Leading Drugs for Psychosis Come Under New Scrutiny
Erica Goode, New York Times- 5/20/2003

They were billed as near wonder drugs, much safer and more effective in treating schizophrenia than anything that had come before. For many years, it seemed that the excitement was fully warranted. There were remarkable stories of recovery. And the new generation of antipsychotic drugs, called atypicals, seemed to have few of the side effects commonly seen with high doses of older medications for psychosis.
    The drugs appeared so successful that doctors began prescribing them for other things, not only for other psychotic illnesses, like manic depression, but also for Alzheimer's, personality disorders and nonpsychotic depression, and for conduct disorder and severe aggression in children. Sales of the drugs soared. More than 15 million prescriptions were written last year for the two leading drugs alone, Zyprexa and Risperdal, industry figures show.
    But 14 years after the first of the drugs entered the market, researchers are questioning whether they are quite as miraculous — or benign — as originally advertised. The first round of antipsychotics had such unpleasant side effects, like dry mouth, stiffness and trembling, that people often just stopped using them. The atypicals are considered by many patients to be more tolerable, and many experts believe they are better than older drugs in treating some aspects of psychosis. But studies suggest that their superiority is at best modest, specific to certain symptoms and variable from drug to drug. Also, there is increasing suspicion that they may cause serious side effects, notably diabetes, in some cases leading to death.
    The issue of risks has become more pressing as the drugs are prescribed for children and for adults with milder conditions. And the states, which pay enormous sums for the atypicals in caring for the severely mentally ill, are questioning whether the benefits of the new drugs are worth their costs. The drugs, experts say, have now reached a turning point where benefits must be balanced by side effects and cost. "Clinicians and investigators alike are taking a harder and closer look at areas in which the newer drugs are supposed to be better," said Dr. Jeffrey A. Lieberman, a professor of psychiatry and pharmacology at the University of North Carolina.
    Psychiatrists will debate the relative merits of older and newer antipsychotics in San Francisco tomorrow in a symposium at the annual meetings of the American Psychiatric Association. In other sessions, psychiatrists are presenting new data on the atypicals' safety. How the debate resolves will be watched not only by the nearly five million Americans who suffer from schizophrenia or manic depression and their families but by many millions of other people who have taken the drugs, and government officials.

The Questions
A New Kind of Drug for Psychosis
When a drug called Clozaril entered the market in 1989, it was hailed as a major breakthrough in the treatment of schizophrenia. European researchers who had stumbled upon the drug years before described it as "atypical" because even at very high doses, it did not produce the stiffness, trembling and other Parkinson's-like symptoms commonly seen in patients taking older antipsychotics like Haldol. Clozaril proved able to help some people with schizophrenia when all other drugs failed. In some cases, long-disabled patients shed their apathy and depression, went back to school, made friends and engaged in work for the first time since falling ill. But in a small percentage of people (0.7 percent, according to the prescribing information provided by Novartis, which sells the drug), Clozaril caused a life-threatening blood disorder called agranulocytosis, and patients required regular blood tests to monitor for the side effect, adding to its expense.
    Over the last decade, a series of other atypical drugs, free from association with the blood disorder, have entered the market. Risperdal, the first such drug, from Janssen Pharmaceuticals, was approved by the Food and Drug Administration in 1994. Zyprexa, by Eli Lilly, won approval in 1996. The new drugs — which also include Seroquel, sold by AstraZeneca Pharmaceuticals, Geodon, sold by Pfizer, and most recently, Abilify, sold by Bristol-Myers Squibb — have proved to be impressive moneymakers for the pharmaceutical industry.
    "It's probably the best growth market in the business," said Richard T. Evans, a senior research analyst at Sanford C. Bernstein. National sales of antipsychotics reached $6.4 billion in 2002, making them the fourth-highest-selling class of drugs, behind cholesterol-lowering drugs, ulcer drugs and antidepressants, said IMS Health, a company that tracks drug sales. According to NDCHealth, another company that tracks the industry, in 2002, more than 7.4 million prescriptions were written for Zyprexa and more than 7.6 million for Risperdal.
    Many doctors and patients prefer the drugs to the older medications. Bretta M., 34, a Brooklyn woman, for example, said that the Zyprexa she takes is an improvement over Haldol, an old-generation drug that she said made her feel "like a zombie." "I'm less stiff," Bretta M. said. "I can concentrate more. I'm more alert."
    But the drugs have hardly proved to be a panacea, experts say, and some are more effective and less likely to cause the side effects of older medications than others. "There has been what I see as a kind of myth-making," said Dr. William Carpenter, a professor of psychiatry and pharmacology at the University of Maryland and the director of the Maryland Psychiatric Research Center. "It's like: 'The new generation of drugs is safe, patients like them and they're more effective."' "Patients probably do like them a little bit more," Dr. Carpenter said, and therefore might be slightly more likely to keep taking their medication "But we still have plenty of trouble with the new-generation drugs."
    Like other experts, Dr. Carpenter believes that the atypicals have an edge over the older drugs in some areas. He and others said they seem better at easing the emotional blunting, withdrawal and depression often seen in schizophrenia. Studies have indicated that they are better at preventing relapse and that they carry a lower risk of the most pernicious side effect of older drugs: tardive dyskinesia, a disorder that causes repetitive movements -- chewing motions, lip-smacking and contortions of the arms and legs -- that sometimes persisted even after the drugs were stopped. The drugs may help with problems in memory, decision-making and other mental functions that can keep schizophrenia patients from working, but this is still debated. "I think the new-generation drugs have shown advantages," said Dr. John Kane, the chairman of psychiatry at Zucker Hillside Hospital in Queens and an expert on schizophrenia. "They may not be consistent across every study or every drug, but when you take them in their totality, they are meaningful."
    But determining how much more effective the drugs are is not easy. As in all areas of medicine, many studies, including those that appear in peer-reviewed journals, are financed by drug companies. Others are financed by government insurers. Complicating matters further, many studies are small and they a variety of methodologies, making comparison difficult. Analyses that examine the findings from many studies have come up with mixed results. For example, in a presentation at a schizophrenia meeting last month, Dr. John Davis, a professor of psychiatry at the University of Illinois at Chicago, reported on an analysis of 124 studies comparing newer and older drugs. Ten atypical antipsychotics were included, some of them available only in Europe. Five of the newer drugs, including two not on the market here, were moderately more effective in treating psychotic symptoms than the conventional treatments, the analysis found. Of those sold here, Clozaril was the most effective, followed by Risperdal and Zyprexa. Four of the drugs, however, offered no advantage, and one drug, sold only in Europe, was actually worse. Dr. Davis said he receives no financing from pharmaceutical companies for his research.
    But a 2000 analysis, by Dr. John Geddes, a psychiatrist at the University of Oxford, created a stir by finding no difference in effectiveness between the two classes of drugs. The study, financed by the British government and published in the British Medical Journal, examined 52 studies comparing atypicals and older drugs. Some patient-advocacy groups have criticized the study as biased toward the lower-cost, older-generation drugs. In a telephone interview, Dr. Geddes said that, like other clinicians, he had seen patients improve remarkably on the newer medications. "But I remember over the last 20 years I had quite a lot of people who did really well on the older ones, too," he said. Part of what gave the older drugs a bad reputation, Dr. Geddes contends, was that in the past they were given in very high doses that may have made them less effective and increased side effects. Too, he said, many atypicals "were quite new, and it's not good to go spraying around new drugs without knowing about the long-term effects."
    In a report this month in the medical journal Lancet, Dr. Stefan Leucht, a research associate at Zucker Hillside Hospital, and his colleagues found that although most atypicals produced fewer Parkinson's-like side effects than high-potency older drugs like Haldol, when compared to older drugs of lower potency, some of the new drugs were just as likely to cause the side effects. The analysis indicated that only Clozaril and, by a hair, Zyprexa had fewer of the side effects than the conventional antipsychotics, while the other drugs, including Risperdal, showed no fewer side effects. Dr. Leucht cautioned that the number of studies examined in the analysis was small and that the findings needed confirmation through further research.
    Joel Yates of Brooklyn, 53, who has schizoaffective disorder, said he took Haldol at low doses for 15 years and had no bad side effects. Three months ago, Mr. Yates's doctor, concerned about the risk of tardive dyskinesia on the older drug, switched him to Abilify, a new atypical. "It's hard to notice any particular difference," Mr. Yates said But Regina Moran, a spokeswoman for Novartis, the maker of Clozaril, said that the atypicals had made a large difference for many patients and their families. Before the drugs, she said, "there were many, many schizophrenic patients who never left the back wards of mental institutions." Researchers say the final verdict is not in. Some experts hope that a large study comparing atypical and traditional antipsychotics, underwritten by the National Institute of Mental Health and directed by Dr. Lieberman, will help resolve the issue when its results come out next year. But whatever its outcome, the trial will say nothing about the newer antipsychotics' effects in psychotic disorders, for which they are increasingly being prescribed.
    Even less is known about how the drugs affect children. Psychiatrists say they are helpful and necessary for children who suffer from psychosis or who demonstrate severe aggression. But there is so far little data on their effectiveness or safety, though pharmaceutical companies are now beginning to study the drugs in children and adolescents.

