice president of Lilly Research Laboratories. There were in fact a lot of customers, including many who would never before have thought of taking a drug to alleviate emotional distress.
    Talk therapies have been shown to be effective for depression, especially when combined with antidepressants. But getting Prozac did not even require seeing a mental health professional. General practitioners wrote -- and continue to write -- the majority of prescriptions. The drugs gradually became an option for the mildly depressed, the bereaved, the stressed and the rejected. Antidepressants are now the second-largest class of prescription drugs, their sales exceeded only by heart medications. Last year, according to NDCHealth, a company that tracks drug sales, 7.1 million Americans took antidepressants, an increase of 700,000 over the year before.

The Pitfalls in a Pill
Yet even as the numbers have grown, it has become clear that the drugs are more prone to side effects and in some cases less effective than many people assumed. Many S.S.R.I.'s cause sexual dysfunction -- loss of libido and an inability to have orgasms -- a side effect many are unwilling to put up with for any length of time. Other patients complain of apathy and emotional flatness. "All it did was make me feel like I had no emotions," said Zachary Howard, 22, of Boston, who took Zoloft for a month in high school. "I felt like a zombie." In still other cases, the antidepressants simply quit working after months or years. Stopped abruptly, they could cause dizziness, sensations of electrical zapping in the brain, irritability and other unpleasant withdrawal reactions, a problem that can be solved by tapering off very slowly.
    A lawsuit filed last August against GlaxoSmithKline, the maker of Paxil, another drug in Prozac's class, claims that it deliberately did not warn of problems that could arise if the drug was stopped too quickly. A spokeswoman for GlaxoSmithKline said the company was "vigorously" contesting the suit. In December, the manufacturer added a precaution to Paxil's packaging about stopping suddenly.
    There is no question that antidepressants have saved many lives. Recent studies have linked drops in suicide rates in Hungary and Sweden, among other countries, to an increase in the prescription of antidepressants over the last 15 years. But a 1999 review of studies by the Agency for Health Care Policy and Research in the Department of Health and Human Services found that Prozac and its cousins had more tolerable side effects than older drugs but were no better -- though also no worse -- at treating depression.
    Other patients, studies show, get better but not well. Susan L., 45, a graphic designer in Manhattan who spoke on condition that her last name not be used, switched from an older drug to Prozac when it entered the market in the late 1980's. At first she did well. But five years later, the drug lost its potency. In the years since, she has tried a series of drugs and drug combinations. "I tried Zoloft, I tried Effexor, I was on Wellbutrin and Effexor for a while, now I'm on Wellbutrin and Celexa," she said. "It's still not that great. I couldn't say that I'm happy."

Patents, Generics and Jingles
Apart from the drugs' mixed effectiveness, the pharmaceutical companies have another problem on their hands. Eventually, every new drug loses its exclusive patent, which lasts 20 years from the date of application and wards off the encroachment of generic copies that other companies can sell at a much lower price. In the decade and a half since Prozac arrived, patented antidepressants have helped transform their makers into powerhouses. Forest Laboratories, the maker of Celexa, was a little-known manufacturer of generic' drugs. Now it is a darling of Wall Street, with sales rising by 35 percent last year, most of them from Celexa.
    But Proxac's swift sales decline in the last year has given drug manufacturers a glimpse of a dimmer future. Even though the market is expected to improve next year, the fast-paced growth of the 90's is not likely to return soon, according to Mr. Evans, the market analyst. For one thing, insurance companies, like Wellpoint Health Systems, the large California insurer, are trying to steer patients to fluoxetine, the low-priced generic equivalent of Prozac, by charging them higher co-payments for brand-name drugs. Dr. Robert C. Seidman, Wellpoint's chief pharmacy officer, said the company was giving doctors free samples of fluoxetine. "The health care system cannot afford to pay for a brand-name drug when a generic works just as well for a fraction of the price," Dr. Seidman said.
    To keep sales growing, the industry is pouring more money than ever into marketing and promotion. Last year, drug companies spent $1.5 billion to market the antidepressants to doctors, according to IMS Health, another company that monitors drug sales. They spent $200 million more on television and print advertisements aimed at consumers, according to CMR, a firm that tracks advertising. The companies are also coming out with formulations that make drugs easier to take -- GlaxoSmithKline, for instance, is working on a once-a-day form of Wellbutrin. They are also getting antidepressants approved for new uses, creating new advertising angles. "It's like I never get a chance to relax," says a man in a recent commercial advertising Paxil for treating generalized anxiety disorder. "At work, I'm tense about stuff at home. At home, I'm tense about stuff at work."
    Refining older drugs is also a sales strategy. Forest Laboratories' new drug Lexapro is a refined version of its other antidepressant, Celexa. Both drugs were developed by a Danish company and licensed by Forest for sale in the United States. Charles Triano, the company's president for investor relations, said, "We believe Lexapro has better potency, fewer side effects and may work faster." But others say the new medication's superiority has yet to be proved.
    "I haven't seen any data that suggests it's an improvement in side effects and efficacy at this point," said Dr. Dennis S. Charney, director of the mood and anxiety disorder research program at the National Institute of Mental Health. "But maybe when it hits the market, that will become apparent." To make Lexapro, scientists split their older drug, Celexa, into two mirror-image isomers or chemical compounds, then used one isomer in the new drug. Other companies have done this to try to reduce or eliminate side effects. Allegra, for example, the heavily promoted allergy drug, is a split version, or enantiomer, of Seldane, a drug taken off the market in 1997 because it could cause heart complications.
    Forest must convince doctors that half of Celexa is better than the whole. Generic companies will be allowed to sell Celexa in early 2004, although Forest predicts it will take another year before they get their lower-priced versions to the pharmacies. Once Lexapro is approved, Forest plans to dispatch its 2,150 sales representatives to doctors' offices with free samples.
    But here again, Prozac offers a cautionary tale. Two newer versions offered by Lilly after it lost its patent -- Prozac Weekly, meant to be taken once a week, and Sarafem, prescribed for severe premenstrual distress -- have not done much to offset declining Prozac sales. Sarafem sales were $84 million last year but only $13 million in the first quarter of 2002. "People know that it's Prozac, just with a different name," said Dr. Leonard Yaffe, an analyst with Banc of America Securities.

