Sexual Identity Hard-Wired by Genetics, Study Says
Reuters News Service, 10/20/2003

LOS ANGELES -- Sexual identity is wired into the genes, which discounts the concept that homosexuality and transgender sexuality are a choice, California researchers reported on Monday. "Our findings may help answer an important question -- why do we feel male or female?" Dr. Eric Vilain, a genetics professor at the University of California, Los Angeles School of Medicine, said in a statement. "Sexual identity is rooted in every person's biology before birth and springs from a variation in our individual genome." His team has identified 54 genes in mice that may explain why male and female brains look and function differently. Since the 1970s, scientists have believed that estrogen and testosterone were wholly responsible for sexually organizing the brain. Recent evidence, however, indicates that hormones cannot explain everything about the sexual differences between male and female brains.
    Published in the latest edition of the journal Molecular Brain Research, the UCLA discovery may also offer physicians an improved tool for gender assignment of babies born with ambiguous genitalia. Mild cases of malformed genitalia occur in 1 percent of all births -- about 3 million cases. More severe cases -- where doctors can't inform parents whether they had a boy or girl -- occur in one in 3,000 births. "If physicians could predict the gender of newborns with ambiguous genitalia at birth, we would make less mistakes in gender assignment," Vilain said.
    Using two genetic testing methods, the researchers compared the production of genes in male and female brains in embryonic mice -- long before the animals developed sex organs. They found 54 genes produced in different amounts in male and female mouse brains, prior to hormonal influence. Eighteen of the genes were produced at higher levels in the male brains; 36 were produced at higher levels in the female brains. "We discovered that the male and female brains differed in many measurable ways, including anatomy and function." Vilain said. For example, the two hemispheres of the brain appeared more symmetrical in females than in males. According to Vilain, the symmetry may improve communication between both sides of the brain, leading to enhanced verbal expressiveness in females. "This anatomical difference may explain why women can sometimes articulate their feelings more easily than men," he said.
    The scientists plan to conduct further studies to determine the specific role for each of the 54 genes they identified. "Our findings may explain why we feel male or female, regardless of our actual anatomy," said Vilain. "These discoveries lend credence to the idea that being transgender --- feeling that one has been born into the body of the wrong sex -- is a state of mind.

Prescription Drug Abuse on the Rise in America
Judith Graham and Michael Higgins, Chicago Tribune- 10/20/2003

At colleges across the country, students are taking pills they've sneaked from home, tossing them into bowls and swallowing handfuls with a chug of beer or a sip of a margarita. It's called "pharming," for the pharmaceuticals ingested. In office towers, workers sitting at computers are barraged with spam e-mail offering prescription drugs at low prices, no prescription required. "No physical exam," promised one message widely circulated last week, touting painkillers, stimulants, tranquilizers and anti-depressants.
    The face of drug addiction is changing in America, from cocaine or heroin addicts snorting or shooting up to teenagers and grandmothers popping pills purchased at the local pharmacy or delivered through the mail in plain packages. Rush Limbaugh turned a spotlight on the epidemic this month when he admitted being hooked on prescription painkillers and told his radio audience he intended to get help. Prescription drug abuse is the fastest-growing type of substance abuse in the United States, a phenomenon fed by aggressive drug marketing, Americans' habit of taking pills for any ailment, physicians' tendency to overprescribe and the Internet, which is expanding the availability of drugs exponentially.
    About 6.2 million Americans, including disproportionately high numbers of young people and the elderly, abuse prescription drugs, according to government data released in September. More than 14.5 million people report they've taken such drugs for non-medical purposes during the past year. Meanwhile, 2.4 million people in 2001 started abusing pain relievers--the drugs Limbaugh allegedly asked his housekeeper to buy for him--almost a fourfold increase over the 628,000 reported as abusers in 1990, according to the U.S. Substance Abuse and Mental Health Services Administration.

Prevention efforts increase
The problem is so acute that parents may need to start locking their medicine cabinets, just as liquor cabinets were locked decades ago to keep children away from booze, said Joseph Califano, president of the National Center on Addiction and Substance Abuse at Columbia University. Former New York Mayor Rudolph Giuliani has turned his attention to the issue and next month is expected to announce a new national organization, Prescription Action Alliance, aimed at preventing and controlling this type of substance abuse. Law enforcement, medical professionals, drug companies and government agencies are to participate.
    For many people, popping pills may appear to be a more sanitized, less stigmatized way to get relief from the stress of daily life. Instead of dealers on mean streets, frequent sources are doctors duped by patients or pharmacies responding to call-ins for fake prescription refills. Califano, a former Cabinet secretary, cites 2002 figures for legal prescriptions in the U.S.: 153 million for narcotics, such as Vicodin, Percocet or OxyContin; 53 million for tranquilizers such as Xanax or Valium; 23.5 million for stimulants such as Adderal or Ritalin; and 5 million for sedatives such as Soma. On top of that is an unknown quantity of counterfeit prescription drugs streaming into the country through the Internet and other sources, often of unknown quality and diverted to the underground market. Officials from the Food and Drug Administration, Secret Service, Justice Department and pharmacy groups met last week in Washington to develop strategies for keeping counterfeit pills out of the country.
    OxyContin, which some experts call "prescription heroin" because of its similarity in effect to that illegal narcotic, illustrates the expanding scope of the problem. The powerful narcotic, meant for people with chronic and severe pain, has moved into urban and suburban areas from rural areas where authorities first began tracking its abuse several years ago. Abuse of OxyContin "has taken hold across the country," said Dr. Andrea Barthwell, deputy director of drug demand reduction for the Office of National Drug Control Policy. OxyContin is one of the drugs that Limbaugh allegedly took in large quantities. A criminal probe in Palm Beach County, Fla., involving dealers who reportedly supplied Limbaugh is under way; it is not clear whether the radio commentator will face prosecution.

Next step heroin?
There are an increasing reports of OxyContin users turning to heroin when they no longer can get prescription drugs, and some concern that OxyContin abuse may be a precursor to the heroin epidemic sweeping parts of the country, said Robert Lubran, director of pharmacologic therapies at the Substance Abuse and Mental Health Services Administration.
    The Drug Enforcement Administration reports that OxyContin is a "highly abused substance" in Illinois while also noting concerns over the illegal use of other narcotics such as Vicodin, Lorcet and Lortab, and the rising illegal distribution of Ritalin, a stimulant, and Valium, a tranquilizer.
    Purdue Pharma, which manufacturers OxyContin and co-markets it with Abbott Laboratories, is spending more than $200 million educating health-care professionals about the drug, running ads on radio and television warning parents not to make it available to teens, distributing fraud-resistant prescription pads, researching ways to make OxyContin less addictive and developing systems to track and control abuse more quickly.