The Side Effects
'Thorazine Shuffle' Vs. Diabetes
Old antipsychotic drugs were notorious for their side effects, not only tardive dyskinesia but the dull-eyed stare and stiff-legged walk that became known in the back wards of state hospitals as the Thorazine shuffle. Such problems are less frequent in the newer generation of drugs, but they are not unheard of. If researchers agree on anything, it is that the new medications have side effects of their own, some serious.
    Most disturbing are cases of diabetes, Type 11 and Type I, and hyperglycemia that have been reported in adults and some children taking atypical antipsychotics. A study presented yesterday at the psychiatric meetings by Dr. P. Murali Doraiswamy, chief of the division of biological psychiatry at Duke University, and his colleagues raises the possibility that some newer drugs may also be linked to pancreatitis.
    Excessive weight gain is common on some atypicals, and may be linked to cases of diabetes: Some patients have reported gaining up to 65 pounds. Some developed diabetes or glucose abnormalities after gaining weight. Others already had the disease and grew worse while taking the drugs. Still others fell ill quickly after starting an atypical and got better once the drug was stopped. For some, the illness was fatal.
    Many experts suspect that the drugs are somehow causing or bringing out diabetes and that some drugs may do so more than others. But they are not yet certain that this is the case. Nor do they know how big the problem is. The number of reported cases so far is relatively small, given the many millions of people who have taken the drugs. More than 12 million people have taken Zyprexa alone, according to Eli Lilly. Complicating matters further, diabetes is common and increasing in the general population. And some studies of patients in the 1940's suggest that diabetes may be higher in people with schizophrenia even without antipsychotic medication. But the cases are worrisome because it took many years for psychiatrists to recognize that the older drugs were causing tardive dyskinesta. "The emergence of tardive dyskinesia was gradual," said Dr. Joseph Deveaugh-Geiss, a consulting professor of psychiatry at Duke University. "There were probably a lot of cases that simply weren't recognized and then, over time, people realized that there was an association." The diabetes link, Dr. Deveaugh-Geiss said, "is looking a lot like what we saw 25 years ago with T.D."
    In three studies, researchers led by Dr. Elizabeth A. Koller examined cases of diabetes in patients taking Clozaril, Zyprexa or Risperdal in an eight-year period. The drugs had 384 reported cases, 289 cases and 132 cases, respectively. On Clozaril, 25 patients died; on Zyprexa, 28; and on Risperdal, 5. The patients who developed diabetes tended to be young and male. The data were gathered from reports filed with the F.D.A. and from medical journals. The researchers cautioned that reporting of adverse drug reactions to the F.D.A. is voluntary on the part of doctors, making it hard to know whether the higher numbers for some drugs truly reflect differences in relative risk. The agency says the reports it receives represent perhaps 10 percent of the actual number of adverse reactions.
    Another study found higher rates of diabetes for patients on Clozaril, Zyprexa and Seroquel but not Risperdal. In their study of Zyprexa, published last year in the journal Pharmacotherapy, Dr. Koller, an endocrinologist then working at the F.D.A., and Dr. Doraiswamy concluded that the number of cases, the timing of the illnesses and the relatively young ages of the patients who fell ill "suggest a causal relationship" between the drug and the development or worsening of diabetes. Also suggestive, they wrote, was that many patients improved when the drug was stopped.
    Marni Lemons, a spokeswoman for Eli Lilly, which has been served with five lawsuits involving patients who developed diabetes while on Zyprexa, said the company did not believe its product was causing diabetes. "This is not an issue for a specific drug, but for this patient population," she said. Ms. Moran, the Novartis spokeswoman, said, "At this time, there is no evidence suggesting" that diabetes is more common or more serious in patients on Clozaril than "outside the context of Clozaril treatment." The issue is far from settled, and more than 20 papers on the topic will are being presented at the psychiatric meetings.
    The F.D.A. is also looking closely at the diabetes issues. A spokeswoman said the agency is waiting for the findings of a large analysis by the Veterans Administration, to be completed this year, before deciding whether to require warning labels on some or all of the atypicals. Some drugs already carry such labels in Japan or Europe, including Zyprexa and Seroquel. However, psychiatrists say patients taking antipsychotic drugs should be monitored on a regular basis for glucose abnormalities. Eventually, Dr. Geddes said, the two classes of antipsychotic medication may come down to a tradeoff of side effects: The risk of tardive dyskinesia posed by the older drugs versus the risk of diabetes. "It's not up to me to say, is it?" Dr. Geddes asked "It's up to the patient to say."

The Future
Cost, Consequences & Patients in Need
Of the billions of dollars spent each year on antipsychotic drugs, a large part comes from government insurance programs. Dr. Joseph Parks, the medical director of Missouri's Department of Mental Health, said that his state spent $104 million, or 11.6 percent of the total Medicaid payout, on three atypical antipsychotics, Zyprexa, Risperdal and Seroquel, between April 2002 and March 2003. The three drugs topped the list in dollar volume of all drugs covered by the state Medicaid program, including cancer, H.I.V. and heart medications. "They are good medications," said Dr. Parks, who is also the president of the National Association of State Mental Health Directors' medical directors' council, "and they seriously help a lot of people. I would not want to give up any of them." But for the price of treating one person with Zyprexa at $303 for a month's prescription, he said, or two on Risperdal, at $159 per month, the state could treat 8 or 10 people with Haldol at $35 per month. Ohio, a larger state, spent $174 million on antipsychotic medications in 2002, close to $145 million of that on the atypical drugs, said Dennis Evans, a spokesman for the state's Medicaid program.
    Yesterday, researchers at the psychiatric meetings presented a study of the cost effectiveness of Zyprexa in treating patients at 17 Veterans Affairs medical centers. The study, led by Dr. Robert Rosenheck, a professor of psychiatry and public health at Yale and the director of the Department of Veterans Affairs Northeast Program Evaluation Center, found that Zyprexa cost the V.A. $3,000 to $9,000 more per patient, with no benefit to symptoms, Parkinson's-like side effects or overall quality of life. Zyprexa was less likely to produce the physical restlessness called akisthesia, the study found, and was associated with slightly better memory and motor skills. The study was financed by Eli Lilly.
    Advocacy groups like the National Mental Health Association worry that the price difference in the drug classes might cause some states, pressed by shrinking budgets, to include only some atypicals in their formularies or even to eliminate them altogether. Because different drugs work for different people, said Jennifer Bright, the association's senior policy director for health care reform, forcing people to choose from two or three medications increases the chances that none will work, and increases the risk of hospitalization or other, higher cost care. "We believe there ought to be open access to all medications," she said.
    Whatever the final verdict on the atypicals, many experts believe what is really needed is new and better drugs. "Many patients are taking multiple drugs, and that suggests that clinicians are not finding it as easy as they'd like to control all the signs and symptoms with one antipsychotic," said Dr. Kane. He and other experts said that no drug, however effective, would make up for larger deficiencies in services for people with severe mental illness. Meanwhile, few psychiatrists -- and perhaps even fewer patients -- would want to lose any of the newer generation of anti-psychotics now on the market. But how they are used and how much value they add, experts say, is ultimately a question for society.

