Did Famed Nurse Nightingale Have Bipolar Illness?
Brian Witte, Associated Press- 5/2/2003

BALTIMORE -- Florence Nightingale, the founder of modern nursing who said God called her to her work, ''heard voices'' and suffered from a bipolar disorder, a mental health expert said Friday. Nightingale was 31 when she asked God in a letter why she couldn't be happy: ''Why, oh my God, can I not be satisfied with the life that satisfies so many people and told that the conversation of all of these clever men ought to be enough for me? Why am I starving, desperate and diseased on it?''
    Dr. Kathy Wisner, a professor of psychiatry at the University of Pittsburgh Medical Center, cited the note as evidence that Nightingale suffered from a bipolar disorder that caused long periods of depression and remarkable bursts of productivity. Nightingale was the subject of a conference Friday at the University of Maryland School of Medicine that discussed Wisner's theory. The annual conference has diagnosed the ills of historic figures since 1995.
    ''Florence heard voices and experienced a number of severe depressive episodes in her teens and early 20s symptoms consistent with the onset of bipolar disorder,'' Wisner said. She cited the diary and letters that Nightingale wrote throughout her life as evidence. She said some of the writings also reveal the other side of the illness. ''This is the life,'' Nightingale wrote in 1851, around the same time she wrote the first letter cited by Wisner. ''Now I know what it's like to live and love life, and I will be really sorry to leave life. I wish for no other earth, no other world but this.''
    Nightingale gained her reputation as a tireless nurse during the Crimean War. She was appointed to oversee the introduction of female nurses into the military hospitals in Turkey in 1854. Once there, she found unsanitary conditions in British army hospitals and worked to improve hygiene and nutrition for sick soldiers. When she returned to Britain, Nightingale was hailed as a national heroine, and she raised the nursing profession to a respectable profession for women. But even before her return, she fell ill, suffering from extreme fever and fatigue, according to a case study conducted for the conference. For most of the next 40 years, Nightingale complained of spinal pain, insomnia, anorexia, nervousness and depression. Her symptoms often have been attributed to chronic brucellosis. ''She may very well have contracted the infection in the Crimean War,'' Wisner said. ''But that illness alone does not account for her severe mood swings, or the fact that she could be so incredibly productive and so sick at the same time.''
    Wisner also said the effects of bipolar disorders tend to ease when people reach their 60s. When Nightingale reached the age of 68, her symptoms lessened. Dr. Lesley Hall, an archivist and historian at the Wellcome Library for the History and Understanding of Medicine in London, described the diagnosis as an interesting theory but said no one knows for sure. ''I think retrospectively diagnosing distinguished Victorian invalids is a positive parlor game,'' Hall said.

Addicted, Neglectful Moms Offered Treatment, Custody
Henri E. Cauvin, Washington Post- 5/2/2003

For many of the drug-dependent mothers who end up in D.C. Superior Court, charged with neglecting their children, the choices are rarely good. Going into residential treatment might be their best hope for curing their destructive addictions, but it would often leave their children languishing for months in foster care, far from the one person they depend on.
    A program launched yesterday by the D.C. courts and the city's social services agencies aims to give at least a few troubled mothers a better choice. Instead of being forced to choose between treatment and their children, a few dozen mothers will enter a six-month drug rehabilitation program with their children, under the supervision of the District's new Family Treatment Court. In a city with just 100 District-funded residential treatment slots for an estimated 60,000 addicts, the 18 beds that the new program will add will be precious.
    By housing the children with their mothers and keeping them in the schools they were attending, officials hope to avoid the anxiety and depression that young children frequently feel when they are separated from the people and places they know best. At the facility, the mothers will have help caring for the children but still will be expected to feed and dress them.
    Anita Josey-Herring, the Family Court judge who will preside over Family Treatment Court, said she was skeptical about the proposal at first. "I actually had to be convinced that having kids accompany the parent into residential treatment was a good idea," she said. The initiative, a pilot project, is modeled after efforts in Virginia, Florida and elsewhere. Seeing those programs at work persuaded Josey-Herring that they can give parents "an incentive to stop using drugs. They could see their child. They could hold their child."
    Krista Evans, coordinator of women's programs at the city's Addiction Prevention and Recovery Administration, said that children and their mothers typically benefit from the new setting. "In most cases, it's a better environment, because it's highly structured and there's a lot of support," Evans said. "The child was probably, in most cases, parenting themselves, and now, being in a safe environment, they are able to react as children," she said.
    The District's child welfare system has long been criticized as among the country's most dysfunctional. For years, it has struggled, often unsuccessfully, to deal effectively with a large caseload. With more than 2,000 neglect cases in the court system as of Jan. 1 and more than half of those affected by drug use, the Family Treatment Court for now will reach a small number of mothers. In all, 36 women will be chosen to participate, 18 of them in the next few days and 18 more six months from now, after the first group has completed its treatment program and moved into aftercare. Officials declined to say where the privately run residential facility will be located, saying they need to protect the privacy and ensure the safety of participants.
    At the center of the new initiative is Family Court, created by Congress in 2001 after calls for reform. The court faces new local and federal mandates to resolve a child's fate in abuse and neglect cases within 18 months. Josey-Herring said the Family Treatment Court will give judges an important tool. Finding stable, permanent homes for the children in these cases is the overriding goal, she and others said. If a mother overcomes her drug habit, completes the program and demonstrates progress toward becoming a good parent, her chances of being reunited with her children are good. But a parent who fails to do so, in spite of the intensive support and supervision, risks having her child or children put up for adoption and other consequences. "We're not guaranteeing that the children will be returned to the parents," Josey-Herring said. "What we're saying is: If you are successful, it enhances your chances. But it does not guarantee it."
    The project, about a year in the planning, is a collaboration by D.C. Superior Court; the Department of Health; the deputy mayor for children, youth, families and elders; and the Child and Family Services Agency, which will foot the $1.4 million bill for the treatment and supervision of participants. Officials set up a plan to identify candidates for the program. Once a neglect case has been identified by a police officer or social worker, the city will conduct an initial screening to determine whether a mother and her children might be eligible. Within a couple of days, a more exhaustive screening by social workers from the court and the Addiction Prevention and Recovery Administration would take place. A few days later, the candidate could be before Josey-Herring, who will make the final decision on who enters the program, which is voluntary and requires participants to sign a contract. Not every drug-addicted mother will be a candidate. Only those accused of neglect are eligible; mothers accused of abuse will not participate. Mothers with severe psychiatric problems or histories of violent behavior also will be excluded.
    Along with their drug treatment, the women will be counseled on education, health and nutrition, with yoga a planned part of the program. While in the program, they will appear every two weeks before Josey-Herring for progress reports. "You're rebuilding people, essentially," she said. "You're helping them to understand that they are valuable and they have a life worth living."

L.A. County to Pull Mentally Ill Residents Out of Centers
Charles Ornstein, Los Angeles Times- 5/2/2003

Citing numerous escapes and lapses in patient care, Los Angeles County officials on Thursday said they would not renew their contract with two private psychiatric facilities in Sylmar and must now find new quarters for 170 seriously ill patients by June. The decision follows a months-long investigation into Foothill and Sylmar health and rehabilitation centers that county officials say showed a failure to correct problems or even to consistently report them.
    Marvin Southard, director of the county Department of Mental Health, said the decision to end the 16-year relationship with the owner, Golden State Health Centers Inc., was highly unusual. It resulted from a "growing lack of confidence in the commitment of the agency to patient care," he said. "We decided it was in the best interest to take our patients out."
    Los Angeles County is the largest source of patients for Foothill and Sylmar, which together house 400 patients. Other patients are placed by the state of California, several other counties, and the U.S. Department of Veterans Affairs. Some counties, including Orange and Fresno, say they may reevaluate their own contracts, based on L.A.'s decision.
    Officials at Golden State said they regret L.A. County's decision and called it particularly troubling because of "the first-class mental health programs that have been provided to Sylmar and Foothill's residents." "While the staff at both facilities have worked diligently to avoid any deficiencies, it is a fact of life at institutions of mental disease that issues will arise that require corrective action," company spokesman Dan Durazo said. For Los Angeles County officials, transferring so many residents before the contract lapses June 30 could be difficult.
    Foothill and Sylmar are among 12 centers, akin to nursing homes for psychiatric patients, in Los Angeles County. Such centers house patients who, because of such illnesses as schizophrenia or bipolar disorder, need close supervision. Demand has increased markedly as state hospitals have emptied their mental wards. Operators of similar centers in the county, called Institutions for Mental Disease, say they have little room for more patients. "They'll just have to work with it day by day and see what happens," said Monica Fenton, administrator at View Heights Convalescent, which has 10 vacancies in the 99 beds in its locked ward.
    After recent complaints from a labor union about conditions at the Foothill and Sylmar facilities, county officials twice extended their contracts for six months, rather than the usual three years. It was not until March, however, after The Times began inquiring about problems at the centers, that county and state officials launched a major inspection. The inspectors found "inconsistent reporting and an excess number" of escapes and attempted escapes at Foothill and Sylmar — which had among the worst records in the county for such facilities. Foothill and Sylmar together logged 64 escapes and attempted escapes in 2002, according to figures provided by Golden State. County investigators who examined the logs said some of those escapes had not been reported to authorities as required.
   In addition, state regulators have fined both Sylmar and Foothill three times in recent years for patient-care violations, including a fine of $3,000 against Foothill in September for failing to protect a 33-year-old female patient from being raped by a male patient. Sylmar was fined $3,000 in March because an employee had sex with a psychiatric patient. Golden State spokesman Durazo said Sylmar and Foothill have fewer patient-care violations per bed than similar facilities in the county. Foothill recently installed a security system to prevent escapes, and Sylmar is following suit, he said.
    Golden State fired Foothill's administrator, Rich Terrell, this week after he wrote a letter accusing county officials of singling out his center for frequent inspections and holding it to a higher standard than similar locked institutions. County Supervisor Zev Yaroslavsky, whose district includes the centers, said he supports the decision to end the relationship with Golden State. "When we contract with somebody we expect that agency to place at least as much importance on the interests of the clients as we do, if not more," Yaroslavsky said. "That wasn't the case here, and repeated efforts to bring this to the attention of the owners fell on deaf ears time and again. "Enough is enough," Yaroslavsky said. "We don't owe anybody a contract. That's what every contractor needs to know. They are privileged to do business with us. They are not entitled to do business with us."
    The state Department of Mental Health said it has no plans to relocate 20 Foothill residents accused of major crimes who have been found not guilty by reason of insanity. Agency spokeswoman Nora Romero said Foothill's program for those residents complies with state regulations. The state agency did, however, send Foothill a letter Thursday concluding that the facility had "an unacceptable level" of escapes and attempted escapes and asking for a plan of correction.
    Orange County officials, who have 73 residents at the two facilities, said they were worried that L.A. County's decision to remove its patients might leave the centers unable to maintain their treatment programs. "If they cannot operate the facility appropriately, obviously we would want to move our clients," said Sandra Fair, Orange County's chief of behavioral health operations. "We have a great deal of confidence in the L.A. County Mental Health Department and we would want to have a conversation with them about the reasons they're taking this action."

