Noteworthy News Articles on Mental Health Topics, January 20-31, 2010

Those ages 8 to 18 spend more than seven and a half hours a day with such devices, compared with less than six and a half hours five years ago, when the study was last conducted. And that does not count the hour and a half that youths spend texting, or the half-hour they talk on their cellphones.

And because so many of them are multitasking — say, surfing the Internet while listening to music — they pack on average nearly 11 hours of media content into that seven and a half hours. “I feel like my days would be boring without it,” said Francisco Sepulveda, a 14-year-old Bronx eighth grader who uses his smart phone to surf the Web, watch videos, listen to music — and send or receive about 500 texts a day.

The study’s findings shocked its authors, who had concluded in 2005 that use could not possibly grow further, and confirmed the fears of many parents whose children are constantly tethered to media devices. It found, moreover, that heavy media use is associated with several negatives, including behavior problems and lower grades.

The third in a series, the study found that young people’s media consumption grew far more in the last five years than from 1999 to 2004, as sophisticated mobile technology like iPods and smart phones brought media access into teenagers’ pockets and beds.

Dr. Michael Rich, a pediatrician at Children’s Hospital Boston who directs the Center on Media and Child Health, said that with media use so ubiquitous, it was time to stop arguing over whether it was good or bad and accept it as part of children’s environment, “like the air they breathe, the water they drink and the food they eat.”

Contrary to popular wisdom, the heaviest media users reported spending a similar amount of time exercising as the light media users. Nonetheless, other studies have established a link between screen time and obesity.

While most of the young people in the study got good grades, 47 percent of the heaviest media users — those who consumed at least 16 hours a day — had mostly C’s or lower, compared with 23 percent of those who typically consumed media three hours a day or less. The heaviest media users were also more likely than the lightest users to report that they were bored or sad, or that they got into trouble, did not get along well with their parents and were not happy at school. The study could not say whether the media use causes problems, or, rather, whether troubled youths turn to heavy media use.

“This is a stunner,” said Donald F. Roberts, a Stanford communications professor emeritus who is one of the authors of the study. “In the second report, I remember writing a paragraph saying we’ve hit a ceiling on media use, since there just aren’t enough hours in the day to increase the time children spend on media. But now it’s up an hour.”

The report is based on a survey of more than 2,000 students in grades 3 to 12 that was conducted from October 2008 to May 2009.

On average, young people spend about two hours a day consuming media on a mobile device, the study found. They spend almost another hour on “old” content like television or music delivered through newer pathways like the Web site Hulu or iTunes. Youths now spend more time listening to or watching media on their cellphones, or playing games, than talking on them.

“I use it as my alarm clock, because it has an annoying ringtone that doesn’t stop until you turn it off,” Francisco Sepulveda said of his phone. “At night, I can text or watch something on YouTube until I fall asleep. It lets me talk on the phone and watch a video at the same time, or listen to music while I send text messages.”

Francisco’s mother, Janet Sepulveda, bought his phone, a Sidekick LX, a year ago when the computer was not working, to ensure that he had Internet access for school. But schoolwork has not been the issue. “I’d say he uses it about 2 percent for homework and 98 percent for other stuff,” she said. “At the beginning, I would take the phone at 10 p.m. and tell him he couldn’t use it anymore. Now he knows that if he’s not complying with what I want, I can suspend his service for a week or two. That’s happened.”

The Kaiser study found that more than 7 in 10 youths have a TV in their bedroom, and about a third have a computer with Internet access in their bedroom. “Parents never knew as much as they thought they did about what their kids are doing,” Mr. Roberts said, “but now we’ve created a world where they’re removed from us that much more.” The study found that young people used less media in homes with rules like no television during meals or in the bedroom, or with limits on media time.

Victoria Rideout, a Kaiser vice president who is lead author of the study, said that although it has become harder for parents to control what their children do, they can still have an effect. “I don’t think parents should feel totally disempowered,” she said. “They can still make rules, and it still makes a difference.”

In Kensington, Md., Kim Calinan let her baby son, Trey, watch Baby Einstein videos, and soon moved him on to “Dora the Explorer.” “By the time he was 4, he had all these math and science DVDs, and he was clicking through by himself, and he learned to read and do math early,” she said. “So if we’d had the conversation then, I would have said they were great educational tools.”

But now that Trey is 9 and wild about video games, Ms. Calinan feels differently. Last year, she sensed that video games were displacing other interests and narrowing his social interactions. After realizing that Trey did not want to sign up for any after-school activities that might cut into his game time, Ms. Calinan limited his screen time to an hour and half a day on weekends only. So last Wednesday, Trey came home and read a book — but said he was looking forward to the weekend, when he could play his favorite video game.

Many experts believe that media use is changing youthful attitudes. “It’s changed young people’s assumptions about how to get an answer to a question,” Mr. Roberts said. “People can put out a problem, whether it’s ‘Where’s a good bar?’ or ‘What if I’m pregnant?’ and information pours in from all kinds of sources.”

The heaviest media users, the study found, are black and Hispanic youths and “tweens,” or those ages 11 to 14. Even during the survey, media use was changing. “One of the hot topics today is Twitter, but when we first went into the field and began interviewing, Twitter didn’t exist,” Ms. Rideout said.

Dealing With the Financial Burden of Autism
Walecia Knorad, New York Times- 1/23/2010

WHEN Jeff Sell’s twin sons were found to have autism 13 years ago, he, like so many other parents in the same situation, found himself with a million questions: Will my children be able to function? What are the best treatments and where do I find them? How will this affect the rest of my family? And besides those monumental worries, Mr. Sell kept asking himself another fundamental question as he began the long string of doctor and therapist visits with his sons: “How in the world am I going to pay for all this?”

Autism trends, treatments and therapies routinely make headlines. Often overlooked, though, is the financial burden for many families with autistic children. Treatment is extremely expensive. Direct medical and nonmedical costs can add up to as much as $72,000 a year for someone with an extreme case of the disorder, and even $67,000 a year for those on the lower end of the spectrum, according to a study from the Harvard School of Public Health.

That figure includes medical costs like doctor visits, prescriptions and occupational and speech therapy, as well as expenses for things like special education, camps and child care, said Michael Ganz, the author of the study, who is now a health care consultant. “It can cost $3.2 million to take care of an autistic person over the course of his or her lifetime,” the study said.

More families are grappling with the disorder than ever before. One of every 110 8-year-old children in the United States has been diagnosed with autism — and one of every 70 boys, according to the latest survey from the Centers for Disease Control and Prevention, released last fall. That is up from one in 150 children in a comparable report released in 2007.