Fresh hurdles surface
But the rise of the Internet as a source of illegal prescription drugs presents new challenges. At least 2,000 Web sites now sell prescription drugs, the FDA estimates. Traditionally, investigators have looked for geographic "clusters" of drug-related problems--whether admissions to emergency rooms or to jails--to identify physicians who may be overprescribing, buyers who may be doctor-shopping and other drug scams. With the Internet, though, clusters aren't readily detectable.
     In the past several months, authorities have seen "a new and troubling evolution of this business," from the Internet sale of lifestyle drugs such as Viagra and diet aids to the pervasive marketing of all kinds of prescription drugs, said William Hubbard, assistant commissioner at the FDA.
The FDA and the Drug Enforcement Administration last week teamed to form a task force, Operation Gray Lord, that will aggressively pursue outfits that market prescription drugs illegally over the Internet. Doctors who prescribe drugs over the Internet based only on customers' answers to e-mail questionnaires also may be targeted.
    While some Web-based outfits are legitimate--filling prescriptions written by patients' doctors online for a reduced price--many are rogue pharmacies, offering to be both doctor and drug salesman to anyone with a credit card. They're typically secretive, rarely listing their full corporate names, business addresses or the names of doctors and pharmacists they employ.

Easy access
Many are based in foreign countries. Most require only that the shopper fill out a short online questionnaire and provide no oversight of the often dangerously addictive drugs they so easily distribute. "Basically, you can get as much as you want of anything if you know how to do it," said Dr. Daniel Angres, director of Rush Behavioral Health, a treatment program with several sites in the Chicago area. "It's so frightening. None of us wants to think about it in terms of where it might go."
    Several Chicago-area treatment clinics report that 10 percent to 25 percent of their clients abuse prescription drugs obtained from the Internet, up from almost none just two years ago. "It's so easy. You don't have a doctor saying, `I'm not going to write their prescription anymore,'" said Dr. Jake Epperly, president of Midwest Rapid Opiate Detoxification Specialists in Chicago. "I've worked in addictions for 24 years and I've never seen anything like it."

Treatment for Addiction Meets Barriers in the Doctor's Office
Howard Markel, New York Times- 10/21/2003

While progress has been made in combating alcoholism and drug addiction in the United States, the medical establishment is still failing in large numbers to diagnose the disease in their patients, several experts said at a recent conference. "Although doctors and nurses have the best opportunity to intervene with alcoholics and substance abusers, our research indicates they are woefully inadequate of even diagnosing someone with this disease," said Joseph Califano Jr., the chairman and president of Columbia University's National Center on Addiction and Substance Abuse.
    At the conference sponsored by the Columbia center this month, policy makers and addiction specialists evaluated recent research on addiction, which affects 2 of 10 Americans at some point in life and costs billions of dollars for health care each year. Surveys conducted by the center's researchers found that 9 of 10 primary care doctors fail to diagnose substance abuse in patients who display classic symptoms of the problem. The researchers attributed these failures to insufficient training in the treatment of addiction, doctors' frustration with afflicted patients, the common perception among doctors that treatment for substance abuse does not work, and a poor rate of insurance reimbursement for such services.
    Public health policy makers at the Center on Addiction and Substance Abuse have made several recommendations to address these problems including increasing formal substance abuse training for medical students, residents and doctors so they can recognize the symptoms and understand the treatment tools; expanding coverage provided by Medicare, Medicaid, private insurers and managed care for treatment; and adding legal accountability for primary care doctors who fail to diagnose substance abuse or addiction and encourage their patients to seek help.
    Dr. Catherine D. DeAngelis, editor in chief of The Journal of the American Medical Association and a pediatrician, said that "caring for patients with substance abuse is one of the most difficult things I have ever had to deal with as a doctor."Dr. DeAngelis added: "But I am hardly alone. Doctors are trained to figure out a specific pathology and effective treatments for diseases. But when the ailment in question carries a substantial behavioral component, like substance abuse, physicians get frustrated and don't do as well." Dr. June E. Osborn, president of the Josiah Macy Jr. Foundation, which is concerned with the education of doctors, agreed. "Most doctors want to be helpful as well as knowing exactly what they are doing," Dr. Osborn said. "They are taught primarily about acute medical care. In clinical situations where they don't know exactly what they are doing, doctors tend to walk away and adopt an attitude of blaming the patient. But there is no place for blame in health care."
    Doctors have a particularly hard time accepting that there are no easy cures for the chronic and often relapsing disease of addiction, unlike surgical problems that can be corrected by an operation or infections that can be conquered by antibiotics."There never will be a magic bullet against addiction," said Dr. Alan Leshner, the executive director of the American Association for the Advancement of Science and the former director of the National Institute of Drug Abuse. "It's not going to happen." "But we have treatments available that do work," Dr. Leshner added. "Doctors need to learn how to match the treatment modality to a specific patient's needs just as they do for chronic diseases like diabetes or hypertension."
    Surprisingly, scant formal training on addiction and substance abuse is available in American medical schools. Now, most of them offer only a few hours on these complex subjects and even less is offered during most residency or postgraduate programs. Dr. Stanley E. Gitlow, an internist in Manhattan who has treated patients with substance abuse problems for over 50 years, suggested that doctors attend meetings of Alcoholics Anonymous or other treatment groups to hear what alcoholics and addicts go through and how they recover. "Doctors need to learn the natural history of this disease," Dr. Gitlow said. "We must listen to patients," he added. "If a doctor does not have the clinical picture of substance abuse and its treatment in his head, he won't be able to help." 
    Teaching medical students to remain current on certain issues and to work as team members with social workers and psychologists may help provide them with tools needed to treat diseases like addiction, said Dr. Louis Sullivan, the president emeritus of Morehouse School of Medicine. Dr. Osborn agreed that effective teamwork among doctors and other health professionals would go a long way in solving the problem. "We need to rebalance the heavy emphasis on facts that soon become obsolete with universal tools all doctors need. Students and residents are eager for this type of curriculum." One approach involves having medical students sit in all-day treatment sessions with patients and addiction specialists over a week or more at the Betty Ford Center in Rancho Mirage, Calif., said John T. Schwarzlose, the president and chief executive of the center.
    Still, another major obstacle to effective treatment is the presumption among many doctors and patients that it is a matter of personal responsibility rather than a bona fide disease with treatments that can work. But scientists are steadily unlocking the critical biological secrets of addiction and the reasons that some people become addicted to specific substances but others do not. And there is promising research to develop medications that may help addicts overcome their habits.
    Dr. Steven Hyman, provost of Harvard and former director of the National Institute of Mental Health, said: "Choice is a complex issue. We know from scientific studies that the addicted person has constrained volition once the brain has been rewired by chronic drug use. "These brain changes give the utmost priority to scoring drugs or getting a drink under many circumstances. That does not mean that the person has become a zombie."
    One factor that may discourage doctors from learning about substance abuse, let alone tackling it in their clinics, has to do with reimbursement from insurers. Medicaid, Medicare and most private insurance or managed-care companies offer minimal coverage. Dr. Christopher L. Barley, a physician in private practice in Manhattan, said the financial aspect was as critical as any other issue in discouraging doctors from treating addicted patients. He said: "How can you maintain a practice, see the numbers of patients you need to see to earn a living, and successfully treat substance abuse problems? You can't."
    When asked how the medical profession should approach the problem, Dr. Steven Schroeder, a professor of medicine at the University of California at San Francisco, said that "insurers and the health care system need to be more responsive to people with substance abuse problems by covering their treatment just as we cover asthma or hypertension." "But the second problem to surmount is the mind-set of doctors themselves," Dr. Schroeder added. "They need to see substance abuse not as an either-or issue, but as a chronic illness. Doctors need to feel successful when they are keeping people with substance abuse problems out of trouble, even if it is only for a finite period of time."

