Migraine Sufferers Get More Options
Amanda Onion, ABC News- 9/18/2002

"I was looking out the window at school at a green field and my head really hurt. I was seeing spots and stars," recalls Coleman. "My teacher told me to put my head down and I saw a huge mass of clouds approaching. Then I felt nauseous." Since that first onset, Coleman, who heads up MAGNUM, a Washington, D.C.-based migraine awareness group, has struggled with migraines his entire life, getting them at least twice a week. He says his migraines feel like "a gang of thugs" are smashing him in the head with baseball bats — over and over again. Like many migraine sufferers, his headaches are also preceded by an aura, a temporary state during which his vision is blurred and he sees spots. The pain has been so brutal and unrelenting that he has had four surgeries to try and treat his condition. None have worked and instead made him feel worse.
    But recently — only recently — he has become more hopeful about his condition. Better scientific understanding of migraine pain has led to drugs that can target specific causes, rather than offering a blanket-like numbing of head pain. Still, researchers admit, there's a lot left to learn. "The problem with migraines is they seem to be a very heterogeneous disorder," explains Lawrence Newman, a neurologist at St. Luke's Roosevelt and Beth Israel Medical Center in New York City. "We're on the fringe of discovering its causes — we're close, but not yet close enough."

Fuzzy Outline
In the 17th century a physician named Sir Thomas Willis suggested that the intense headaches were caused by a rush of blood to the head. This increased blood flow led to swollen blood vessels that, in turn, placed uncomfortable pressure on the brain's nerve fibers. That theory held up for centuries. But in the past decade, through the use of new noninvasive technology, such as MRI, PET and CT scans, researchers have learned that migraines may be caused by a series of complicated processes and that swollen blood vessels are likely a result, not a cause of the headaches.
    Current research suggests that some migraines begin when nerve-rich arteries at the back of the brain spasm and lead to a reduction in neural activity throughout the brain. This reduction may be linked to the migraine aura, a condition experienced by about one in five people before a migraine. Researchers at the University of Essen in Germany recently demonstrated that the process causing an aura is likely separate from those leading to the headache of a migraine.
    In what the German researchers say may be a parallel process, a trigger in the brain stem causes the release of a cascade of chemicals. These chemicals aggravate the trigeminal nerve, the largest cranial nerve that branches along the jaw line, ear, face and into the sides and front of the brain. The agitated nerve then releases neurotransmittors, including the brain chemical serotonin, which come in contact with the brain's blood vessels and cause them to swell. The swelling is perceived as pain.
    "The whole series of events is not entirely worked out. What causes the release of chemicals, for example? And where, exactly, does the process begin?" says Elizabeth Waterhouse, an associate professor of neurology at the Virginia Commonwealth University School of Medicine. "The general outline is there, but not the details." Even having a "general outline" of migraine's causes, however, has boosted effective treatment of migraines.
    Certainly times have improved from the 16th century when, according to MAGNUM, early physicians tried such approaches as drilling a hole through the skull to free "evil spirits," applying a hot iron to the site of pain or inserting a clove of garlic through an incision in the temple. While treatment wasn't nearly as brutal in the 20th century, Coleman claims they weren't terribly effective either. In fact, he says it was often difficult to convince doctors that his pain was real. "There was a common perception in this country that migraines were a psychological disorder," he says. "After spending two to three days in agony, with no sleep and projectile vomiting, I was often told by a physician that I wasn't really in any pain."
    Until the early 1990s, a common treatment for migraines was narcotics — drugs that essentially put the whole brain to sleep to numb pain. Today medicines are available that can turn off the receptors of the trigeminal nerve and the brain's blood vessels. A class of drugs, called triptans, emerged on the market in the early 1990s and have provided huge relief to migraine suffers (or migraineurs, as they're sometimes called). These drugs, which can now be taken in pill form, can kill a migraine within minutes since they directly hinder migraine chemistry.

Reducing Migraines — and Wrinkles
Through trial and error, more has also been learned about prevention. Among the most surprising finds was that Botox, a diluted version of the botulism toxin injected into the forehead to reduce wrinkling, can help prevent migraines. "I may have been one of the biggest skeptics when this news came out," says Newman, who is a migraine sufferer as well as a specialist in the condition. "But I've been amazed at how well it works."
    The first indications that Botox may prevent migraines first came from patients who had the procedure done for cosmetic reasons. They reported back to their doctors that their regular headaches had gone following the injections. Two years ago, a study led by Todd Troost, chairman of neurology at Wake Forest University, found that among 134 patients, Botox had a 92 percent success rate of decreasing migraines. Other medications shown to ward off migraines include calcium-channel blockers that improve blood flow to the brain, antidepressants that regulate levels of the brain chemical serotonin and anti-seizure medicines. A recent study even suggested that the friendly bacteria found in yogurt might help reduce migraines. This was based on the finding that some migraines may be linked to infection with a common bug and the bacteria in yogurt and other dairy products could fight them off.
    The trick is finding which treatments work for which people. In the future, researchers hope to have a more precise tool for fighting migraines — gene therapy. Nearly all people who suffer from migraines report they have family members with the same condition, suggesting a genetic factor is almost certainly at play. By knowing which genes make people vulnerable to migraines, it may be possible to manipulate these genes and prevent any onset of the headaches. The hunt is now on to find these genes.
    Aarno Palotie, a professor of pathology and laboratory medicine at the University of California in Los Angeles, recently scouted out a particular band on a chromosome that, among 50 Finnish families, was consistently linked to a common form of migraine. Now his group is pursuing the actual genes at play on this chromosome. Dutch researchers, meanwhile, have found a definitive genetic link to a more rare version of migraines called familial hemiplegic migraine. "At some level, I suspect genes are at play in all migraine patients," says Palotie. "The tough part is understanding the interplay between the environment, the individual and genetic factors."

Avoiding Chocolate, Diet Sodas
    The environment plays a clear role in triggering migraines, and through trial and error, migraineurs and researchers have pinpointed a few common triggers. Alan Rapoport, director and founder of the New England Center for Headache in Stamford, Conn., and a colleague recently showed that 39 percent of migraine patients were sensitive to weather changes, such as increased humidity or temperature (although 90 percent believed they were). Other work shows that 70 percent of women with migraines experience them during their menstrual cycles. Since women make up 75 percent of migraine sufferers, the female hormone estrogen is thought to play a certain role in triggering the condition.
    Other kinds of triggers are more avoidable. Chocolate, red wine, aged cheeses, cured meats, too much tea or coffee and overripe bananas have been shown to trigger migraines in many people. Coleman reports that aspartame — the sweetener found in many diet soft drinks — can give him a severe migraine within minutes. Other common migraine-inducing factors include too much or too little sleep, bright or flashing lights, strong perfumes, second hand smoke and air travel. "The bottom line is if you can learn what's bothering you," says Coleman, "then you can avoid them and usually avoid a migraine."

Georgia's Child Abuse Experts Are Seldom Used
Tasgola Karla Bruner, Atlanta Journal- 9/19/2002

Members of the Child Abuse Investigative Support Center, such as Dr. Lora Darrisaw, were called in on only 41 of the thousands of child abuse cases in Georgia last year. By the time Dr. Lora Darrisaw got involved in the case of 13-year-old Rhiannon Gilmore, she was doing the autopsy. Darrisaw and a collection of experienced child abuse investigators might have been part of the investigation into Gilmore's neglect case much sooner, but no one asked them.
    The experts at the Child Abuse Investigative Support Center are rarely consulted, although the arm of the Georgia Bureau of Investigation was created to help agencies looking into possible child abuse. But the center's two-year effort to remove barriers and connect social service workers with experts in child abuse investigations hasn't taken hold. Of the 63,488 incidents in which the state Division of Family and Children Services investigated abuse or neglect last year, 41 were referred to the center for help.
    Clear cut cases don't require consultation with center experts, which are considered specialists who handle cases with "special needs," said Renee Huie, spokeswoman for DFCS. But child advocates recognize barriers. "We see autopsy cases coming through the lab. There's more that could be done but if we don't have the request we can't do it. We act after the fact but it's too late. It's discouraging," said Janet Oliva, one of two child abuse specialists and one of the center's supervisors.
    The center, created after 844 Georgia children died over six years although their families had been reported for abuse or neglect to county DFCS offices, also has a pediatric forensic pathologist in Darrisaw and a program coordinator. In addition, it can draw on the GBI's forensic pathologists and child abuse investigators if needed. Of 103 cases referred in two years, the center, with an operating budget of about $300,000, found abuse or neglect in slightly more than half.
    J. Tom Morgan, a three-term DeKalb County district attorney who made his reputation prosecuting child abusers, lauded the GBI for creating a center that is a direct line between social service workers and child abuse investigation experts. "This goes back to the days when no one was talking and kids were falling through the cracks. The more chances you have to open up communication, the better. The GBI is taking the step to open communication," he said. But the deputy director in the Cherokee County Department of Family and Children Services office that handled Rhiannon's case didn't know about the center. A state child welfare spokeswoman said state programs often take a while to "filter down" to Georgia's 159 counties.
    Lon Roberts, who is reviewing how his own agency, the state Division of Family and Children Services, handled the Gilmore case, said he "definitely" would have had the support center look at the "red flags." Among them: Gilmore's rashes, her infection in the area where the feeding tube entered her body, and the circumstances of how Gilmore broke her leg, which was observed by a caseworker in August 2001. "The center may have thought nothing was wrong. I doubt it," he said.
    Creating the center was supposed to break another barrier. Before the center, the relationship between DFCS and GBI "wasn't good," there was a "fear factor" and case workers felt they needed permission from the GBI to seek the agency's advice, said D'Anna Liber, manager of the Division of Family and Children Services' Special Investigations Unit. The new alignment gives social workers better tools. "A parent may say a child was injured falling off a couch and we know it's not true, but with a pathologist consulting, we have evidence to show in court," Liber said. "Without that component a lot of our cases weren't upheld in court. " "What scares me is how many cases we've missed because we didn't have an expert to say 'This is abuse.' It's frightening," he said.