“The numbers are just amazing,” said Pat Kemp, executive vice president of the advocacy group Autism Speaks, “Unless we attack this like a national health crisis, we’re going to have a huge economic crisis on our hands.”

Certainly families feel the financial strain. Many health insurance policies do not cover autism treatments, while those that do often have severe limits. And there is very little government or private financial assistance available. In many cases these children will need assistance all their lives, Mr. Ganz points out. Making sure there is money for the future is something else parents worry about.

When his sons received their diagnosis, Mr. Sell was practicing personal-injury law in Texas, and he began paying for many of their treatments from his own income and savings. In 2005, as he became more involved in autism issues, he joined the staff of the Autism Society of America in Bethesda, Md., where he is now a vice president.

His sons are now 15. One, Joe, is talkative and considered “high functioning.” The other, Ben, is nonverbal with profound autism. “What works for one child doesn’t necessarily work for the other,” Mr. Sell said. “So we’re talking about finding and paying for twice as many treatments.”

In the early years, the Sell family had some autism coverage under Mr. Sell’s health insurance. But claims for certain therapies, tests and treatments were often denied. “I was very aggressive about appealing those denials, and I often won,” Mr. Sell said.

But even with coverage, Mr. Sell found he needed to pay enormous amounts out of pocket to come close to giving his sons the 20 to 40 hours of behavioral therapies each week that were often recommended. (Eventually, as discussed below, Mr. Sell was also able to obtain financial assistance through a special part of the Medicaid program.)

Although direct financial support may be scarce and hard to obtain, there are several autism information and advocacy groups that routinely help parents navigate financial hurdles. Here is a road map parents can use to get started.

CHECK YOUR INSURANCE Coverage for autism treatments is still far from common, but it is improving. Some large employers offer policies that cover treatment, and 15 states have passed laws mandating at least some autism-related coverage. The Autism Society’s Web site lists the relevant states. (That section of the site is still under construction, but you can scroll down to see the states.) In addition, Maine and New Hampshire both have legislation pending that could pass soon, Mr. Kemp said.

If you do have coverage, watch for limitations. Because treatment for autism is so individualized, there are few uniform standards or protocols for insurance companies to follow. That means parents often have to argue that a certain therapy or treatment is necessary. Also, be sure to check any caps on treatment, Mr. Sell warns. What may look generous — say $36,000 a year — can be spent quickly. Or there may be limits on how many sessions of a particular type of therapy will be paid for each year.

And you will want to coordinate your insurance coverage with the services you may be receiving from your child’s school. If an occupational therapist sees your child regularly in school, for example, you may want to save your insurance dollars for social interaction therapies.

In addition, you may need to be especially aggressive about coverage for some medical conditions. Gastrointestinal problems, for instance, are extremely common in autistic children. Mr. Sell found himself fighting for such coverage for Ben, his nonverbal son. The insurance company had denied the claim for gastrointestinal testing, saying that because Ben’s behavior problems were related to autism, the testing was not covered. Mr. Sell, convinced Ben was in pain and could not tell anyone what was wrong, appealed and won. The tests showed that Ben had ulcers and lower-intestine problems that still occasionally flare up and require treatment.

MEDICAID WAIVERS Some states offer Medicaid coverage for children with autism without taking the family’s income into account — only the child’s diagnosis. This is usually reserved for fairly serious cases but is worth exploring, Mr. Sell said. “This was a godsend for us,” he said. The waiver, he said, allows families access to services that private insurance won’t cover and that they wouldn’t be able to afford otherwise.

With the waiver, Mr. Sell was able to get more home-based speech and occupational therapies for his sons to supplement the sessions they receive at the public school they both attend. Medicaid also covers recreational therapy during which a specialist takes Ben and Joe on hikes and other outings, giving the parents some downtime.

To see if your child is eligible for a Medicaid waiver, go to the Centers for Medicare and Medicaid Services Web site and click on your state.

Because Medicaid is one of the few government lifelines available, waiting lists for waivers can be extremely long. Mr. Sell, for example, waited nine years to get waivers for his sons. “Just go ahead and get on the list and try not to be too discouraged,” advised Mr. Sell. “Many states are moving faster now.”

GO LOCAL Many autism advocacy organizations, including Autism Speaks and the Autism Society of America, are affiliated with local chapters throughout the country. In addition, most states, counties, towns and cities provide lists of local autism resources and support groups.

It is people in the local groups who will know all the resources available. They can also help you keep up with the latest research, so you don’t spend time and money chasing the many unsubstantiated “cures” out there. They will also have lots of practical advice, like which dentists, optometrists and even barbers are good with autistic children. “You think going to the barber is no big deal?” Mr. Sell asked. “Just try it with an autistic child.”

OTHER RESOURCES A handful of organizations like Easter Seals and the National Autism Association offer financial help to struggling families. Autism Family Resources and United Healthcare Children’s Foundation also offer grants to pay for autism treatments.

This unnerving possibility springs from recent research by a loose group of anthropologists and cross-cultural psychiatrists. Swimming against the biomedical currents of the time, they have argued that mental illnesses are not discrete entities like the polio virus with their own natural histories. These researchers have amassed an impressive body of evidence suggesting that mental illnesses have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places. In some Southeast Asian cultures, men have been known to experience what is called amok, an episode of murderous rage followed by amnesia; men in the region also suffer from koro, which is characterized by the debilitating certainty that their genitals are retracting into their bodies. Across the fertile crescent of the Middle East there is zar, a condition related to spirit-possession beliefs that brings forth dissociative episodes of laughing, shouting and singing.

The diversity that can be found across cultures can be seen across time as well. In his book “Mad Travelers,” the philosopher Ian Hacking documents the fleeting appearance in the 1890s of a fugue state in which European men would walk in a trance for hundreds of miles with no knowledge of their identities. The hysterical-leg paralysis that afflicted thousands of middle-class women in the late 19th century not only gives us a visceral understanding of the restrictions set on women’s social roles at the time but can also be seen from this distance as a social role itself — the troubled unconscious minds of a certain class of women speaking the idiom of distress of their time.

“We might think of the culture as possessing a ‘symptom repertoire’ — a range of physical symptoms available to the unconscious mind for the physical expression of psychological conflict,” Edward Shorter, a medical historian at the University of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’ Symptom.” “In some epochs, convulsions, the sudden inability to speak or terrible leg pain may loom prominently in the repertoire. In other epochs patients may draw chiefly upon such symptoms as abdominal pain, false estimates of body weight and enervating weakness as metaphors for conveying psychic stress.”