Rise in Income Improves Children's Behavior
Anahad O'Connor, New York Times- 10/21/2003

The notion that poverty and mental illness are intertwined is nothing new, as past research has demonstrated time and time again. But finding evidence that one begets the other has often proved difficult. Now new research that coincided with the opening of an Indian casino may have come a step closer to identifying a link by suggesting that lifting children out of poverty can diminish some psychiatric symptoms, though others seem unaffected.
    A study published in last week's issue of The Journal of the American Medical Association looked at children before and after their families rose above the poverty level. Rates of deviant and aggressive behaviors, the study noted, declined as incomes rose. "This comes closer to pointing to a causal relationship than we can usually get," said Dr. E. Jane Costello, a psychiatric epidemiologist at Duke who was the lead author. "Moving families out of poverty led to a reduction in children's behavioral symptoms."
    The study took place over eight years in rural North Carolina and tracked 1,420 children ages 9 to 13, 25 percent of them from a Cherokee reservation. Tests for psychiatric symptoms were given at the start of the study and repeated each year. When the study began, 68 percent of the children were from families living below the federally defined poverty line. On average, the poorer children exhibited more behaviors associated with psychiatric problems than those who did not live in poverty. But midway through the study, the opening of a local casino offered researchers a chance to analyze the effects of quick rises in income.
    Just over 14 percent of the American Indian children rose above the poverty level when the casino started distributing a percentage of its profits to tribal families. The payment, given to people over age 18 and put into a trust fund for those younger, has increased slightly each year, reaching about $6,000 per person by 2001. "This is unique because it's a situation where everybody got the extra money," Dr. Costello said. "You can't take a bunch of babies and randomly assign them to grow up in comfort or poverty. So this is about as close to a natural experiment as you can get."
    When the researchers conducted their tests soon after, they noticed that the rate of psychiatric symptoms among the children who had risen from poverty was dropping. As time went on, the children were less inclined to stubbornness, temper tantrums, stealing, bullying and vandalism — all symptoms of conduct and oppositional defiant disorders. After four years, the rate of such behaviors had dropped to the same levels found among children whose families had never been poor. Children whose families broke the poverty threshold had a 40 percent decrease in behavioral symptoms. But the payments had no effect on children whose families had been unable to rise from poverty or on the children whose families had not been poor to begin with.
    The researchers also found that symptoms of anxiety and depression, although more common in poor children, remained the same despite moving out of poverty. The deciding factor appeared to be the amount of time parents had to supervise their children. Parents who moved out of poverty reported having more time to spend with their children. In the other groups, the amount of time the parents had on their hands was not much different. "What this shows very nicely is that an economic shift can allow for more time and better parenting," said Dr. Nancy Adler, professor of medical psychology at the University of California at San Francisco.
    In children, acting out is often a result of frustration that can stem from feeling ignored or not getting enough validation from the parents, said Dr. Arline Geronimus, a professor of public health at the University of Michigan. As a result, behaviors associated with frustration would be the first to change when parents had more attention to devote to their children. "Anxiety and depression, on the other hand, are a little more extreme and might not be as susceptible to change," Dr. Geronimus added. Recent research suggests that anxiety disorders and depression run in families and probably reflect a mix of genetic and environmental causes.
    The study highlights the role that adult supervision may have on mental health in children, but another factor, Dr. Geronimus said, may be the psychological benefits that the casino payments produce. The Indian families were much more likely to be poor than their non-Indian neighbors at the start of the study. After the payments, though, a higher proportion of Indian families moved out of poverty. "There's the possibility that this improved the general outlook of the families — that the whole community has more than before," Dr. Geronimus said. "In addition to the material resources, there might have been some psychological benefits."
    Those psychological benefits may also be a byproduct of the jobs that the casino has generated, said James Sanders, director of an adolescent drug and alcohol treatment center on the reservation. "The jobs give people the chance to pull themselves up by their bootstraps and get out of poverty," said Mr. Sanders, whose son took part in the study. "That carries over into less juvenile crime, less domestic violence and an overall better living experience for the families."
    But one question that lingers is why the economic change had a significant effect on only a small proportion of the children. All of the families that received the payment were given the same amount of money, but only 14 percent moved out of poverty while 53 percent remained poor. The answer could be related to the number of siblings in each family. A $6,000 payment could be a huge help to a poor family with one child, for example, "but that money might not go as far for a family with multiple children," Dr. Adler said. In 2002, the average poverty threshold for a family of three was $14,348.
    Though some questions remain, the study ultimately suggests that poverty puts stress on families, which can increase the likelihood that children will develop behavioral problems. That, said Dr. Geronimus, speaks to the notion that welfare policy is heading in the wrong direction. "Parents on welfare are increasingly required to work more and more hours while spending less time with their families," she said. "These findings suggest the opposite: parents value having more time to spend with their kids, not less, and their kids respond favorably to that."

In Defense of Electroshock
New York Times, 10/21/2003

"Electroshock: Healing Mental Illness," by Max Fink, M.D. Oxford University Press, $12.95.