The Unknown Brain
The problem, in some ways, is simple: as much as scientists have learned about depression, they still do not know enough to be able to aim chemical treatments precisely. Older theories of depression's cause were based on oversimplified notions about how the brain worked. Researchers knew that antidepressants seemed to raise the brain's levels of messenger chemicals called neurotransmitters, so they theorized that depression must result from a deficiency of these chemicals. Yet a multitude of studies failed to prove this.
    Over the last two decades, helped by advances in molecular science and technologies that offered a window on the working brain, scientists have realized that depression is more symphony than solo; its symptoms a result of the chattering of neurons in many brain areas, mediated by many neurotransmitters. Nor are these processes set off by a person's inherited vulnerability alone. Far from being a static organ, the brain; research has made clear, is enormously plastic, its very architecture affected by environmental influences throughout life, including learning, stress and medication,
    Studies by Dr. Bruce McEwen, director of the laboratory of endocrinology at Rockefeller University, and others have shown that prolonged stress can permanently damage neurons in the hippocampus, an area of the brain involved in memory. Studies by Dr. Ronald Duman at Yale, Dr. McEwen and others show that antidepressants stimulate the growth of hippocampal nerve cells and, in animals, appear capable of reversing harm to the cells done by stress. Yet scientists are far from knowing exactly what such findings mean for depressed patients. Nor have they come close to untangling the interaction of genetics and experience that determines whether a particular person will fall ill.
    Making matters more complicated, a consensus is growing among researchers that depression is not a single entity. Dr. Jerrold F. Rosenbaum, a professor of psychiatry at Harvard Medical School, said, "There are differences in symptoms, there are differences in course, there are differences in the age of onset and differences in the relationship to external precipitants, whether they be seasonal changes or stress may not be the drug that works for another.

The Next Miracle Drug
With increasing knowledge will come the' promise of significant breakthroughs. But what is not known poses a formidable challenge to drug companies frantic to come up with more effective and more widely tolerable treatments. "If you found any agent that would work fairly quickly and in a large percentage of patients," said Dr. Stephen M. Stahl, an adjunct professor of psychiatry at the University of California at San Diego, "it would have a huge impact."
    Cymbalta, Lilly's new drug, reflects researchers' suspicion that hitting two neurotransmitters at once may be better than hitting only one. Like Effexor, a drug introduced by Wyeth in 1994 and now one of the fastest-selling antidepressants, Cymbalta belongs to a class called selective serotonin and norepinephrine reuptake inhibitors, or', S.S.N.R.I.'s, because it affects both neurotransmitters. "Most of the data suggests that the more chemical systems one engages, the bigger the bang for the buck," said Dr. Frederick Jacobsen, a clinical professor of psychiatry; and behavioral sciences at George Washington University.
    Other new drugs, still being tested, are entirely novel compounds, their potential resting on a mixture of theory and trial and error. One such class acts on a particular brain chemical, a neuropeptide known as Substance P. No one knows exactly what Substance P does in the brain, but it is released by intense physical pain and has been implicated in a variety of diseases.
    Because the peptide is present in brain centers tied up with emotion and stress, scientists also suspect it plays a role in the psychic pain of depression. Several companies are exploring drugs that block the action of Substance P, though experts say studies have yielded inconsistent results. At least one company, Merck, has a Substance P drug in clinical trials.
    A clearer rationale underlies the development of antidepressants that block corticotrophin releasing factor, a hormone released in the brain during stress. Studies show that some patients who suffer from major depression also have elevated levels of stress hormones. By interrupting the cascade of hormones that wear away at body and brain, researchers hope they may also be able to relieve depression. Several companies are exploring these drugs, but they are not yet in clinical trials.
    Even RU-486, the so-called abortion drug, is showing promise as a treatment for delusional depression, one of the most serious forms of the illness, said Dr. Schatzberg, of Stanford, who is studying the drug. Further in the future lie medications that could home in on specific genes regulating neuronal growth, drugs that could be tailored to an individual patient's genetic makeup and other advances not yet conceived of, many of them the expected fruit of the decoding of the human genome. Yet like Prozac, experts say, each new "breakthrough" product is likely to follow a predictable trajectory from "miracle drug" to just another useful medication. Perhaps this is not all bad. "It may be too much to think that there will be a single treatment that fits all." Dr. Rosenbaum.