Heroin Hits Small-Town America
Tim Jones, Chicago Tribune- 5/4/2003

LEXINGTON, Ohio -- A costly struggle against heroin rages in the comfy, cedar-paneled home on West Hanley Road, and everyone inside is losing. The adult sons of Steve and Chris Thomas have stolen more than $50,000 from their parents' business to support their heroin addictions. The Thomas home is in a lockdown state, with money and other valuables that could be traded for drugs kept away from the boys. A bolt lock protects the master bedroom. The Thomases now finance their vending machine business on low-interest introductory credit card offers, switching to new cards every 6 months. Last week a Richland County judge arraigned Mark, 22, and Matt, 18, on felony drug possession charges. The next day Mark Thomas was caught by his parents using heroin again and, as has happened before, was thrown out of the house. It's a war with no victory in sight. "I don't know what we're going to do," Chris Thomas said.
    This is but one snapshot of a rising tide of small-town heroin abuse in the Midwest, occurring in tidy little communities with town squares, bicycles on front lawns and American flags flapping in the breeze. Hospitals and drug counselors note an alarming spike in overdoses, and overmatched police agencies are scrambling to address a drug onslaught once deemed the exclusive purview of big cities and longtime addicts.
    In the northern Ohio railroad town of Willard, population 6,800, police are investigating five fatal heroin overdoses since December, two of them on a recent weekend. "All of a sudden it blossomed," is how Capt. Robert McLaughlin of the Huron County Sheriff's Department described the arrival of heroin. "We're up to our eyeballs in it."
    Although marijuana, sheltered among the tall stalks of cornfields, and crack cocaine, brought in from Detroit, had long been the mainstays in the tightly defined universe of illegal drug users, police officials and treatment experts say the heroin market has expanded beyond the predictable clientele. More troubling, the price of heroin is dropping, the availability is increasing and the purity of the drug is rising. "It is much stronger than what abusers are used to," said Mansfield Police Chief Phil Messer, who leads a 10-county drug task force called METRICH.
    This region of Ohio, described ruefully by one undercover police officer as "conveniently located" amid the inverted urban triangle of Detroit, Cleveland and Columbus, is especially susceptible to drug trafficking because of easy access to several major highways. Formerly isolated and exclusively rural communities are now primarily bedroom communities. It was often considered the "Crossroads of America," but many of Ohio's small towns have lost their insularity and are now part of interstate drug traffic.
    Deb Kline, a nurse in rural Crestline, said the number of intravenous heroin addicts treated at Freedom Hall Treatment Center, about an hour north of Columbus, has quadrupled. Worse, Kline said, the universe of drug abusers is expanding from hardened addicts in their 40s and 50s to people in their early 20s. "Kids who come from upper-middle class families, kids who had pretty decent high school careers," she said. "I wish I knew why."
    Few people wonder more than the Thomases, who built their home 15 years ago amid the tall pines in rural Lexington, population 4,200. As Steve Thomas put it, they came to raise their boys "away from the bull-crap of the city." He was building what would become a thriving vending machine business. "We're first-generation success," the 54-year-old Thomas likes to say, pointing to the 61-inch Sony TV in the living room. The TV is a symbol of achievement, he said. Leading by the example of hard work was the best teacher for his boys, Thomas believes.

Early signs of trouble
There were early signs of drug trouble with Mark, who started smoking marijuana at 14. Steve Thomas said he would occasionally smoke marijuana in front of his boys. "I knew when to stop and I expected the boys to be just as responsible with drugs as I was," he said. They weren't. Then teenagers, Mark and Matt would help their parents empty the coin trays from pop, cigarette, candy, pinball and other machines. Every night the Thomases would bring bags of coins home. They said they wanted to be home for their boys.
    The skimming began at least two years ago--a few hundred here and there that would soon end up in the eager hands of heroin dealers on the east side of Columbus, about an hour away. Both boys had cars and every other day would make the run to Columbus. "Steve would come home and wonder where the money was going," Chris Thomas said. "We never dreamed our kids would take it."
    Their sons had stolen at least $50,000, but Round 2, the in-house war, had only begun. More thefts followed--money, alcohol, prescription drugs, keys to vending machines. After throwing the kids out of the house, they changed the locks. Mark and Matt crawled through the attic and dropped in through a ceiling entry. "We don't keep any money here, and what we do have we hide. We don't keep keys to anything here," Steve Thomas said. "It's like the enemy living right beside you, right under your nose."
    Chris Thomas, 52, rattles off the specific dates, seared in her memory, of devastating events in the family's war with heroin. The car accidents, multiple DUI charges, the credit card spending binges, the relapses into drug use, the days they threw their sons out, and last New Year's Eve--when they were arrested for possession of heroin--are recounted, sometimes by the time of day. The question "Is he alive?" has worked its way into the daily vernacular.

`I feel very betrayed'
Steve Thomas said he could shoot the person who turned Mark onto drugs, but he won't. "I feel very betrayed, especially by my oldest son. They should give loyalty to their parents. They deceived me," he said. "I don't understand why my son doesn't have this hunger for knowledge and growth and achievement." And he doesn't understand how anyone could take heroin. "And you never will because you're not an addict," Chris Thomas said.
    Their anger is mixed with guilt and second thoughts about all the long hours spent building a business. Chris Thomas clings to hope, however frail, and pulls the lyrics of music that Mark recently wrote, expressing remorse for his addiction:
"I was so numb and had no feeling to feel,
I was so dumb because I never realized this was real.
I still didn't care when you gave all you could give,
I just got around and got high with no reason to live."
    That hope withered last week when she found a bag of heroin in Mark's room. Once again, Mark is out of the house. He is living temporarily in a family-owned apartment in nearby Mansfield, paying $20 a day to his parents. "I told him that was the last kind gesture," Chris Thomas said. "That was hard for me. For now, Matt stays at home with his parents. He passed a milestone Friday. He has been drug-free for 90 days. That gives his mom cause for hope. But neither parent expressed much confidence about their sons' future. They've been through too much to be optimistic. "I really get the feeling that Mark's never gonna quit," Steve Thomas said. "With Matt it can go either way. "We just want the boys to get on with their lives so we can get on with ours," he said.
    The nightmare for the Thomases reflects, in part, the new availability of illegal drugs. The reasons for the surge in heroin use vary--a poor economy, proximity to big cities and increased competition among dealers. Sgt. Rick Sexton of the Willard Police Department said the annual influx into the region of migrant workers from Mexico, a country that is a major source of illegal drugs, is also a factor. Some police officials point to the post-9/11 obsession with terrorism, saying it has diverted attention from the drug fight.