Few procedures performed by the medical profession have struck more fear in the general public than electroconvulsive therapy for the treatment of severe mental illness. Referred to in nonprofessional writings as electroshock, the treatment has been depicted chillingly in many films and still raises the specter of brain alteration and personality and character changes. "Many consider it so, dangerous that they fear it as much as the disease," writes the author of this defense of the procedure, which was introduced in 1934.
    Dr. Fink, who is an emeritus professor of psychiatry and neurology at the State University of New York at Stony Brook, writes about the use of electroshock in the treatment of depression, mania and schizophrenia among other disorders. He cites numerous studies that he says demonstrate its effectiveness, its record in reducing the cost and length of patient treatment, and its ability to bring on antidepressant effects earlier "and more robust than those of antidepressant drugs."
    Dr. Fink's assessment is generally confirmed by the National Institute of Mental Health, which characterizes electroshock therapy as "one the most effective yet most stigmatized treatments for depression." Eighty to 90 percent of people with severe depression, according to the the institute, improve drastically. But there are negative effects, including some memory loss and other mental problems. A current research question is how best to maintain the benefits of the therapy over time.

Experts Try Magnets for the Mind
New York Times, 10/21/2003

Patients whose depression failed to respond to drugs showed improvement when treated with magnetic stimulation of their scalps, according to a new study. Researchers have been exploring magnetic stimulation as an alternative to electroshock therapy for severely depressed patients who do not respond favorably to other treatments, according to an article last week in The Archives of General Psychiatry.
    Most similar studies used high-frequency bursts of magnetic stimulation, delivered through the scalp to an area in the left side of the brain that has been linked to low levels of activity during deep depressions. The study's lead researcher, Dr. Paul B. Fitzgerald of Monash University in Melbourne, Australia, said the magnetic stimulation technique was beginning to be used in Canada and Europe.
    In the study, Dr. Fitzgerald and his colleagues tested. a newer approach as well, applying lower-frequency pulses to a part of the right side of the brain that is also affected by depression. Lower-level pulses are more comfortable and hold a lower risk of generating seizures, he said. In the study, 60 patients who had not been helped by several medicines were divided into three groups and given high-frequency, low-frequency or sham treatments. All were hooked up to magnetic coils 10 times a day, 5 days a week. But in the sham group, the coil was misapplied and had no effect.

The scores on a variety of measures of depression fell significantly for the two magnetic stimulation  groups, and virtually no change occurred among those receiving the sham treatment, Dr. Fitzgerald said. The treatments took about a month to become effective, and while some patients reported headaches, none dropped out because of side effects.

Mental Health and Protection Debated
Laura Potts, Detroit Free Press- 10/22/2003

On his way back home to Missouri this week, Charles Heisinger will stop a final time at the Kalamazoo bus station where his 24-year-old son was beaten to death three years ago by a man with chronic mental illness.  "That's where Kevin was last alive and I just feel like he has a presence there," said Heisinger, who is to testify today in Lansing on legislation that supporters say will protect people with mental illness from hurting themselves or others. Spurred by Kevin Heisinger's death, the package of bills is under review by the Michigan Senate Health Policy Committee.
    The so-called Kevin's Law bills would enable courts to order some people with mental illness into outpatient treatment. It is part of pending legislation to improve Michigan's mental health system.  Finishing a series of hearings on mental health earlier this month, the committee is considering several bills that mental health advocates say address issues that have long demanded attention. Among them:
* Making insurers reimburse mental health services on the same level that they pay for physical health care.
* Taking most major mental health drugs off a Medicaid list that requires approval before they can be prescribed.
* Strengthening the grievance process for people who aren't satisfied with the services provided by Community Mental Health authorities.
    Committee chair Sen. Beverly Hammerstrom, R-Temperance, said more mental health legislation likely will be introduced before the end of the year. The tricky part, she and others say, is striking a balance between what is best for people with mental illness and for the state as a whole.
    Kevin's Law would enable people with psychiatric hospitalizations or incarcerations who have a history of violent behavior to be ordered into outpatient care if they refuse to comply with their prescribed treatment. Courts could require that people be hospitalized.  But Hammerstrom and others worry about some facets of the legislation. Would it violate civil rights? Is there money to support such a program? Would it perpetuate stereotypes that all people with mental illness are violent and dangerous?  "You have to weigh the desire to honor anyone's preferences with the fact that we have a lot of people in our state with serious, untreated mental illness and is it in their best interest to do more to get them care and treatment," said Mark Reinstein, president and chief executive officer of the Mental Health Association in Michigan.  Reinstein said his group "isn't automatically opposed to the concept," but he wants to see some revisions, including a provision to annually examine the program's progress.  But supporters of the legislation say it's what is best for all involved -- including people with mental illness.
    "Kevin would want to help people and this legislation would help mentally ill people from harming themselves and harming other people," said Heisinger, who lives in Black Jack, Mo.  On Aug. 17, 2000, Kevin Heisinger was beaten to death at a Kalamazoo bus station by Brian Williams, who had been diagnosed 20 years earlier with schizophrenia.  Williams, who is in a psychiatric hospital, had for weeks before Heisinger's death exhibited the kind of erratic and violent behavior -- including brandishing a knife -- that supporters of the legislation say would be key to ordering someone into treatment.  

Study Finds Hundreds of Thousands of Inmates Mentally Ill
Fox Butterfield, New York Times- 10/22/2003

