WASHINGTON -- Alcohol-related traffic death rates increased or held steady in 19 states between 1998 and 2002, according to new federal data suggesting efforts to curb drunken driving have reached a plateau. The National Highway Traffic Safety Administration's report, which was released Thursday, calculated the fatality rate per 100 million miles driven. NHTSA considers a crash alcohol-related if a driver had anything above a 0.01 blood-alcohol level, which is far lower than the 0.08 legal limit in 45 states.
        South Carolina saw the greatest increase in its death rate during the four-year period, followed by Kansas, South Dakota, Rhode Island and Wisconsin. The states with the highest numbers of alcohol-related deaths per miles traveled were Montana, South Carolina, South Dakota, Nevada and Louisiana. Barbara Harsha, executive director of the Washington-based Governors Highway Safety Association, said experts can't explain why some states have far fewer drunken driving deaths than others. "There don't seem to be any patterns," she said. "Some have seen increases after a period of decreases and they're doing the same things as they were in the past." Harsha suspects rates remain high in some places because of a growing number of alcohol-related motorcycle accidents in the last five years. She also said motorists are driving faster than they used to, so they're more likely to be in fatal crashes that may be fueled by alcohol.
        Drunken driving deaths declined markedly during the 1980s and early '90s as organizations such as Mothers Against Drunk Driving were formed and drew attention to the problem. NHTSA's report showed 26,173 alcohol-related traffic deaths in 1982, or 60 percent of all traffic deaths, falling to 16,572, or 40 percent, in 1999. For 2002, the figures were 17,419 alcohol-related deaths, or 41 percent of all traffic fatalities. "We seem to be stalled or stuck at relatively the same fatality rate," said Dennis Utter, chief mathematician for NHTSA's National Center for Statistics and Analysis.
        Earlier this month, NHTSA administrator Dr. Jeffrey Runge said the nation needs to establish special drunken driving courts, screen medical patients for alcohol abuse and enlist the help of alcohol manufacturers in order to combat the rise in death rates.
        Thirty-one states and the District of Columbia saw alcohol-related death rates decrease, NHTSA says in its report. Four states -- Vermont, Indiana, Oregon and Iowa -- and the District of Columbia saw their rates fall by 25 percent or more. Vermont, Utah, Maine, New York and Indiana had the lowest overall death rates. Vermont was the only state that showed consistent annual declines in its alcohol-related traffic deaths, NHTSA said. The state had an overall decline of 54.1 percent between 1998 and 2002.
        NHTSA's numbers don't necessarily match data collected by states, because states vary widely in the amount of information they gather at accident sites. In cases where the dead weren't tested for blood-alcohol levels, NHTSA uses estimates and statistical procedures to determine the likelihood that alcohol was involved.
        ON THE INTERNET National Highway Traffic Safety Administration www.nhtsa.dot.gov

Experts Warn Texas Privatization Could Affect Mental Health Care
Polly Ross Hughs, Houston Chronicle-12/22/2003