In any given era, those who minister to the mentally ill — doctors or shamans or priests — inadvertently help to select which symptoms will be recognized as legitimate. Because the troubled mind has been influenced by healers of diverse religious and scientific persuasions, the forms of madness from one place and time often look remarkably different from the forms of madness in another. That is until recently.

For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.

DR. SING LEE, a psychiatrist and researcher at the Chinese University of Hong Kong, watched the Westernization of a mental illness firsthand. In the late 1980s and early 1990s, he was busy documenting a rare and culturally specific form of anorexia nervosa in Hong Kong. Unlike American anorexics, most of his patients did not intentionally diet nor did they express a fear of becoming fat. The complaints of Lee’s patients were typically somatic — they complained most frequently of having bloated stomachs. Lee was trying to understand this indigenous form of anorexia and, at the same time, figure out why the disease remained so rare.

As he was in the midst of publishing his finding that food refusal had a particular expression and meaning in Hong Kong, the public’s understanding of anorexia suddenly shifted. On Nov. 24, 1994, a teenage anorexic girl named Charlene Hsu Chi-Ying collapsed and died on a busy downtown street in Hong Kong. The death caught the attention of the media and was featured prominently in local papers. “Anorexia Made Her All Skin and Bones: Schoolgirl Falls on Ground Dead,” read one headline in a Chinese-language newspaper. “Thinner Than a Yellow Flower, Weight-Loss Book Found in School Bag, Schoolgirl Falls Dead on Street,” reported another Chinese-language paper.

In trying to explain what happened to Charlene, local reporters often simply copied out of American diagnostic manuals. The mental-health experts quoted in the Hong Kong papers and magazines confidently reported that anorexia in Hong Kong was the same disorder that appeared in the United States and Europe. In the wake of Charlene’s death, the transfer of knowledge about the nature of anorexia (including how and why it was manifested and who was at risk) went only one way: from West to East.

Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression of the illness itself. As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard. Lee once saw two or three anorexic patients a year; by the end of the 1990s he was seeing that many new cases each month. That increase sparked another series of media reports. “Children as Young as 10 Starving Themselves as Eating Ailments Rise,” announced a headline in one daily newspaper. By the late 1990s, Lee’s studies reported that between 3 and 10 percent of young women in Hong Kong showed disordered eating behavior. In contrast to Lee’s earlier patients, these women most often cited fat phobia as the single most important reason for their self-starvation. By 2007 about 90 percent of the anorexics Lee treated reported fat phobia. New patients appeared to be increasingly conforming their experience of anorexia to the Western version of the disease.

What is being missed, Lee and others have suggested, is a deep understanding of how the expectations and beliefs of the sufferer shape their suffering. “Culture shapes the way general psychopathology is going to be translated partially or completely into specific psychopathology,” Lee says. “When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.”

The problem becomes especially worrisome in a time of globalization, when symptom repertoires can cross borders with ease. Having been trained in England and the United States, Lee knows better than most the locomotive force behind Western ideas about mental health and illness. Mental-health professionals in the West, and in the United States in particular, create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard. American researchers and institutions run most of the premier scholarly journals and host top conferences in the fields of psychology and psychiatry. Western drug companies dole out large sums for research and spend billions marketing medications for mental illnesses. In addition, Western-trained traumatologists often rush in where war or natural disasters strike to deliver “psychological first aid,” bringing with them their assumptions about how the mind becomes broken by horrible events and how it is best healed. Taken together this is a juggernaut that Lee sees little chance of stopping. “As Western categories for diseases have gained dominance, micro-cultures that shape the illness experiences of individual patients are being discarded,” Lee says. “The current has become too strong.”

Would anorexia have so quickly become part of Hong Kong’s symptom repertoire without the importation of the Western template for the disease? It seems unlikely. Beginning with scattered European cases in the early 19th century, it took more than 50 years for Western mental-health professionals to name, codify and popularize anorexia as a manifestation of hysteria. By contrast, after Charlene fell onto the sidewalk on Wan Chai Road on that late November day in 1994, it was just a matter of hours before the Hong Kong population learned the name of the disease, who was at risk and what it meant.

THE IDEA THAT our Western conception of mental health and illness might be shaping the expression of illnesses in other cultures is rarely discussed in the professional literature. Many modern mental-health practitioners and researchers believe that the scientific standing of our drugs, our illness categories and our theories of the mind have put the field beyond the influence of endlessly shifting cultural trends and beliefs. After all, we now have machines that can literally watch the mind at work. We can change the chemistry of the brain in a variety of interesting ways and we can examine DNA sequences for abnormalities. The assumption is that these remarkable scientific advances have allowed modern-day practitioners to avoid the blind spots and cultural biases of their predecessors.

Modern-day mental-health practitioners often look back at previous generations of psychiatrists and psychologists with a thinly veiled pity, wondering how they could have been so swept away by the cultural currents of their time. The confident pronouncements of Victorian-era doctors regarding the epidemic of hysterical women are now dismissed as cultural artifacts. Similarly, illnesses found only in other cultures are often treated like carnival sideshows. Koro, amok and the like can be found far back in the American diagnostic manual (DSM-IV, Pages 845-849) under the heading “culture-bound syndromes.” Given the attention they get, they might as well be labeled “Psychiatric Exotica: Two Bits a Gander.”

Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world’s psyche, and applying it around the world represents simply the brave march of scientific knowledge.

Of course, we can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. Modern science has begun to reveal these causes. Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways. In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

EVEN WHEN THE underlying science is sound and the intentions altruistic, the export of Western biomedical ideas can have frustrating and unexpected consequences. For the last 50-odd years, Western mental-health professionals have been pushing what they call “mental-health literacy” on the rest of the world. Cultures became more “literate” as they adopted Western biomedical conceptions of diseases like depression and schizophrenia. One study published in The International Journal of Mental Health, for instance, portrayed those who endorsed the statement that “mental illness is an illness like any other” as having a “knowledgeable, benevolent, supportive orientation toward the mentally ill.”

Mental illnesses, it was suggested, should be treated like “brain diseases” over which the patient has little choice or responsibility. This was promoted both as a scientific fact and as a social narrative that would reap great benefits. The logic seemed unassailable: Once people believed that the onset of mental illnesses did not spring from supernatural forces, character flaws, semen loss or some other prescientific notion, the sufferer would be protected from blame and stigma. This idea has been promoted by mental-health providers, drug companies and patient-advocacy groups like the National Alliance on Mental Illness in the United States and SANE in Britain. In a sometimes fractious field, everyone seemed to agree that this modern way of thinking about mental illness would reduce the social isolation and stigma often experienced by those with mental illness. Trampling on indigenous prescientific superstitions about the cause of mental illness seemed a small price to pay to relieve some of the social suffering of the mentally ill.