As many as one in five of the 2.1 million Americans in jail and prison are seriously mentally ill, far outnumbering the number of mentally ill who are in mental hospitals, according to a comprehensive study released Tuesday. The study, by Human Rights Watch, concludes that jails and prisons have become the nation's default mental health system, as more state hospitals have closed and as the country's prison system has quadrupled over the past 30 years. There are now fewer than 80,000 people in mental hospitals, and the number is continuing to fall.
    The report also found that the level of illness among the mentally ill being admitted to jail and prison has been growing more severe in the past few years. And it suggests that the percentage of female inmates who are mentally ill is considerably higher than that of male inmates.
    "I think elected officials have been all too willing to let the incarcerated population grow by leaps and bounds without paying much attention to who in fact is being incarcerated," said Jamie Fellner, an author of the report and director of United States programs at Human Rights Watch.  But, Ms. Fellner said, she found "enormous, unusual agreement among police, prison officials, judges, prosecutors and human rights lawyers that something has gone painfully awry with the criminal justice system" as jails and prisons have turned into de facto mental health hospitals. "This is not something that any of them wanted."
    Reginald Wilkinson, director of the Ohio Department of Rehabilitation and Correction, said the "mere fact that this report exists is significant." "Some people won't like it, and the picture it paints isn't pretty," Mr. Wilkinson said. "But getting these facts out there is progress." Many of the statistics in the study have been published before by the Justice Department, the American Psychiatric Association or states. But the study brings them together and adds accounts of the experiences of dozens of people with mental illness who have been incarcerated.
    The study found that prison compounds the problems of the mentally ill, who may have trouble following the everyday discipline of prison life, like standing in line for a meal.  "Some exhibit their illness through disruptive behavior, belligerence, aggression and violence," the report found. "Many will simply — sometimes without warning — refuse to follow straightforward routine orders." Where statistics are available, mentally ill inmates have higher than average disciplinary rates, the study found. A study in Washington found that while mentally ill inmates constituted 18.7 of the state's prison population, they accounted for 41 percent of infractions.
    This leads to a further problem — mentally ill inmates who cannot control their behavior are often, and disproportionately, placed in solitary confinement, the study found.  Solitary confinement is particularly difficult for mentally ill inmates because there is even more limited medical care there, and the isolation and idleness can be psychologically destructive, the report says.
    Medical care for mentally ill inmates is often almost nonexistent, the study says. In Wyoming, a Justice Department investigation found that the state penitentiary had a psychiatrist on duty two days a month. In Iowa, there are three psychiatrists for more than 8,000 inmates.
    There is no single accepted national estimate of the number of mentally ill inmates, in part because different states use different ways to measure mental illness. The American Psychiatric Association estimated in 2000 that one in five prisoners were seriously mentally ill, with up to 5 percent actively psychotic at any given moment. In 1999, the statistical arm of the Justice Department estimated that 16 percent of state and federal prisoners and inmates in jails were suffering from mental illness. These illnesses included schizophrenia, manic depression (or bipolar disorder) and major depression.
     The figures are higher for female inmates, the report says. The Justice Department study found that 29 percent of white female inmates, 22 percent of Hispanic female inmates and 20 percent of black female inmates were identified as mentally ill. One reason some experts have suggested for the higher numbers among female prisoners is that psychologists and psychiatrists working in prisons tend to be more sympathetic to women, finding them mentally ill, while they tend to evaluate male inmates as antisocial or bad. But Mr. Wilkinson said, "I think the differences are real; more female inmates are mentally ill." He suggested that prisons were seeing more severely mentally ill inmates now "only because the volume is greater," meaning that the number of people in prison has increased.

Report on State Prisons Cites Inmates' Mental Illness
Paul von Zielbauer, New York Times- 10/22/2003

Nearly one of every four New York State prisoners who are kept in punitive segregation — confined to a small cell at least 23 hours a day — are mentally ill, according to a new report by a nonprofit group that has been critical of state prison policies.
    One in five of the roughly 5,000 prisoners punished with that isolation have a serious drug problem, the report said. But despite graphic evidence that the most acutely ill prisoners in punitive segregation, or lockdown, often grow only more troubled and violent, the state Department of Correctional Services, which runs the state's 70 prisons, rarely does anything to help them, said the report, released yesterday by the group, the Correctional Association of New York. To the contrary, when inmates in punitive segregation try to hurt or kill themselves, the department's policy is to punish them with additional lockdown time, according to the report. About half of the 258 inmates interviewed by the report's authors said they had attempted suicide in prison. Many prisoners spend years under lockdown.
    The findings of the association, an inmate-advocacy group, are based on state records, the authors' visits to 29 state prison lockdown units and interviews with hundreds of prisoners, correction officers and prison supervisors. The association, established in 1844, is authorized by state law to visit prisons and interview inmates and employees.
    The Correctional Services commissioner, Glenn S. Goord, declined to comment yesterday on the report's specific conclusions and recommendations, which include changing prison rules so that emotionally disturbed inmates who misbehave would be treated instead of sent to isolation. Instead, Mr. Goord accused the Correctional Association of proffering "phony issues," and criticized the report's principal author, Jennifer Wynn, as unprofessional. But in interviews, several prison experts, psychiatrists and state officials who are familiar with the report agreed with its conclusion that the prison system is unprepared to properly treat mentally and physically ill inmates.
    Yesterday, an independent report by Human Rights Watch found that as many as 25 percent of prisoners nationwide are mentally ill.  "The 25 percent is very much like it is for other states; there are probably some that are even worse, and it's a scandal," said Michael L. Perlin, a professor at New York Law School who has studied prison mental health issues. "It reflects a mentality that we should have discarded a century ago." Professor Perlin, who sits on the Correctional Association's advisory board, said Commissioner Goord, who has dismissed criticism of punitive segregation in the past, should heed the association's findings. "There should be a tremendous obligation on the part of New York's authorities to deal with this frontally and forthrightly," he said.
    In the association's 51-page report, the authors paint a grim portrait of the lockdown units in some state prisons. They describe observing one inmate alone in his cell, smeared with his own feces; another inmate sprawled on the floor because his wheelchair was confiscated for security reasons; a prisoner with AIDS, dying and barely able to lift his head; and dozens of others with symptoms of acute psychoses or covered in scars from self-inflicted cuts.  "These are serious human-rights abuses," said Robert Gangi, the Correction Association's executive director. "There are people who die needlessly in New York State prisons because they are put in there when they are mentally ill, and they kill themselves." He added, "The state's political leaders should recognize how important a matter this is."
    Using nearly $200 million in federal grants, New York has built 10 prisons with 3,788 beds since 1997, solely for punitive segregation, Mr. Gangi said. Beyond those units, there are more than 20 "segregated housing units" in the state's seven maximum security prisons, as well as lockdown cells in separate blocks within other prisons. About 7.6 percent of the 65,000 inmates in the state prison system were in lockdown in April, according to the report. The report said department records indicate that the average prisoner in 23-hour lockdown remains there for five to six months before returning to the general prison population. (One hour a day is allowed for what is called recreation in a small, empty outdoor cage.) But in interviews with inmates, the association reported their average stay to be three years. Most punitive segregation is solitary confinement; some units house two inmates.