AUSTIN -- A little-noticed privatization change in state law, unless reversed, could unravel mental health safety nets across the state, several mental health experts fear. "It would be a disaster. There's probably very little question about that," Melanie Gantt, public policy director for the Mental Health Association in Texas, said of the plan many are working to change. "It's a hastily conceived notion that does not take into account ramifications to the consumer and the public safety net," she added.
        Proponents of privatization say it can lead to more patient choice, access to better-quality care and greater administrative efficiency. Opponents fear the opposite could result if privatization is taken statewide and warn it isn't wise to experiment with a vulnerable population.
        The main problem, Gantt and others say, is mental patients could be left with no care at all if private providers replace the current system but later decide to bolt when it isn't as profitable as they'd like. The privatization plan is stirring passions as confusion spreads among public mental health workers about what the Legislature intended to do and whether it will change its mind. So far, the signals are mixed.
        Rep. Talmadge Heflin, R-Houston, inserted the privatization provision into a mammoth social services overhaul bill, stating that private providers would get preference in serving the mentally ill and the mentally retarded. While several contractors already provide services for the mentally retarded, the idea is far more controversial when applied to the mentally ill, a population with complex needs. Starting in 2006, patients would be referred to a network of private providers contracted by the state. They could turn to the community centers for health services only as a "provider of last resort."
        Rose Childs, who oversees mental health services at the Harris County Mental Health and Mental Retardation Authority, said she believes officials expect that most services would be contracted out under the plan. "Sometimes when you privatize and people get dissatisfied with the rates, they will drop out ," she said, noting state workers leave the centers as clients disappear. "Then you've kind of destroyed the community mental health system. If you have to take those services back, you have to rebuild the personnel to provide the service."
        Texas' only large privatization of community mental health care, the NorthStar program in Dallas and six surrounding counties, began four years ago with two managed care companies. When the state refused to raise provider rates enough, one company, Magellan, pulled up stakes after only one year. However, the remaining company, Value Options, has run the entire program for the past four years and earned high marks in a recent report by the LBJ School of Government at the University of Texas.
        Carole Matyas, Value Options vice president for public programs, said privatization does not have to result in dismantling the public safety net. She notes that more than half of the providers in the NorthStar mental health and substance abuse network work at the community mental health centers previously managed by the state. "Privatization doesn't mean elimination of the public program. I think some people get confused about that," she said.
        State officials last month told the community centers they have until March 1 to advertise in newspapers, newsletters, mailings and on the Internet for providers interested in taking over their business. The providers would have 60 days to respond. At that point, state mental health officials would decide whether to ask the providers for specific proposals, said Don Rogers, spokesman for the Texas Department of Mental Health and Mental Retardation.
        "They told the community center to put their services up for bid on eBay. That's what it looks like," said Joe Lovelace, an attorney who volunteers with the Texas chapter of the National Alliance for the Mentally Ill. Lovelace predicts the privatization idea will be withdrawn from the mental health system. He contends that the private mental health system in Texas is failing to meet real needs.