Doctor Admits He Did Needless Surgery on the Mentally Ill
Clifford J. Levy, New York Times- 5/20/2003

An eye doctor who preyed on the severely mentally ill pleaded guilty yesterday to a nearly $1 million fraud scheme in which he routinely rounded up residents of some of New York City's most notorious adult homes and subjected them to unnecessary surgery or charged for thousands of procedures that were never done. At the heart of the fraud was an effort by the doctor, Shaul Debbi, to take advantage of the most vulnerable among the mentally ill residents of the poorly supervised homes to ensure that he would go undetected, prosecutors said in documents filed in United States District Court in Manhattan. They said that on patient charts, Dr. Debbi made notations like: "Smart. Do not invite," or "Confused. Must invite." The word "invite," prosecutors said, meant that he would instruct the residents, some delusional and barely aware of their surroundings, that they needed surgery, to which they typically consented.
    Dr. Debbi acknowledged in court yesterday that from 1998 through 2001, he billed for more than 10,000 services that were either improper, unnecessary or never conducted, ranging from cataract surgery to routine eye examinations. Dr. Debbi's scheme was so flagrant that at one point, prosecutors said, he billed the government for multiple services on a resident's eye even though the resident was missing that eye.
    By pleading guilty to two counts of health care fraud, Dr. Debbi is likely to face a prison sentence of roughly three years, according to an agreement between prosecutors and his lawyer. Dr. Debbi, 48, who lives in Great Neck, N.Y., will also lose his medical license and is required to pay $934,088 in restitution to the government. Taken together, the penalties are among the harshest received by a local doctor for medical fraud in recent years, officials said.
    The guilty plea is also a milestone in what has turned into a wide-ranging investigation into the state's adult homes, which shelter about 15,000 mentally ill people — many of them former state psychiatric hospital patients — and have long been a troubled backwater in the mental health system. Investigators are now examining not only the homes' operators and doctors, but also pharmaceutical distributors and social service agencies.
    The federal inquiries, which are being overseen by United States attorney's offices in Manhattan and Brooklyn, were prompted by a three-part series in The New York Times in April 2002 that examined neglect and abuse in the adult homes. One article, which focused on the homes' operators, doctors and others who exploited the residents, described how Dr. Debbi had built an adult-home practice, and included comments from residents who said they had no idea why he had operated on them. Soon after, prosecutors began investigating Dr. Debbi.
    To some experts, Dr. Debbi's ability to work in the homes for so long without scrutiny exemplifies how poorly the homes have been supervised by state officials. Until recently, adult-home regulators at the New York Health Department had largely ignored such fraud at the homes, despite signs that it was rampant. The Pataki administration is now vowing to reform the system.
    Dr. Debbi appeared in court yesterday wearing a dark suit and responded tersely to questions from Judge Jed S. Rakoff about whether he understood the charges. The judge, who is to sentence Dr. Debbi in September, later said he was bothered by Dr. Debbi's attitude, criticizing his "callous arrogance." After the hearing, John R. Wing, Dr. Debbi's lawyer, said in a statement that Dr. Debbi regretted his crimes. "Shaul Debbi is a good man and a good doctor who spent years of his life providing medical care to the least fortunate members of our society," Mr. Wing said.
    At the hearing and in court records, the two prosecutors, Paul B. Radvany and Daniel S. Ruzumna, disclosed numerous details that they contended showed the dimensions of Dr. Debbi's fraud. They said he had billed for more than 400 procedures during periods when he was actually out of the country. On 900 occasions, he billed for procedures that were conducted by a medical assistant. After he learned he was being investigated, he fabricated or hid medical records, prosecutors said. Prosecutors worked with an F.B.I. team led by Special Agent John J. Casale Jr., as well as with the State Office of Professional Medical Conduct, which assigned one of its most respected lawyers, Daniel Guenzburger, to the case.
    Dr. Debbi has not visited an adult home in more than a year, but in places like Queens Adult Care, formerly known as the Leben Home, the residents still remember him. Gail Barnabas, 54, a resident there who had cataract surgery performed by Dr. Debbi even though she had not complained about vision problems, said she was relieved he would be going to prison. She said that given what she had learned about him, she was upset that she had agreed to the operation. "I didn't know him, but I trusted him," she said.

Pregnant Women Often Suffer Depression Untreated
Associated Press, 5/20/2003

DETROIT -- One out of five pregnant women suffer from depression which can adversely affect the baby's development, according to a University of Michigan study released Tuesday. The study, published in the Journal of Women's Health, says pregnant women are not immune to depression's effects. "Doctors used to think of pregnancy as a 'honeymoon' away from depression risk, but this is turning out to be a myth," Dr. Sheila Marcus, a clinical assistant professor of psychiatry at Michigan's Medical School and lead author of the study, told The Ann Arbor News.
    Previous studies have shown that babies born to depressed mothers can suffer a series of problems like low birth weight, colic, delayed cognitive and language development and behavioral problems. Those issues often begin in the early stages of pregnancy. "We now know that the hormones and brain chemistry involved in depression are known to be affected by changes in other hormones related to pregnancy. And we know this may affect the fetus," Marcus said.
    Depressed mothers may also affect the relationship with their baby after birth. For example, mothers with depression often have a more difficult time breast-feeding and bonding with their children, according to Heather Howell, a social worker in Yale University's Department of Psychiatry. Mothers with depression during pregnancy are also more likely to suffer from postpartum depression, said Dr. Lee Cohen, director of the Center for Women's Mental Health at Massachusetts General Hospital.
    But doctors often are worried about prescribing antidepressants to treat the condition. One concern is the drugs may cause organ abnormalities in babies, although a direct link has not been established between the two. "The FDA has not signed off on taking antidepressants during pregnancy. There haven't been any controlled studies for ethical reasons," Cohen said.
    Taking medication to solve depression then becomes a decision that must be approached with caution.  "You have to take a look at the impact of depression on your life. If depression has you functionally impaired, then it may be worth the risk," Howell said. There are other options to medication for pregnant women with depression, according to the experts. Cohen suggested psychotherapy to treat the depression. Howell said support groups and less formal interventions may also be effective ways to manage the condition.

Mentally Ill Adjusting to Community Settings
Phuong Ca Le, Seattle Post-Intelligencer- 5/20/2003

Jesse Dodd's words still come out jumbled. Delusional thoughts persist. He has learned to do his own laundry, but he often forgets to watch for traffic when he crosses the street.  Not everyone thought the 57-year-old with schizophrenia could make it outside of locked doors. Now living in Oak Harbor, he spent the past 32 years in institutions -- first in prison, then five years in the locked psychiatric ward of Western State Hospital.
    When the Legislature two years ago ordered two state hospitals to close 180 beds to save money, many worried whether mentally ill patients such as Dodd would get proper care in community settings. But Dodd and others are learning to find their way, advocates say. Ironically, it took hospital ward closures before the state provided additional resources needed to help them succeed in the community, they say.
    This month the state Department of Social and Health Services will place the last of 120 patients, ending a two-year push to close beds at Western and Eastern State hospitals that will save millions of dollars. Civilly committed patients -- some who've been in the hospital for decades -- have been released into adult, group or nursing homes with the promise of more state money to serve them so they won't have to go back to the institution. No criminally committed patients were released under the program.
    The move represents the latest attempt by the state to downsize costly institutions and shift longtime residents to community settings.  While critics question it as a pure cost-cutting measure, mental health workers say it holds the promise of helping many to live more independent lives. "They're getting more attention," said Seattle case supervisor Beth Hammonds. "This is the way the system should work."

Successes and failures
Since July, the polite and friendly Dodd has been living in a quiet neighborhood where his private room overlooks a yard with cherry trees. Keeping him at Western costs the state about $400 a day. Housing him in this ranch-style home costs the state about $119 a day. The state agreed to pay social service agencies $119 more a day to care for released patients, sometimes allowing 24-hour care and more specialized mental health services.
    Dodd still hears voices and sees things that aren't there, but his case manager Eve Schutt said he's doing more on his own.  He has learned to microwave Cream of Wheat for breakfast, reheat canned soups for lunch and cash checks at the bank. Soon no one will have to accompany him to the coffee shop or watch him cross the street. "He's adjusted very well," said Schutt, with Compass Health Skagit.
    Others have struggled since leaving the state hospitals, whether with taking their medication or trying to find ways to keep themselves busy. Some were hospitalized for short stays. Three didn't make it and were returned to the state hospitals. Two died of medical conditions, and DSHS is investigating a third death.   Though it's early, case managers say a majority are learning to manage mental illness. They're learning to cook for themselves, take the bus on their own, buy groceries and plan meals. "They're experiencing joys in their lives," said Mark Doidge, a case manager with Compass Health Snohomish. "They're gaining insight into knowing how to take care of themselves."