Study: Most Drug Inmates Not Violent
Associated Press, 9/20/2002

WASHINGTON -- Most drug offenders in state prisons are black males with no history of violence or high-level drug dealing, an interest group says. The Sentencing Project, which advocates for alternatives to incarceration, says that just over half of these state inmates - 58 percent, or 124,885 people - are nonviolent offenders. "They represent a pool of appropriate candidates for diversion to treatment programs or some other type of community-based sanctions," the authors wrote. "The 'war on drugs' has been overly punitive and costly and has diverted attention and resources from potentially more constructive approaches."
    Based largely on the government's 1997 Survey of Inmates in State Correctional Facilities, issued every five years, the study found that four out of every five drug offenders in state prisons are minorities. This is more than three times the rate of minority drug use in society, according to the 1997 National Household Survey on Drug Abuse. Blacks constitute 56 percent of drug offender inmates, while Hispanics make up 23 percent of that group. Their respective proportions of all monthly drug users nationwide are 13 percent and 9 percent, the group said. Meanwhile, three-quarters of all state drug inmates have no convictions for violence, the study said.
    Todd Gaziano, who studies criminal justice as a senior fellow at the Heritage Foundation, criticized the study for relying on a survey that asks inmates to describe their own level of criminal activity. And he said the Sentencing Project lumped many drug dealers together with those convicted of possession. "Retail drug dealers may not be as culpable as international drug kingpins, but it is highly misleading to suggest that they are all merely low-level drug users who need nothing more than treatment and counseling," Gaziano said.
    About 251,200 drug offenders reside in state prisons, the study says. Those inmates cost taxpayers about $5 billion every year. Treatment versus incarceration for drug offenders is a decades-old debate mediated in some places by specially assigned drug courts that typically include drug treatment in their sentences for drug offenders. While some advocate for alternatives to incarceration for minor drug offenders, others say the threat of incarceration has a deterrent effect.
    On the Net: The Sentencing Project: http://www.sentencingproject.org

Illinois Medicaid Suggests Splitting Zoloft
Shankar Vedantam, Washington Post- 9/21/2002

In an unusual effort to keep costs down, the Medicaid program in Illinois has decided to ask doctors to prescribe a double dose of a popular antidepressant which costs about the same as a smaller dose and then to tell patients to split the pills in half. State officials said the measure would save about $3 million a year. It came after the pharmaceutical company that makes the popular medicine Zoloft implored officials not to remove the drug from the state's list of preferred medicines. "We were very cautious in going down this road and researched it after Pfizer brought in the proposal," said Ellen Feldhausen, a spokeswoman for the Illinois Department of Public Aid. "We were skeptical."
    Officials decided to take the step this week after Pfizer assured them that the pills could easily be scored in half and would not lose their potency, she said. The agency had not ruled out doing the same with other medicines, if they met the same criteria, she said. Zoloft is unusual in that 100-milligram tablets cost $2.79 -- about the same as 50-mg tablets that cost $2.73. "Instead of prescribing 30 50-milligram pills, doctors can prescribe 15 100-milligram tablets," she said.
    An official at the federal Centers for Medicare and Medicaid Services in Washington, who asked not to be identified, said that other state programs were contemplating similar steps, in response to rising costs. The official said there was no national policy yet on whether to recommend such a move, and the agency was still weighing the safety implications.
    Health and advocacy groups were divided about the Illinois move, which was first reported in yesterday's Chicago Tribune. Some patients with physical or serious mental disabilities could be put at risk by either not understanding how to get the right dose or not be able to split the pills properly.
    While the Illinois Medicaid program appears to be in the vanguard, many individuals, especially seniors, have long resorted to pill-splitting on their own to control costs, some experts said. "We know it's happening but we discourage that type of behavior," said Steven Hahn, a spokesman for AARP, formerly known as the American Association of Retired Persons. "Following drug regimens as prescribed reduces relapses. It's something patients should consult their doctor before doing." "We learned 41 states are going to have to cut back their programs under Medicaid to control costs," he added. "The stories that people are making daily choices between food and medicine are true."
    Jeff Trewhitt, a spokesman at the Pharmaceutical Research and Manufacturers Association of America, an industry trade group, said, "Pill splitting is potentially dangerous if done by a patient unless it involves a collaboration between doctors and pharmacists who make sure patients have been carefully screened and the medication is suitable for splitting."
    The state will allow doctors to prescribe the 50-mg tablet if they think a particular patient would be unable to cut the pills properly, Feldhausen said. Pharmacists could cut pills for patients, she said, but the state would not require them to do so.
    Darrel Regier, director of the division of research at the American Psychiatric Association, said asking patients to split the antidepressant pills was less onerous than forcing them to take certain medicines instead of others. "The major concern from a medical standpoint is to preserve the flexibility for the individual tailoring of treatments to the specific needs that an individual patient may have," he said. Regier said the Illinois development was unusual in that a pharmaceutical company had come forward with the suggestion: "It's a concession on the part of Pfizer to make this recommendation," he said. "What they are doing by having the scored pills and suggesting this is the way to go is recognizing you can treat someone at half the cost."

Quilt Helps Patch Lives Torn by Abuse
Francis X. Clines, New York Times- 9/23/2002

RICHMOND, Va., Sept. 19 -. Battered women in Virginia's 68 shelters designed to hold off abusive spouses and boyfriends are resorting to an old homespun outlet for their fears and frustrations. At night in their sanctuaries they are concocting a giant quilt filled with confessional messages of depression and resistance in the common hope for a safer existence.
    "Mine was a classic self destructive relationship," said Sheila Mandt, a Salvation Army worker. ' "I clung to it. I fled across four states, fleeing him, fleeing myself." After all the battering at the hands of her former boyfriend, Ms. Mandt said, she decided she had a bigger score to settle with herself. So she started the statewide quilting project to bring forth some of the victims she finds hiding, cowering and surviving in solitude and in need of some mutual sign of perseverance. "I figured quilting, sewing, that's the stereotype of what women do, right?" said Ms. Mandt, 36, grateful for any sense of irony the public might perceive when the 150-by-10 foot quilt is unveiled this fall. Exhausted mothers, teenage girls wary of beaus, gray-haired grandmothers slapped around by family patriarchs, plus children and at least one male spouse have been making individualized panels for the quilt to show the public how widespread and dismal the problem of domestic violence remains.
    There is a sad panel commemorating the death of Sigrid, a woman who was killed along with her two children by her husband. There is a defiant panel celebrating the continuing life of Guinette, repeatedly stalked at night, beaten and stabbed, Ms. Mandt said, but still alive enough to contribute to the quilt. "It's not what people imagine -- some poor, African American woman with children, dependent and trapped by an abuser," said Ms. Mandt, a native New Yorker. "It crosses racial and economic barriers and can touch anybody."
    She said she has admitted her own past weakness in clinging to a relationship that turned out to be special solely for the chronic beatings she suffered. "I had all the opportunities in the world and still went down the wrong road," she said. "I ended up in a relationship that, to save my life, I couldn't get out of. The police and prosecutor turned me away when I sought help, telling me I was asking for trouble by choosing to stay in that environment. I had people at work reduced to laughing at me because of the bruises on my face." Ms. Mandt said that when her boyfriend began delighting in describing in detail how he would murder her, she finally mustered the courage to flee to another part of the country. In the last decade, she managed a new life, happily marrying a gentle man and plunging into social work. She is director of development for the Salvation Army's Richmond region. An instinctive organizer, Ms. Mandt comes across all manner of human conflicts and needs in her job. But none she found, are so repetitive and relentless as battering syndrome that had been quietly haunting her from the life she fled 12 year ago.
    "A beating every 15 seconds, a murder every 27 minutes," summarizing the national statistics on domestic violence. This is such a routine part of life's fabric that a quilt from the hands of its victims strikes her as a worthy statement. Ms. Mandt started the quilt project; with help from Virginians Against Domestic Violence, a private advocacy group. She found eager support from state Attorney General Jerry Kilgore, who became the project cochairman, plus corporate help here from the Philip Morris headquarters. "We needed a celebrity so I looked up Sissy Spacek's address, wrote to her, and got a reply that she'd be happy to be co-chairperson," Ms. Mandt said.
    She is the first to acknowledge that a quilt is nothing much -- simplicity itself, in fact, tangible and work intensive, but ideal, she says, for trying something creative from the misery being shared in the 68 shelters. Eventually, the giant quilt is to be divided into 14 quilts that will hang in corporate headquarters. "That's where the message should go, not in the shelters," Ms. Mandt said. "Battered women already know all about the problem."