After Detox, The Hardest Part of Treatment Begins
Sandra G. Boodman, Washington Post- 10/24/2003

Now that he has embarked on his third formal attempt to kick an addiction to prescription drugs, conservative radio talk show host Rush Limbaugh is likely to find that getting off narcotic painkillers is the easy part. The hard part, experts say, will be staying clean. "The problem is that people want to go into treatment, have that episode be over and then live happily ever after, which is not the way it works," said Wilson Compton, a psychiatrist at the National Institute on Drug Abuse, who spent a decade as medical director of a treatment program.
    When it comes to kicking a prescription drug habit, Compton and others say, relapse is the rule rather than the exception. Recovery is a lifelong process that requires an addict to fashion a new life without a pharmacological cushion that exerts profound effects on the brain as well as the psyche. The painkillers Limbaugh abused, which reportedly include Vicodin and OxyContin, a drug known as "Hillbilly Heroin" because of its popularity in rural southern communities, serve multiple purposes. They create a powerful sense of euphoria and well-being; blur the distinction between fantasy and reality; quell depression and anxiety; and relieve the physical misery that drives many users to take the drugs in the first place.
    The drugs, known as opiates, attach to receptors in the brain and spinal cord and block the transmission of pain messages to the brain. Excessive long-term use of opiates appear to alter brain chemistry by overstimulating the brain's reward pathways, reinforcing the desire for greater doses of the drug.
    Limbaugh has said he started taking the painkillers, which are chemical cousins of heroin, five or six years ago to treat pain from failed spinal surgery. He said that his two previous attempts at rehab failed.
    Experts in drug treatment say that is not unusual: Most addicts relapse at least once, as do most people who try to stop drinking or smoking. Researchers say they do not know how many times it takes to achieve sobriety, because that question has not been well studied in users of drugs other than nicotine. But most agree that overcoming a painkiller habit tends to be more difficult than treating an addiction to alcohol, cocaine or nicotine.
    "Treating this kind of addiction is more complex," said Jon Morgenstern, director of the division of treatment research at the National Center on Addiction and Substance Abuse at Columbia University. "There are tremendous cravings initially to go back and use which must be managed to prevent relapse."
    While statistics vary widely and there are few studies of prescription drug abusers, about half of heroin addicts who undergo treatment are either dead or on long-term methadone maintenance 30 years later, Morgenstern said. Methadone, a synthethic opiod, is a legal substitute for heroin; it is also used to treat prescription drug addicts. "We think the incredibly poor recovery rates among heroin addicts may be related to significant changes in their brain chemistry," said Marvin D. Seppala, medical director of Minneapolis-based Hazelden, one of the nation's oldest and best known inpatient substance abuse programs.
    While many people start taking narcotic painkillers after surgery or an accident, most of them automatically taper their dose as the pain recedes and then stop taking the drugs altogether. Addicts behave differently, ratcheting up the dose as the pain subsides because they like -- and then crave -- the feelings the drugs induce. Most depend on the medications to manage their moods, not pain.
    Cindy McCain, wife of Sen. John McCain (R-Ariz), has said her addiction to Vicodin, which began after she started taking the drug after back surgery, helped her get through the "Keating Five" savings and loan scandal of the 1980s in which her husband was implicated. "The pills made me feel euphoric and free" even while she was sitting through blistering testimony about her husband in Senate hearings, McCain has written. She said she overcame her addiction years ago.

Hooked on a Pathway
While federal statistics illustrate a dramatic increase in the number of people abusing addictive painkillers, particularly OxyContin, most people who take these drugs never get hooked. "Addiction is defined by addictive behaviors," Seppala said. These include taking more pills than prescribed, shopping for doctors who will prescribe medication, filling prescriptions at multiple pharmacies, and clandestine or compulsive use of medication. Cindy McCain has described locking herself in the bathroom to gobble five or six pills so no one could see how many she was taking.
    Despite the popular notion that there is an "addictive personality," experts dismiss the concept as a myth. Researchers simply do not know why some people can take OxyContin for years to treat severe chronic pain without becoming hooked, while others become addicted in a matter of weeks. The reasons, Morgenstern speculated, probably include a complex mix of poorly understood factors, among them a genetic predisposition to addiction, an inability to handle stress and impulsivity.   "We know that all addictive substances interact with a common reinforcement pathway," said Compton, director of prevention research at NIDA. "We're still trying figure out exactly what the pathways are."
    Compton and other experts say that prescription drug addicts face a hurdle not shared by alcoholics or people who take street drugs. Many pill addicts delude themselves into thinking that they don't really have a problem because the drug they are taking is legal and has been prescribed by a physician for a medical problem.
    Overcoming that denial is critical, said psychologist John Schwarzlose, president of the Betty Ford Center in Rancho Mirage, Calif., which has treated more than 62,000 people since its founding more than 20 years ago. About 10 percent of these patients, Schwarzlose said, were primarily addicted to painkillers.  "An addict is an addict," Schwarzlose said, adding that this is a view treatment centers try to impress on all patients. "And a person who can still function no matter what they're addicted to is the most difficult to intervene on." Most addicts, he noted, are working and some can function at a high level, as did Limbaugh, who until his recent leave of absence hosted a regular five day a week radio show.

The Usual Treatment
Regardless of the drug of choice -- painkillers, heroin, crack, tranquilizers -- inpatient drug treatment typically follows a similar path: detoxification followed by behavioral therapies, usually group and individual therapy, and faithful attendance at Narcotics Anonymous (NA) meetings. The self-help group, founded 50 years ago by recovering heroin addicts in Los Angeles, is similar to Alcoholics Anonymous and is predicated on a combination of anonymity, spirituality and personal responsibility. Addicts are encouraged to attend self-help meetings for months or years after they leave treatment for the support and to help prevent relapse.
    Withdrawal from opiates is riskier and more unpleasant than detox from alcohol or cocaine, experts say. "With normal alcohol detox, you rarely run into any complications," Schwarzlose said. "But with opiate addiction, even if you use the right medications and the right treatment approach, addicts can go through incredible mental and physical difficulties when they detox." Detox is similar to a bad case of the flu and can take about a week, he said. Patients typically experience intense feelings of jitteriness and bouts of sleeplessness, which can last much longer. Earlier this year, the Food and Drug Administration approved a drug called buprenorphine, which blunts the symptoms of withdrawal and the cravings addicts feel. Some treatment centers also administer clonidine, a blood pressure drug, to ease withdrawal.
    While some patients who undergo withdrawal from painkillers find that a few weeks after detox the physical misery that initially caused them to take the drugs has vanished, others must confront chronic pain. For these patients, Hazelden and other treatment centers usually try alternatives to narcotics: acupuncture, relaxation techniques including yoga, nonnarcotic painkillers and sometimes surgery. If these fail, officials may consider a tightly controlled treatment with lower doses of opiates. "The ideal is complete abstinence, but for a small group of patients in rare cases we would set up an extensive program of monitoring and support," Hazelden's Seppala said. One such program involved a recent Hazelden patient who suffered multiple injuries and underwent many surgeries after a devastating motorcycle accident; opiates were the only things that eased his pain. Hazelden helped set up a program that requires he receive treatment from only one physician experienced in both pain management and addiction, and that he get his prescriptions filled at a single pharmacy.
    One factor that will inevitably affect Limbaugh after treatment is his celebrity. While fame and wealth may have prolonged his addiction, his future is at stake. And that, they say, may help him, as it has other addicts. "He's got a tremendous motivation -- his career is on the line," observed Joseph A. Califano Jr., president of the Center on Addiction and Substance Abuse at Columbia University. Califano noted that studies have found that the prospect of job loss, more than other factors such as the threat of divorce or loss of custody, tends to force people to stay clean. Schwarzlose said that has been the experience at Betty Ford, which has treated more celebrities than most centers.
    "Our most successful group of patients are airline pilots," Schwarzlose said. He notes that more than 90 percent of pilots treated at Betty Ford for drug or alcohol abuse do not relapse. The reason, he said, is this: The Federal Aviation Administration does not give them a second chance. "They're told they can be tested at any time and if their urine is dirty, they'll never fly again," he noted. Actors and other entertainers, Schwarzlose added, don't fare nearly as well. "In that world," he said, "there's no incentive."