        Heflin, meanwhile, said last week he intended his amendment to House Bill 2292 to give preference to private providers in the mental retardation system, not the mental health system. Others note the language he inserted into law plainly states that it applies to both. "The legislation speaks for itself. It doesn't make a distinction between mental health and mental retardation. We haven't heard from Representative Heflin," Rogers said.
        Rep. Arlene Wohlgemuth, R-Burleson, authored HB 2292 and says a special legislative committee she chairs will take a closer look at the issue before deciding what should be done. She and Heflin said lawmakers believed they were only addressing a perceived conflict of interest problem in the mental retardation system, which contracts many of its services. Private providers had complained that the state was prescribing treatment plans for the mentally retarded and "cherry-picking" the easiest patients to serve for the cost. The problem does not exist for the mental health system, where the state has not used contractors. "I think we legislators need a little more information on how to best direct the implementation of the mental health side and frankly whether or not it needs to be implemented," Wohlgemuth said. Wohlgemuth said she wants the committee to look at the NorthStar program in particular. Under that agreement, Value Options must spend at lease 86 cents of every dollar contracting for direct care, Matyas said
        Rep. Vicki Truitt, R-Keller, a health care consultant and member of the House Public Health Committee, remains leery. "I don't want to see our safety net dismantled," Truitt said. "I am of the opinion we should not dramatically change the MHMR center model without open debate and open discussion. . . ." Rep. John Davis, R-Houston, said he's convinced lawmakers will halt privatization to focus on revamping the system. Lawmakers cut services for a host of behavioral syndromes to beef up services for those with a diagnosis of major mental illness: schizophrenia, bipolar disorder or clinical depression. He said he envisions the system will be patterned after model state-run programs for disease management and jail diversion.



Why Introverts Are More Vulnerable to Illness
Lee Dye, ABC News- 12/24/2003

Scientists believe they are close to answering a question that has baffled them for centuries:
Why are people who are introverted, or shy, more vulnerable to infectious diseases, including AIDS, than people who are extroverted and more outgoing? Ever since the second century physicians have wondered why personality should have any impact on health, particularly why someone of "melancholic temperament," as it was called in the days of ancient Greece, should get sick easier, and have a tougher time recovering, than your typical happy-go-lucky life of the party. "Physicians who had a keen eye spotted this many, many years ago," says Steve Cole of the AIDS Institute at the University of California, Los Angeles. Cole and his colleagues have been searching for the biological mechanism that explains that, and they think they've found it.

Reserved Racked by Stress
While studying the replication of the AIDS virus in 54 men who were in the early stages of the disease, the researchers found a rather startling fact. The men who were clinically diagnosed as introverted did not respond nearly as well to AIDS drugs as those who were more outgoing. In fact, when given AIDS medications, the shy men's "viral load," or replication of the virus, shot up as much as 100 times faster than the more outgoing patients.
        Further research has demonstrated that stress, or how people respond to stress, is the key to understanding the mystery. Shy people do not handle stress as well extroverts, and stress causes the body to release a chemical called norepinephrine that leaves the person more vulnerable to viruses.
        "It looks as though sensitive people are simply wired to respond to stress more strongly than resilient people," says Bruce Naliboff of the UCLA Neuropsychiatric Institute, one of the authors of a paper reporting the research in the Dec. 15 edition of Biological Psychiatry.
One theory that has been making the rounds for years now holds that shy people "are born with essentially more sensitive brains and nervous systems and they find normal social existence to be more stressful than they are comfortable with," says Cole. "They are just kind of high-strung."