Money drives change
How Dodd came to leave Western began with a big money problem in Olympia two years ago. At the time, state officials and lawmakers pointed to growing pressure nationwide to allow people in institutions to have the option to live outside. A new generation of medication made it possible for mentally ill patients to manage their symptoms and live in the community. "The main driver is to say that we have individuals in the hospitals that should be in the community," said Andy Toulon, who manages the program for DSHS.
    But critics saw signs of the deinstitutionalization of the 1960s, when hospitals nationwide shut wards and dumped thousands of mentally ill patients into the streets without proper care or follow-up.  County officials responsible for the patients also had concerns. "There is more and more need for these hospital beds at the same time they're closing down beds," said Amnon Schoenfeld, acting director of mental health services in King County.  "The Expanded Community Services is good, but it's not nearly enough given the need." And not all the money saved by closing Western went into community support, prompting Pierce County to file a lawsuit against the state in December. But several ombudsmen, even early critics, say they haven't gotten complaints so far and that these patients are learning to adjust.

New homes
Loren White, a 39-year-old with manic depression and schizophrenia, is one of them. He bounced in and out of Western for 16 years before last December when Hammonds found him his new home in South Seattle. Like White, patients released under the program have severe and persistent mental health conditions. Some have a history of violence. Many failed to make it in the community on previous occasions. This time may be different for White, who grew up in Seattle.
    Extra money from the state pays for a caseworker who has several clients, including White, rather than a typical caseload of 40 or so. His caseworker comes on weekdays, taking him to the store and teaching him to cook. A nurse, doctor and a psychiatrist make regular visits. Case managers are available by phone at night. At Western, he used to pace the hallways for exercise because he couldn't leave the grounds when he was in the locked ward.  He had no privileges at Western, and couldn't smoke whenever he wanted to. "I didn't go anywhere," White recalled one afternoon, sitting at his dining room table.
    White said he likes having sidewalks in front of his house, though going outside is a struggle.  Doctors aren't sure whether White developed agoraphobia before or after his diagnosis of manic depression and schizophrenia. Anxiety attacks come frequently, and when they do, he can't sleep. The medication that he gets helps some. But "if they get love and care, and if we can do it in a normal setting, then they have a much better ability to recover and learn to live with their mental illness," said Hammonds, who oversees White and nine other clients.
    "It got us out of the hospital," said Gretchen Williams, a 53-year-old with bipolar disorder who left Western last June. "I can go for walks by myself. I can go on the bus by myself. I can smoke when I want to. It's a lot better than Western. I have more freedom." Williams has been in and out of Western so many times, she can't remember them all. The longest stay was three years when she moved into a seven-bedroom group home overlooking Mount Vernon fields. She now takes the bus on her own to group meetings, and spends more time with her mom, who lives nearby.
    While she's glad to be out of Western, life hasn't been easy for Williams, who still struggles with manic depression and mood swings. She returned to Skagit Valley Hospital for a few days last spring.  On days when she can't get out of bed, she gets help from the staff member who lives in the house and from her case manager, who meets with her frequently. "She's doing the best that she can," said case manager Eve Schutt.  Last week, when the two met for a session, Williams wrote that her No. 1 goal was to stay out of locked hospitals.  "She does not want to go back there," Schutt said.

Narcolepsy Drug Eyed as Alternative to Ritalin
Naomi Aoki, Boston Globe- 5/21/2003

The narcolepsy drug Provigil significantly improves the symptoms of children with attention deficit hyperactivity disorder, according to studies released yesterday at the annual meeting of the American Psychiatric Association. The results fuel hopes among children, parents, and doctors for a safer and effective alternative to Ritalin and other stimulants widely used to treat the disorder. The stimulants improve concentration and reduce impulsiveness in many children with the disorder, which affects about 5 percent of school-age children in the United States. But parents have grown increasingly concerned about risks of stimulants like Ritalin, including addiction, weight loss, and insomnia. Currently, studies show that one in three children don't do well on the drugs.  ''For close to 70 years, the only thing we've had to treat the disease are stimulants in various forms, so the availability of options is extremely important,'' said Dr. Joseph Biederman, chief of clinical research in pediatric psychopharmacology at Massachusetts General Hospital and an investigator in the Provigil study.
    Provigil was approved in 1998 by the Food and Drug Administration to treat narcolepsy, but doctors have been prescribing it to treat attention deficit disorder in what is called an off-label use. That's common for many drugs, though without FDA approval, companies are not allowed to market their drugs for such off-label uses. For patients, winning insurance coverage for an unapproved use of a drug can also be difficult.
    Getting FDA approval would allow Provigil's maker, Cephalon Inc. of West Chester, Pa., to promote the drug in a large and growing market. Sales of drugs for the disorder are nearly $2 billion a year and are growing at a rate of nearly 20 percent a year. Children with the disorder struggle in school. They have difficulty concentrating and sitting still and are prone to outbursts and tantrums.
    The attention deficit disorder studies Cephalon did for Provigil are the first step in seeking FDA approval for its added use. Cephalon has already sought approval from the FDA to market the drug for a wider variety of sleep disorders. Provigil illustrates a trend in which many drug companies, struggling to invent new cures, try to broaden the sales of existing products. Doctors are excited because the Provigil studies add credence to what many have seen anecdotally. ''It's really exciting to have the study and the data to be able to say to families, `This is out there, and it's known to work,''' said Dr. J. Thomas Megerian, a physician in behavioral neurology at the Children's Hospital in Boston.
    Scott Mylchreest's three sons all suffer from attention deficit disorder. His oldest son, Spencer, 16, was diagnosed with the condition nearly a decade ago after teachers chalked up his poor performance and inappropriate behavior to mental retardation. Victor, 12, was diagnosed a few years later when he started school. Both boys did well on Ritalin. So when Jesse, the youngest, also began exhibiting signs of the disorder, Mylchreest thought he knew the drill. But 9-year-old Jesse didn't respond to Ritalin well. He seemed heavily sedated, even falling asleep in class. The Mylchreests' doctor suggested trying Provigil. Mylchreest, whose family lives in Manchester, N.J., had no scientific evidence to back up his decision. But the stimulants weren't working for Jesse, and there were few other options. ''It's a fine line you walk as a parent,'' Mylchreest said. ''You try to find a medication that addresses some of the symptoms, like the unprovoked emotional outbursts, the shouting or the singing loudly for no reason, while letting the child's personality still come through. For Jesse, this drug seems to strike that balance.''
    Ritalin is made by Novartis Pharma AG of Basel, Switzerland. Company officials could not be reached for comment on the Provigil study and what effects it would have on Ritalin sales. In December, the FDA approved Strattera, a drug made by Eli Lilly & Co., the first drug for attention deficit disorder that is not a stimulant.  On a hunch, doctors started using Provigil. The drug helps keep narcoleptics awake by stimulating a part of the brain responsible for alertness, so doctors theorized it might also help treat attention deficit disorder. Cephalon estimates it will sell $300 million of Provigil this year, and that 15 percent of those sales are for attention deficit disorder. The attention deficit study Cephalon did for Provigil is what's known as a Phase 2 study, the same kind a company would do to examine the safety and effectiveness of any new drug. The four-week study of 248 patients showed Provigil improved childrens' ability to focus and think before they acted, reducing the impulsiveness, hyperactivity, and inability to pay attention that marks the disorder. The study suggests that the drug is somewhat less effective than Ritalin and other stimulants. But patients in the study suffered relatively few side effects -- the chief complaint was a headache. Cephalon plans to begin the final phase of clinical study -- which involves a much larger number of patients -- required for FDA approval this fall. If that study confirms the earlier findings, the company said, it will ask regulators to expand the drug's approved uses to include attention deficit disorder.
    Even with full FDA approval, Wall Street analysts don't expect that Provigil will unseat stimulants as the first drug of choice to treat attention deficit disorder. But they see the disease as one of several additional conditions the drug could treat with FDA sanction. For instance, the drug might also prove effective in treating fatigue associated with illnesses such as depression and multiple sclerosis. ''There's a trend developing here,'' said Corey Davis, an analyst with JP Morgan Chase in New York. ''This drug could potentially be used for any ailment that comes with fatigue. The market is enormous, and Provigil wouldn't really have any competition in that area. Attention deficit disorder is important, but it's just one piece of a big pie.''