Availability increasing
"The feds are claiming there are more drugs being seized at the border. But we haven't seen the effects of that locally. We haven't seen a spike in prices that would occur if interdiction efforts were working," Messer said. "The availability is increasing. We're seeing a lot of young people--high school kids--using heroin," Messer said. That analysis is confirmed by addicts, who were accustomed to dealing with older adults and driving an hour to get their fix.
    "When I first started, I had to go to Cleveland or Columbus to get it," said a heroin addict who now does undercover drug buys for METRICH in Mansfield. "It's much easier to get now. I don't have to run all over the place to find it. Now it's just down the street. "People figure they can deal drugs because of terrorism and the war. They figure everybody's got their minds on that," the addict said.
    An old industrial city of 50,000, Mansfield offers a grim reminder of possible consequences of drug trafficking--three state penitentiaries and the now-abandoned gothic prison used in the movie "The Shawshank Redemption." At SCCI Hospital, emergency room doctors have a ringside seat to the effects of the drug trade. "We see a ton of prescription drug abuse, and I've seen more heroin in the last two years than I've seen in the previous 10," said Dr. Anthony Midkiff.
    To be sure, heroin is not the only drug threat in the region. In some rural counties, crystal meth is a bigger problem. In Richland County, it's crack cocaine. Paul Jones, an investigator with the Richland County Coroner's Office, said drug users are mixing prescription drugs. When combined with heroin, the powerful pain reliever OxyContin or methamphetamine, an addictive stimulant, "it can be just enough to push them over the edge, and they don't realize it," Jones said.

Concussions and Depression May Have Link
Lauran NeerGaard, Associated Press- 5/5/2003

WASHINGTON -- Retired football players who suffered three or four concussions have twice the risk of later developing clinical depression - a risk that rises with even more injuries, new research says. It's the latest finding that suggests what many people consider merely a bang really can have long-term repercussions. Now scientists are beginning intensive studies to pin down just what happens inside the brain when someone has a concussion. Concussions, a mild brain injury, can be caused by any hard blow or jolt to the head - from whiplash during a car accident to a tumble onto a sidewalk. Each year, an estimated 1.1 million Americans get a concussion.
    But pro and amateur athletes are more likely than the average person to have repeated concussions. That's a particular problem because concussions can be hard to diagnose -- and getting banged around again before full healing can lead to potentially deadly brain swelling. "I always say, 'You can ice your ankle but you can't ice your brain,'" says Dr. Julian Bailes of West Virginia University's School of Medicine. "You don't send a player who's still symptomatic back to play."
    Most people fully recover from a concussion. But a fraction suffer lingering, sometimes severe, problems with memory and other functions - and doctors wonder if sufferers of bad or repeated concussions are more prone to neurologic disease later in life. As a first step in studying that question, Bailes and colleagues from the University of North Carolina's Center for the Study of Retired Athletes analyzed data from almost 2,500 retired NFL players. Bailes found no link between concussions and later Alzheimer's disease or strokes, two common worries. But 263 of the retired players suffered depression. Having three or four concussions meant twice the risk of depression as never-concussed players - and five or more concussions meant a nearly threefold risk.
    The study, presented last week at an American Association of Neurological Surgeons meeting, supports earlier research that linked concussions suffered by World War II soldiers to depression decades later. For better proof, University of Pittsburgh neuropsychologist Mark Lovell now is tracking how NFL and NHL players fare in the years after a concussion. More intriguing, he's using advanced MRI scanners on the brains of high school athletes in a study that will rescan up to 250 of them who later have a concussion -- providing before-and-after shots that could finally show just what the injury does to delicate brain tissue.
    Scientists already know a concussion somehow throws crucial brain-chemical reactions out of whack, but they're not sure for how long or if that imbalance could cause a chain reaction leading to later problems like depression. For now, Lovell and other specialists want athletes and their coaches and relatives to start taking concussions more seriously. "If you get hit and have a headache, don't do the macho routine - you need tell somebody," Lovell says.
    Look hard for symptoms - they're not always obvious in an adrenaline-pumped athlete. Loss of consciousness, from a few seconds to a half-hour, is the best-known symptom but doesn't always occur. Other symptoms include confusion, persistent headache, cognitive problems, fatigue and changes in mood, vision or hearing. Particularly crucial is short-term memory: How long before you were hit can you remember? The longer the period of amnesia, the worse the concussion. Watch for changes in behavior, signs that signal pain the patient denies. Rest is the only way to heal, and Lovell's research suggests that takes about a week.

Abused Kids More Likely to Turn to Crime
Jonathan D. Salant, Associated Press- 5/5/2003

WASHINGTON -- Children who are abused or neglected are far more likely to become criminals as adults, according to a study released Monday by an organization of police chiefs, prosecutors and crime victims. The report by Fight Crime: Invest in Kids recommends more money for pre-kindergarten programs and parenting classes, saying the cost will be offset later when children who might have been burdens on society grow up to be upstanding citizens. "Children who survive abuse and neglect can be significantly injured," said one of the report's authors, Dr. Randell Alexander, director of the Center for Child Abuse at the Morehouse School of Medicine in Atlanta. "Many go on to hurt others. If you are born into a world of violence, you wire yourself for violence, not for peace."
    Using various federal data and academic and advocacy group studies, researchers said child abuse and neglect is vastly underreported. The 900,000 cases reported annually by the Health and Human Services Department may be only one-third of the actual total, the report said. The report cited a study published in 2000 by Dr. Cathy Spatz Widom, a professor of criminal justice and psychology at the State University of New York at Albany, that found individuals who had been abused or neglected as youngsters were 29 percent more likely to become violent criminals than other children. Using that estimate, researchers said 36,000 of the 900,000 children cited in the HHS report will become violent criminals when they reach adulthood, including 250 who will become murderers.
    The report's authors include four local prosecutors and two sheriffs. They said the findings illustrate the need for more federal funds for pre-kindergarten programs and parenting classes for families considered high-risk for child abuse, primarily those on welfare or headed by high school dropouts. The 1996 welfare overhaul bill earmarked $2.8 billion for the states under a social services block grant, but congressional Republicans cut funding to $1.7 billion in the current budget year. David Landefeld, the Republican district attorney for Fairfield County, Ohio, said crime connected to child abuse costs Americans $50 billion a year -- 50 times the amount of money cut from the social services block grant. HHS officials said it was up to Congress to decide whether to provide the money.
    In Elmira, N.Y., a parenting program for single, poor mothers reduced incidents of child abuse or neglect to one-fifth of what they had been. In Chicago, a combination of parenting classes and pre-kindergarten cut cases of abuse and neglect in half, according to the report. "It is possible to prevent child abuse and neglect instead of waiting for the next horror story to occur," said Brooklyn, N.Y., District Attorney Charles Hynes.
    Brendina Tobias of Newport News, Va., is a social worker whose son was killed in New York in 1993 while walking to a restaurant to get food for his elderly grandmother. The murderers had been neglected as children and learned to take whatever they wanted to survive, Tobias said. "Abuse and neglect can be prevented," Tobias said. "Maybe my son would still be alive."
    On the Net:
Fight Crime: Invest in Kids: http://www.fightcrime.org
Widom study: http://www.ncjrs.org/pdffiles1/jr000242b.pdf

Author Sees Prozac From Psychiatric and Pop Culture Perspective
Anne Martino, Ann Arbor News- 5/5/2003

Like its patients and practitioners, psychiatry does have its issues. In "Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs," Jonathan Metzl looks at some of these issues in a mind-bending, literate way.  Metzl is an assistant professor of psychiatry and women's studies at the University of Michigan. He probably has a broader view of psychiatry than most laypeople and professionals because he has studied both medicine and popular culture. On Wednesday at 8 p.m., he will discuss his book at Shaman Drum, alongside Kimberlyn Leary, associate director of the U-M Psychological Clinic. It should be lively.
    Metzl decided to write "Prozac on the Couch" because he was seeing psychiatric drugs from two views. As a psychiatrist, he was trained to know chemical and physiological properties of antidepressants, mood stabilizers and other drugs, so a good part of his thoughts focused on such things as the half-life of Celexa and the starting dose of Prozac.  But as a scholar of popular culture, Metzl became increasingly interested in how psychiatric medications act as symbols. "More than any other type of medications, psychiatric drugs convey a host of connotative implications in American culture," he says via e-mail. "These range from patients' preconceived beliefs about drugs, to unspoken messages when doctors prescribe, or don't prescribe, certain medications, to social and cultural meanings attached to medications by mass media, fiction, TV and advertisements."  To illustrate this, Metzl points to a 21-year-old college senior who went for an evaluation carrying a copy of Newsweek, and, when asked the reason for his visit, pointed to a Prozac advertisement and said, "This is me."  Another example is a 43-year-old businesswoman who became frustrated when Paxil apparently didn't help her get a promotion. Says Metzl, "Understanding the symbolic functions of the medications is as important as knowing their half-lives or suggested dosing regimens."
    In the book, Metzl traces the history of psychiatric medications beginning in the 1950s, explaining the fine line that sometimes exists between a drug and its marketing. Although advertisements can empower consumers and open new treatment options, Metzl's research also showed that over time, ads convey a variety of non-medical messages. He focuses in the book on gender, exploring how drug ads can present psychiatric drugs as treatments for seemingly normal women's life events, including menstruation, menopause, sexuality and motherhood. Judging by some ads, drugs might be seen as agents for restoring "normal" womanhood, Metzl says.  Metzl urges doctors and patients to see and discuss "how prescription drugs, and our hopes for them, can become tangled in a host of social perceptions and misperceptions." Such discussions, he says, are particularly important in an era of shortened office visits and quick prescription refills.
    So far, feedback on the book has been favorable, says Metzl, who when he answered my questions was just back from the first leg of a promotional tour in New York City. In New York City, Metzl gave public lectures, including one sponsored by the New School University's Department of Social Sciences. That audience, he reports, "was a wonderful mix of students, professors, psychiatrists, psychoanalysts and retirees."
    One of the most engaging parts of the book is Chapter 5, in which Metzl explores how Prozac became "a character in American literature." He surveys "Prozac narratives," from Peter Kramer's "Listening to Prozac," Peter and Ginger Breggins' "Talking Back to Prozac," Elizabeth Wurtzel's "Prozac Nation," Joseph Glenmullen's "Prozac Backlash" and a set of lesser-known works including Lauren Slater's essay "Black Swans" (1996), Pagan Kennedy's and Gary Krist's short stories "Shrinks" and "Medicated," respectively, and Persimmon Blackbridege's novel "Prozac Highway."  This book is extraordinarily researched and written in an engaging style that invites professionals and laypeople to open their minds to a broad and informed view of modern psychiatry and psychiatric drugs.