Chicken and Egg
Efforts to test that have produced mixed results, but one fact has emerged quite clearly, he adds.
"As people were testing that theory it did become clear that introverted people certainly have higher nervous system responses to stress," he says. That begs the question of which came first, the chicken or the egg. Are shy people more vulnerable because they are shy, or are they shy because they are more vulnerable? "That's not clear," Cole says, at least at this point. "But we can say there's a correlation there. It's sensitivity to stress."

Putting Introversion in Perspective
Cole emphasizes that being shy, or introverted, is not all bad. We probably need a fair percentage of people around who are more likely to be cautious in the face of danger, or more thoughtful about what's going on around them, for our species to survive. If everybody's the life of the party, who's going to watch the fox that's watching the henhouse? "That's the general agreement on why this temperament survives in the gene pool," he says. "If you look back through history, some of our most esteemed public figures, the people who really made important political or scientific or philosophical or literary contributions, you'll find introverted people terribly over-represented relative to their prevalence in the population as a whole." They may get sick a lot easier, but many of them are driven to do things "that are exceptional or remarkable," he says.
        It took a deadly virus to point the way toward understanding the relationship between personality and health. During the early years of AIDS, researchers kept close tabs on patients who were suffering from that horrible disease, and they soon saw a correlation. Among those infected with the virus, the "socially inhibited, shy, sensitive, introverted people got sick and died something like two to three years earlier" than others with the virus, Cole says. "So we knew there was something going on there, a real relationship," he adds.

Supporting Evidence
The participants in the recent study were given a series of psychological tests to determine which ones were truly introverted. Then all 54 men were subjected to various types of stress, like answering simple math questions and being chastised if they got the answer wrong. Response to that stress was measured by monitoring such things as blood pressure, perspiration, and pulse, all conditions that are influenced by the autonomic nervous system which controls involuntary bodily functions. The researchers also measured the rate at which the virus was replicated in each patient and other indicators of how the patient was responding to treatment.
        "The study surprised us by showing that it's precisely the people who have these high nervous system responses, the shy, sensitive, introverted people, who fail to show complete benefit following drug treatment," Cole says. "There is something about their body that is supporting the virus more than in other patients."

The Next Step to Understanding
That shows there is an "exceptionally strong correlation" between personality and infectious diseases, he says, but one more step is needed. The researchers have just embarked on a new project, and they hope that it will show whether the stress that is so inflamed in shy people is the villain. They aren't going to try to change anybody's personality, but they are going to try to inhibit the consequences of stress, and they can do that with off-the-shelf drugs used for heart disease, common beta blockers.
        These drugs suppress the effects of stress by keeping such things as blood pressure in check. If patients who are diagnosed as introverted respond just as well as extroverts while their autonomic nervous system is suppressed then it clearly is stress, induced by their heightened sensitivity, that is the link between personality and infectious diseases, Cole says. It will be a year or two before he knows if he is right. If he is, it should be possible to produce drugs that reduce the physiological impact of stress among ailing shy folks, thus helping them fight off an infectious disease.

In Mental Health Research, a Clash Over Funding Priorities
Shankar Vedantam, Washington Post- 12/24/2003