Wayne County Mental Health Care Threatened
Wendy Wendland-Bowyer, Detroit Free Press- 5/23/2003

Nearly 3,000 Wayne County residents with autism, Down Syndrome, severe retardation and other developmental disabilities could soon find themselves without care unless their provider gets more funding. The head of the largest Wayne County mental health care provider network for people with developmental disabilities said Thursday that the provider will end its contract with the county June 2 if a solution isn't found. An emergency meeting is expected to take place today between the Detroit-Wayne Community Mental Health Agency and Synergy Partners LLC. Synergy provides care to about 45 percent of all developmentally disabled people in Wayne County, said Ron Ostroff, its chief executive officer and president.
    Ostroff said the network is not getting enough money from the county to cover the cost of care. "We are doing everything humanly possible to avoid disturbing . . . care to the people we serve, but the other side of it is the reality we have to pay providers for the service they provide," said Ostroff. His company is running a $9.1-million deficit for the first seven months of this fiscal year. He said the county contract is for about $40.5 million annually.
    On Oct. 1, Wayne County's mental health system dramatically changed. Six provider networks -- one of which is Synergy -- took over most services. Today, five of the six networks are running a deficit. Several providers within the networks say they are not being regularly paid, making it difficult to keep staff. Some mental health clients and their families say services they once relied on have ended or been significantly reduced.
    Patricia Kukula, interim director of the Detroit-Wayne Community Mental Health Agency, said Thursday she expected the networks to run a deficit the first year because it is a time of transition. Each of the networks receives a set amount of money per client based on past care expenses. Those clients are then placed into one of 20 rate payment systems based on the cost of services they previously received. Kukula said she is confident there are ways to work with Synergy to resolve the current crisis. On Thursday, her agency approved using more than $4 million in reserve funds to help the new networks. The board also is in the process of updating payment rates.
    The agency has a $530-million budget to provide mental health and substance-abuse services to 75,000 people a year. About $416 million goes to the network contracts, including $176 million that is split among three developmental disability networks and $240 million that is split among three networks that serve people with mental illnesses, Kukula said. But some networks and agencies say the distribution of money does not make sense. Synergy, for instance, gets about 20 percent of the disability money to treat about 45 percent of the clients, Ostroff said. More than half of Synergy's clients are in the lowest payment system even though many require more costly services, Ostroff said.
    Karen Schrock, executive director of Adult Well Being Services, a mental health provider that is part of Synergy and another network, was one of several providers who said Thursday that the agency never explained how it came up with the amount of money the networks receive. "We've been ringing the alarm bells for almost a year, letting people know the way this is being set up is not going to work," Schrock said. "Now the deficits are accumulating at such a rate it is irresponsible for us to continue to pretend it is working."

‘Evil’ Behavior in Ordinary Life
Oliver Libaw, ABC News- 5/25/2003

There is evil in everyday life, says Michael Welner. And Welner, a forensic psychiatrist and New York University professor who studies depraved behavior, is trying to develop a scale to measure just how evil regular life can be. "Evil is not confined to the criminal realm," he said, arguing that some acts of evil aren't even against the law. For instance, a boss who boosts his ego and gains stature by publicly humiliating his employees should be considered not just a tough guy to work for, but evil. Or a health-care worker who deliberately exploits the physical weakness of a patient is not just bad, but depraved. "These are exceptional cases, but they do happen in everyday life," Welner said.
    Welner is working to create criteria of what exactly constitutes everyday evil in hopes that the work will eventually help juries in civil cases decide when a defendant should be punished for "outrageous" actions. It could also help mental health professionals and ordinary individuals look out for warning signs of people capable of truly evil behavior, he says.

Ignoring or Intensifying the Harm
Welner unveiled his criteria this week. They include a set of 14 traits such as "creatively causing suffering," "exploiting physical, mental, emotional vulnerability," or "maximizing destruction of another, or property." The list also includes stalking and inspiring others to commit evil acts.  The common thread is that evildoers don't just commit bad acts. They choose to make their actions even worse by behaving sadistically and deliberately ignoring or intensifying the damage and suffering they cause.  "Of all of these 14 items, none of them happened by accident," Welner said. "There is much more of an element of intent." Welner hopes to get public and professional feedback on his list to show there truly is a consensus on what constitutes everyday evil.  Most people's lapses into bad behavior don't qualify as evil, he believes. A normal person might exhibit some of Welner's criteria — "choices not to remedy another's suffering," for example. But it would be evil only in an extreme case, such as choosing not to help someone who had just been sexually assaulted.

Helping Juries Judge Evil
Drawing a clear line between the merely bad and the truly depraved would help make juries fairer, Welner believes. All 50 states have laws in civil trials that elevate damages for "extreme and outrageous" behavior. A specific, standardized definition would help prevent juries from relying on their emotions or personal experience, he says. Developing criteria for evil would help in criminal cases, where juries routinely decide whether crimes are heinous, cruel, "wantonly vile," or inhuman — aggravating factors that can lead to longer prison terms and in some cases the death penalty.
    Other researchers into the question of evil aren't sure a rock-solid definition can be reached. "What is really evil? In some instances it's quite relevant as to who's side you're on," said Carl Goldberg, a psychologist and author of Speaking With the Devil: A Dialogue With Evil. "You can agree on some criteria for evil, but others are tough or impossible."
    William Banks, a psychology professor at Pomona College in Claremont, Calif., who has taught courses on evil, thinks some actions — like gratuitously torturing someone — are clearly evil. But he thinks the word is often more a matter of emotion than objective fact. "What is the difference between a bad act and an evil act?" he asked. "It strikes me that the word 'evil' doesn't add very much." Like Goldberg, Banks thinks evil is often in the eye of the beholder. "It's impossible to say there's an objective measure of evil."

Seeking a Consensus on What’s Evil
But Welner is convinced people broadly agree on standards for evil. In a related project called the "Depravity Scale," Welner set out to see if people generally agreed on which cases of criminal behavior are so bad as to be genuinely depraved. He believes his results show they do. "The American public regardless of geographic state, regardless of opinion, regardless of orientation, in a variety of issues can achieve an agreement about a number of qualities of crimes that make them beyond-the-pale depraved."
    While Welner believes criminal depravity tends to be easy to spot — just about anyone can agree that Charles Manson and Jeffrey Dahmer were evil — he says figuring out when you have been the victim of a malevolent act in normal life can be harder. "Everyday evil, it encompasses a myriad of everyday actions," he said. "The possibilities are literally limitless."

Heroin Is Surpassing Cocaine As Users' Choice
Farah Stockman, Boston Globe, 5/26/2003