But does the “brain disease” belief actually reduce stigma? In 1997, Prof. Sheila Mehta from Auburn University Montgomery in Alabama decided to find out if the “brain disease” narrative had the intended effect. She suspected that the biomedical explanation for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of, so she thought up a clever experiment.

In her study, test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness.

The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” (These were termed the “psychosocial” explanation and the “disease” explanation respectively.) The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock.

Analyzing the data, Mehta found a difference between the group of subjects given the psychosocial explanation for their partner’s mental-illness history and those given the brain-disease explanation. Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.

“The results of the current study suggest that we may actually treat people more harshly when their problem is described in disease terms,” Mehta wrote. “We say we are being kind, but our actions suggest otherwise.” The problem, it appears, is that the biomedical narrative about an illness like schizophrenia carries with it the subtle assumption that a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events. “Viewing those with mental disorders as diseased sets them apart and may lead to our perceiving them as physically distinct. Biochemical aberrations make them almost a different species.” In other words, the belief that was assumed to decrease stigma actually increased it. Was the same true outside the lab in the real world?

The question is important because the Western push for “mental-health literacy” has gained ground. Studies show that much of the world has steadily adopted this medical model of mental illness. Although these changes are most extensive in the United States and Europe, similar shifts have been documented elsewhere. When asked to name the sources of mental illness, people from a variety of cultures are increasingly likely to mention “chemical imbalance” or “brain disease” or “genetic/inherited” factors.

Unfortunately, at the same time that Western mental-health professionals have been convincing the world to think and talk about mental illnesses in biomedical terms, we have been simultaneously losing the war against stigma at home and abroad. Studies of attitudes in the United States from 1950 to 1996 have shown that the perception of dangerousness surrounding people with schizophrenia has steadily increased over this time. Similarly, a study in Germany found that the public’s desire to maintain distance from those with a diagnosis of schizophrenia increased from 1990 to 2001.

Researchers hoping to learn what was causing this rise in stigma found the same surprising connection that Mehta discovered in her lab. It turns out that those who adopted biomedical/genetic beliefs about mental disorders were the same people who wanted less contact with the mentally ill and thought of them as more dangerous and unpredictable. This unfortunate relationship has popped up in numerous studies around the world. In a study conducted in Turkey, for example, those who labeled schizophrenic behavior as akil hastaligi (illness of the brain or reasoning abilities) were more inclined to assert that schizophrenics were aggressive and should not live freely in the community than those who saw the disorder as ruhsal hastagi (a disorder of the spiritual or inner self). Another study, which looked at populations in Germany, Russia and Mongolia, found that “irrespective of place . . . endorsing biological factors as the cause of schizophrenia was associated with a greater desire for social distance.”

Even as we have congratulated ourselves for becoming more “benevolent and supportive” of the mentally ill, we have steadily backed away from the sufferers themselves. It appears, in short, that the impact of our worldwide antistigma campaign may have been the exact opposite of what we intended.

NOWHERE ARE THE limitations of Western ideas and treatments more evident than in the case of schizophrenia. Researchers have long sought to understand what may be the most perplexing finding in the cross-cultural study of mental illness: people with schizophrenia in developing countries appear to fare better over time than those living in industrialized nations.

This was the startling result of three large international studies carried out by the World Health Organization over the course of 30 years, starting in the early 1970s. The research showed that patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.

Trying to unravel this mystery, the anthropologist Juli McGruder from the University of Puget Sound spent years in Zanzibar studying families of schizophrenics. Though the population is predominantly Muslim, Swahili spirit-possession beliefs are still prevalent in the archipelago and commonly evoked to explain the actions of anyone violating social norms — from a sister lashing out at her brother to someone beset by psychotic delusions.

McGruder found that far from being stigmatizing, these beliefs served certain useful functions. The beliefs prescribed a variety of socially accepted interventions and ministrations that kept the ill person bound to the family and kinship group. “Muslim and Swahili spirits are not exorcised in the Christian sense of casting out demons,” McGruder determined. “Rather they are coaxed with food and goods, feted with song and dance. They are placated, settled, reduced in malfeasance.” McGruder saw this approach in many small acts of kindness. She watched family members use saffron paste to write phrases from the Koran on the rims of drinking bowls so the ill person could literally imbibe the holy words. The spirit-possession beliefs had other unexpected benefits. Critically, the story allowed the person with schizophrenia a cleaner bill of health when the illness went into remission. An ill individual enjoying a time of relative mental health could, at least temporarily, retake his or her responsibilities in the kinship group. Since the illness was seen as the work of outside forces, it was understood as an affliction for the sufferer but not as an identity.

For McGruder, the point was not that these practices or beliefs were effective in curing schizophrenia. Rather, she said she believed that they indirectly helped control the course of the illness. Besides keeping the sick individual in the social group, the religious beliefs in Zanzibar also allowed for a type of calmness and acquiescence in the face of the illness that she had rarely witnessed in the West.

The course of a metastasizing cancer is unlikely to be changed by how we talk about it. With schizophrenia, however, symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia. Collectively referred to as “high expressed emotion,” these reactions include criticism, hostility and emotional overinvolvement (like overprotectiveness or constant intrusiveness in the patient’s life). In one study, 67 percent of white American families with a schizophrenic family member were rated as “high EE.” (Among British families, 48 percent were high EE; among Mexican families the figure was 41 percent and for Indian families 23 percent.)

Does this high level of “expressed emotion” in the United States mean that we lack sympathy or the desire to care for our mentally ill? Quite the opposite. Relatives who were “high EE” were simply expressing a particularly American view of the self. They tended to believe that individuals are the captains of their own destiny and should be able to overcome their problems by force of personal will. Their critical comments to the mentally ill person didn’t mean that these family members were cruel or uncaring; they were simply applying the same assumptions about human nature that they applied to themselves. They were reflecting an “approach to the world that is active, resourceful and that emphasizes personal accountability,” Prof. Jill M. Hooley of Harvard University concluded. “Far from high criticism reflecting something negative about the family members of patients with schizophrenia, high criticism (and hence high EE) was associated with a characteristic that is widely regarded as positive.”

Widely regarded as positive, that is, in the United States. Many traditional cultures regard the self in different terms — as inseparable from your role in your kinship group, intertwined with the story of your ancestry and permeable to the spirit world. What McGruder found in Zanzibar was that families often drew strength from this more connected and less isolating idea of human nature. Their ability to maintain a low level of expressed emotion relied on these beliefs. And that level of expressed emotion in turn may be key to improving the fortunes of the schizophrenia sufferer.