Brutal Killing Galvanizes Foes of Domestic Violence
Jeffrey Gettleman, New York Times- 10/24/2003

MONROE, N.C., -- Experts say that every day in this country, three women are killed by domestic violence. On Thursday, one was buried here. Tracey Helms, a young mother of two, was trying to shelter a friend from an abusive husband when, the police say, he showed up at Ms. Helms's house and beat her to death with a steel shovel. "As she crawled away across the front lawn, he hit her again," said Bobby Haulk, the Monroe police chief. "And again and again." Ms. Helms's husband and children were sleeping inside. Her husband found her body that morning, after he looked out a window and saw an apron lying on the grass. It is one thing to die, her family says, and another to be killed. "If it was a car wreck," said Freddy Smith, Ms. Helms's father-in-law. "If it was some sort of accident." His voice trailed off. "But helping a friend?"
    There is no shortage of domestic violence horror stories, but this one seems to have struck a nerve. Publicity has spread the grief far beyond the soybean fields and pastures that ring Monroe, 18 miles southeast of Charlotte. Domestic-violence crusaders from all over are citing the brutal killing, last Saturday, in urging a new direction in the movement, one focused not so much on empowering women as on changing men. "This case indicates that the only thing that can stop this violence is him," said Rita Smith, executive director of the National Coalition Against Domestic Violence. "It's not about her. It's not about why she didn't leave. 'She did."
    Advocates for abused women note that October is Domestic Violence Awareness Month, by proclamation of President Bush, and say some of the most interesting programs addressing the issue involve men and boys. Patrick Lemmon, co-founder of Men Can Stop Rape, a nonprofit organization based in Washington, holds workshops for teenage boys where they play a game called Who de Man? Instructors show pictures of male celebrities from Eminem to Yoda and ask the boys to identify what it means to be a "real man." "The idea is to show how caught up we are in doininance and control," Mr. Lemmon said.
    Marie Brodie French, a training specialist with the North Carolina Coalition Against Domestic Violence, agreed that the new emphasis was on working with men. "I mean, what guy who beats his wife is going to listen to a woman?" Ms. French said. After the killing here, she said, her office was besieged by callers asking what they could do. On Tuesday, a silent march was held in Charlotte. In Durham, there is a maple tree with one origami bird for each life lost to domestic violence in North Carolina this year. Ms. Helms's was No. 48. Soon there will be a bird for her.
    Ms. Helms, daughter of a preacher, grew up in Albuquerque. After high school she moved with her parents to North Carolina, where she met D. J. Helms. He wore a ponytail and laid hardwood floors. They married, had a boy and a girl, and moved into a little brick house in a blue-collar neighborhood in this blue-collar town, population 28,000, known for farms and a few factories. Ms. Helms, 25, waited tables at Logan's Roadhouse, a diner where customers are given buckets of raw peanuts and told to toss the shells on the floor. Last week another waitress there, Holly Blount, moved in with the Helmses. Ms. Blount told them she was scared of her husband, Michael W. Blount, whom she had wed only a month or so earlier.
    Mr. Blount has a history of abuse. In 2001, he spent 10 months in jail after being found guilty of breaking into a girlfriend's house, lying in wait for her, holding a knife to her throat and choking her so badly she could not speak for three weeks. In a small-town kind of coincidence, it was Ms. Helms's father-in-law, then a police officer, who arrested him.
    Experts on domestic violence say North Carolina is on the leading edge of preventive programs. One new tactic is "evidence-based misdemeanor prosecution," in which officers take photographs of smashed plates, ripped-out phones and other signs of rage to prove in court that a woman has been harmed or threatened, even if, as is often the case, she recants her accusation. "We don't even ask the victim if she wants to proceed with charges," said Sgt. John Guard of the sheriff's office in Pitt County, in eastern North Carolina.
    In the 30 years of the organized movement against domestic violence, many laws have been passed to address spousal abuse. Largely as a result of those efforts, the number of women killed by domestic violence has dropped nationally over the years, to 1,197 in 2001 from 1,600 in 1976, according to the Justice Department. Most of the dead are wives or girlfriends. A few are just friends. Early Saturday, morning, Ms. Helms and Ms. Blount had just returned from a late-night shift at the roadhouse when they saw Mr. Blount hiding behind a tree with a shovel, officers said. Ms. Helms tried to run inside. Mr. Blount swung his shovel. He then dragged his wife to her car and forced her to come with him. He was arrested that day and is now in jail facing a charge of first-degree murder.
    On Thursday, in her coffin, Ms. Helms rested on a bed of white satin, dressed in her favorite leather jacket. "I just want to say Tracey was my best friend, and I love her," a weeping Ms. Blount said. Janice Smyrl, Ms. Helms's aunt, spoke next. She quoted the Bible: "Greater love hath no man than this, that a man lay down his life for his friend."

The Roots of Temptation
Benedict Carey, Los Angeles Times- 10/25/2003

A simple plea for reassurance — You'd tell me, wouldn't you? — is about all the discussion many couples can manage on the topic of marital infidelity. It's rarely a genuine request: Everyone knows it could happen, but very few of us would really want to know that it did. The topic of infidelity is off limits for most couples. That's one reason social scientists have left the study of hidden love largely to novelists and poets. "Although we can describe sexual desire, we don't know how to measure it scientifically," said Dr. Stephen B. Levine, a psychiatrist at Case Western Reserve University's School of Medicine and co-editor of the Handbook of Clinical Sexuality, a guide to help doctors address sexual concerns.
    For many years, most of what scientists knew about infidelity came from marital therapists' interviews with clients or from psychologists who asked men and women to answer questions about hypothetical affairs. In the last few years, however, researchers have finally begun to conduct larger, more rigorous surveys, asking about real experiences. The evidence has contributed to an emerging body of thinking about who cheats, when and why.
    Contrary to one commonly held view, many people who report being in happy marriages commit adultery. Their yearning for variety warps their judgment, even when they fully appreciate the risks of infidelity. For when an affair is revealed, clinicians report, the impact on the marriage is usually catastrophic. "Those who assume that only bad people in bad marriages cheat can blind themselves to their own risk," said Beth Allen, a researcher at the University of Denver who, with colleagues David Atkins, of the Fuller Theological Seminary in Pasadena, and the late Shirley Glass, a Baltimore family psychologist, recently completed an extensive review of infidelity research. "They're unprepared for the risky times in their own lives, the dangerous situations when, if they aren't careful, they'll suddenly be very tempted," Allen said.