Bipolar Drugs: Easy Rx, Hard to Take
G.B. Bloom, Washington Post- 9/24/2002

"Doctor, pleeeease, no more of these," my mind sang to the tune of the Rolling Stones' "Mother's Little Helper." That 1966 song, about a housewife begging her doc for more pills, told a story far different from mine. I was having yet another bad experience with a drug intended to treat my bipolar disorder, and all I wanted to do was get it out of my system. The drug, called Zyprexa, had me wide-eyed at 5 a.m., with no signs of my energy's flagging. And so I left another message on my doctor's answering machine, telling him I was totally awake. He was a new psychiatrist for me, and this was the first drug I had taken under his watch.
    About a month earlier, I had disappeared into darkness with sudden, shocking speed, and my new doctor considered my medication mix to be the culprit. Ironically, until the bright December day I fell into depression and woke up in a hospital bed, I had been enjoying an upbeat, productive period. In fact, I felt so good I had cut back on my meds. Like many people treated for mental disorders, when I was feeling good I didn't think I needed drugs. So I quit taking them and then: wham. The darkness swept in, plunging like the barometer before a thunderstorm, twisting my thoughts and mood into a despair so controlling I saw no reason to go on. I just wanted to sleep. Forever.
    I was stabilized in the hospital and a few weeks later I was back to life -- working, swimming, practicing yoga and being treated by yet another shrink when I found myself roaring along on the Zyprexa express at dawn. Zyprexa is what's called an atypical antipsychotic, which means it has fewer side effects than the older generation of antipsychotics. For bipolar disorder, it's been approved as a mood stabilizer. While I was eager to try a drug that might work, I also had to suppress my disdain for the idea of taking an antipsychotic. I am an energetic, high-functioning person, not someone out of touch with reality.
    Some antipsychotic drugs can tame mania in bipolar people, so I gave it a try. Following my psychiatrist's orders, I increased the dose slowly over seven days to five milligrams, half the standard dosage. Now the drug that was supposed to calm me had me incredibly alert. But as many veterans of the bipo wars can tell you, being "up" doesn't always feel like a bad thing -- at least for a while. After all, the computer functions 24/7. So I jumped onto the World Wide Web, researching every site I could find about the drug that was charging me up. New ideas sparked in my brain and all night long I printed out information and sent e-mails with comments and queries to a network of strangers in the online mental health community. As daylight appeared, being "up" began to scare me. The sun was shining when I dialed my doctor's number again.

Bipolar? Me?
When I was diagnosed as bipolar in 1995, it was long overdue. Fortunately the wreckage caused by my condition was mostly forgivable, but not forgettable. In my line of work, directing public affairs activities for trade associations, tireless energy is viewed as an asset. But in my private life, mania and its partner, impulsivity, took me on some strange trips. In 1997 I ended up on a first-class flight at 6 a.m. to Portland, Ore. -- a city where I know nobody -- following a mania-fueled argument with my husband. I had no luggage and no plans. I spent several days walking the streets and swimming in the hotel pool.
    Nonetheless, for a long time I was reluctant to accept the diagnosis of bipolar disorder, also known as manic depression. I thought my soaring highs and occasional deep depressions were normal. They were all I knew. So after my diagnosis I launched an intensive research campaign into the condition, a campaign that continues today. I read books and scour the Web. In therapy I've begun to identify the stimuli of my erratic feelings and behavior, and to understand some disturbing life incidents and patterns that may contribute to the condition.
    I've also learned just how cunning bipolar disorder is, how important it is to pay attention to even minor energy surges or drops, which can occur even when one is medicated properly. Often they warn of a coming swing. I've become determined to manage this disorder instead of letting it manage me. Easier said than done.
    Since being diagnosed, I've tried more than a dozen medications, some of them two and three times, in different combinations with different doctors. Some have had no effect, some have had bad side effects and one almost did me in. They have included anticonvulsants, antimanics, antipsychotics and antidepressants. I tried lithium, of course, although it was ineffective the first few times. Depakote (valproate), increasingly viewed as a therapeutic alternative to lithium, was profoundly depressive during my three tries. Neurontin, a cutting-edge anticonvulsant when I tried it, caused violent vomiting.
    Another anticonvulsant, Tegretol, resulted in life-altering disorientation after a doctor rapidly rushed up the dosage. Despite my history of low medication tolerance, she took me from 200 milligrams to 1,600 milligrams over the course of three weeks. In an effort to be open to new treatments, I went along with it. But after a few days of increasingly confused thinking, I found myself in traffic with my hands on the steering wheel and without a clue about what I was supposed to do next. I fired my doctor, took myself slowly off the Tegretol and found another psychiatrist.
    Like many people suffering from a mental illness, I resisted taking any drugs at first. No way was I going to poison my body or mess around with my brain chemistry , I told my first shrink. And sometimes, when I've been running smooth and steady for a while, I wonder again if I really need these meds. Despite all the frustrations and bad experiences, I know the answer is "yes." Just as a person with impaired vision can't throw away her glasses and expect to see, I can't toss out my meds and expect to maintain mental and emotional equilibrium.

Lithium Rules
Amid the introduction of new drugs and evolved versions of old drugs, one medication for bipolar disorder still reigns supreme: lithium. Despite the side effects, despite the need for blood tests to check for therapeutic levels and hypothyroidism, despite its throwback status and jokes about the "lithium shuffle" in the psych wards, lithium continues to be a treatment of choice for bipolar people all over America.
    It's been more than 50 years since lithium's discovery as a treatment for mania by an Australian physician named John Cade who in 1949 found that guinea pigs (yes, he really used guinea pigs) became agitated when injected with the fresh urine of manic patients. Cade surmised that the mania of manic-depressive humans was caused by excessive urea. When he tested the theory by injecting the animals with lithium urate, the soluble form of uric acid, they became calm. Cade subsequently administered lithium urate to 10 manic humans, who also became serene. It took decades for scientists to develop Cade's discovery into a usable medication.
    Kay Redfield Jamison, a professor of psychiatry at Johns Hopkins University, suffers from bipolar disorder herself and is an enthusiastic advocate of lithium. In her book "An Unquiet Mind" she writes, "I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy. Lithium prevents my seductive but disastrous highs, diminishes my depression, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive and makes psychotherapy possible."
    While most people tolerate lithium well, it's not for everyone. Some are lithium-resistant, meaning it doesn't work its soothing magic on them; for others it works but requires partnering with other drugs. In some cases, fear of the side effects -- which can include kidney problems, nausea and diarrhea, acne, thyroid problems, frequent urination and weight gain -- effectively deter its use. The trick for me is combining it with other meds and finding the proper relatively low therapeutic doses. Despite all the scientific advances in the field, knowing how much of what to prescribe to whom remains as much an art as a science.
    Recently lithium has been facing competition in the form of valproate, which has been gaining users since 1995, when the Food and Drug Administration okayed it for the short-term treatment of bipolar manic episodes. In its latest Practice Guideline for the Treatment of Patients with Bipolar Disorder, the American Psychiatric Association (APA) gives valproate top billing for maintenance treatment of the condition, right alongside lithium. But clinical trials into the drug's long-term use are still underway.
    Meanwhile, the number of drugs used and the combinations that are possible are mind-boggling: There are the other anticonvulsants, including Tegretol, Lamictal, Neurontin and Topomax. There are the antipsychotics Zyprexa, Risperdal, Seroquel and Geodon. And there are the antidepressants, like Prozac, Zoloft, Luvox, Paxil and Celexa, as well as Effexor and Serzone. And guess what: I've tried most of them over the past seven years, often multiple times in different combinations with a range of reactions from severe to benign.
    "It's trial and error," one doctor after another has blithely told me each time a medication has run amok through my system and, sometimes, my life. This even included the doctor who put me on Lamictal, which resulted in vomiting, flu-like symptoms and eventually a body rash and lips so swollen they looked like they'd been pumped full of collagen. For other bipolar people, Lamictal works very well.