A recent report criticizing the funding priorities of the federal government's National Institute of Mental Health has reignited controversy over the organization's direction and destiny -- with the top official at the institute echoing some of the criticism himself. The percentage of funds devoted to severe mental illnesses has shrunk even as the institute's budget has doubled, according to the report issued last month by psychiatrist E. Fuller Torrey's Treatment Advocacy Center, the Public Citizen Health Research Group and other mental health experts.
        The report has created sharp divisions among the many mental health experts, advocacy groups and professional organizations that have stakes in the agency's mission and direction, and has illustrated the growing gap between scientific and popular visions of mental health research. Ultimately, the issue may be decided not within the NIMH but on Capitol Hill. "If you are a psychologist out there studying people with schizophrenia and bipolar disorder, it's hard work," Torrey said in an interview. "It's infinitely easier and much more pleasant to study the romantic lives of your college students or how the students decorate their dorm rooms."
        The report calls for a sharp cutback in government funding for basic neuroscience, animal studies and human behavior studies that do not directly pertain to the treatment of mental illnesses, especially six serious disorders: schizophrenia, bipolar disorder, persistent major depression, autism, panic disorder and obsessive-compulsive disorder.
        The report has found more critics than friends. Many health groups accuse Torrey of using misleading statistics, and caricature instead of scientific criticism. Advocacy groups for illnesses not included on Torrey's list of serious conditions criticize the report for its lack of inclusiveness, while neuroscientists and psychologists who do basic research argue that the study of normal behavior and brain biology is essential to developing new treatments for disorders.
        But Thomas Insel, the director of the NIMH, said the report was "partly right, in that there is a tradition at NIMH on spending money in ways that have not necessarily contributed to reducing the burden of illness. It was an institution that was very interested in studying poverty and social ills." While saying many of Torrey's statistics and judgments were wrong -- the proportion of funds for serious illnesses has grown, not shrunk, he said -- Insel agreed that too many studies of human behavior being funded by his agency are not directly linked to disorders. He promised cuts. "Some people feel I am driving the National Institute of Mental Health to become the National Institute of Mental Disorders," Insel said. "That is a valid complaint. My vision is we have a public health mission to address mental disorders, and we are not there to do extensive research on mental health."
        Like many of the disorders they treat, the difference between the positions of Torrey and other mental health experts lies in the details: What constitutes a serious mental disorder? What is the best way to measure the impact of a disorder? What basic neuroscience or behavioral research is relevant to a disorder? Torrey's six disorders, for instance, are a small fraction of the total number described in the American Psychiatric Association's Diagnostic and Statistical Manual, which now runs to nearly 1,000 pages. The psychiatrist, whose sister suffers from severe schizophrenia, said the six serious disorders cost the United States at least $41.2 billion a year, more than half of the direct costs of all mental illnesses. The serious illnesses are relatively rare, but extremely disabling. Someone with persistent major depression, Torrey said, cannot hold a job and "stays in bed for 13 hours a day, and a trip to the store is all they can manage -- and they have to think for a couple of hours before they can do even that."
        The serious disorders are also a major cause of deprivation and poverty: Of 400,000 homeless people in the United States, Torrey said about 130,000 have one of the six serious mental disorders. Implicit in the report is a criticism of the psychiatric establishment, which Torrey and his co-authors said is more interested in treating the milder disorders of richer people. "It's more comfortable for psychiatrists to be seeing those who don't have serious mental illness and are functioning and working," said co-author Sidney Wolfe, director of Public Citizen's Health Research Group. "You have drug companies invent new disorders like social anxiety disorder and doctors taking care of people who are shy."
        Darrel Regier, director of the American Psychiatric Association's division of research, rejected the criticism. If psychiatrists examined the costs of disability, more general forms of depression had the highest burden on society because they afflicted so many more people, he said. Regier, who formerly worked at the NIMH, said there are greater economic benefits in treating milder conditions, because more effective treatments are available for these disorders. With schizophrenia, he said, medications could alleviate dysfunction by 50 percent, at best. "The majority of disorders that affect children are not counted in this list," added Cynthia Folcarelli, executive vice president of the National Mental Health Association, an advocacy group. "We find it disturbing that the report ridicules research on cultural competence. They make fun of studies about ethnic perceptions of well-being that looked at how different cultures define function."
        The National Alliance for the Mentally Ill, a group that has traditionally focused on more serious illnesses and has previously sided with Torrey in his criticism of NIMH funding priorities, also agreed that it was a mistake to pit some illnesses against others. "Any mental illness can become serious if it is untreated," said Richard Birkel, executive director of NAMI. "Garden-variety depression can become a serious illness. What we are going to find is you have to intervene early before the illnesses become serious."
        Some of the biggest divisions among the various health groups are over the importance of basic research. Torrey's report questioned funding for animal research -- it made fun of a number of NIMH grants to study birds -- and grants to scientists co-funded by basic science groups such as the National Science Foundation. Insel, before becoming NIMH director last year, received funding from both the NIMH and the NSF for work into the neurobiology of social attachment in voles. Insel found that the placement of certain brain receptors determined whether the rodents were monogamous -- basic science that might one day offer insights into autism. Folcarelli and the NIMH public affairs office defended the bird research -- they said one study on songbirds had demonstrated for the first time that adult brains can regenerate nerve cells. "In Fuller's view, most grants should have 'schizophrenia' in the title," said Steven Hyman, former NIMH director and now provost at Harvard University. "But that would rule out of bounds critically important basic science."
        Although Regier and Birkel agreed with Torrey and Insel that the NIMH's behavioral research portfolio was too broad, psychology groups defended such work. Robert Sternberg, president of the American Psychological Association said that NIMH grants should go to the best science proposals -- and the current process of peer review at the institute ensures that, he said.
Alan Kraut, executive director of the American Psychological Society, which promotes psychological research, said that even the outcome of genetic disorders such as Down syndrome hinges on behavioral and social interventions. "The legislative mandate of the NIMH says it ought to be studying behavioral aspects of mental health and mental illness," said Kraut, citing Title 42 of the U.S. Code, which charges the NIMH with supporting both biomedical research into mental illness and "the psychological, social and legal factors that influence behavior." Kraut noted that, like Torrey, he has not hesitated to take his concerns to Congress, saying it is right that disagreements between Torrey and the other groups be resolved through scientific and political debate. "It's not Fuller's NIMH," he said.