So Much for the Madman Theory
Erica Goode, New York Times- 5/5/2003

By his word he could kill them, have them tortured, have them rescued again, have them rewarded. Life and death depended on his whim." The psychoanalyst Erich Fromm used these words to describe the "refined sadism" of Josef Stalin, who took delight in playing with the minds of his victims before he ordered the destruction of their bodies. But the revelations of recent weeks suggest that they might as easily be applied to another former dictator, Saddam Hussein.
    The objects unearthed at Iraqi prisons, palaces and safe houses speak of brutality and indulgence. A gold machine gun. A cable used to deliver electric shocks to ears and genitals. Fantasy paintings of snakes, monsters and unclad women. A red wire cage with a cement channel in the floor for human excrement. The stories behind the objects tell of paranoia and caprice -- arbitrary imprisonment and equally arbitrary release, opulently furnished rooms never inhabited. And behind it all is a man who acted out his fantasies of omnipotence using a nation as his theater and its citizens as his props.
    Psychoanalyzing political leaders is a dicey business, and psychiatrists are quick to caution that without extensive research or personal contact with Mr. Hussein, nothing can be said with certainty about his psychological makeup. But what is already known about Mr. Hussein is suggestive, the psychiatrists say. Like Stalin and Hitler, Mr. Hussein has sometimes been referred to as a madman, in part because people are reluctant to accept such ruthlessness and cruelty as the product of anything but insanity. But bad does not equal mad. Most historical analysts have rejected the notion that mental illness could explain the actions of either Stalin or Hitler. Experts familiar with Mr. Hussein's upbringing and years in power said that there was no evidence that he suffered from psychosis or any severe mental illness. The very fact that he was able to stay in charge for so long and exert such complete control argues against insanity, the experts said.
    Two researchers, Jerrold M. Post and Amatzia Baram, concluded in a psychological profile of Mr. Hussein that he was more accurately described as a malignant narcissist, a label that has also been applied to Stalin and Hitler. Dr. Post, a psychiatrist at George Washington University, and Dr. Baram, an expert on Iraq at the University of Haifa in Israel, wrote the profile for the United States Air Force Counterproliferation Center. Dr. Post was also the founding director of the Central Intelligence Agency's political profiling program.
    Malignant narcissism, as defined by psychiatrists, is a severe form of narcissistic personality disorder. Like classic narcissists, malignant narcissists are grandiose, self-centered, oversensitive to criticism and unable to feel empathy for others. They cover over deep insecurities with an inflated self-image. But malignant narcissists also tend to paranoia and aggression, and share some features of the antisocial personality, including the absence of moral or ethical judgement, said Dr. Otto Kernberg, a psychiatry professor at Cornell University and an expert on personality disorders.
    Far from being psychotic, malignant narcissists are adept at charming and manipulating those around them. Political leaders with this personality, Dr. Kernberg said, are able to take control "because their inordinate narcissism is expressed in grandiosity, a confidence in themselves and the assurance that they know what the world needs." At the same time, he said, "They express their aggression in cruel and sadistic behavior against their enemies: whoever does not submit to them or love them." Dr. Kernberg added that while he had studied Hitler and Stalin, and would categorize them as malignant narcissists, he knew little about Mr. Hussein and could not comment directly about him.
    Dr. Post, however, said that the concept of malignant narcissism fit Mr. Hussein quite nicely. The overarching theme is the centrality of the self -- that he is Iraq," Dr. Post said. This self-glorification, he said, was combined with "a deep-seated need to reassure himself through public adulation of how magnificent he is." Dr. Post added that the bunker built beneath one of Mr. Hussein's palaces was a perfect metaphor for his personality. "Here, under this grandiose palace with its inlaid woods and fine marbles, is this underground bunker with reinforced concrete and steel," Dr. Post said. "That's his psychology: a grandiose facade and under it a siege state, ready to be betrayed, to be attacked, to strike back."
    In their profile of Mr. Hussein, compiled from news accounts and interviews, Dr. Post and Dr. Baram attributed much of the Iraqi leader's psychopathology to his early childhood. They described how Mr. Hussein's mother suffered the death of both her husband and an elder son while she was pregnant with him. She tried to commit suicide and to abort her son, but was prevented in each case by members of a Jewish family who became her benefactors. When Saddam Hussein was born, the researchers wrote, his mother refused to look at him or take him in her arms. Saddam went to live with a maternal uncle, Khairallah Tulfah, who imbued him with dreams of becoming a great Arab leader, like Saladin and Gamal Abdel nasser. At 3, he returned to live with his mother for several years, but was pychologically and physically abused by her new husband, according to, the profile. "One course in the face of such traumatizing experiences is to sink into despair, passivity and hopelessness," Dr. Post and Dr. Baran wrote. "But another is to etch a psychological template of compensatory grandiosity, as if to vow, `Never again, never again shall I submit to superior force.' This was the developmental path Saddam followed."
    Other psychiatrists, however, cautioned that it was difficult to draw conclusions about psychological development from sketchy information about a leader's child hood, particularly when another culture was involved. "Certainly, childhood experiences are very important," Dr. Kernberg said, "but very often that's what we know least about, and what is most easily distorted by fancy speculation." What is not speculative is the adult that Mr. Hussein became, a man obsessed with molding the world into a reflection of his own power.
    Malignant narcissism is not the exclusive province of dictators. In another country, at another time, with a different set of dice, some psychiatrists say, Mr. Hussein might instead have become a corporate executive, a lawyer, a cult leader or politician. His ambition, paranoia and violence might have been modulated by legal codes and tempered by the checks and balances of a free society. Unfortunately, this was not the case. "The best way to understand; this," said Dr. Kerry J. Sulkowicz, a psychoanalyst in private practice in Manhattan, "is that occasionally in history there is a confluence of events, in which the severe psychopathology of a leader is allowed to flourish.'

Maine Mental Health Cuts Decried
Francis X. Quinn, Associated Press- 5/6/2003

AUGUSTA, Maine -- Almost apologetically, Maine's mental health chief spelled out a new round of proposed cutbacks Tuesday before a roomful of protesters, many wearing stickers that read ''Enough is enough.'' ''Our goal remains to maintain core services and keep a network of service providers intact,'' Acting Commissioner Sabra Burdick of the Department of Behavioral and Developmental Services told the Legislature's Appropriations Committee. ''However, we recognize that some of the budget reductions to be discussed today will necessitate painful reductions in services, and will challenge the ability of providers to maintain them,'' Burdick said.
    Burdick went on to detail some of the major cuts in Gov. John Baldacci's plan for offsetting a $48 million revenue shortfall in the two-year cycle beginning July 1: reductions of $1.3 million in fiscal 2004 and $1.2 million in fiscal 2005 for adult mental health services; cuts of $545,041 in fiscal 2004 and $607,041 in fiscal 2005 for adult mental retardation services; reductions of $402,740 in each year for substance abuse services.  ''Obviously, these reductions in funding for services, on top of those that have already been made, will pose difficult challenges for us, for providers and for the people we serve,'' Burdick said.
    Throughout the afternoon, witness after witness, people who described living with mental illness and people who told of working with them seconded Burdick's dire assessment of the impact of the proposed spending curbs. The absence of community support services, warned veteran Bangor social workers Mary Ellen Quinn, ''will mean an increased number of homeless people, increased suffering with psychosis, increased risk of criminal exploitation, increased risk of self harm and suicide and ultimately will mean an increased census in our emergency rooms, our state hospitals and our jails.'' Quinn added: ''The pendulum of support will swing rapidly from community services to institutional services at a much greater price to taxpayers.''  After about three hours of testimony, at least some lawmakers were prepared to look for alternatives.  Judging from my conversations with other committee members, there's pretty darn near universal feeling that there's got to be a better way to balance the budget,'' said Rep. Ben Dudley, a Portland Democrat on the Appropriations panel. ''I haven't had a conversation with anybody on the committee that wants to do this,'' he said.
    To bring the upcoming $5.3 billion biennial budget into balance, Gov. Baldacci originally recommended that mental health services be cut by about $5 million. Baldacci is also proposing to use nearly $9 million from an accounting correction in the state's business equipment tax reimbursement and to take advantage of reductions in debt service totaling more than $10 million.