Beyond Mania
Despite the popular focus on controlling manic-phase "highs," psychiatrist Robert Hirschfield says, bipolar disorder is particularly devastating in its depressive phase. "Depression, not mania, is the real bane of bipolar disorder," he says. Bipolar's most awful and too common result is suicide. According to the Depression and Bipolar Support Alliance (formerly known as the National Depressive and Manic-Depressive Association), 30 percent of bipolar people attempt suicide. Hirschfield, chairman of the committee that developed the APA's practice guideline, stresses the importance of evaluating patients complaining of depression for bipolar disorder as well.
    This is striking.  In my long experience with doctors, the emphasis of my treatment has been on calming mania -- despite my two life-threatening dives into depression. The most common question from whichever doctor is managing my meds is, "Have you been having racing thoughts?" While this question always strikes me as absurdly simplistic, it reveals most doctors' preoccupation with lowering highs. Instead, I now wish they'd asked about the lows. Although I have spent more time flying than crying, and although I've usually snapped out of my depressive episodes, doctors inevitably turn their attention to treating my more pervasive high-energy states. When my energy finally slackens, as it eventually does, I become anxious and deeply depressed, as if there simply is no future. That's a very dangerous place to be.
    So perhaps if someone like Hirschfield had been treating me in December 2000, there may have been clues uncovered to ward off my impending crash. I certainly had no idea I would end up in intensive care that day: My morning had consisted of my regular therapy session, swimming and working on a new freelance project. But then the darkness blew into my mind and it took me down, methodically and ruthlessly. It was as if I were in a trance, in which I knew only that I had had enough. Overpowering thoughts were telling me: "This life isn't working." I prepared myself for an exit.

Mind, Body and Spirit
Acceptance is a spiritual concept, one whose definition I've expanded to include my need to take medication. I've also come to accept that being bipolar is nothing to be ashamed of. But there are ways to even out the highs and lows that don't involve pills. They include therapy, which can help bipolar people distinguish between "normal" behavior and the extremes that seem normal to someone used to dramatic swings from omnipotence to nightmarish despair. In conjunction with medication, psychotherapy can help a bipolar person stay alert to triggers that might cause or foretell a bipolar episode. It can also support healthy life habits -- such as eating well, exercising and getting enough sleep regularly -- that can control stress and deter out-of-control incidents. I've added yoga to my lifelong routine of daily vigorous swimming, and together the two activities complement my meds and therapy and foster a little inner peace, too. Bipolar illness can be managed; it doesn't have to mess up your life or interfere with your work or play. It isn't a death sentence. But it does require finding doctors you trust, consistently taking your medications, staying healthy and cultivating self-awareness. For me, for now, it's working.

Panel Urges Change In New York Homes For the Mentally Ill
Clifford J. Levy, New York Times- 9/24/2002

A New York State government panel recommended today the abandonment of most of the state's decades-old system of adult homes for the mentally W, and called for hundreds of millions of dollars in spending on new services and housing for residents of the homes. The advisory panel said that to improve conditions immediately the . state should begin placing as many as 1,000 nurses and trained mental health workers in the privately run homes, which care for some 15,000 mentally ill residents. The state should then embark on a long-term plan to create more than 5,000 units of housing, typically overseen by nonprofit groups, that would be used to relocate residents of the homes. The new housing would have less of an institutional setting and be more intent on helping the mentally ill become self-sufficient. What remains. of the system should be revamped so that the homes, some with over 150 beds, would be smaller, the panel said.
    The panel was established last May by the state health commissioner, Dr. Antonia C. Novello, after The New York Times published a series of articles that detailed a yearlong investigation into the largest homes in New York City that found that they had become little more than psychiatric flophouses. Deaths under questionable circumstances went uninvestigated, minimum-wage aides supervised residents while haphazardly distributing large amounts of psychotropic drugs, and medical fraud was common. The recommendations, which were presented at a meeting here today, were devised by administration officials in conjunction with advocacy groups and others, and include suggestions from Dr. Novello herself. Gov. George E. Pataki's aides said he was traveling and not available to be interviewed.
    Some members of the panel said New York was facing a crisis in the adult homes akin to the one that it confronted with the Willowbrook scandal of the 1970's, which led to landmark changes in the state's care of retarded people. "Adult home residents with psychiatric disabilities have finally found their time," said one panel member, Geoff Lieberman, executive director of the Coalition of Institutionalized Aged and Disabled. "This is as significant and far-reaching as what happened in the 1970's." The coalition and a legal services group, MFY Legal Services, are among the few advocacy groups that have regularly taken up the cause of mentally ill adult home residents. Jeanette Zelhof, managing attorney at MFY, also praised the proposals.
    The state has a multibillion-dollar budget deficit in its next fiscal year, which will mean that if the governor wants the panel's work to become reality, he will have to make the hiring envisioned by the panel one of his highest priorities. The nurses and case managers could cost as much as $100 million annually. The new housing is expected to take a decade to create. Its total cost could be more than $500 million.
    The recommendations represent the first significant attempt at reform of a system that arose more than 30 years ago, when New York began closing its bleak psychiatric wards under deinstitutionalization and put patients in the homes, because there was nowhere else, for them to go. The homes were intended to give the mentally ill a chance at lives in which they might have jobs, receive better care and join the mainstream. Instead, the homes became one more place where the mentally ill were abused, exploited and neglected. By some official, estimates, 15,000 mentally ill people live in more than 100 adult homes in the state, most in the New York City area; the Pataki panel used a more conservative figure of 12,000.
    The Pataki panel issued its recommendations as oversight of the homes has become an issue in the governor's race. The Democratic candidate, the state comptroller, H. Carl McCall, first raised alarms about the homes in an audit that he issued in 1999. Last week, he accused Mr. Pataki of making "11th-hour, election-year promises." Today, Steven Greenberg, a spokesman for the McCall campaign, called Mr. Pataki's record on adult homes abysmal. "The governor has failed the people in these homes," Mr. Greenberg said. "While these recommendations are very important, and we would like to see them enacted, there is just very little confidence that this governor, who has tried at every turn to hurt the residents of adult homes, is going to actually follow through this time." Robert R. Hinckley, a Pataki spokesman, said, "No other administration has tackled this issue the way this administration has, and the governor is looking forward to determining the next steps we must take,"
    At the heart of the panel's short-term recommendations are proposals to hire nurses to distribute medication in the homes, and mental health workers to supervise closely the services for the residents. Some homes distribute hundreds if not thousands of pills of psychotropic and other medications daily; the state says the average resident takes six to nine medications a day. For years, state inspectors have found chaotic medication practices at the homes. The home operators say they have received so little money from the state that they cannot afford to hire nurses.
    The homes' residents have long been exploited in medical schemes to make money. A recent state report, echoing findings in The Times's articles, concluded that many of the services received by residents were wasteful or fraudulent. The report said Medicaid pays $27,000 annually for services for the average resident in the New York City area. The panel called for the state to finance more than 5,000 new housing units in the next decade. The units would range from private apartments visited regularly by case managers to supported housing developments, with social services on site.

A Clue to Why Gays Play Russian Roulette With H.I.V.
Richard A. Friedman, M.D., New York Times- 9/24/2002