Mental Health Board Sues Wayne County
Associated Press, 12/24/2003

DETROIT -- Wayne County's head administrator has been sued by the Detroit-Wayne County Mental Health Board to force him to reinstate the mental health board's director. Executive Robert Ficano, the former Wayne County sheriff, put director Patricia Kukula on leave in November. She already has asked a federal judge to halt Ficano's order, but he declined. Now she and the board have sued the executive to force her reinstatement, The Detroit News reported Wednesday. The board wants the court to order that Kukula be allowed "to go back to work and to perform her duties without any interference or hindrance," said board Chairman Samir Mashni.
        Ficano placed Kukula on administrative leave in November, citing contracting irregularities, an ongoing federal investigation and poor record keeping. Kukula says most of those problems existed prior to her April 2002 appointment. She has helped improve the agency's finances and has reorganized how contracts are issued and managed, she said.
        The county on Tuesday had not received the lawsuit, which was described as frivolous by Ficano spokeswoman Sharon Banks. "This represents a county agency filing suit against the county, which is a suit against itself," Banks said. "It is a misuse of taxpayer dollars." In November, Ficano named Edith Killins, formerly of the states department of community health, as interim director.

When Shopping Fails As Therapy
Benedict Carey, Los Angeles Times- 12/24/2003

For most of us, holiday sales and ad blitzes are so much window dressing. Lights, Sinatra music, gadgets in mall windows, catalogs of beautiful people in beautiful sweaters - all very nice, and usually worth an impulse buy, or two, maybe more. But for a small number of adults, the season of buying and giving yields a harvest of heavy debt -- the kind that means you can't pay your utility bills or threatens a marriage -- and closets full of clothes, books, electronics and other products, some with the tags still attached. "I had a friend say that she knew what it was like, she had to go to six different stores to buy one thing," said Ada Spade, 52, of Cupertino, Calif., who at one time had enough arts and crafts supplies piled up in her house to start a store. "Well, she has no idea. If I'd been in six stores, I'd have at least six things, one from each store. At least."
      Compulsive shopping is not a widely recognized medical diagnosis and hardly merits being called a disorder, because researchers are only beginning to study it. But psychiatrists say it's a real problem for people who shop several or more times a week, bringing home things they don't need and rarely use. Like compulsive gambling or shoplifting, researchers say, the buying seems to soothe low-level depression, anger or unease, giving the person a sense of excitement and control, without breaking any rules. It's shopping therapy, taken to an extreme.
     Because the holidays provide a license to buy, they also offer an opportunity to identify the problem in yourself or a family member. One way to know you've "hit bottom," compulsive shoppers say, is when the just-bought goodies in the closet far outnumber those under the tree or wrapped up and given away.
      Counselors at Debtors Anonymous, which holds weekly meetings in cities across the country, say their groups swell this time of year with habitual shoppers, and often more so in January and February when the bills roll in. "First off, most of what these shoppers buy for themselves they don't use; they totally lose interest once they've bought it," said Dr. Lorrin Koran, a psychiatrist at Stanford University who studies impulse control problems. "It's the act of buying itself that brings pleasure."
      In the early 1990s, a University of Minnesota professor interested in consumer behavior mailed questionnaires to about 800 adults, selected at random, in Illinois, seeking responses to statements such as "I feel anxious on days when I don't shop," and inquiring about time spent thinking about shopping. Of the some 300 people who responded, 1% to 2% had a shopping compulsion, the survey suggested. According to Dr. Donald Black, a psychiatrist at the University of Iowa, 80% to 95% of those affected are women. The habit usually takes hold in their late teens or early 20s and usually is chronic. Its consequences are measured in dollars: The typical U.S. household carries about $8,000 in credit card debt, according to U.S. Census figures; habitual shoppers typically carry $10,000, often more, experts say. In some cases, the problem is hardly a secret. A man treated in one study had 2,000 wrenches; a woman in another filled an empty bedroom with unused clothes.
      In one of the few attempts to directly compare the buying behavior of problem shoppers with that of more typical shoppers, researchers in Paris found several differences: Compulsive shoppers tended to associate purchases with social status, were less likely to use what they bought and were more likely to consider their purchases as "occasions not to be missed." Advertisers understand this, of course; products are said to be in "limited supply" and sales are "for a limited time only." Yet it takes a habitual shopper to turn this manufactured urgency into a way of life. "There were some stores, I knew everything they had in stock, everything," said Spade, who controlled her habit with counseling and medication. "I'd still go in all the time, to see what was new, to make sure I wasn't missing something. Every day was a treasure hunt." Like others with a persistent shopping urge, Spade bought things not only for show, but also to improve herself and her skills. She makes quilts and clothes, and still has fabric for about 400 shirts, stockpiled from her buying days three years ago. "I had no time to pursue my hobbies, because, of course, I was too busy shopping," she said.
      Self-awareness alone may help control the habit. In some cases, psychologists have found that asking a shopper to keep a diary of purchases can slow the person's spending. Identifying thoughts or moods or people who may trigger a mall run also can help -- by knowing the bait, a shopper can avoid the trap at least some of the time. Along with talk therapy, several researchers have been experimenting with drugs to address underlying mood problems, when they're evident. In a Stanford University study published in August in the Journal of Clinical Psychiatry, 11 of 15 compulsive shoppers who began to control their habit by taking the antidepressant citalopram were managing well up to a year later. Others have reported improvement with naltrexone, which reduces cravings in some habitual drinkers. "It is treatable; people should know that," Koran said.