First Sexual Abuse Shelter for Men & Women Opens
Associated Press, 5/6/2003

BARRE, Vt. -- Vermont has opened a shelter for victims of sexual abuse. The Barre shelter is the first in Vermont, and perhaps the country, open to both men and women. ''I remember what it was like years ago when there was no place to go, and that can't happen anymore,'' Keith Goslant, president of the organization's board, said at the grand opening on Monday. Goslant was raped by a group of young men three decades ago in the small Vermont town where he grew up.
    Men make up about 8 percent of the people who sought help for sexual assaults last year in Vermont, and about 10 percent nationally. The Sexual Assault Crisis Team has a much higher percentage of men using their services than other groups. About 70 of the 249 people who sought help in the last fiscal year were men. Goslant and Sexual Assault Crisis Team Director Bobbi Gagne said their mission was to treat all survivors of sexual violence equally and give them access to the same services.
    The Sexual Assault Crisis Team of Washington County runs the Barre shelter. The group came up with the concept of a shelter after years of frustration with the limits on their ability to help victims. The group was able to buy and renovate a building with the help of about $323,000 in state and federal grants and loans.  The shelter has housed about two dozen men and women, Gagne said. They have received referrals from all over the state, and some from out of state.
    The idea is that the shelter is for people going through a crisis. Most people stay two or three days, but some have stayed several weeks, Goslant said. People are referred from hot lines and organizations, and from police, Gagne said. Some come immediately after an attack and stay until their attacker is arrested or they get a restraining order.  Most people assume that a woman who has just been assaulted by a man does not want to be near other men. But Goslant said that the connection victims make through their common experience is more powerful than their differences in gender and the women rarely ask to be separated from the men who are staying at the shelter. For men, the coverage of the Catholic church scandal has shown that men can be victims and are not afraid to speak out.

Experts See Mind's Voices In New Light
Erica Goode, New York Times- 5/6/2003

It was just one voice at first, loud and male, coming from the ceiling, saying, "Hi, John," calling him by name as if they were buddies. But after a while, the voice, which he came to know as the "evil genius," urged him to steal other people's brain cells and told him that he had a cancerous tumor in his head. Eventually, other voices joined in, maybe 50 of them, male and female, yelling "as loud as humans with megaphones," John recalled, from the moment he awoke in the morning until he fell asleep at night, cursing or ordering him to kill himself or, once, when he picked up a ringing telephone, screaming in chorus, "You're guilty! You're guilty!" "It was utter despair," John said. "I felt scared. They were always around."
    Auditory hallucinations are a hallmark of schizophrenia: 50 percent to 75 percent of the 2.8 million Americans who suffer from the illness hear voices that are not there. Like John, whose schizophrenia was diagnosed in 1981 and who spoke on the condition that he not be identified, many people with schizophrenia spend years pursued by verbal tormentors as relentless as the furies of Greek mythology. Suicide is sometimes the result, death seeming the only escape unending harassment.
    Yet psychiatrists who study schizophrenia have traditionally shown little interest in the voices their patients hear, often dismissing them as simply a byproduct of the illness, "crazy talk" not worthy of study. Recently, however, a small group of scientists has begun studying auditory hallucinations more intensively. Aided by new brain imaging techniques, they have begun tracking such hallucinations back to abnormalities in the brain, finding that certain brain regions "light up" on brain scans when patients are actively hallucinating. And the experts are listening far more carefully to what patients say about their hallucinatory experiences.
    The research has led to new theories of what may cause such bizarre alterations in perception and has spawned at least one promising new treatment: the delivery of low-frequency magnetic pulses to areas identified by the brain scans seems to quiet, at least temporarily, the voices of patients who have not found relief through standard treatment with antipsychotic medications.
    Ultimately, the researchers say, knowing more about what causes auditory hallucinations may help them understand more broadly the mechanisms that underlie schizophrenia and other psychotic illness. "These are critical, core experiences that really constitute what having schizophrenia is all about," said Dr. Ralph Hoffman, a psychiatrist at Yale who is studying the magnetic stimulation treatment, called transcranial magnetic stimulation or T.M.S.
     In research described in a recent issue of Archives of General Psychiatry, Dr. Hoffman and his colleagues found that schizophrenic patients who received 132 minutes of the magnetic stimulation over 9 days showed a significant reduction in auditory hallucinations compared with control subjects given a dummy treatment. Half of the subjects in the study experienced a return of their symptoms within 12 weeks, though in some cases, the hallucinations remained at bay for up to a year. All the patients were also taking antipsychotic medication.
    Schizophrenic patients describe voices that not only talk to them but talk about them, haranguing, insulting and sometimes provoking them to hurt themselves or to perform other actions. In many cases, the hallucinations become more intense when the patient is under stress. In a study of 200 patients with schizophrenia and other psychotic illnesses, Dr. David L. Copolov, director of the Mental Health Research Institute of Victoria in Melbourne, Australia, and his colleagues found that 74 percent said they heard voices more than once a day. More than 80 percent described the voices as "very real," rather than "dreamlike" or "imaginary," and 34 percent experienced the voices as coming from outside their heads (38 percent said they came from both inside and outside their heads and 28 percent from inside only). A small minority of the patients said the voices they heard were always or almost always supportive and positive in tone. But more than 70 percent described them as always negative. Dr. Hoffman of Yale said some of his research subjects heard voices intermittently, but others heard them continuously, the only respite coming when they slept. One patient who committed suicide described her voices as "a constant state of mental rape," Dr. Hoffman said.
    Nicole Gilbert, 37, received a diagnosis of schizophrenia in 1985. For years, she said, she could not read anything because her voices "would tell me that it was about me." "They would say things to try to make me believe that I was Jesus," she recalled. "Then they would torture me and say: `We're just joking. You're so stupid, how could you believe this?'" Ms. Gilbert, who is much recovered and is now a case manager at a mental health agency in California, said the voices seemed so real that she could not believe it when her friends told her she was hallucinating.
    The findings of studies using brain scanning techniques like positron emission tomography (PET) or functional magnetic resonance imaging (M.R.I.) underscore how persuasive auditory hallucinations are to those who experience them. When patients are hallucinating, areas of the brain involved with auditory perception, speech, emotion and memory show increased blood flow, indicating greater nerve cell activity.   "These people are not just crazy; they're telling you what their brains are telling them," said Dr. David Silbersweig, an associate professor of psychiatry at Weill Medical College of Cornell University who has studied hallucinations with brain-imaging. Still, studies so far have come up with differing patterns of brain activation. For example, both Dr. Hoffman's group and a team led by Dr. Philip McGuire, a professor at the Institute of Psychiatry in London, found heightened activity in Broca's area, a region of the frontal lobe involved with speech perception and processing. But Broca's area was not identified in Dr. Silbersweig's research or in a study by Dr. Copolov that will be published soon. The precise areas of the brain's temporal and parietal lobes that show activity during hallucinations also differ from study to study. The discrepancies are difficult to interpret and reflect the imprecision of even advanced technology in capturing highly complex brain processes. The data are further clouded because the high costs of scans limit the size of most studies.
    But the disparity in the findings has also led to different theories about how hallucinations arise. Schizophrenia typically strikes in adolescence or early adulthood. Extensive research over the last few decades has indicated that the brains of people with the illness differ in significant ways from those of healthy people. Experts agree that schizophrenia stems from a combination of genetic predisposition and unknown environmental influences. What everyone who studies hallucinations agrees on is that schizophrenic patients misperceive signals generated inside the brain. But scientists are still debating what is being misinterpreted and how this occurs.
    Dr. Copolov, for example, suggests that the "voices" patients hear are really fragments of auditory memories "that come to consciousness fused with emotional content" and are then incorrectly evaluated as originating from an outside source. The fact that in some studies the hippocampus and other brain structures known to be involved in memory retrieval are active during hallucinations is consistent with this theory, Dr. Copolov said.
    Other researchers, including Dr. McGuire of the London institute, have argued that what is misperceived is internal speech--the running dialogue most people engage in while thinking. In schizophrenia, in this view, a mechanism that normally distinguishes between internal and external speech breaks down. Dr. Judith Ford, an associate professor of psychiatry at Stanford, and Dr. Daniel Mathalon, an assistant professor of psychiatry at Yale, have proposed that the brain's auditory cortex may play a role in this failure to identify speech correctly as internal or external. In studies, they recorded electrical activity in the auditory cortices of schizophrenic patients and healthy control subjects. In the control group, the auditory cortex showed a dampening of activity in response to internal speech, they found. But this inhibition was lacking in schizophrenic patients. "When you and I have these thoughts," Dr. Ford said, "we are inhibiting the response of our auditory cortex, saying, 'Don't pay attention to this; it's me, talking.' But the schizophrenic patients do not inhibit the response the way normal healthy people do."
    Dr. Hoffman has a slightly different theory. In schizophrenia, he suggests, a loss of gray matter may intensify the link between Broca's area, involved in speech production, and Wernicke's area, responsible for speech perception. In the normal course of affairs, Dr. Hoffman said, Weinicke's area receives information from a variety of nearby brain areas and distant structures like Broca's. But in schizophrenic patients, who in imaging studies show a loss of gray matter in the superior temporal lobe containing Wernicke's, the signals sent from more local regions may be knocked out or greatly decreased. If so, Dr. Hoffman suggests, the signals coming from Broca's may then become more salient, bombarding Wernicke's area with internally generated words and phrases that are in some way interpreted by Wernicke's as external speech. Dr. Hoffman noted that transcranial magnetic stimulation applied to Wernicke's area appeared to suppress hallucinations in some schizophrenics. "My view is that in schizophrenia it is not just inner speech or an acoustic memory that is misinterpreted," Dr. Hoffman said. Instead, he said, patients "are actually having perceptual experiences that have the same clarity and vividness of external speech."
    Dr. Hoffman's research team is now using M.R.I. scanning with each research subject to determine which brain regions are active when the subject is hallucinating, and then delivering stimulation to that area. But whatever the research on magnetic stimulation yields, it is already helping some of the 25 percent of hallucinating patients whose voices are not stopped by antipsychotic drugs. "Just stimulating in a single site appears to have a significant impact," Dr. Hoffman said. Other experts call the results impressive. In the treatment, an electromagnetic coil shaped like a Figure 8 is held to the patient's head. The coil produces a quarter-size magnetic field which is then rapidly turned on and off, inducing an electrical field in the cerebral cortex's gray matter. Scientists do not know exactly how the treatment works, but they believe it dampens the reactivity of neurons, an effect that is then passed on to other connected brain regions.
    Unlike electroshock therapy, long used for severe depression, transcranial magnetic stimulation does not induce seizures at the levels used in the studies and has a far more selective effect on the brain. Nor does the treatment appear to have the serious side effects, like memory loss, of electroshock therapy. The most common side effect, Dr. Hoffman said, is mild contractions of the scalp that some patients find uncomfortable. Also, in contrast to electroshock, patients receiving the magnetic stimulation remain awake, unsedated, through it.
    John, who participated in Dr. Hoffman's research last summer, said the procedure did not bother him. "This thing kind of taps on your head every second and it's not intrusive," John said. He said his voices got "smaller and not as loud" after treatment, but they did not go away entirely, and the improvement lasted only six months. Without a full cure in sight, John said he has developing his own tactics for fighting the hallucinations, which persist despite the medications he takes. He talks back to them in his head, he said, and criticizes them when they criticize him. Between his own efforts and the treatments, John has made much progress. He now attends school, has his own apartment, goes out with friends and has a girlfriend. "I wanted to try to make the voices my friends, but I found out later that that is not realistic," John said. "I was kicked around by them for a long time. Now, if they start bothering me, I just kick them around instead."