Of course, to the extent that our modern psychopharmacological drugs can relieve suffering, they should not be denied to the rest of the world. The problem is that our biomedical advances are hard to separate from our particular cultural beliefs. It is difficult to distinguish, for example, the biomedical conception of schizophrenia — the idea that the disease exists within the biochemistry of the brain — from the more inchoate Western assumption that the self resides there as well. “Mental illness is feared and has such a stigma because it represents a reversal of what Western humans . . . have come to value as the essence of human nature,” McGruder concludes. “Because our culture so highly values . . . an illusion of self-control and control of circumstance, we become abject when contemplating mentation that seems more changeable, less restrained and less controllable, more open to outside influence, than we imagine our own to be.”

CROSS-CULTURAL psychiatrists have pointed out that the mental-health ideas we export to the world are rarely unadulterated scientific facts and never culturally neutral. “Western mental-health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal,” Derek Summerfield of the Institute of Psychiatry in London observes. He has also written: “The problem is the overall thrust that comes from being at the heart of the one globalizing culture. It is as if one version of human nature is being presented as definitive, and one set of ideas about pain and suffering. . . . There is no one definitive psychology.”

Behind the promotion of Western ideas of mental health and healing lie a variety of cultural assumptions about human nature. Westerners share, for instance, evolving beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We’ve come to agree that the human mind is rather fragile and that it is best to consider many emotional experiences and mental states as illnesses that require professional intervention. (The National Institute of Mental Health reports that a quarter of Americans have diagnosable mental illnesses each year.) The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence. These ideas remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as the many self-help philosophies and schools of therapy that have encouraged Americans to separate the health of the individual from the health of the group. These Western ideas of the mind are proving as seductive to the rest of the world as fast food and rap music, and we are spreading them with speed and vigor.

No one would suggest that we withhold our medical advances from other countries, but it’s perhaps past time to admit that even our most remarkable scientific leaps in understanding the brain haven’t yet created the sorts of cultural stories from which humans take comfort and meaning. When these scientific advances are translated into popular belief and cultural stories, they are often stripped of the complexity of the science and become comically insubstantial narratives. Take for instance this Web site text advertising the antidepressant Paxil “Just as a cake recipe requires you to use flour, sugar and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.” The Western mind, endlessly analyzed by generations of theorists and researchers, has now been reduced to a batter of chemicals we carry around in the mixing bowl of our skulls.

All cultures struggle with intractable mental illnesses with varying degrees of compassion and cruelty, equanimity and fear. Looking at ourselves through the eyes of those living in places where madness and psychological trauma are still embedded in complex religious and cultural narratives, however, we get a glimpse of ourselves as an increasingly insecure and fearful people. Some philosophers and psychiatrists have suggested that we are investing our great wealth in researching and treating mental illness — medicalizing ever larger swaths of human experience — because we have rather suddenly lost older belief systems that once gave meaning and context to mental suffering.

If our rising need for mental-health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress.

Theirs are among hundreds of names a Manhattan court has changed over the last few years for transgender New Yorkers. That tally, specialists in the relatively new field of transgender law say, may make the borough’s workaday Civil Court one of the country’s biggest official name swappers — male names for female, vice versa and ambiguous.

Changing a name might seem like a minor matter for those who are changing their gender identities and, for some, facing challenges like finding knowledgeable doctors, trying hormones and experimenting with painful hair-removal procedures. But many who have gone through the switch say a name change sends an important message to the world, a message solidified and made official with a court’s approval.

In many courts around the country, what were once risky or shocking name-change requests are becoming more routine as the sting of gender taboo has lost a little of its edge. But in few places has this shift been more dramatic than in New York, where two recent and little-noticed rulings helped clarify the murky area not only of the law but also of modern gender identification. They have contributed to Manhattan’s becoming a capital of Joe-to-Jane proceedings. A rare network of some 200 lawyers now works on such cases filed in the Centre Street courthouse, and nearly 400 of their transgender clients so far have, more or less, become someone else.

“There is a long emotional, physical process that a lot of us have to go through,” said Katherine Cross, 22, of the Bronx, who got her new name in July. She said her transition included learning how to force her voice into a higher register and the basics of shopping for women’s clothing. “For me,” she said, “the centerpiece was the name change.”

Efforts to extend legal rights to transgender people have increasingly been in the news, including the December announcement by Gov. David A. Paterson of New York to extend antidiscrimination protections to transgender state employees.

Over the last two years, volunteer lawyers from 19 big corporate law firms in New York City have worked on nearly 400 transgender name change cases, according to the advocacy group that is running the project, the Transgender Legal Defense and Education Fund. “In a way, it’s a big coming-out process — with a judge,” said the group’s executive director, Michael D. Silverman.

The lawyers have represented clients from every borough in the Manhattan court, with applicants ranging from occasional cross-dressers to people who have completed gender reassignment surgery. No one knows how many others have gone to the court on their own or with other lawyers. Indeed, the very number of transgender people in the country and the state is hard to pin down. One survey suggests there are 300,000 in New York State, but others dispute that.

The process of changing a name can be intimidating, said Kit Yan, a 25-year-old poetry slam artist and performer with a hint of facial hair who was born Laura. He failed twice when he tried on his own to get the law to recognize the name a friend suggested after seeing a cartoon character named Kit that looked like him, a little boy in a suit. With a lawyer in May, Mr. Yan said, he felt relief when he heard “Laura” to summon him for the last time when his case was called. “It felt like giving away, say, an ugly Christmas sweater your mom made you,” Mr. Yan said.

The two recent rulings in New York courts helped clear the way for more such moments on Centre Street. In one case, an appeals panel overruled a Manhattan civil court judge who had insisted on doctors’ notes giving reasons for name changes in transgender cases. The panel said there was “no sound basis in law or policy” for the requirement and noted that the law generally permits people to change their names unless there is some fraudulent intent involved.

In the other decision, a Westchester judge made an exception to a general requirement that name changes and home addresses be advertised in newspapers, saying the safety issues for people in gender transition were obvious in a world that can be hostile.

The publication requirement insisted upon by some of the Manhattan judges has fed an eerie subculture of readers, many of them prisoners, who follow the newspaper notices. One man forced to advertise that he was becoming a woman received several seductive letters with prison return addresses. “Hello Angel!” said one of the letters. “I am not afraid to take new roads,” said another.

At the gray Manhattan courthouse, where matters like debt collection are the bulk of the work, officials said they were aware of numerous transgender name-change cases. But those petitions are mixed in with more traditional name-change filings, like applications from immigrants Anglicizing their names. Name-change cases over all increased at the court to 3,109 in 2009 from 202 in 1995, but officials said they did not keep count of the reasons for the requests.