The two drugs were once considered twin threats of equal dangerousness, and Steven Richard knew them both. First, the young car salesman from Sandwich fell for cocaine's expensive, hyperactive high. Then, years later, he was introduced to heroin pure enough to snort. Its euphoria came cheaper than beer.  In 1992, heroin and cocaine each drove about 11,000 addicts into state-funded treatment centers in Massachusetts. But since then, the number of cocaine admissions has steadily fallen while the number of heroin admissions has steadily climbed. By 2001, 4,334 admitted patients in Massachusetts named cocaine as their nemesis, while heroin haunted 37,399, according to a report by the National Drug Intelligence Center. Those numbers solidify the commonwealth's position as one of a handful of states to see a dramatic rise in heroin admissions accompanied by a steep fall in cocaine admissions.
    ''Heroin has emerged as the greatest drug threat to Massachusetts,'' reads the report, which was released this month. The yearly report, which comes as state lawmakers wrangle over whether to cut funding to methadone clinics that treat heroin addicts, blames the growth of heroin addiction on fallen prices and increased purity that allows the drug to be sniffed or smoked instead of injected. The House would like to stop paying for the clinics, but the Senate's proposed budget continues their funding.
    The rise in heroin use is ominous because the drug is far more likely to create a lifelong addiction than cocaine, according to specialists and users. ''It takes a very long time to conduct heroin treatment, and a lot of providers will tell you the success rate is very low,'' said Jim Dreier, an analyst with the Drug Intelligence Center, an agency within the Department of Justice, based in Johnstown, Pa. ''With cocaine, there are higher success rates for treatment. It is not as lengthy a process. . . . The physiological dependence is not as strong.''
    Heroin users make up only a small percentage of all drug treatment admissions in most Southern and Midwestern states. Clinics in California have seen a decline in the number of heroin addicts who are being displaced by amphetamine users, according to a Globe review of statistics compiled by the US Department of Health and Human Services. In New York, heroin admissions have surpassed cocaine admissions, but the gap between the two numbers is not nearly as wide as it is in Massachusetts. ''It's an East Coast phenomenon,'' said Thomas Clark, Boston's former representative to the Community Epidemiology Work Group, a federal program run by the National Institute on Drug Abuse, which tracks drug-use trends across the country.
    The decline in cocaine admissions has puzzled researchers, who say it could reflect everything from supply patterns to regional drug fads to repeat visits by heroin users, who, because of the difficulty of breaking their addiction, may be trumping cocaine abusers at treatment centers. ''The treatment system has a limited number of slots, so as one goes up, the other almost has to come down,'' Clark said. ''The heroin users are coming in and displacing the cocaine users.''
    Using data from treatment centers may mask some of the cocaine usage, Clark said, because cocaine addicts, who have no medically treatable symptoms of withdrawal, have a harder time getting insurance companies to pay for treatment. But, if the decline in cocaine admissions raises questions, the rise of heroin is an all-too familiar tale. In the early 1990s, the same Colombian drug cartels that sell cocaine on the East Coast decided to wrestle the heroin market away from Asian producers. Their strategy: to push down the price and make heroin so pure it could be smoked or snorted, Dreier said. ''It was a marketing decision,'' he said, adding that there was a false belief that snorting the drug or smoking it -- a practice called ''chasing the dragon'' -- would not be addictive.
    The price of a thumbnail-size bag of heroin dropped from about $15 in the 1970s to about $5. The average purity of heroin sold to small-scale users rose from 3 percent in 1981 to nearly 30 percent in 2000, according to nationwide statistics compiled for the Office of National Drug Control Policy. The purity of some heroin on Boston's streets has been found to be as high as 70 percent.
    Low prices and high potency have fueled a new generation of heroin users in Massachusetts who are, by and large, younger, wealthier, and more suburban than the heroin addicts of the past. ''I see people from the upper middle class. I see 18- and 19-year-old kids,'' said Dana Moulton, 52, who once abused heroin and is now a project assistant with the Massachusetts Organization for Addiction Recovery, a nonprofit education group. ''I could see the transition. . . . In the 1980s, you didn't see young people using heroin the way we do now. You had to be in the loop'' to get it.
    Unlike in California, where much of the heroin comes from Mexico in forms too impure to inhale, the purer heroin in Massachusetts began to attract a following from people who had never used the drug. One recovering addict at Phoenix House Springfield Center, a state-funded residential treatment facility in Springfield, recalls the disgust he felt for heroin when he was in high school. ''It was taboo. I had the mental image of a guy with hair down his back who never shaves and weighs 100 pounds soaking wet,'' said the man, a 37-year-old drywall finisher. ''I swore I would never put a needle in my arm.''
    But, nine years ago, his cousin told him he didn't have to use a needle, so he began sniffing it. He got hooked, and could not believe how many of his co-workers and acquaintances were sniffing heroin, too. He said he started off buying it from teenagers on Blue Hill Avenue, he said, but soon began to buy it from men in suits with offices on Boylston Street. ''You get a business card, beep them, they come see you, and go have a social drink over lunch,'' he said. At $5 a bag, he said, ''I thought I had discovered gold.''
    Steven Richard, now 31 and recovering at Phoenix House from his addictions, said snorting the drug also lured him into becoming a user. ''I was always against needles,'' he said. ''I never, ever thought that I would inject drugs.'' Richard's journey toward hard-core addiction began when he was a teenager who had moved from Cape Cod to Florida to be with a girlfriend. One day, he was driving down the highway in Florida, and a friend passed him a pipe full of crack. He puffed and nearly veered off the road. The hit was instant. The next three years were sleepless and wired as he broke into homes so he could afford to ''chase'' the high. Going to jail at age 20 was enough to motivate him to stay clean, and he moved back to his family's home on Cape Cod, got a job selling cars, bought a house, and began living with his girlfriend.
    But seven years later, in 1997, a childhood friend asked for a ride to Boston and, somewhere near the Forest Hills T station, handed him a bag of heroin to snort. He didn't resist, and the drug became a full-time addiction he could afford on earnings from a paper route. ''There were nights where I spent almost $1,500 in one night on cocaine,'' said Richard. ''With heroin, $400 could last me close to a week.''
    After a few years of sniffing, he graduated to injecting the drug, asking a friend to do it the first time because he was scared of the needle. Now, five years, $60,000 in credit card debt, and countless court arraignments later, what public health officials call ''an epidemic'' has cost Richard not only his home, but also the seven-year-long relationship that he lost when heroin became his only passion. ''She's got a baby now,'' he said wistfully of the girlfriend who married someone else. ''It's been four years now, and I still think about it.''

If Biology Is Destiny, When Shouldn't It Be?
Barron H. Lerner, M.D., New York Times- 5/27/2003

W hat would you do if your baby was born intersex, with sex organs and external genitalia not clearly male or female? How would you choose whether to bring up your child as a boy or a girl and decide whether doctors should perform corrective genital surgery? A series of new studies and a book, "Intersex and Identity" (Rutgers University Press, 2003), seek to provide the answers to these questions. Yet despite this research, the ultimate choices may have less to do with a child's medical condition than with the hospital selected for childbirth. If this sounds like an anomaly in an era of evidence-based medicine, you are right.
    It was only a dozen years ago that decisions about intersex children, who make up roughly 1 in 2,500 births, were made independently by physicians. So when infants were born with congenital adrenal hyperplasia, in which the female sex organs do not respond to hormones in utero, doctors shortened the enlarged clitorises and created vaginas. Surgeons converted boys born with extremely small penises, a condition known as micropenis, into girls, building clitorises and vaginas.
    What led physicians to make such monumental decisions, often without consulting parents? The years after World War II represented a high watermark for Freudian psychiatry, with its emphasis on the significance of external genitalia. Physicians adopted this notion of anatomy as destiny, using surgery to create a clear gender identity. Postwar surgeons readily removed ovarian or testicular tissue and refashioned external sex organs. As the saying went, "A chance to cut is a chance to cure."
    The trouble was, it wasn't clear what was being cured. Or so said a group of intersex people who became activists in the 1990's. Some learned about their histories because of sexual or medical problems involving their genitals. Others obtained their medical records. What united them was anger that their variant genitalia had been treated like a disease and "corrected" secretly.
    Foremost among these activists is Cheryl Chase, born in 1957 with a micropenis. Although initially considered to be a boy, doctors eventually amputated her genitals and told her parents to raise her as a girl. She lived with deception and shame for years before going public. Ms. Chase worked with other intersex people, academicians and doctors to found an advocacy organization, the Intersex Society of North America, in 1993. Like other health related advocacy groups that emerged after 1970, the society promoted full disclosure of medical information and informed consent. In the case of intersex, this strategy meant making parents active partners in decisions.
    Dr. Alice D. Dreger, a historian of medicine who until recently was the chairwoman of the intersex society's board, says that surgeons had sought to convert complex psychosocial issues into simple anatomical problems that could be fixed. This strategy, she adds, is based on supposition, not research. Given that such claims challenged long accepted dogma, it is not surprising that many surgeons and endocrinologists responded defensively. Some called the activists zealots. Today, almost all doctors involved with intersex infants say they believe that parents must actively participate in decisions. But that is where agreement ends. The intersex society has recently called for a moratorium on all nonlifesaving surgery on intersex children until they are old enough to participate in decisions. This policy stems in part from several recent studies, which found sexual and psychological problems among intersex adults who had surgery as infants.
    In one study, published in The Lancet in April, Catherine L. Minto, a British researcher, surveyed 39 intersex adults who were reared as women. All 28 who were sexually active reported having sexual difficulties; 18 who had undergone clitoral surgery said they had often experienced inability to achieve orgasm. Sharon E. Preves, a sociologist at Hamline University in Minnesota, who interviewed 37 intersex adults for "Intersex and Identity," agrees, adding that the surgery is "experienced as degrading and shaming." "I have yet to read about, hear or meet an intersex person who is grateful for surgery done on them as an infant," said Dr. Monica J. Casper, a sociologist who is executive director of the intersex society.
    When certain physicians, like Philip Gruppuso, a pediatric endocrinologist at Brown, see an intersex infant, they now usually recommend against surgery. Lacking proof of its value, Dr. Gruppuso says, deferring surgery is easy. Other doctors, however, object to such a blanket policy. It is one thing to advocate for patient autonomy, Dr. Kenneth I. Glassberg, a pediatric urologist at Columbia University, wrote in The Journal of Urology, but quite another to allow children with variant genitalia to "be considered freaks by their classmates." While Dr. Glassberg acknowledges that some celebrated cases of corrective surgery have gone poorly, he adds that most patients — akin to a silent majority — are content with their outcomes. A hard-and-fast rule against early surgery, he says, "is itself experimental, and more of an experiment" than the operations.
    One possible solution lies in collecting more data. A new task force, led by by a Medical University of South Carolina pediatric urologist, Dr. Ian A. Aaronson, is to issue formal guidelines. Yet gathering such information and applying it to the lives of newborns will not be easy. For one thing, most of the survey data come from intersex people who belong to activist groups. While compelling, these interviews may represent a biased sample. An intersex condition is not pneumonia, a medical problem amenable to antibiotics and outcome studies. Given the wide variety of intersex conditions and the intensely personal issues they raise, not even better data will provide parents with easy answers.