Most young gay and bisexual American men who were found to be infected with the AIDS virus in a recent study were unaware of their infection, according to a finding reported recently at the 14th International AIDS Conference in Barcelona by Dr. Duncan MacKellar, an epidemiologist at the Centers for Disease Control and Prevention. The study surveyed 5,719 men, ages 15 to 29, of whom 573 were discovered to be H.I.V.- positive. Of those 573 men, 77 percent did not know that they were infected. Despite having engaged in frequent high-risk sex like unprotected anal intercourse, most of these men still believed that they were at low risk of contracting H.I.V.
    How can one explain such potentially fatal self-destructive behavior? After all, the route of H.I.V. transmission and safer sexual practices are well known. "Knowledge has never been shown to be enough," said Dr. Robert L. Klitzman, an assistant professor of clinical psychiatry at Columbia University College of Physicians and Surgeons and the author of "Being Positive: The Lives of Men and Women With H.I.V." (Ivan R. Dee, 1997). "Study after study shows that people have unsafe sex that puts them at risk of H.I.V. infection despite their knowledge of safe sex. Sex makes people do dumb things. And when you add in drugs and alcohol during sex, then judgment can be really impaired."
    Still, there is an aspect of this dangerous behavior that has eluded explanation: the strikingly self-destructive nature of unsafe sex. Why would anyone knowingly expose himself to a potentially lethal infection? One possible answer is a phenomenon called internalized homophobia. Most everyone has heard of homophobia, which is a bit of a misnomer since phobia connotes fear and avoidance, while homophobia involves aversion and even hatred of gays. With internalized homophobia, the perpetrator and the victim are one and the same. Dr. Richard C. Friedman (no relation), an author with Dr. Jennifer I. Downey of the new book "Sexual Orientation and Psychoanalysis" (Columbia University Press), describes internalized homophobia as a common and often serious psychological problem in gay men and women that lies at the root of many self-destructive behaviors, including risky sex.
    "Many gay and lesbian individuals who are raised in a society like ours that disapproves of homosexuality will internalize those negative attitudes and values," Dr. Friedman said. "Every time such a person feels sexual desire for someone of the same sex, he will experience shame, guilt and self-hatred without necessarily understanding why, because these feelings often operate on an unconscious level."
    Dr. Friedman gave an example of a gay patient who sought help for depression and sexual behavior that he labeled self-destructive. Without knowing why, he was having unprotected anal intercourse with multiple partners. In therapy, the patient revealed that his parents had been highly critical, abusive and homophobic. As a result, he always felt that they hated him because he was gay. His risky behavior arose from unconscious self-hatred.
    This is not to say that internalized homophobia can explain all acts of unsafe sex; often, it probably takes no more than the ordinary lapses in human judgment. But two recent epidemiologic surveys in The Archives of General Psychiatry show that gay men and women are at higher risk of certain psychiatric disorders than heterosexuals. In one study, Dr. Theo Sandfort of Utrecht University found higher rates of substance abuse in lesbians and of mood and anxiety disorders in gay men compared with heterosexuals. The other study, by Dr. Richard Herrell of the University of Illinois, examined suicide risk in identical male twins in which only one twin was gay. He found that gay men were 6.5 times as likely to have attempted suicide as their heterosexual twins, even after controlling for other psychiatric disorders and alcohol and drug abuse.
    If gay men and women really have higher rates of certain psychiatric disorders than heterosexuals, it may reflect social and biological factors or a complex interaction. Though these studies did not assess homophobia, it may be that any increased prevalence of psychiatric disorders is due, at least in part, to homophobia and internalized homophobia. This is because other studies have found a strong correlation between experiences of stigma and the mental health of gay men and women.
    But what makes some people homophobic in the first place? "We know that homophobic people tend to be authoritarian, conservative and come from religious backgrounds which condemn homosexuality," Dr. Friedman said. "They also have little or no contact with gay people. A provocative clue to the psychological origin of homophobia comes from a study of self-described homophobic and non-homophobic heterosexual men by Dr. Henry Adams of the University of Georgia. The two groups were shown gay pornography while penile circumference was monitored. None of the non-homophobic men had erections; the homophobic men did and but denied any subjective feelings of sexual arousal.
    For some, a potentially lethal threat from within: internalized homophobia. Does this mean that all homophobic heterosexual men are closeted gays themselves? "It's clearly relevant for some of these men," Dr. Friedman said, "but you can't generalize from such a small study." The origins of homophobia may be unclear, but the effects are widespread and vivid. Think of the common schoolyard bully who torments an effeminate child or the brutal murder of Matthew Shepard, the 21 year-old college student who was beaten to death in Wyoming just because he was gay. In 2000, for example, there were 1,299 reports of hate crimes based on sexual orientation made to the F.B.I. But the true prevalence of violence against gays is unknown; because it is not a federal violation, the F.B.I. has no jurisdiction to investigate.
    Most people who disapprove of homosexuality are not violent. But when they are, what explains their aggressive behavior? "The violent perpetrators are almost exclusively men who also have tremendous feelings of insecurity about their own masculinity," Dr. Friedman said. "In brutalizing other men, they experience an enhanced sense of power and dominance."
 

Stressed Out? Just Forget About It
Reuters News Service, 9/25/2002

WASHINGTON — Ignoring trauma may be healthier than pouring out your heart about it, Israeli researchers reported on Tuesday. Report after report has detailed the post-traumatic stress suffered by the US population after the September 11 attacks on New York and Washington, DC, but a study published in the journal Psychosomatic Medicine suggests it may be better to suppress those feelings.
    "The findings of this study suggest that a repressive coping style may promote adjustment to traumatic stress, both in the short and longer term," Karni Ginzburg of the Bob Shapell School of Social Work at Tel Aviv University in Israel, who led the study, said in a statement. Ginzburg and colleagues studied 116 patients who were hospitalized for a heart attack and suffering from anxiety over their near-miss with death. The researchers compared the patients with 72 people who had not had heart attacks. "The damage to the heart, with its symbolic meaning as the essence of the human being, may shatter the patient's sense of wholeness and safety," Ginzburg said.
    The patients took standardized tests for acute stress disorder, which check for symptoms such as distress, trauma flashbacks, difficulty carrying out everyday tasks, insomnia, and poor concentration. This syndrome is called post-traumatic stress disorder if the symptoms last or occur more than a month later, and the patients were re-tested after 7 months. They were also asked questions about coping style--whether they ignored their anxiety or tended to dwell on it. People who tended to repress their anxiety had the lowest levels of post-traumatic stress, the researchers reported.
    Many people have done studies on how to cope with stress, and results are mixed. But Ginzburg and colleagues cited studies that suggest that if the patient does not go too far into denial, repression may work well. "Prior studies report that repressors tend to perceive themselves as competent, self-controlled and having adequate coping skills," Ginzburg said.
    SOURCE: Psychosomatic Medicine 2002;64:748-757.

Study: Women's Brains Better at Handling Anger
Lee Dye, ABC News- 9/25/2002

Researchers at the University of Pennsylvania School of Medicine say they have evidence that shows there is a physiological reason for why men are more aggressive than women. Men tend to be more hot headed than women, the researchers suggest, because our brains are fundamentally different. In a nutshell, the research indicates that men are more aggressive than women because the part of the brain that modulates aggression is smaller in men than it is in women. Both genders have about the same ability to produce emotions, but when it comes to keeping those emotions in check, men have been shortchanged.

Battling Brain Parts
The research is part of an ongoing effort by a husband and wife team who are using the latest tools of their trade to peer inside the human brain and see what's really going on. Psychologist Ruben C. Gur, director of Penn's Brain Behavior Laboratory, and psychiatrist Raquel E. Gur have completed several research projects showing that a sizeable portion of human behavior can be laid directly at the doorstep of neurological differences in the brain, especially between the two genders. They have shown, for example, that just because men have bigger heads than women, they aren't smarter. Women's brains are smaller, but they have a higher processing capacity, thus offsetting the difference.
    For their latest project, published in a recent issue of the Journal of the Cerebral Cortex , the Gurs made use of past research that shows that different areas of the brain are responsible for different functions. The region at the base of the brain includes the amygdala, which is involved in emotional arousal and excitement. A frontal area around the eyes, called the "orbital frontal cortex," is involved in the modulation of aggression. The amygdala makes it possible for us to get stirred up while the orbital region tries to keep us in check.
    So if you're deeply insulted by the tone of this article, the amygdala section of your brain might say "kill the writer." But fortunately, the "orbital frontal area might say, 'well, you are angry, but killing may not be such a great idea, there can be consequences, so how about if you just say I am angry,"' explains Ruben Gur.
    Scientists have understood for a number of years now that the frontal region plays modulator in an emotionally charged situation, because damage to that part of the brain can leave a person unable to keep his or her temper under control. "I've known several cases where fairly regular people ended up on death row because they started doing some very bad things after a head injury," Gur says.

Woman With a Temper
The researchers, who included Faith Gunning-Dixon and Warren B. Bilker of Penn's Department of Epidemiology, wanted to take it a step farther. They wanted to see if there was a significant difference between men and women in the size of the orbital frontal cortex ( call it the "modulator") and the amygdala (call it the "emotional stimulator.") They took 116 healthy adults (57 men and 59 women) and scanned each of their brains with a magnetic resonance imaging device. They then used those brain scans to measure the ratio between the orbital frontal cortex and the amygdala of each participant.
    The result, Gur says, is very compelling. They found that the women had a significantly higher volume of orbital frontal cortex than the men, although the amygdala remained about the same. What that suggests is that when anger is aroused, women are better equipped neurologically to step on the brakes than men. In fact, only one man had a "modulator" that was at least seven times larger than his "emotional stimulator," compared to eight women, and only three women had a really small modulator (less than 3.5 times the size of the stimulator) compared to about a quarter of the men.
    But oddly enough, one woman had the smallest modulator of all, less than two times the size of her amygdala, suggesting that it might not be a good idea to rile her up. But that can't be said for sure, because no effort has been made yet to determine if the subjects in the study really were as mellow, or violent, as the ratio of their modulator to their stimulator would suggest. That may come next, because Gur is intrigued by the woman with the dinky modulator. "I would really like to get to know her," he says.

Takes All Kinds
Although this research, like several previous projects, indicates that there are fundamental differences between men and women, Gur says it doesn't mean that one gender is superior to the other. Even aggression has its place. "We do need men who can express aggression when it's appropriate," he says. "Otherwise there will be some bad people out there who will do us harm."
    But it's equally important to be able to keep aggression under control, and the researchers believe this work may point the way to better clinical treatment for persons with serious aggressive tendencies. It may be possible, for example, to come up with drugs that will stimulate the "modulator," making it more effective in controlling the rage boiling out of an emotional encounter.