Even the Healthy Hear Voices
Not everyone who reports hearing voices has a mental illness. Some neurological conditions produce hallucinations. And over the centuries, saints, philosophers, scientists and writers have reported receiving guidance or inspiration from voices that only they could hear.
    More recently, a few studies have found that healthy college students -- 45 percent in one study -- report having heard a voice at some point when no one was speaking. (Experts note that the studies are small and in some cases methodologically flawed.) Hearing the voice of a deceased spouse is also not uncommon among recently widowed people, according to a study in 1998.
    Dr. Marius Romme, a Dutch psychiatrist, said he believed that in healthy people hearing voices could be a coping strategy, often in reaction to a traumatic event. The voices, Dr. Romme said, are often used as advisers. But other experts say such experiences differ from the hallucinations of schizophrenia, which are more frequent, more intense and more emotionally charged. "There's a big difference between hearing a voice and voice illness," said one man with schizophrenia.

Cocaine Blocker to be Tested
Jamie Talan, Newsday, 5/6/2003

Scientists are testing an experimental vaccine that could help fight cocaine addiction. If it's proven effective, it could help prevent former cocaine users from relapsing. Historically, vaccines have been developed to prevent disease by exposing the body to snippets of the infecting agent, which allows the body's immune system to mount a defense against-the disease. The antibodies formed during this process act like soldiers guarding against invasion. But recently, a different vaccine approach has emerged. Again, the theory is based on the body's calling upon the immune system for help. This new approach is based on the antibody's ability to block cocaine as it enters the bloodstream on its way to the brain, where it triggers euphoria.
    About 500,000 Americans are addicted to the powerful stimulant. About 2 million others are occasional users. The cocaine molecule is small and can easily sneak into the body without letting the immune system know it's present. In vaccine development, scientists attached the cocaine molecule to a larger molecule, and thus were able to generate an immune response -- antibodies -- which proceeded to mop up cocaine in the bloodstream before it got to the brain.
    Scientists say the vaccine is designed to prevent relapse and would probably not work to stop cocaine use. "It doesn't affect the craving for cocaine," explained Dr. John St. Clair Roberts, medical director of Xenova Group, a biotech company in England. "But it can prevent reinforcement of the craving." For the former addict "it means that if they fall off and take a snort of cocaine, it would neutralize that slip."
    A small number of human addicts has received injections of the vaccine in a test of its safety. A study now under way at Columbia University College of Physicians and Surgeons will test how well it works. The study is being run by Margaret Haney, associate professor of clinical neuroscience at Columbia. Haney worked closely with the late Marian Fischman, who in the late 1980s created one of the country's first 24-hour cocaine research laboratories at Columbia.
    Volunteers in the study will be given cocaine under strict laboratory conditions and then receive four injections over eight weeks. At 12 weeks, they will be given cocaine again in an effort to determine if the vaccine is effective. The scientists have permission from the Food and Drug Administration to study 10 patients. "We expect the changes (in the experience of pleasure) to be significantly reduced after vaccination," St. Clair Roberts said. The study will be completed within a year.
    But some cocaine researchers worry that users will learn how to overcome the antibody response. "We'll certainly need many different ways to help cocaine addicts," said Dr. Nora Volkow, associate lab director for life sciences at Brookhaven National Laboratory in Upton, N.Y. Next month, Volkow becomes the new director of the National Institute on Drug Abuse, which is funding the study. "The vaccine by itself will not be sufficient." That's because cocaine is a powerful stimulant that turns on the brain's dopamine cells, which signal that something is pleasurable. Cocaine works directly on these cells, Volkow explained.
    The British scientists developing the vaccine admit that it's not likely that the treatment would block all cocaine in the bloodstream from getting into the brain. "It's an interesting strategy," said Michael Kuhar, the Chandler professor of pharmacology at Emory University in Atlanta. He has been studying cocaine. for decades and has discovered about 500 molecules that look like cocaine "but are more selective, more potent or slower to get into the brain," he said.

A Zealous Quest for Chemicals to Heal Ailing Brains
Claudia Dreifus, New York Times- 5/6/2003