Vermont Shelter for Sex Abuse Victims Welcomes Women and Men
New York Times- 5/29/2003

BARRE, Vt. — A bright burgundy door and trim signal that the house at the beginning of Carriage Street is different from the others on the block. In the converted carriage house run by the Sexual Assault Crisis Team of Washington County is what some say is the only shelter for male and female sexual abuse victims. Bobbi Gagne, executive director of the team, and Keith Goslant, president of the board, opened the shelter because they could not bear to send victims back to the homes where they were abused or to sterile hotel rooms. Shelters in the region housed primarily women who had been victims of domestic violence and were not equipped for the needs of the sexually abused. Ms. Gagne and Mr. Goslant set out to create a place that offers independence and support. "We're trying to create a safe space where survivors can have control over their environment and are treated with respect and dignity," Ms. Gagne said.
    The shelter, financed by nearly $300,000 in grants, loans, contributions and in-kind donations, opened in October. Renovations finished in April. The shelter can accommodate up to five victims and one or two friends or family members. Mr. Goslant, the "house mother," lives in an apartment in the house and can immediately respond if a victim is in trouble or needs to talk. About 25 people from this county of 58,000 people have used the shelter, roughly half men. Many were abused as children. Stays typically last no longer than three days, but can be extended. The three employees of the team and volunteers can visit a woman's house and remove the bed where she was assaulted or place posters in a man's bedroom, to change the atmosphere.
    The two leaders concede that placing men and women in the same site is risky but say that they have had no problems. Barriers tend to break down between victims, Mr. Goslant said. Many times, men prefer to speak with advocates or counselors who are women, and women with men. "We seem to be the only people in the country attempting to do this," Mr. Goslant said. "This is a risk. We are trying something there really is no road map for." The director of the National Sexual Violence Resource Center in Enola, Pa., Susan Lewis, said she and her staff had not found any shelters nationally similar to the one here.
    Ms. Gagne said she and Mr. Goslant did not have a "magic key" for helping the abused. Rather, they draw on their backgrounds and the experiences of others in support groups. Ms. Gagne, who has worked with the team since 1990, said she had some experience with sexual abuse. Mr. Goslant said a group of teenagers beat and raped him at 18 because he was the sole openly gay person in his small Vermont hometown. "We'll share the experiences we've had over the years with you and let you pick what works for you," Ms. Gagne said.
    The shelter has a number of room choices. One has a window, as some people need to see light. Another is all walls and ceiling. The bed in that room is littered with stuffed Bananas in Pajamas dolls and small brown bears. Every bed faces the door, and all the rooms have a radio and door lock. A common area has a television set, a microwave range and snacks.
    Chris Massey, 36, who said he was physically and sexually abused by his mother from 6 to 12, has been working with Ms. Gagne for more than a year. He likened his years chasing treatment to "entering a turnstile and not getting all the way around." Working with Ms. Gagne, Mr. Massey said, has helped him discover a person who is not defined by his childhood. A few weeks ago, he found himself in a bad patch. It was not a full-scale crisis, he said, but he knew he would spiral out of control if he did not do something. He did not want to check into a mental hospital. He called Ms. Gagne in the middle of the night, drove to the shelter and stayed for four days. "It has a nice, safe feel," he said. "I didn't need to come to a place where I would be hooked up to blood pressure machines. I needed somewhere to relax and find a sense of safety."
    Ms. Gagne and Mr. Goslant have received queries about the shelter from program directors and victims across the country. They have also received letters from victims thanking them for "giving us a place to call our own, to know what our needs are," Ms. Gagne said. The two leaders would like to expand their staff, as well as see similar shelters open nationally and services for men grow. "I want people to see this as a safe place that they can use," Mr. Goslant said. "But ultimately, I hope we're not needed."

In Hard Times, Bitter Divorces
Diane Lewis, Boston Globe, 5/29/2003

The economic downturn has injected an extra dose of venom into Massachusetts divorce courts, lawyers say.  Residents across the state are going to court to amend divorce judgments over alimony, child support, and visitation in drawn-out confrontations that appear to be more numerous and more acrimonious than in better economic times. There is anecdotal evidence that a greater number of initial divorce filings are more contentious, and in some cases, more costly.
    Take the case of Barry and Jessica Weinstein of Swampscott. Three years after the couple sought to dissolve their 14-year union in Essex County Probate and Family Court, Associate Justice John P. Cronin noted in an April 2003 judgment that their prolonged battle had led to unusually high legal fees: $190,000 for him and $150,000 for her. More than that, the judge wrote, ''Both parties were rigid and unyielding in their approach.'' The case turns on Barry Weinstein's reduced earnings after being laid off from a $250,000-a year executive position at State Street Bank. Cronin found that despite a good-faith job search conducted over two years, there was little likelihood that the former banker would readily obtain a position at a similar level of income and benefits in a difficult job market. The judge rejected Jessica Weinstein's contention that her husband had actual income of about $235,000 a year and said her request for $90,000 a year support was not reasonable.
    Divorce lawyers say such cases are becoming more commonplace as expectations built in more prosperous times clash with the realities of lost jobs and decreased income. Court statistics seem to support these claims. From fiscal year 2000, the number of filings to reopen judgments increased 27.3 percent to 12,559 in fiscal year 2002, which ended June 30, according to court records.
    The number of contempt complaints over the same period, an indication that a spouse may have defaulted on payments, increased to 13,375 from 12,922 over the same period, an increase of 3.5 percent. The figures were provided by the office of Chief Justice Sean M. Dunphy of the Massachusetts Probate and Family Court Department.
    An informal poll of the American Academy of Matrimonial Lawyers at their annual meeting last November found that 173 lawyers felt that contentiousness in divorce was increasing, while only 38 thought it was on the decline. An overwhelming majority saw cases based on lessened financial capacity increasing or staying the same; only two lawyers saw a decline.
    Clinical psychologist Carol Cole of Newton sees a clear economic influence on the divorce courts. She said the war in Iraq and recent terrorist attacks have also fueled tensions. ''Since Sept. 11 and with the terrorism alerts, war, the economy, job insecurity, and the loss of people's nest eggs, there has been heightened anxiety,'' Cole said. ''People are less hopeful, less trusting, and they feel less safe. Take those emotional reactions and put them into a marriage that is not working right and everything is exacerbated. Money is the only thing people can think of that will make them feel safer.''
    Such domestic battles certainly aren't hurting lawyers. In a sampling of hourly legal rates and salaries, Massachusetts Lawyers Weekly reported that a sole practitioner in Amesbury with 22 years of experience handling family and probate disputes earns about $225 per hour. For some lawyers who specialize in domestic relations, business couldn't be more hectic.
    Prior to 2001, the divorce cases handled by Nancy Van Tine, a partner at Burns & Levinson in Boston, rarely went to trial. ''Everything came along and everything settled,'' she said. ''Since 2001, I have had trial after trial after trial. Things are generally intractable. I have cases where the person who was getting support lost her job, and now needs more support. I have another case where someone lost a job in the middle of the divorce and is now sitting around saying, `I can't find work, therefore, I can't pay alimony.' ''   Acton lawyer Barry Harsip also has observed stepped-up business. ''Because of layoffs in the high-tech industry, there are more modifications and many more contempts involving people who have not lived up to court orders,'' he said. ''It's tough in this economy.''
    The Weinsteins' economic woes began in November 2000 when Barry Weinstein, then senior vice president and chief information officer of the Financial Markets Group at State Street Bank, accepted a buyout of $250,000 in base pay for one year and the ability to vest in previously granted stock options with a pretax value of $500,000, according to court papers. Soon after, Weinstein and two partners launched a venture called ForwardCast Inc. But after Sept. 11, 2001, Citibank, the company's only client, canceled its contract. In February 2002, ForwardCast shut down.  In court papers, the couple accused each other of extravagance or inappropriate expenditures. Barry Weinstein alleged his ex-wife had bought numerous $1,000 designer handbags. Jessica Weinstein alleged that he was seen sharing a $400 dinner with a New Jersey woman who had identified herself as his date.  Jessica Weinstein did not respond to requests for comment. However, Barry Weinstein commented on his job search and briefly discussed the three-year-old battle. ''Over the last two years, I have sent out more than 250 resumes and have gotten interviews with maybe 20 organizations,'' he said. 
    Weinstein is now looking for work in New York and Atlanta, where he would be far from his two children.  ''That rips my heart out -- to have to choose between seeing them and having a career so that I can provide for them.'' Pausing, he added: ''We've spent a God-awful amount on lawyers.'' The two probably will spend more. In April, Cronin ordered the Weinsteins to divide their marital assets equally, ruling on stock options, real estate, retirement accounts, jewelry, and other assets. Cronin further ruled that neither party would be required to pay alimony but both would share the children's expenses. The judge's ruling has been appealed.
    Legal specialists say that divorce cases have grown more complex. The reason: mutual funds, golden parachutes, severance payments, 401(k) plans, IRAs, Keough plans, executive bonuses, and other forms of compensation. ''Because of the economy, people are working different jobs or they are self-employed and they are deducting a lot of expenses,'' said attorney Cheryl Handley of Acton. ''So, what are legitimate expenses? Some expenses are legitimate for tax purposes, but not when calculating child support. Then, you have base pay and bonuses or severance. It all muddies the water.''