Students' Prescriptions Worry Health Counselors
Ellen Barry, Boston Globe- 9/26/2002

Students have always entered college full of ardor, uncertainty, and angst. But in the past decade a growing number of freshmen are arriving with prescriptions for psychoactive drugs. Gertrude Carter, a psychologist at Bennington College in Vermont, noticed the change in her practice and started to count the number of undergraduates visiting her office who had been prescribed stimulants, antidepressants, or other popular psychiatric drugs. Throughout the 1990s, Carter said, the percentage of students on psychoactive drugs rose from 5 percent to 40 percent. At Bennington, as at Dartmouth and Williams, future freshmen and their families quiz counseling staff on the mental health facilities.
    This month, mental health providers from nine institutions -- Yale, Harvard, Dartmouth, Amherst, Williams, Middlebury, Bennington, Smith, and Simon's Rock -- gathered at the Austen Riggs Center, in Stockbridge, to grapple with the issue of why so many students are taking psychoactive drugs at much earlier ages.
    Although the first national survey of psychoactive medication among college students will not yield data until next year, another survey by the University of Pittsburgh in 2000 showed that nearly all of the counseling center directors polled said they had seen an increase in the number of students already on medication when they first visited campus mental health facilities.
    Some mental health professionals said they were pleased that many students diagnosed with depression and bipolar disease are getting the medication they need to help them cope with college. But others have begun to worry that doctors are too quick to medicate adolescents. Steeped in the tradition of psychotherapy, the health counselors said that some students may avoid fully experiencing the emotional milestones of young adulthood: the first great romantic disappointment, separation from family, and churning identity questions. Adolescents who don't learn coping skills could run into worse challenges later, they warn. ''These are big markers,'' said Gary Margolis, who has been counseling students at Middlebury College for 32 years. ''The ability to experience it, to feel it, to name it and grow by it, for a lot of colleges that's really what we're about.''
    Pediatric prescribing practices turned a corner in the early 1990s, as expanding school mental health services converged with more biological psychiatry and an increasing willingness to medicate children. Antidepressant prescriptions to children increased three- to five-fold between 1988 and 1994, with the steepest increases among students ages 15 to 19, said Dr. Julie Magno Zito, associate professor of pharmacy and medicine at the University of Maryland.
    Nationwide, mental health services in large colleges report that 1 to 60 percent of their clients are using psychoactive medications, said Gregory Snodgrass, president of the Association of University and College Counseling Center Directors. Many say that college students' mental states have been worsening, and that counseling centers -- whose main job was once to help students handle romantic breakups and make career choices -- are struggling to keep up with the demand.
    In 1988, University of Pittsburgh psychologist Robert Gallagher surveyed almost 300 college counseling centers, asking them whether they had seen an increase in severely disturbed students. Just over half answered yes. In 2001, when asked the same question, 85 percent said yes. But there are also changes in students' attitudes. The children who came of age just as prescription practices were changing are knowledgable and less self-conscious consumers of mental health services than students 10 years ago, said clinicians. ''The Internet makes a huge difference,'' said Dr. Mark Reed, one of Dartmouth's two full-time psychiatrists. ''When they come into my office, they tell me they've been studying the signs of obsessive-compulsive disorder, and they say, `I need cognitive behavior therapy, and I need an SSRI' My jaw drops to the floor, and I say: `OK, humor me. Can you take me through the evaluation?'''
    Other counselors have become increasingly concerned about the shift in the way students cope with emotional problems. At Bennington College, Carter, the director of psychological services, became frustrated and then alarmed by the number of students who visited her offices with the sole purpose of refilling prescriptions, often with little interest in therapy. ''I haven't seen sicker students,'' Carter said. ''I've seen students labeled as sicker.'' To handle the demand, Carter hired a full-time psychiatrist, Dr. Jeffrey Winseman, who shared her leaning toward psychotherapy and made a stir by banning drug company representatives from his offices.
    Bennington requires an extensive mandatory intake interview that includes discussion of psychiatric medication, and the results have been astonishing, Carter said. ''A lot of students aren't happy that they're on the meds,'' she said, and some of them decide to try going off them in college.
    Carter and Winseman's writings on the subject have attracted the attention of Dr. M. Gerard Fromm, director of the Erikson Institute at the Austen Riggs Center, which has long approached serious mental illness with a view to the developmental challenges of adolescence and young adulthood. College counselors ''are in a position where they can begin to speak to a larger culture and what messages these kids are carrying in from the larger culture,'' Fromm said.
    Their dismay may reflect a generation gap between students and the professionals who treat them on campus, said Dr. Richard Keeling, editor of the American Journal of College Health. Mental health professionals may find themselves encouraging introspection among teenagers who have long accepted that their moods and behavior are the result of a chemical imbalance. Keeling also said that developmental milestones, such as coming to terms with sexual identity, may be happening earlier in teenagers' lives. And stigma, he said, is another relic of a past generation. ''Many college counseling programs are set up with the idea that students are embarrassed to go to a counselor and stigmatized for doing so,'' he said. But, he said, ''students are generally very open.''
    College campuses may be one of the last American settings where young people have the space and encouragement to look deeply into themselves, said Winesman. ''If there's a gap, it's between people who are trying to understand the depth of these problems and others who are comfortable skimming the surface,'' he said. ''If they're not getting it in the schools, if they're not getting it through social mores, and they're not getting it in their families, where are they going to get an appreciation of depth?''

Texas Judge Defends Mentally Ill
James Kimberly, Houston Chronicle- 9/26/2002

The criminal justice system has traded more than 700 years of established law for "a spirit of vengeance" in its dealings with the mentally ill, one of the most influential judges in Texas history said Wednesday. For proof look no further than the Andrea Yates case, U.S. District Judge William Wayne Justice said during an address to psychiatrists and others at the University of Texas-Houston Medical School. "Andrea Yates did a monstrous thing, but is not a monstrous human being," Justice said. "She is, ultimately, a pathetic and tragic figure. What is most disturbing about the Yates case, Justice said, is that it conformed to the law as it exists today. "We punish those we cannot justly blame," Justice said. "Such a result is not, I believe, worthy of a civil society."
    Justice, who was appointed to the federal bench by President Johnson in 1968, used his seat to end unjust Texas policies. It was Justice who ordered Texas schools and public housing complexes desegregated. In the federal lawsuit Ruiz v. Estelle, Justice ordered Texas prisons to treat prisoners more humanely. Justice also ordered public schools to educate the children of illegal immigrants. Justice spoke Wednesday as part of the school's Louis Faillace Lectureship series.
    Because of changes made to Texas law in 1983, Yates, who drowned her five children two years ago, is serving a life sentence in prison rather than receiving treatment in a mental institution for the delusions that drove her to commit the crime, Justice said. The change reversed an element of law that could be traced back to English common law of 1278, Justice said. Texas and most other states changed laws regarding the insanity defense after John Hinckley was found not guilty by reason of insanity to charges related to his 1981 attempted assassination of President Reagan.
    Texas reacted by striking from its law a clause that said a defendant could be found not guilty by reason of insanity if he "was not capable of conforming his conduct to the requirements of the law." The change made it easier for prosecutors to win convictions, Justice said, because they had to prove only that the defendant knew what he was doing and knew his conduct was wrong.
    The way the criminal justice system treats the mentally ill reflects poorly on society, Justice said. "If we reject the moral necessity to distinguish between those who willingly do evil, and those who do dreadful acts on account of unbalanced minds, we will do injury to these people. But the ultimate injury is the one we will inflict on ourselves, and on the rule of law."

Study: Ecstasy Party Drug May Harm Brain
Todd Ackerman, Houston Chronicle- 9/26/2002