Gender switches would not necessarily draw much attention at the courthouse, said the court’s supervising judge, Jeffrey K. Oing. New York being New York, he said, the threshold for surprise can be high. There was a “buzz in the courthouse,” he conceded, after one man renamed himself Jesus Christ.

But the judge said he was not surprised to hear that transgender people had found a receptive audience in many of the 10 Civil Court judges in Manhattan. “I like to think that we live in a very open society here in New York County,” he said.

Still, routine changing of gender identification can be startling to some. The Rev. Jason J. McGuire, executive director of New Yorkers for Constitutional Freedoms, which helped defeat the gay-marriage proposal in Albany, said the courts might be ahead of the public on gender issues. “Oftentimes, the courts are used to advance an agenda,” he said, adding that the name changes created loopholes people could use to hide for any number of reasons.

Some of the Centre Street petitioners said they did in fact want to obliterate their old identities. The newly named Em Whitney, a 23-year-old with a toothy smile and a button nose, said the change was part of a long gender journey that began when he was a Texas child with a girl’s name and a fascination with androgynous characters like Peter Pan and Shakespeare’s Puck.

Mr. Whitney, who has written for The New York Observer newspaper and sometimes introduces himself as Emerson, said daily experiences like presenting a driver’s license could be a minefield. “Showing someone a picture and a name of someone who doesn’t exist drove me crazy,” he said.

Ms. Schnur, the retiree who changed her name in October, took out some old identification cards to make a similar point. The pictures of the man with thinning hair never seemed right, she said. “I always knew that I wasn’t what other people thought I was,” she said.

For a graduate research project at Harvard in the mid-1990s, the psychologist Susan A. Clancy arranged to interview adult survivors of childhood sexual abuse, expecting to confirm the conventional wisdom that the more traumatic the abuse had been, the more troubled an adult the child had become.

Dr. Clancy figured she knew what she would find: “Everything I knew dictated that the abuse should be a horrible experience, that the child should be traumatized at the time it was happening — overwhelmed with fear, shock, horror.”

But many carefully documented interviews revealed nothing of the sort. Commonly, the abuse had been confusing for the child but not traumatic in the usual sense of the word. Only when the child grew old enough to understand exactly what had happened — sometimes many years later — did the fear, shock and horror begin. And only at that point did the experience become traumatic and begin its well-known destructive process.

Dr. Clancy questioned her findings, reconfirmed them and was convinced. Her audience, when she made the data public, was outraged. First, her data flew in the face of several decades of politically correct trauma theory, feminist theory and sexual politics. Second, Dr. Clancy found that the world had little appetite for scientific subtlety: “Unfortunately, when people heard ‘not traumatic when it happens,’ they translated my words to mean, ‘It doesn’t harm victims later on.’ Even worse, some assumed I was blaming victims for their abuse.”

Dr. Clancy reports that she became a pariah in lay and academic circles. She was “crucified” in the press as a “friend of pedophiles,” colleagues boycotted her talks, advisers suggested that continuing on her trajectory would rule out an academic career.

All that fuss about one little word — “trauma” — and a change in its timing. Why should it matter one way or the other? Dr. Clancy suggests several reasons her data aroused such passion. For one thing, a whole academic and therapeutic structure rides on the old model of sexual abuse; her findings had the potential to undermine a host of expensive treatment and prevention projects.

Meanwhile, she argues, it is her model that may really help victims. Adult survivors of childhood abuse are commonly mortified by their own behavior as children. By not fighting back or calling for help, they blame themselves for effectively colluding with their abuser. It can be intensely comforting for them to hear that their reaction, or lack thereof, was completely normal.

Dr. Clancy’s model also makes some sense of the whole sticky question of repressed memory. Most traumatic events are likely to be vividly remembered. But if instances of sexual abuse are simply among the many confusions that characterize childhood, they are perfectly forgettable: “Why should a child remember them if, at the time they happened, they were not particularly traumatic?” Only when reprocessed and fully understood do the memories leap into focus.

Even without all these practicalities, the moral of Dr. Clancy’s story is clear: science should represent truth, not wishful thinking. When good data fly in the face of beloved theory, the theory has to go.

Dr. Clancy writes with the precision and patient repetition of a good teacher on complicated terrain. Her prose could not be clearer, and her points are restated many, many times over. But at Amazon.com, an outraged customer-reviewer has already pounced.

“It is appalling,” the reviewer wrote, “that ‘experts’ like Susan Clancy can get away with having a book published with a title that is not only false, but one that tells sexual perpetrators, ‘Go ahead, sexually abuse children, they like it, and they aren’t going to be traumatized by it.’ ”

Doctors Cautioned on Zyprexa for Adolescents
Melisa Healey, Los Angeles Times- 1/29/2010

The Federal Drug Administration on Friday issued a warning to doctors that adolescents taking the drug olanzapine have an "increased potential" -- in comparison with adults taking the new-generation antipsychotic drug -- for weight gain and metabolic disturbances that could result in diabetes or elevated blood cholesterol levels. "Clinicians should consider the potential long-term risks when prescribing to adolescents," the FDA said in a statement released Friday night. "In many cases, this may lead to prescribe other drugs first," the statement went on.

The agency has not approved the marketing of olanzapine -- sold under the commercial name Zyprexa by the drug maker Eli Lilly -- for use in children under 13 who are diagnosed with schizophrenia or bipolar disorder. But the medication, one of a class of psychiatric medications called the "atypical antipsychotics," is widely prescribed for young patients, despite growing evidence that call its safety profile into question for this population.

The warning comes in the wake of the October publication in the Journal of the American Medical Assn., in which a study showed that children and adolescents taking their first-ever course of Zyprexa gained, on average, more than 17 pounds over a 12-week period, as well as dramatic increases in triglycerides and cholesterol levels -- all factors that put them at higher risk of developing cardiovascular disease. While two other antipsychotic drugs -- Seroquel and Risperdal -- were implicated in significant weight gain and metabolic changes, Zyprexa was found to carry the highest risks of all three.  

The FDA said that in cases where physicians opt to prescribe olanzapine, the drug should be part of a "comprehensive treatment program," which could include psychological, educational and social counseling as well as medication therapy.

A reason migraines are so maddeningly elusive is that they are not simply bad headaches. They stem from a genetic disorder (yes, you have your parents to blame) that afflicts 36 million Americans and manifests as a group of symptoms that besides head pain may include dizziness, visual disturbances, numbness and nausea.