The Telephone Is a Powerful Tool to Help Smokers Quit
Karen Pallarito, Washington Post- 12/25/2003

Kathy Dowdy of Hillsville, Va., tried once or twice to break a decade-long addiction to cigarettes. She used nicotine patches but couldn't stop smoking a pack to a pack and a half a day. Finally, the 31-year-old mother of two called a toll-free number advertised on television and got the help she needed to give up cigarettes for good. Dowdy's call to the American Cancer Society's "quitline" triggered a series of free phone sessions with a counselor who offered her tips like breathing deeply or taking a drink of water to counter the urge for a smoke. The counselor assured Dowdy that feeling irritable is a normal symptom of withdrawal. "I think it made an extreme difference. I looked forward to the calls and I was committed," Dowdy said. "I wanted to make it to that next phone call" without lighting up.
     With New Year's Eve approaching, millions of Americans will resolve to quit. Surveys suggest about 70 percent of the nation's 46 million smokers want to give up smoking, and 40 percent will try to quit sometime during the year, but few succeed on their own. Some experts say telephone counseling can make a big difference.
     The nation's first quitline started in California in 1992. Distinct from services that provide information only, quitlines also offer telephone-based counseling and support. Smokers who enroll can expect to receive four to six phone calls over a three-month period. Thirty-nine states operate quitlines, according to the Centers for Disease Control and Prevention (CDC). The District, Maryland and Virginia are not in that group. But by calling the American Cancer Society at 877-YES-QUIT, smokers in the Washington area may be able to join a national program like the one that helped Dowdy.
The limited research that has been done on quitlines shows that they work. In California, smokers who got telephone counseling quit at twice the rate of people who received only self-help materials, according to a study published last year in the New England Journal of Medicine. "They are very much accepted as a cost-effective way of helping reach out to smokers and help them quit," said Lyndon Haviland, chief operating officer of the American Legacy Foundation (ALF), an anti-smoking group based in Washington.
     Quitlines proliferated in the wake of a $206 billion agreement that states reached with tobacco companies in 1998. The 25-year pact settled complaints alleging that for decades the industry concealed tobacco's harmful effects and nicotine's addictive qualities. The agreement is the major source of funding for ALF.
     Only 3 to 4 percent of U.S. smokers who try to quit each year succeed without counseling or drugs, according to Linda Bailey, director of the Center for Tobacco Cessation, which is funded by the Robert Wood Johnson Foundation and the American Cancer Society. By contrast, some quitlines report that 20 to 25 percent of their clients are successful. Yet even long established programs now reach only 7 to 10 percent of smokers, Bailey noted. "We think we can probably reach 30 percent of all smokers with a quitline, and that's a tremendous reach," she said.
     The Department of Health and Human Services (HHS) has set a goal of reducing smoking prevalence among U.S. adults to 12 percent by 2010, down from 22.8 percent in 2001 and 42.6 percent in 1966, when smoking prevalence began to decline. "We have an incredible paradox in America," said Michael Fiore, professor of medicine and director of the University of Wisconsin's Center for Tobacco Research and Intervention. While most health insurance plans will pay "the tens of thousands of dollars" it costs to treat a heart attack, stroke or case of cancer caused by smoking, only about half invest the roughly $200 per smoker it costs to help people quit, he said.
     Some quitlines struggle for funding as states spend the bulk of their tobacco settlement dollars on programs that have little to do with smoking. Without adequate funding, quitlines often cannot advertise their services as much as they would like. In many instances, the reach of quitlines is stunted by a lack of awareness among health care providers and smokers, proponents of telephone counseling say.
     The quality of quitlines varies from state to state, said Abby Rosenthal, a public health educator in the CDC's Office on Smoking and Health, with the better programs offering smokers several one-on-one counseling sessions at appointed times, as opposed to a one-time dose of advice.
Public health officials, national health organizations and researchers are forming a consortium to boost quitline access, use and effectiveness. Founders of this effort hope to help identify and promote best practices. Every quitline caller for whom it is medically appropriate, for example, should receive free over-the-counter nicotine replacement drugs or vouchers for prescription medication, according to a panel that reported to HHS Secretary Tommy Thompson earlier this year.
     Research shows quitlines are most effective and have the highest rates of use when they are paired with easily available medication, said Fiore, who chaired the panel. "It increases dramatically the number of callers to that quitline," Bailey agreed. Calls to South Dakota's quitline spiked during a one-year period in which nicotine replacement drugs were offered free to anyone who enrolled and stayed in the counseling program, said Joanne Pike of the American Cancer Society, which operates programs under contracts with several states. The incentive helped prompt 10 percent of the state's smoking population to call the quitline. Now that there's a co-payment for the medication, calls to the quitline have dropped. It's easy to see the attraction of free stop-smoking aids. A two-week supply of over-the-counter nicotine patches or gum costs $45 to $55. American Cancer Society research also has identified another key to success in quitting. What seems to matter most is providing support near someone's quit date, Pike explained. "The most critical period seems to be the 24 hours after someone has quit."
     Dowdy said she has been free from cigarettes for more than a year. She no longer suffers from shortness of breath, and she has begun exercising. Quitlines can help smokers, she says, but only if they're ready to make the commitment. "If they're sick and tired of smoking, it will help." The National Cancer Institute provides information and resources for smokers seeking to quit at smokefree.gov