Ecstasy, the illegal party drug that landed the owners of two Houston clubs in jail last week, may cause brain damage that increases users' risk of developing neurological diseases such as Parkinson's, a new study says. Parkinson's, characterized by rigid or slow movements and tremors, affects men and women equally, usually after 55. There is no cure and it is always fatal. The study, done with monkeys, was met with skepticism by some researchers. It suggests that several doses of the drug taken during an evening damages dopamine-producing neurons, the brain cells destroyed in Parkinson's. "People contemplating using Ecstasy should be aware it can damage brain cells and should recognize that its neurotoxic effects are likely to occur after doses commonly used in recreational settings," said Dr. George Ricaurte, a neurologist at Johns Hopkins University School of Medicine in Baltimore and lead investigator of the study. "We already know brain dopamine declines with age. This study suggests a young individual who sustains injury to these cells and depletes their reserve will be at greater risk."
    In the study, published in today's edition of the journal Science, Ricaurte injected squirrel monkeys and baboons with three shots of Ecstasy, an amphetamine known chemically as methylene-dioxymethamphetamine, or MDMA, over six hours. Although large areas of the brain were affected, the monkeys and baboons did not develop any symptoms. Ricaurte acknowledged it is not clear if the damaged neurons will repair themselves, a key factor in whether Ecstasy can cause Parkinson's, but he said the damage was still evident two to six weeks later.
    However, some researchers called the injection of Ecstasy one of the study's flaws, noting that such a delivery system doubles an oral dose. In effect, they said, Ricaurte's experiment was the equivalent of giving a 150-pound person 800 milligrams of Ecstasy in six hours, or 10 tablets containing 80 milligrams, far more than the average recreational user takes in one night. That, they said, is likely why it killed one in five monkeys that received the shots.
    "No researcher has ever shown any dopamine damage in chronic users," said Julie Holland, a professor of psychiatry at the New York University School of Medicine and author of Ecstasy: The Complete Guide -- A Comprehensive Look at the Risks and Benefits. "And no studies with animals have shown Ecstasy causes dopamine damage. But he's found a way where no one else could." Holland emphasized she's not saying recreational use of Ecstasy is safe, just that Ricaurte is exaggerating the risks. One of a number of researchers who see Ecstasy's potential for therapeutic uses, Holland said Ricaurte's continuing campaign to "demonize" Ecstasy limits funding that could explore possible benefits.
    Ecstasy has become a badge of youth subculture in the United States and Europe and a weekend favorite of night-clubbers looking to boost the high of a night on the town. An estimated 6 million Americans have tried Ecstasy. Overdoses can be lethal, although the nation's annual number of deaths are usually in the teens or less, Ricaurte said. On Sept. 17, federal authorities announced they dismantled a Houston Ecstasy-trafficking ring that used two downtown nightclubs to launder profits. The Houston ring was supplied by an international network considered among the world's largest.
    Previous studies of Ecstasy's effects on most animal species have shown only damage to neurons that produce serotonin, brain cells involved in regulating mood and behavior. Dopamine is important to muscle movement. Ricaurte's study was praised by Alan Leshner, former head of the National Institute on Drug Abuse, who said it shows that "even the occasional use of Ecstasy can lead to significant damage to brain systems. It should send an important message to young people -- don't experiment with your brain." The NIDA funded the study. Leshner is now chief executive of the American Association for the Advancement of Science, the organization that publishes Science.

Murder Suspect Had Psychiatric Illness
Michael Rosenwald & Ellen Barry, Boston Globe- 9/27/2002

On Sunday, Jason Potter, a troubled young man with a history of mental illness, told his mother he ''couldn't abide by himself'' and needed help. So, as Marie Sheehan had done before, she helped her son check into the psychiatric ward of Caritas Carney Hospital near their Dorchester home. After two days under heavy sedation, Potter, 21, signed himself out; by Wednesday, however, his bizarre behavior had returned. But a state-contracted emergency psychiatric team apparently decided that Potter didn't need immediate hospitalization and asked him to come back yesterday afternoon. Within hours, police said, Potter had slain his mother and hacked her husband, Richard Sheehan, a retired Boston police officer, to death inside the family home on Jo-Anne Terrace.
    Potter, who authorities say has suffered from mental illness since he was a teenager, called 911 and said he found his mother and ''some other person'' stabbed to death in the house, prosecutors said yesterday. Potter was found at the crime scene, spattered with blood. After taking him for psychiatric evaluation at Caritas Carney, police arrested Potter, who detectives said made incriminating statements, including, ''You got me,'' and ''You solved the case.'' Potter was arraigned on two counts of murder in Dorchester District Court and ordered held without bail. He also was sent to Bridgewater State Hospital for a 20-day psychiatric evaluation.
    Tiny Jo-Anne Terrace was cordoned off as a crime scene late yesterday, with lights on inside the Sheehans' tan Cape Cod-style home. George Kenneally, 75, whose house faces the Sheehans' home, said his neighbors had been friendly. If their son had mental problems, Kenneally said, it wasn't obvious. ''It's an awful thing to think,'' Kenneally said. ''I feel like I want to be under a blanket.''
    The killings and arraignment sent a shiver through the Dorchester courthouse, where Sheehan worked supervising cases in the final years of his 35-year police career. He retired five years ago, having earned a medal of honor for resuscitating a woman who had passed out in a convenience store in 1979. Police said Sheehan, 71, and his 46-year-old wife were dead when EMS crews arrived shortly before midnight. Investigators also said Potter, who is tattoed and has a criminal record, did not get along with Richard Sheehan. Potter has been arrested five times since July 9, once for threatening to stab his ex-girlfriend. He was released from Nashua Street Jail on Sept. 18 after serving about 30 days for violating a restraining order and driving under the influence, court records show.
    At the arraignment, Bernard Grossberg, Potter's court-appointed lawyer, said Potter has been suffering from mental illness since age 14, including schizophrenia and manic depression, and is now considered a suicide risk. Shortly after he was released from jail, Grossberg said, Potter's behavior began to deteriorate, and he began complaining ''he couldn't abide by himself.'' His mother took him to Caritas Carney on Sunday and asked doctors to commit him involuntarily, meaning he couldn't leave without a doctor's approval. Instead, Potter agreed to be committed, spending the next two days sedated and sleeping, Grossberg said. When he awoke on Tuesday, Potter left the hospital, and by Wednesday he began acting strangely again, Grossberg said. During a home visit, Potter's probation officer urged him to get psychiatric help.
    Grossberg said Marie Sheehan took her son to his long-term therapist, who referred him to the Boston Emergency Services Team (BEST) -- a service of Tufts-New England Medical Center, Massachusetts General Hospital, and several community health centers -- which is under contract with the state to provide emergency psychiatric care for poor, mentally ill patients. Rather than admit him to a hospital immediately, the BEST team sent Potter home on Wednesday afternoon with a return appointment for 1 p.m yesterday, Grossberg said. Potter also had an appointment with a psychiatrist today. By yesterday morning, Potter was under arrest on charges of killing the Sheehans.
    BEST teams work out of several community mental health centers and respond to acute psychiatric crises, such as suicide attempts or violent behavior, by recommending hospitalizations, counseling, or other interventions. Dr. Marshal Folstein, chief of psychiatry at Tufts- New England Medical Center, who directs the BEST team, did not return a call from the Globe. Officials from the state's Department of Mental Health also did not return calls yesterday seeking comment.
    Bruce Bird, chief executive of North Suffolk Mental Health Association, said psychiatric decisions about a patient's dangerousness are ''very hard, of course, because the technology and science behind making this decision isn't where it needs to be.'' The BEST team ''could have made a most appropriate decision for that moment,'' he said. ''But things changed three hours later.''
    In a statement released yesterday, Caritas Carney Hospital said it could not release information about its ''extremely brief'' care of Potter, citing confidentiality rules. ''However, we would never release a patient if we believed that patient to be a threat to himself or others,'' said the statement, signed by hospital president Joyce A. Murphy. ''That's a responsibility we take very seriously - a responsibility both to our patients and our community.''
    Some time Wednesday evening, Marie Sheehan phoned Barnet Potter, her ex-husband, urging him to come help calm down their son, according to a family friend who asked not to be named. The friend said Barnet Potter, who had kept a good relationship with his ex-wife after their divorce a decade ago, rushed to Jo-Anne Terrace. He stayed for a while, then left when his son calmed down. ''He seemed fine, so Barnet left,'' the friend said. The friend said Barnet Potter told him he was trying to get help for his son, but the young man waffled between agreeing with treatment suggestions and arguing he did not need medical assistance.
    Court records show that Potter twice violated a restraining order obtained by his ex-girlfriend, repeatedly calling her and threatening to stab her if she didn't lie to authorities about his arrest on charges of drunken driving and leaving the scene of an accident. Potter was also arrested in July on charges of trespassing at Boston Bowl on Morrissey Boulevard, where he allegedly ran onto an alley and caused a disturbance.

Of Massachusetts Social Workers Cut, Half Bilingual
David Abel, Boston Globe, 9/27/2002