Taking a closer look
The prevalence of infidelity is coming into sharper focus. Several recent surveys suggest that the majority of people do not cheat, either because they cannot bear the thought of betrayal, cannot drum up the interest or perhaps have already known the profound pain of losing an important relationship. Yet the studies find that more than one in five Americans do have an affair, at least once in their lives, and that women are now about as likely as men to cross the line.
    The first few years of marriage are clearly a red zone, new research shows. An analysis conducted in 2000 by sociologists in New York found two distinct patterns in the timing of affairs. A married woman's likelihood of straying is highest in the first five years, and falls off gradually with time, according to the survey of 3,432 U.S. adults. Men have two high-risk phases, one during the first five years of marriage and again, after the 20th year.
    The psychological underpinnings of early affairs often are tied up with the vows themselves, some experts believe. As well-intentioned as they can be, vows are still open-ended pledges — of unknown cost, of blind sacrifice. Very often, their gravity doesn't sink in right away; and young married men and women often have a lingering appetite for the flirtation and sexually charged attention that was the lifeblood of their single lives, marital therapists say.
    Newlyweds' expectations of wedded bliss can set them up for profound disappointment, after the florists and caterers are gone and the reality of living with a spouse becomes clear. And if there are no children on the way, to deepen and broaden the character of the bond, the yearning for variety and attention outside the marriage often still runs very high, psychologists find. "One reason for starting an affair, especially for young couples, is rebelliousness against the vows, against the very idea that 'I'm never ever going to make love to another person,' " said Joel Block, a clinical psychologist in New York and author of "Naked Intimacy" (McGraw Hill, 2003).
    Even when people welcome the sacrifice, and honor vows without reservation, the promises can lend a false sense of security. The commitment is firm, but the imagination may lag behind. In one recent study, University of Vermont psychologists surveyed 180 couples who were either married or living with a partner. Fully 98% of males and 80% of females reported having a sexual fantasy about someone other than their partner, at least once in the previous two months. The longer couples were together, the more likely both partners were to report having fantasies; but the imagined flings were still very common in young married couples, who often assumed that they should be immune. In short, almost everyone is doing it — at least in their heads. And usually they can't talk about it, especially with the person closest to them. This creates one of the universal paradoxes of romantic desire, a tension between public faithfulness and private longing for another, a secret life of the imagination.
    Some married people can live with this paradox and understand it as an entirely internal drama that in no way presages a real affair or reflects any need to stray. Yet even long-married people who are acutely aware of this double life and can joke with themselves about it aren't always able to resolve their tension. In a psychological sense, free-floating desire has provided the brain with an idea of infidelity, complete with expectations, curiosities and what-ifs. The frequency and vividness of these thoughts may themselves lead a man or woman to believe their love for a partner is fading, Levine said. Then something happens. A blowout argument. A promotion. A school reunion, the loss of a job, an e-mail from an old boyfriend. Some triumph or loss that opens a door through which a person is now primed to walk. The delights of an affair have already been richly imagined. The consequences are now minimized: "Many couples survive affairs; stop depriving yourself; it's an experience, part of the richness of life," a person might tell herself or himself. "Whatever the final provocation," Levine said, "the person decides — actively makes a choice to participate at every step along the way."
    The evidence that this kind of logic can lead people astray from apparently satisfying, long-lived, stable relationships is circumstantial but compelling. In one recent analysis, researchers at UC Irvine found that people who claimed their marriage was "very happy" were two times as likely to cheat on their spouses as those who said their marriage was "extremely happy."

What drives them?
The given reasons for these affairs range widely. In research for a book, Diane Shader Smith, a Los Angeles writer, has conducted in-depth interviews with more than 175 married women who have had or were currently involved in an affair. There were "revenge" flings: One woman had a brief affair after she found out that her (now former) husband had cheated on her. There were "motivational" flings: An L.A. doctor's wife has had affairs whenever she needs some impetus to lose weight. And certainly love can come into play: One middle-aged woman living out in the country had a 10-year affair with her neighbor's husband.
    "One thing many had in common was chemistry," Smith said. "They all described that, the chemistry with another man, the casual brush against the arm, that orgasm-on-the-spot feeling," she said. Most of the women interviewed were unapologetic, Smith said; many had kept their secret, and preferred to stay in their marriage, risks and all. In previous surveys, men have expressed similar motives, although primarily focused on the thrill of sensual pleasure.
    Psychologists may never know the true impact of infidelity on marriage. Most couples do not seek therapy, whether an affair is suspected or revealed. Among couples who do pursue counseling, however, there's little doubt: Infidelity hits like Hurricane Isabel. In one recent study of 62 Israeli couples seeing therapists to help cope with their affairs, a third eventually divorced; about half limped along in still-troubled marriages, according to researchers at Hebrew University, in Jerusalem. Only nine of the couples, or 14%, seemed to bounce back and show signs of real growth and optimism in their marriage, the psychologists reported.

Traveling a rocky road
Several recent studies have tracked how men and women react when a partner's affair is revealed. The pattern is familiar: emotional chaos, which can last for months; then reflection and self-questioning, which can go on even longer; and finally, a decision whether to forgive, if not forget.
    In one ongoing study, researchers at UCLA and the University of Washington in Seattle have been tracking 134 couples in marriages deemed "very troubled" as they attend weekly therapy sessions. Those couples whose relationships were most damaged, by psychological measures, tended to be the same ones who were reeling from affairs, said Atkins, of the Fuller Theological Seminary. Yet after six months of therapy, these 19 couples had made greater gains in repairing their relationships than the others. In part, that's because they started at the bottom, he said. But there also appeared to be something else at work.. "These couples were very unhappy at the start, but they also had shown heroic perseverance in the face of this betrayal," Atkins said. "In no way do we want to say that infidelity is good. But it may be that, at least for these couples, the affair gave them one huge major issue to focus on in the therapy."