DENVER-- As a young physician in the 1960's, Dr. Floyd E. Bloom was part of the team from the National Institute of Health that uncovered the principles behind the drugs that are now used to treat depression. Since then, he has been the director of behavioral neurobiology at the Salk Institute, the chairman of the neuropharmacology department at the Scripps Research Institute and the chief of the neuropharmacology laboratory at the National Institute of Mental Health. Now, he is the chairman of Neurome, a San Diego company involved in brain research.
    Throughout his career, he has been looking at chemicals and the ways they affect the nervous system. Dr. Bloom, who is 66, has often been active in places where the skills of science and politics intersect. From 1995 to 2000, he was editor in chief of Science magazine. Last year, he was president of the American Association for the Advancement of Science, the largest general membership science organization in the United States, and he continues as chairman. He spoke with an interviewer here after giving a lecture on health care policy.
Q. You call yourself a physician-scientist. Did you ever actually practice medicine?
A. I was an intern and resident for two years after my medical degree at Barnes Hospital in St. Louis. I loved it. My father's dream had always been for me to become a physician. This had been his dream for himself. But because of poverty and discrimination in medical schools at that time, he became a pharmacist. In his mind, if you were a doctor, you had an infallible occupation. And he wanted that for me. I trusted my father, Jack Bloom. I understood where he was coming from. He was very concerned with the anti-Semitic experiences he had experienced in Minnesota, where he'd grown up in the 1920's. He moved his family to Texas because he thought it was the land of opportunity. And he was successful there. I couldn't argue with his success. I went to medical school. When I graduated, my father gave me prescription pads for his Gaston Avenue pharmacy with "Floyd E. Bloom, M.D." printed on them. He never got a prescription from me to fill. Not for anyone.
Q. What led you away from practicing medicine?
A. I discovered research. After my residency, in 1962, I went to the National Institutes of Health as a research associate there. It was my intention to compete to be chief resident of ward medicine when I returned to Barnes. Spending a few years at the N.I.H. was the accepted route to that. But at the N.I.H., I got hooked on brain research. I never got back to St. Louis. At the N.I.H., I was assigned to the National Institute of Mental Health research program led by Dr. Seymour Kety, a pioneer in the biochemical aspects of depression. He developed the first realistic description of how the brain's chemistry changed during depression. Five years later, one of Dr. Kety's colleagues, Dr. Julius Axelrod, figured out how the initial antidepressant drugs might work, by bolstering the levels of the neurotransmitters that Dr. Kety's thesis had predicted were deficient.
Q. Is it accurate to say that you were present at the birth of modern psychopharmacology?
A. Yes. And it was so inspiring to be there. You felt you had the whole world in front of you.
Q. Which drug did you work on?
A. Reserpine, an herb from India, used to treat people with high blood pressure. The drug had a nasty side effect: About 20 percent of the people who took it became seriously depressed. Laboratory rats given it also became depressed. In those days, nobody knew what norepinephrine, one of the neurotransmitters related to depression did in the brains of humans or rats. Now, if you gave an animal reserpine, it got depressed. And if at that point you ground up the brain, you could determine what the chemical differences were. You saw that norepinephrine, dopamine and serotonin were all greatly diminished in the animal's brain. Then, when you gave the animal reserpine and it eventually recovered from its depression, you discovered that the neurotransmitters had been replenished. This eventually led to the current class, or serotonin selective reuptake inhibitors, the Prozac-like compounds that so many people take today.
Q. As a witness-participant to one revolution, how did you react when the human genome was mapped?
A. I felt this is the great story of my time. The world of medicine and health will change because of it. Instead of diagnosing people after they have begun to experience illness, we will, at some point in the future, be able to predict who is likely to be vulnerable to a problem. For a physician to be able to stop something from going wrong is much better than trying to fix something once it has gone wrong. Many of the most frequently occurring diseases such as Alzheimer's and depression have genetic aspects. By pursuing genomic clues, we will be able to figure out interactions and maybe delay the onsets of these conditions. Yet as astounding as this breakthrough is, my big fear is that the health care delivery system is in such crisis that we may not be able to translate the fruits of this revolution to everyday medical practices.
Q. What are your concerns about the future of medicine?
A. Despite all the advances, we cannot afford to pay for the new technologies because of how we deliver health care, through a patchwork system that includes H.M.O.'s, Medicare, Medicaid. And that is falling apart in front of our eyes. The current system is under such duress that it is unable to accept the new medications and therapies of the future, which are going to be tailored to people's particular genetic problems and will be expensive. At this moment, because of rising insurance costs, some specialties -- obstetrics, radiology, neurosurgery -- are seriously understaffed. Nationally, we're short a million nurses. If you add this to other system-wide problems such as the poor handling of information and the loss of consistent patient-doctor relationships and the failure to educate physicians in preventive medicine, I see a failing system.
Q. Why does health care policy concern researchers in a laboratory?
A." I can speak personally. My dedication to bench work has always been predicated on the belief that we'd always have a pipeline for translating scientific advances into medical practice. I always thought discoveries would be made, then there would be clinical trials, and the results would be handed off to the system. Well, the present system simply does not work well enough to do that anymore. I see this everyday in my wife, Jody Corey-Bloom, and her practice. She is a dedicated neurologist. Yet she spends most of the time allotted for contact with patients trying to get their insurance providers to allow the treatments she knows are the most needed and completing endless paperwork to keep benefits coming. Her worst fears are confirmed every time a clerk with barely a high school education vetoes her recommended treatment because another medicine may be less costly in the short term. Watching her, I can see the stress on practitioners and patients. So when I gave my speech as the outgoing president of the A.A.A.S., I decided to use the opportunity to call for a national commission to restore the American health system. The idea is to get patients, providers, insurers, employers, caregivers and physicians together to think about the future of medicine.
Q. Would another commission on the health care system be different from the countless panels of the past?
A. Quite honestly, I proposed this commission because I wanted to state that we can't keep tinkering with the system. President Bush has been primarily focused on two proposals for the health care system, limiting malpractice rewards for pain and suffering and providing a pharmaceutical benefit for the elderly, especially if they are willing to adapt to some kind of private insurance. Frankly, I'd like for us to consider health care to be regarded as something like a public utility. To me, if we agree that universal coverage is something to be desired, is that really much different than the fact that we've all agreed that everyone in the country is entitled to have electricity, water, telephone connections, if they can pay for it. We have all kinds of ways to help people get those basic provisions of life. And health benefits could be viewed in exactly that same utilitarian way. It could be a corporate network like water power and electricity, with regulatory agencies that set the rates for profit.
Q. What do you think of the health care reform plan offered by a Democratic presidential candidate, Richard Gephardt?
A. Representative Gephardt is quoted in the media as proposing a very expensive plan to provide universal access for those presently employed but uncovered. And if that's correct, then it would be yet another patch to give access to an overloaded, understaffed system while doing nothing for prevention or public health needs, renewal of nursing and physician shortages and ignoring self responsibility for individual health maintenance.
Q. Let's return to your father. Do you find it ironic that for most of your career you have been working in research related to pharmacology
A. It's not ironic. It's more like I was predestined. I was always attracted to the chemical principle that you could alter physiology. That was the basis of my dad's business, right? Giving medications that could help people's symptoms. To me pharmacology is the bridge between the very basic sciences and the clinical sciences. Listen, I've had a great time in my career, a great time. I've been a physician, researcher, editor. And right now, I dabble at trying to do biotech business. I have a small company doing mouse brain research. But I've loved everything I have done. Very few people can say that of 45 years of work.

Psychiatrist Pleads Guilty to Sharing Drugs
Paul Shukovsky, Seattle Post-Intelligencer

A junkie psychiatrist at a Seattle hospital who manipulated patients into sharing drugs he prescribed for them pleaded guilty to a felony count yesterday. Dr. Steven Jewitt, while on staff at the Veterans Affairs Medical Center on Beacon Hill, prescribed narcotics for as many as 10 patients so that he could obtain the drugs for his own use. Jewitt has lost his job at the VA hospital, faces six months of home confinement and the prospect of losing his medical license. State medical licensing authorities say "there is an on-going investigation of Jewitt involving drug issues," said Maryella Jansen, deputy director of the Medical Quality Assurance Commission.
    Jewitt declined to comment following the hearing yesterday. But his attorney, David Allen, said that Jewitt's actions came while he "was really in the ravages of addiction. He has a great deal of remorse for his actions and the effect it had on the hospital and his patients." Since leaving the Betty Ford Center, a chemical dependency clinic in Rancho Mirage, Calif., Jewitt has found employment as a physician. Allen would not reveal where Jewitt works but said he is under the supervision of the Washington Physicians Health Program, which administers random urinalysis to ensure he is clean and sober. As part of the program, he is required to be in therapy, be monitored at his work site and attend mutual help meetings.
    In one instance, authorities say Jewitt shared a narcotics prescription with a mentally ill patient with a history of substance abuse who responded to the drug with a manic outburst so violent that his wife thought she would be killed. In a rampage, the patient -- who said he "had been taking handfuls of Vicodin" -- kicked in the doors of his home and ripped phones from the walls while his terrified wife looked on. "I was scared to death. I thought he was going to kill me," said the wife, who, along with her now-stable husband, related their story on the condition that their names not be used.
    After the outburst, the 48-year-old Air Force veteran checked into the hospital for drug detox treatment at the insistence of his family. His wife, not a medical professional, correctly suggested that her husband suffers from bipolar disorder, a diagnosis that had been missed by Jewitt. And he immediately began to improve when withdrawn from narcotics and given the proper medication to control his tempestuous mood swings. The outraged couple decided to take action because, as the wife put it: "Veterans and people with mental illness don't deserve this kind of treatment."   In October, shortly after his outburst, the patient called a VA patient advocate to complain about having to share his Vicodin and Valium prescriptions with Jewitt. It was that complaint that led to Jewitt's downfall.
    Working with an agent of the VA inspector general's office, a recording was made of a telephone conversation between Jewitt and the patient in which Jewitt asks him not to reveal to anyone that they shared Vicodin prescriptions. Within a couple of hours, Jewitt was summoned to an office at the VA hospital where he was advised of his rights and interviewed by an agent who told him he was under investigation for diverting drugs and being under the influence of a controlled substance while on duty.
    Assistant U.S. Attorney Ronald Friedman worked out an agreement that resulted in Jewitt's guilty plea yesterday to a felony count of acquiring a controlled substance by deception. Because Jewitt came forward after being caught and revealed the names of about 10 patients he made share narcotics prescriptions, the government agreed to recommend six months of home confinement ensured by electronic monitoring.
    VA officials say they are confident in the safeguards in place to prevent diversion of drugs from its internal pharmacy. But in Jewitt's case, he wrote prescriptions for outside pharmacies. "We don't have the ability to pick up what's happening in private pharmacies outside our walls, and no one else does either," said Sandy Nielsen, deputy director of the VA's Puget Sound Health Care System. Shortly after the VA caught Jewitt in October, he checked into the Betty Ford Center, Allen said.
    If Jewitt had contacted the Physicians Health Program before his addiction drove him to abuse the doctor-patient relationship, he might have been able to avoid discipline from state licensing authorities. Dr. Lynn Hankes, who runs the program, said it is helping about 180 Washington doctors who are assured they will not be reported to the state licensing board as long at they attend therapy, pass random urine tests and convince monitors they are clean and sober. But Hankes said any physician who endangers patients is immediately reported to the state licensing authorities. Jansen, of the medical quality commission, said the harshest penalty Jewitt could face for unprofessional conduct is a revocation of his license for 10 years. Jewitt would have to apply for reinstatement of his license if it is revoked.