The state agency that oversees welfare will begin laying off 83 social workers today, more than half of whom are bilingual caseworkers. The move comes less than a year after the Department of Social Services cut more than 200 social workers from its payroll, a quarter of them bilingual.
    The cutback of the state's mainly Spanish-speaking social workers -- a result of their relatively low seniority -- has raised concerns among advocates about whether Massachusetts' growing immigrant population will have less access to services. ''It definitely has a negative impact,'' said Margaret Movelle, a spokeswoman for the Massachusetts Immigrant and Refugee Advocacy Coalition. ''Immigrants are often the ones most in need of these services, and it helps when people speak their language. It's just a bad situation all around.''
    During the 12 years Noemi Arguinzoni has worked for the Department of Transitional Assistance, she has seen a steady rise in Latino clients seeking help at her Holyoke office. Now, with the Western Massachusetts Latino population doubling in the last decade to nearly 80,000, rising to a third of all welfare recipients, and the state's welfare caseload rising 10 percent from last year, the 46-year-old social worker is wondering how she and her coworkers will cope. Five of the 13 bilingual caseworkers in her office are being laid off. ''It means we're going to have a lot more work, and we won't be able to provide people the same quality of service,'' said Arguinzoni, who has enough seniority to keep her job.
    The layoffs, which total 139, include 45 bilingual caseworkers, among other caseworkers, administrators, and support staff. Those cuts are on top of 274 department employees who chose to take early retirement last spring as the state's financial crisis loomed, meaning the welfare agency has lost nearly a fifth of its workforce in the past year. Since welfare changes took effect in the mid-1990s, cutting the state's caseload by more than half, the department has seen the number of its social workers shrink by 28 percent.
    The number of social workers hasn't declined in proportion with the caseload, department officials say, because their roles have expanded significantly in the past few years. ''Before welfare reform, they basically helped fill out applications,'' said Dick Powers, the department's spokesman. ''Since then, they've really become job facilitators. ... They've had fewer clients, but they've had to spend a lot more time with each client.''
    Today's cuts might have been worse. Last month, department officials announced that 174 jobs would be cut, 104 of them social workers. Over the past few weeks, however, many employees decided to take unpaid leaves and job-share, in effect donating $1.1 million of their salaries to save 35 of their peers' jobs.
    Arguinzoni, for example, will forgo thousands of dollars by taking a six-week, unpaid leave. Next month, Jo Irvine, a Springfield social worker, will work four instead of five days a week, collecting unemployment for the balance. Even the department's commissioner, John A. Wagner, will take a 20-day unpaid leave. ''It's a bittersweet moment,'' Wagner said. ''Our budget required painstaking decisions that have been softened by the generosity of so many employees.''
    But some department employees believe the generosity didn't go far enough: Fewer than 200 of the department's 1,200 social workers volunteered for pay cuts. ''It was really depressing how few people volunteered,'' said Jo Irvine, who also serves on the union committee to prevent layoffs. Hoping to save more jobs, Wagner agreed yesterday to a union request to give social workers another week to try to persuade others to donate some of their paychecks to save more jobs.
    The effort, however, brings little consolation to Jose Branco, a bilingual social worker who started working in the department's Springfield office six years ago. The 37-year-old Portuguese speaker believes his lack of seniority puts his chances of making the cut at ''slim to none.'' Now the father of two, who is losing his $45,000-a-year job, is in the same boat as many of his clients. ''I'm just going to have to hit the bricks and find something, just like them,'' he said. ''It's going to be hard, especially when the benefits end in November. But that's life.''

Women Sex Offenders Face Past in Treatment
Jane Elliott, Houston Chronicle- 9/29/2002

GATESVILLE -- Robin Taylor looked around at the dozen women seated in a circle and took a deep breath. She then talked about her sexual relations with a 13-year-old boy, an offense that landed her in prison on a five-year sentence. She also admitted molesting a 15-year-old boy. "If I had not been incarcerated, I might have sexually violated more children," said the former Harris County resident. Taylor, 29, is one of 15 participants in an intensive female sex offender treatment program initiated two years ago by the Texas Department of Criminal Justice. Texas is one of a handful of states with such a program. There are 26,000 sex offenders behind bars in Texas. All but 310 of them are men.
    Judy Johnson, clinical director of the sex offender treatment program for TDCJ, has spent years interviewing male sex offenders. More than half of the men told her that they were introduced to sex at an early age by an older woman. "Males are not as likely to report it because they may not recognize it as abuse," said Johnson. "In an effort to try to prevent this type of behavior in our society, we need to acknowledge the reality that it exists across the spectrum of gender. "It really doesn't have a gender bias."
    The women in the program live, work and participate in therapy together at the aging Hilltop Unit, a minimum- to medium-security prison. Their crimes are ugly. One woman prostituted her daughter for crack cocaine. Others joined their husbands or boyfriends in committing abuse. But reviewing the horrific details and facing up to the harm they caused their victims is key to understanding their behavior. "It's all about honesty. If you can't be honest with yourself, who can you be honest with?" said Taylor.
    Taylor and two other female sex offenders in the program agreed to tell their stories to help the public grasp the nature of the problem. Most participants enter the program when they have 18 to 24 months left on their sentences. The women are taught to understand their "thinking errors" and recognize deviant sexual thoughts. They learn empathy for their victims and coping skills to prevent a relapse once they are released. "No more victims" is the program's goal, reflected in a military-style cadence that Taylor leads at the end of the therapy session. Taylor has only been in the program a few months. This day she was one of two inmates doing a "layout," which includes a brief description of their crime. Later she will write about her sexual offenses in much greater detail and will spend hours trying to feel what her victims went through.
    Taylor said some inmates who are not in the program don't think her crime was a big deal and that young teenagers often have sex. "I'm an adult. They're a child. They're not ready for that type of relationship. I should be more like a mother figure or a friend than your lover when you're 13," Taylor said.
Fourteen of the 15 women in the program committed offenses against a child. Nine acted alone and six acted with a co-defendant. Robin Lane, 44, has been in prison for 15 years for sexually assaulting her daughter. "What I did was horrible. I just want people to know change is possible," said Lane, who has been in the program 14 months. Lane said she now recognizes the low self-esteem and suppressed feelings that contributed to her thinking errors. Like most of the women, she experienced sexual and physical abuse as a child.
    Johnson said 90 percent of the female sex offenders experienced severe trauma in their childhood. "They just continued to act it out once they got a family of their own," she said. That history can get in the way of treatment, Johnson said, when the women think of themselves as victims. "This is an opportunity for them to not only heal their own trauma but to really come face to face with the fact that they made a decision to act on someone else as they were acted on," she said.
    There was little precedent for treating female sex offenders. Johnson drew on her experience with male offenders. Anne Mooney, a social worker, and Nadine Whited, a therapist, had worked with female prisoners and helped design the program. Mooney said the women's time spent together reinforces the program's core lessons. For example, an inmate who is blaming her problems on everybody else will be told to snap out of "victim stance." They learn relationship skills by dealing with one another. If a conflict arises, the inmates are forced to confront each other to work it out. "There are no secrets," Mooney said. "Before they entered treatment, there used to be a lot of secrets in their lives."
    Cynthia Benns, 46, has been in prison since 1995 for sexually assaulting a child. She has spent the past 18 months in the treatment program and soon will be paroled. Benns said she entered the program angry and unwilling to face her past. "I used to couldn't talk about my crime. Now I can. I knew sooner or later I was going to have to talk about it," Benns said. She will leave prison next year with new coping skills. She also has learned how to read. "I'm proud of myself, and I feel good inside and feel blessed to do this," Benns said of her decision to speak publicly about the program. Like many of the women, Benns will have to register as a sex offender. She tearfully explains that she won't be able to be alone with her grandson.
    Johnson said the women have a "grand potential for change." They will be tracked to measure the effectiveness of the program. "Not only will these women go out and return to be mothers, but they can have other children. They want to be able to prove they can have a child and be with a child and not injure a child," Johnson said.

Mentally Ill Could Be Forced into Care
Robert Salladay, San Francisco Chronicle- 9/29/2002

Sacramento -- Mentally ill Californians who consistently refuse psychiatric help could face court-ordered, involuntary treatment for up to six months under a measure signed Saturday by Gov. Gray Davis. The bill, dubbed "Laura's Law" after a 19-year-old Nevada County woman killed by a mentally ill man, is a significant revision to the landmark 1967 Lanterman-Petris-Short Act and a source of division for years among advocates for the mentally ill and homeless. The measure, AB1421, would target a class of mentally ill people who consistently avoid treatment because they do not recognize the need for it. Counties that agree to participate would set up special mental-health teams to monitor the patients during in-home treatment ordered by a judge.
    Under current law, only people who pose a significant and immediate threat to themselves or others can be forced into hospitalized treatment for up to six months, although many patients are released in less than 72 hours. "This legislation will help end the cycle of hospitalization, quitting treatment and relapse," Davis said. "It plugs a huge hole in California's safety net, offering safety, support and compassion."
    But some advocates for the mentally ill believe California will return to a system of coercive treatment at the same time it is cutting back on other voluntary services for the mentally ill. The governor's own Department of Finance opposes the measure because it would cost the state an estimated $15 million in extra court costs. Counties also would have to determine how they want to pay for the new mental health monitors that the law requires. "People end up in crisis because the system is dysfunctional and adding a coercive measure just makes the system more dysfunctional," said Virginia Knowlton, acting legislative director for Protection and Advocacy Inc. "It's going to be costly, and it's not going to do anything to protect society from violence, and it's certainly not going to promote recovery." Nevertheless, some advocates for the mentally ill believe the threat of a court order itself would be enough to prompt patients into voluntary treatment, even before a judge is asked to step in.
    Assemblywoman Helen Thomson, D-Davis, author of the measure, said the law protects patients by granting them legal representation, evaluation by a mental health professional and intensive follow-up treatment during their court-ordered supervision. Thomson acknowledged, however, that nothing in the new law requires forced hospitalization or lockdown for a nonviolent patient. If a mentally ill patient lapses and simply refuses treatment, even under the court order and supervision, only a maximum of 72 hours' hospitalization can be ordered. The law, which takes effect Jan. 1, would work county-by-county, with each board of supervisors required to authorize -- and pay -- for the program. San Francisco Mayor Willie Brown already has written a letter supporting the measure.