Some of the symptoms resemble those from other disorders, like sinus headaches, epilepsy, eye problems or even strokes. And to further complicate matters, sufferers react in varied ways to medications.

“What might be a miracle drug for one person could be a dud for another,” said Dr. Joel Saper, director of the Michigan Headache and Neurological Institute, a treatment and research center in Ann Arbor. “There is no universally effective therapy.”

If that sounds murky, one thing is not: early intervention is important. If you get a migraine every few months and can cope by taking an over-the-counter med, great — you’ve got the problem somewhat under control. But if recurring pain is not responding to your own efforts, seek expert help. “Some early data suggests that if you let headache pain go without treatment it can lower your threshold for pain down the line,” Dr. Saper said. In other words, untreated headaches can make you more vulnerable to pain.

On the other hand, if you are taking over-the-counter or prescription painkillers two to three days a week for months on end, the medications you are taking to dull pain could worsen your condition. You may then start to experience medication-overuse headaches — a risk for migraine sufferers.

Researchers are learning that pain and the medications used to treat pain can potentially change the biology of the brain. Receiving good treatment can help you function more effectively, and will probably also save you money over the long term. And if you have health insurance, it should cover most of the relevant medical evaluations and treatments. Here are suggestions for getting help.

EVALUATION
If you have chronic or disabling headaches that your primary care physician has not been able to manage, see a neurologist who has expertise in treating headaches. Be sure to ask beforehand about that expertise. Not all neurologists have experience treating migraines.

You might want to see a certified headache specialist. Doctors with this new certification have passed board exams in their area of specialty as well as one on headaches. You can find a list of the approximately 200 certified headache doctors on the Migraine Research Foundation’s Web site.

Before you make an appointment, ask your potential doctor’s assistant, by phone, a few key questions. Find out about the doctor’s experience. And be sure to ask how long the first meeting will last. “A good doctor will spend at least an hour with you,” said Dr. David W. Dodick, a neurologist at the Mayo Clinic in Arizona.

It’s important for a doctor to take time to listen to your issues, said Claire Louder, 44, who has had migraines since she was 12. She said she has seen a half-dozen doctors over the years. “The best ones pay attention to what you say,” said Ms. Louder, who is a chamber of commerce executive in Maryland. “One doctor I saw had a treatment plan in mind before I’d said a word. Then she kept telling me my migraines were due to stress, which was an oversimplification.”

A good doctor should be creative and willing to try a variety of treatments. At your first visit, the doctor will make sure that your headaches are not caused by an underlying illness, like Lyme disease or a brain tumor. Once the doctor is satisfied that your condition is indeed what are called primary migraines, the doctor will ask you detailed questions about your attacks, take a thorough medical history and probably have you keep a diary of your migraine patterns.

STRATEGIES VARY
Be prepared for a multi-tiered approach. Doctors typically prescribe a triptan drug or an ergot-related drug to help people control infrequent migraine attacks. Both of these drug types influence brain cell reactions that are part of the migraine process.

There are seven types of triptans. Ms. Louder tried five before she found one, rizatriptan — sold under the brand name Maxalt — that worked for her. The best-seller Imitrex (sumatriptan) is available in an affordable generic version.

Triptans are far more popular, but many people who do not respond well to triptans do well with the ergots, such as D.H.E. (dihydroergotamine), Dr. Saper said.

If you have migraines at least weekly your doctor may prescribe a preventative medicine to reduce their frequency of attacks. “Prescription preventatives are grossly underutilized,” Dr. Dodick said. “They can be extremely effective for some people.”

Preventive medicines, taken every day, include antiseizure drugs, beta blockers and tricyclic antidepressants. Ms. Louder started taking Topomax (topiramate), an antiseizure drug, five years ago and says it has helped to reduce the frequency of her migraines from once a week to once a month.

Your doctor might suggest some natural remedies too — like vitamin B2, coenzyme Q10, magnesium or butterbur, an herb that is sold under the name Petadolex — which some specialists say can help reduce both the frequency and intensity of your headaches. These supplements are not covered by insurers but all are relatively inexpensive.

LIFESTYLE CHANGES
“Migraines are built into the biology of the brain,” Dr. Saper said. Sufferers inherit a hypersensitivity to physical and emotional events — like stress, noise, certain foods and even bad weather. Learning to identify the circumstances that can set off an attack is important in migraine management.

Dr. Dodick said, “Recognizing triggers can prevent attacks from occurring.” After keeping a diary, Ms. Louder learned, for instance, that low-pressure storm systems, meats with nitrates and many other preservatives induced her migraines. “Migraine patients don’t respond well to change,” Dr. Dodick said.

Sometimes just keeping one’s patterns and habits predictable can reduce attacks. Lack of sleep, erratic schedules and lots of plane rides are disorienting for even the hardiest people, but they can literally send migraine sufferers to their beds, or worse, to the E.R.

Insurers cannot set higher co-payments and deductibles or stricter limits on treatment for mental illness and addiction disorders. Nor can they establish separate deductibles for mental health care and for the treatment of physical illnesses.

Such disparities are common in the insurance industry. By sweeping away such restrictions, doctors said, the rules will make it easier for people to obtain treatment for a wide range of conditions, including depression, autism, schizophrenia, eating disorders and alcohol and drug abuse.

For decades, many health plans have had limits on hospital inpatient days and outpatient visits for mental health treatments, but not for other types of care.

Kathleen Sebelius, the secretary of health and human services, said the rules guaranteed that people with debilitating mental disorders would not suffer “needless or arbitrary limits on their care.”

The rules, which take effect on July 1, carry out a 2008 law that was adopted with bipartisan support. They significantly expand the rights of people with mental illness, much of which goes untreated because of insurance restrictions.

Under the rules, insurers can still review claims for “medical necessity,” can still require prior approval of some services and can still charge consumers more for using doctors and hospitals that are not on a list of preferred providers. But under the rules, insurers cannot use these techniques in a more restrictive way for mental health care than for other medical services.

The administration said the new requirements could increase premiums by four-tenths of 1 percent, or $25.6 billion over 10 years. Businesses with 50 or fewer employees are exempt.

The rules apply to group health insurance plans of the kind typically offered by employers. Federal health officials said the rules did not apply to the individual insurance market, where policies are sold directly to individuals and families. However, some states have laws that apply to the individual market.

Irvin L. Muszynski, a lawyer at the American Psychiatric Association, praised the government’s decision to require a single deductible for mental health and medical-surgical coverage. “Patients with mental illness often have general medical conditions like diabetes or high blood pressure that require treatment at the same time,” so a combined deductible makes sense, Mr. Muszynski said.