Massachusetts Mental Health Service Cuts May Be Fatal
Sandy Coleman, Boston Globe- 5/08/2003

Brockton-based HealthCare of Southeastern Massachusetts gets about 4,000 calls a year on its rape crisis hot line. Its 11 family planning clinics annually serve 11,000 clients, most of whom do not have health insurance, and HealthCare's shelter last year temporarily housed about 200 battered women and their children. But after July 1, the start of fiscal year 2004, all three services may be severely cut, or eliminated. A proposed budget recently released by the House of Representatives calls for significant cuts that will affect family planning services, and mental health and substance abuse treatment programs. Proposed cuts to residential mental health programs alone are about $6 million, and another $3.8 million is scheduled to be cut from substance abuse treatment funding. And the budget now being debated completely eliminates state money for methadone treatment programs.
    "This is a very bad hit for us. We're going to find ourselves having to close a number of clinics. The rape crisis program is going to have a problem surviving," said Sheldon Barr, HealthCare's executive director. "This agency has lost $2.5 million in the last two years just in cuts. We've laid off 30-some people. We have given up our offices in places." Barr, like many service providers south of Boston, said he wonders how much more slashing the programs can withstand. In addition to HealthCare, several area mental health and substance abuse centers would be affected by the proposed cuts, including Bay State Community Services, based in Quincy; Brockton Family and Community Resources; Catholic Charities in Brockton; South Bay Mental Health Center, Brockton; Harbor Counseling Center, Westwood; the Old Colony Y Services Corporation, Brockton; Quincy Detox/ Faxon Recovery; South Shore Mental Health Center, Quincy; and Riverside Community Care, headquartered in Dedham.
    "If those come to pass, it will result in cuts in services," said Marsha Medalie, vice president and chief operating officer of Riverside Community Care, which serves 11,000 people annually in about 53 communities in Eastern and Central Massachusetts. The Dedham facility is a residential treatment center for about 130 people needing intensive psychiatric care. Further cuts would force Riverside to reduce its number of beds, Medalie said. "People would become homeless or have to return to hospitals," she said.
    Last week, the House began debate on about 1,025 amendments trying to restore funding to various line items. They also began debating revenue-generating suggestions. Once the House finishes, the Senate will develop its budget, and then the two bodies must agree on a final plan to send to the governor for signing. Charlie Rasmussen, spokesman for House Speaker Thomas Finneran, said that about 55 percent of the state's budget is untouchable because of constitutional or legal requirements. "The state this year is facing a $3 billion shortfall in revenue. Tough economic times dictate very, very difficult decisions. There is not one representative in the House that takes any pleasure in the cuts put forward . . . But, under the Constitution, we can only spend money that we agree is coming in. We have to have a balanced budget."
    Kenneth Tarabelli, executive director of Bay State Community Services based in Quincy, said he is waiting to see the final budget. But he is not optimistic. "We've already dropped eight to 10 programs in the past year," Tarabelli said. "Many of them were prevention and intervention programs trying to go out and reach kids before they have a problem . . . Now, you get into the treatment programs. At some point the whole thing begins to breakdown." Tarabelli's organization, which is a collection of five agencies, began in the 1960s when recreational drug use became more common in the suburbs. Bay State runs residential programming for youths, provides emergency shelter for teenagers and oversees long-term programs for those with severe emotional problems. "I worry every day about how to balance the budget and how to keep going," he said. Tarabelli and others in similar positions say they understand there are no easy ways to close the state's budget deficit. Staffing, which usually constitutes about 70 to 75 percent of a typical program's costs, usually gets slashed first during lean times. But fixed costs cannot be easily cut, Tarabelli said. "First, there has to be a coming together in everyone's mind about what is the responsibility of the government," he said. "The sacred cow of `no new taxes' has to be addressed and addressed courageously. It does not appear that people are ready for that. That will happen when the pain gets great enough."
    In the middle of their struggle to keep going, agencies try to organize fund-raising efforts. And there is plenty of lobbying going on at the State House, thanks to people like Elizabeth Funk, head of Mental Health and Substance Abuse Corporations of Massachusetts, which represents 100 providers. But individual clients don't have much of an impact, said Tarabelli. "They are the people whose voices are not heard," he said. Representative Timothy Toomey has heard them -- in the past two weeks he has filed amendments to the budget to restore funding for methadone treatment, mental health reimbursements, and for family planning services. "Unfortunately, I know a lot of people who need access to methadone services. And, I have visited one of the sites in Somerville," said Toomey. "If they did not have access to those services, there is a strong likelihood they would be back on hard drugs, heroin, and revert back to addiction." But Toomey said he does not believe that the cuts are easier to make politically because of the constituencies being affected. "The cuts were across the board. Every agency took some cuts," he said. "I think everybody shared the pain."
    Medalie and other human service providers say the projected savings from the cutbacks are an illusion. "The actual cost to taxpayers will go up, not down," she said. "It costs much more in financial terms, social terms and community safety terms, if people wind up on the streets, in hospitals, or in jail." Said Tarabelli: "It's funny how people look at substance abuse. They say, `Those are other people than us.' I don't know a family that hasn't experienced some degree of substance abuse in their family. But there is a backlash against people who receive human services, almost a denial we go into. It's not our lives and their lives. It's all our lives."

Science Attempts to Explain Meditation’s Mysterious Ways
Los Angeles Times- 5/9/2003

During the last decade, there has been a growing body of research showing that regular meditation — the practice of quieting the mind through deep, continued thought — can help reverse some of the ill effects of stress. Studies have shown that regular practice of meditation can lower blood pressure, heart rate and respiration, reduce anxiety and anger, and help alleviate insomnia and mild to moderate depression, as well as lead to other benefits. Many doctors and researchers have speculated about the reasons meditation — sometimes called the "relaxation response" — produces these effects. But a credible scientific explanation has been elusive until now. Such an explanation could describe how changes in brain function produced by altering one's mental focus affect people's moods and metabolism.
A new study by researchers at the University of Wisconsin and the University of Massachusetts is likely to provide a significant first step to answering the question of what goes on in the brain during meditation. The study was led by Richard Davidson, director of the laboratory for affective neuroscience at the University of Wisconsin, and Jon Kabat-Zinn, founding director of the Stress Reduction Clinic and Center for Mindfulness at the University of Massachusetts Medical School. It has been accepted for publication in Psychosomatic Medicine, a peer-reviewed journal, according to the researchers.
    The researchers sought to test a particular theory: that in people who are stressed, anxious or depressed, the right frontal cortex of the brain is often overactive and the left frontal cortex, relatively underactive. Many such people also show heightened activation of the amygdala, a key brain center for processing fear. By contrast, people who are usually calm and happy typically show greater activity in the left frontal cortex, relative to the right. These folks also pump out less of the stress hormone cortisol, recover faster from negative events and have higher levels of natural killer cells, a type of white blood cell that battles infection and is a measure of immune system function.
    Each person, notes Davidson, tends to have a natural "set point," a baseline frontal cortex activity level that is characteristically tipped left or right and around which daily fluctuations of mood swirl. What meditation may do, the researchers reasoned, is nudge this balance in a favorable direction. To find out, they recruited stressed-out volunteers from Promega Corp., a large high-technology firm in Madison, Wisc. The volunteers underwent EEGs (electro-encephalographs), in which electrodes were placed on the scalp to collect brain-wave information. The volunteers were then randomly divided into two groups: 25 were placed in the meditation group and 16 into the control group, which received no meditation training.
    The meditators took an eight-week course in which they received 2 1/2 hours a week of meditation training at their workplace. During the sixth week, they had an all-day, silent meditation retreat. At the end of the eight weeks, both meditators and controls were again given EEG tests and a flu shot. All also got blood tests to check for antibody response to the flu shots. Four months later, all got EEG tests again. By the end of the study, the meditators' brains showed a pronounced shift toward the left frontal lobe, while the non-meditators' brains did not, suggesting that regular meditation may have shifted the "set point" to the left, said Kabat-Zinn. He said the findings were significant because the subjects were novice meditators, not people with many years of meditation training and practice. The meditators also had more robust responses to the flu shots. Indeed, the bigger the mood effect, the bigger the immune response.
    The Wisconsin study meshes well with findings of a smaller study published in May 2000 by Sara Lazar, a neurobiologist at Massachusetts General Hospital, Dr. Herbert Benson of Harvard University and others. That study looked at five highly trained Sikh meditators and, using a brain-scanning technique called functional MRI, showed that blood flow in the brain shifts depending on whether the meditators where truly meditating or simply reciting words like "dog" and "cat" to themselves. It also fits with research suggesting that certain drugs produce meditation-like effects on the brain, says Dr. Solomon Snyder, a neuroscientist at Johns Hopkins Medical School in Baltimore. Snyder says meditation may increase the amount of serotonin, a calming neurotransmitter, in the brain. Among those fascinated with this research is the Dalai Lama, the leader in exile of Tibetan Buddhism, who has visited Davidson's lab. One of his goals, according to those who know him, is to see whether scientists can explain objectively the subtleties of the mind that Buddhists have long understood subjectively.
    A few small studies on several dozen novice and experience meditators won't provide a final answer on how meditation effects brain function and health, and some experts caution about expecting too much from research in this area. Meditation is "a wonderful tool," but no one should expect meditation to work miracles, cautions Barrie Cassileth, chief of the integrative medicine service at Memorial Sloan-Kettering Cancer Center in New York City. It "cannot bring about levitation. It cannot control cellular activity in the sense of getting rid of disease." But these early studies do suggest that the subtleties of mind long known subjectively to proficient meditators may prove capable of being understood objectively as well.