Teen Suicide Scare Shakes Des Moines
Martha Irvine, Associated Press- 12/28/2003

DES MOINES - Mary Elliott got the call for help on a Monday night. A "suicidal male teen" was at a convenience store, not far from his high school. When she arrived, Elliott - a nurse on Des Moines' crisis response team - found the young man still dressed in the suit he'd worn that day to the funeral of another teen who'd killed himself. He was relatively calm and, at first, denied that he was considering suicide. But by the end of the night, he told Elliott even more than she'd anticipated: He wasn't the only one who felt like ending his life. And he gave her names of eight other teens from his high school who also talked about suicide - and, in some cases, even said how they'd do it. "All of this is too much for a kid to handle," she recalled him repeating several times that night.
      In the days that followed, media reports referred to a suicide "pact." But those who eventually spoke with the other young people said there was never anything written or signed. It was, they say, a loose verbal agreement - "I'll do it if you do it" - that some of the teens seemed to take more seriously than others. Whatever the case, the events of that night left many in Des Moines shaken - and have since prompted discussions about how to best deal with a problem that plagues communities nationwide.
      In Iowa, suicide is the second-leading cause of death for those age 15 to 24, after car crashes. Nationally, it ranks third for that age group."These kids don't understand, really, that suicide is final - and that prom will go on without them, the football game will go on. Life will go on without them," said Dave Spieker, another crisis response nurse who was on duty that October night. As the midnight hour approached, both he and Elliott met with school officials to pore over registration records and yearbooks to come up with a more complete list of names and addresses. The details they'd been given were sketchy. They knew that all the students attended Lincoln High School. But often, the young man gave only first names. And, in one case, he couldn't remember a girl's name - only that she had "red hair." Still, the crisis team and school officials knew that they had to act quickly.
      It had already been a rough fall for the 2,100-some students at Lincoln High, which has a stately red brick building surrounded by oak trees in a neighborhood of modest homes. In September, three male students died in a single car crash, leaving the young driver - the lone survivor - charged with vehicular homicide. Not long after, Billy Metzger, 15, hanged himself in his bedroom closet. Surviving students mourned together, writing "RIP," "RIP," "RIP," "RIP" in chalk on many of the school's bricks. Another scribbled, "Damn, Billy, we're going to miss you" on the sidewalk. "Most people are doing OK now. But not a day goes by when we don't think about what happened - even if we didn't know the guys who died very well," Josh Rector, a senior at Lincoln High, said recently. Immediately after Billy's death, some students cried and huddled together in groups in the hallways. Still others kept to themselves, stunned and silent.
      School officials did their best to deal with the extreme grief. They offered counseling for anyone who asked and, fearing copycat suicides, asked teachers to watch for students who were struggling emotionally. Still, some wondered whether the school could have much impact because Billy's suicide had happened on a Thursday. On Friday, Oct. 2, students heard the news and gathered that night for a football game. Then they dispersed for the weekend, with Billy's funeral scheduled for Monday. "It's up to the community and the parents now," said Jerry Clutts, a school official who helped devise the district's crisis response plan.
      It was during that weekend, crisis officials say, that the nine students spent hours talking and grieving together - at times so sad that they too considered suicide. Dave Smith, a Des Moines police officer posted at Lincoln High, is among those who doesn't think that those discussions resulted in a "true pact." "You just had some kids who were pretty volatile at the time," he said, adding that they are "good kids, for the most part." Crisis workers also determined that some of the teens had been struggling well before the deaths of their four classmates. One had issues at home and was living in a youth shelter. Another had attempted suicide in the past. And at least one had been treated for depression.
      By 5 the morning after Billy's funeral, authorities had contacted all the students and their parents. Some students were clearly confused and said they knew nothing about it. A few parents were angry. But still others said they too had been concerned about their children. Eventually, four of the nine teens were hospitalized. "As far as I'm concerned, it was worth it to me to get up out of bed to check on them," said Smith, who visited some students' homes with Elliott that night. "We're better safe than sorry."
      Now, more than two months later, things have quieted down at Lincoln High. Billy Metzger has been laid to rest in a small cemetery surrounded by cornfields - his grave's temporary marker covered with a silver chain with a cross on it and a warm fleece hat. And all but one of the nine students have returned to school. (Officials have declined to release their names due to the sensitivity of the matter.) Counseling has remained available to students in need. But almost immediately, the school's principal removed a makeshift shrine placed on Billy's locker.
      Experts say that's as it should be. "It's difficult. But you don't want to see anything that glorifies or sensationalizes it," said Dr. Kevin Took, a child and adolescent psychiatrist at Blank Children's Hospital in Des Moines. Still, he and other experts say it is important to talk about suicide, which many see as a serious public health issue.
      Research shows that one in four teenage girls and one in six teen boys have had serious thoughts about suicide. Many who kill themselves or attempt to do so have psychiatric problems. "We've spent more time educating the public about West Nile virus than we have suicide," said Larry Hejtmanek, head of the Eyerly-Ball Mobile Crisis Response Team, which led the effort after Billy's funeral. "People think everything's fine, until the next crisis." He notes that many states have begun implementing federally funded suicide prevention programs. And some schools are taking steps of their own.
      Des Moines school officials are considering using Teen Screen, a test developed at Columbia University, to pinpoint students with mental health issues. The test, they say, could be given as routinely as hearing and vision screenings. Meanwhile, a few hours east in Camanche, Iowa, students can anonymously submit the name of someone they're worried about by using yellow cards and a box placed in a high school hallway. The idea, started after two Camanche teens committed suicide, came from the nonprofit Yellow Ribbon Suicide Prevention Program.
      Some young people in Des Moines say recent events might prompt them to tell an adult if a friend seemed suicidal. "If it's a really serious thing, it is important to tell somebody," said Jadie VanPelt, a Lincoln freshman. "But first I would try my best to convince them not to do it." Still others, including Lindsey Mason, 19, say it would help if adults - especially parents - felt more comfortable talking about suicide. "It's a hush-hush topic," Mason said. "And it shouldn't be."