The rules were developed by the Labor Department, the Department of Health and Human Services and the Internal Revenue Service, which share responsibility for their enforcement.

The government said the rules would benefit 111 million people in 446,400 group health plans offered by private employers, and 29 million people in 20,000 plans sponsored by state and local governments.

In the new rules, the government says a health plan would be violating the law if it “imposes an annual $250 deductible on all medical-surgical benefits and a separate annual $250 deductible on all mental health and substance-use disorder benefits.”

The rules say that an insurer may require “prior approval that a course of treatment is medically necessary.” But the insurer cannot enforce this requirement in different ways for medical benefits and mental health services. For patients who receive treatment without prior approval, the penalty must be the same.

A number of companies specialize in managing mental health benefits. The Obama administration said the techniques used by these companies would hold down the cost of complying with the new rules. But, it said, the standards and techniques used to manage mental health benefits must be comparable to those for other medical care and cannot be applied more stringently.

In a preamble to the rules, the Obama administration said that patients had typically faced higher co-payments for visiting mental health professionals than for visiting primary care physicians. The rules are likely to reduce this disparity, so more people will be treated by mental health professionals, the administration said. This, in turn, “could lead to more appropriate care and thus better health outcomes,” it said.

The law requiring parity in the coverage of mental and physical illnesses is named for its sponsors, former Senators Paul Wellstone, Democrat of Minnesota, and Pete V. Domenici, Republican of New Mexico.

Iraq’s mental health care system was once advanced for the region, but by 2006 fewer than 100 psychiatrists remained in a population of about 30 million, and almost no psychologists. Patients were isolated in understaffed institutions, apart from their families and communities.

But now the government has embarked on an ambitious program to rebuild its ruined mental health care system in a country experiencing more than its share of traumas and stress. It will be built on a network of clinics that are team-oriented, with an emphasis on outpatient care and respect for patients’ rights — a radical departure from the existing system of institutional care focused on drugs and electroconvulsive therapy, often given without seeking a patient’s consent.

On a recent afternoon, Mr. Adel sat with a community health doctor at the Sara Center for Trauma, the nation’s first multidisciplinary clinic for post-traumatic stress disorder. The center, which opened Dec. 18, includes a psychiatrist, a community health doctor, a gynecologist and a social worker, all working jointly. “This is the first time we’ve had anything like this,” said Dr. Akeel al-Sabbagh, the center’s consultant psychiatrist. “In Iraq, the psychiatrist is like a dictator. Even my colleagues now, they say, ‘Why would you talk to a nurse?’ In the U.S.A. we saw the nurse, psychiatrist, psychologist and social worker all talk together about the patient.”

In 2008, six teams from Iraq spent a month at facilities in the United States, each concentrating on a different area of care. More teams are scheduled to make the same trip this year, with financing from Iraq’s Ministry of Health and the United States Substance Abuse and Mental Health Services Administration. But rebuilding an effective mental health system will take years. In the meantime, primary care doctors are being trained to recognize and treat basic disorders.

Last year, 360 primary-care doctors took two-week crash courses in depression, anxiety, psychosis and other afflictions, using a curriculum developed in London for Nigeria. “This is a turning point in mental health services in Iraq, integrating treatment into primary care,” said Dr. Sabah Sadik, chairman of the Middle Eastern International Division of the Royal College of Psychiatrists, who is coordinating the program.

For Mr. Adel, the change has meant a new start. As a soldier in the war against Iran, Mr. Adel ran away in 1987 after his brother was killed. He was quickly captured and punished with the amputation of his ear. “I started crying and shouting,” Mr. Adel said of the pain. “We were put in a small room, hundreds of prisoners, with no space to sleep. We had to defecate and urinate in the same room. I started to hallucinate from fever.” When he got out of prison after a year and a half, he became depressed and lost his balance when he walked. “I never wanted treatment,” he said, meaning antidepressant drugs. “I wanted to talk.”

But until he discovered the Sara Center last month, he never encountered professionals who offered therapy in addition to medication. Since then he has been enrolled in a program called cognitive processing therapy, which is devised to help trauma victims manage their haunting memories. “To be honest, I’ve only seen this in movies,” he said. “I didn’t know what it was. They told me that whatever I said was a secret between us, and I could talk freely. I haven’t had this treatment in my life.”

His recovery will not be easy. Even after Mr. Hussein’s execution, he said, he felt only sadness. “Because they didn’t torture him,” he said. “They were supposed to cut off his ear and stomp on him. His death was a gift to him.”

Though Iraq’s minister of health, a psychiatrist, supports the multidisciplinary program, Dr. Sabbagh said he had met resistance from peers. At meetings in Baghdad at the mental health council, he said: “When I talk about psychotherapy and dealing with the patient, some of our colleagues say this is a waste of time. When I ask for money to train my staff, they say, ‘This is a waste of time, why not give this money for drugs?’ ”

Some American methods proved unsuitable for Iraq, Dr. Sabbagh added. At one center in Battle Creek, Mich., the director greeted the Sara team with therapy dogs, which Iraqis consider unclean or dangerous. “We were afraid,” Dr. Sabbagh said. “The dogs are standing up, and one of our colleagues is falling down.”

In a room at the Sara Center, Mohammed Ziara, 11, played a violent video game called Street Fighter. Last year, his father got into a quarrel with neighbors, and the police came to arrest him. The boy assumed the worst. “On TV, whenever the police take someone away, they torture or kill him,” he said. “I was afraid he’d be killed.” Even after his father returned home, Mohammed had nightmares and performed poorly in school. When teachers hit him for his mistakes, he became afraid to go to school.

At the Sara Center, a social worker, Nidhal Baden Sultan, had him talk about the night of the arrest and talked to his parents and teachers to explore how his relationships were contributing to his trauma. “We told his teachers to treat him kindly,” Ms. Sultan said. After two sessions, Mohammed said he was starting to feel better, no longer afraid to go to school.

Much of the center’s work consists of this kind of community outreach. Staff members hold sessions for teachers, clerics, police officers and other public figures about the need for mental health care, which carries a stigma here. Dr. Sabbagh said many of his patients first went to faith healers, who often tried to beat the genies out of them with sticks. One man arrived at Dr. Sabbagh’s practice with two broken collarbones.

On a recent day, the center attracted a few patients suffering from trauma, but most had unrelated problems: a mother with a hyperactive 4-year-old, a man depressed after a failed relationship. Dr. Sabbagh was philosophical — for psychotherapy, people had no place else to go. Iraq’s immodest goal is to make entire country rethink its approach to mental health, from patients’ rights to modes of treatment. Getting people in the door, even the wrong door, is a start.