Mentally Ill Tax Juvenile Jail System
Ronald Kotulak, Chicago Tribune- 5/29/2003

Juvenile detention centers were never intended to serve as mental hospitals. Yet that is what seems to be happening as an influx of psychiatrically ill youths threatens to overwhelm facilities not designed to treat them. The problem is evident at the Cook County Juvenile Detention Center, the nation's largest such facility, where the typical inmate is likely to be delusional, psychotic, depressed, manic or suffering anxiety disorders.
    A recent federally funded study found that two out of three 10- to 18-year-old boys and nearly three out of four girls in the center, formerly known as the Audy Home, have diagnosable psychiatric illnesses. These are youngsters who have fallen through the cracks of the mental health system. The late '80s and early '90s saw budget cutters slash away at state and county facilities for mentally ill children. Many who once might have received treatment wind up in juvenile detention when they commit crimes. Their conditions often worsen after that. Bereft of emotional support and lacking psychiatric help, many grow up to a life marred by violence, crime and lost potential. "Most people in the field feel that the problem of kids with mental health issues is probably the No. 1 problem in the juvenile justice system," said Mark Solar of the Youth Law Center in Washington, D.C.
    Preliminary results of the juvenile center study prompted Dr. Venkata Vallury, medical director, to initiate a crash program a year ago to improve mental health services. The center has so far increased its mental health staff by about 75 percent. It now includes three psychiatrists, two psychologists and two social workers for about 500 youths. Despite these improvements, officials acknowledge there is still a long way to go. The final results of the study, the largest and most thorough examination ever of juveniles in detention, appeared in the December issue of General Psychiatry. It was conducted by Northwestern University psychologist Linda A. Teplin and was funded by other organizations in addition to the federal government.
    Experts say the results would have been different in the Audy Home days. "Twenty years ago you would not have seen so many psychiatrically disturbed kids in the detention center because they were in mental health facilities," said Dr. Carl Bell, president of the Community Mental Health Council, which operates in disadvantaged Cook County neighborhoods. "But now they're showing up in the child welfare and juvenile justice systems."
Researchers also have documented a sharp increase in mental, emotional and physical disabilities among all children, especially black children. Such disabilities have increased 77 percent since the 1970s among blacks younger than 18--affecting 67 children out of every 1,000, according to the National Institute of Mental Health. In the mid-'90s the detention center's population swelled, nearly doubling to 800 inmates. It is now down to about 500, still slightly higher than the number of juveniles it was designed to hold. More than 100,000 juveniles are in detention facilities nationwide, Solar said.
Criminal justice experts have long known that many of those kids are emotionally disturbed, even if government officials do not acknowledge it. "No one has wanted to notice that before, because if you admit that you have mentally ill kids in the detention center you put yourself in the legal and constitutional obligation to provide care for them, and that's costly," said Mark Heyrman, clinical professor of law at the University of Chicago.

Few get help
There also is growing evidence that many youngsters at risk of becoming chronic lawbreakers could be diverted from such destructive paths, but few get the help they need to straighten out their lives. "We've pushed our mentally ill children and adults into the correctional system over the last several years," said Benjamin Wolf of the American Civil Liberties Union. The ACLU filed suit last year to force the center to improve mental and physical services for inmates, to which the county has agreed.
    Incarcerating mentally disturbed youngsters often makes them worse. They rebel at the discipline, and many become victims of abuse from other juveniles and staff members. "These kids will typically act out in ways that are usually not dangerous but are usually a pain in the neck to handle," Solar said. "They are often put in isolation rooms or in restraints, often with the staff assuming that it's for the kids' own good."
    Charles Ingoglia, the National Mental Health Association's vice president for research, said most juvenile offenders with a mental illness are detained for non-violent crimes, usually related to impulse control. "As long as people with mental illness are in treatment and free of substance abuse, they are no more prone to violence than the general population," he said. That makes treating such illnesses crucial, experts say. "Once you recognize that a large number of these kids have psychiatric problems and you recognize that treating those psychiatric problems is more likely to make them do well and not commit further crime, then you've got to be able to get the effective services to them," said Patrick Tolan, director of the Institute for Juvenile Research at the University of Illinois at Chicago. Psychologists stress the word "effective." They have seen the failure of many programs intended to help disturbed youths, with some efforts doing more damage to the children.
One program that shows early signs of success--and one that the National Institutes of Health has already poured more than $25 million into--was developed by Scott Henggler of the Medical University of South Carolina. In his program, called Multisystemic Therapy or MST, a therapist works closely with a child and his family for four to six months. The program is operating on a small scale in 30 states, including Illinois, and seven countries. The task of the therapist, who is available around the clock, is to figure out the particular factors in each juvenile's life--family, peers, school, neighborhood influence--that are contributing to the delinquency. The therapist then focuses on changing those factors as a way to decrease anti-social behavior. "We find that a lot of the time the reason the kid's behavior is so outlandish and out-of-control is because the parents are not closely supervising him, not monitoring his behavior on an ongoing basis," said Mary Ann Williams, MST supervisor for the Community Mental Health Council.

Helping parents, teachers
Parents are taught how to supervise their child's behavior, how to monitor his or her association with peers and how to deal with rewards and consequences, she said. In school, therapists work with teachers and counselors to make sure juveniles are in the right class and whether they skip class, do their homework and relate well with other students.
    Children who have been in the relatively new program are 50 percent less likely to spend time in incarceration than non-participants, according to Bell, of the Community Mental Health Council. Their rearrest rate is 40 percent lower than non-participants. But the result that has attracted the most notice is that the program's $5,000 cost per youngster is estimated to save at least $31,000 in incarceration and felony conviction expenses, Bell said. "If the goal is to increase the chances that a kid is going to become a productive citizen and decrease the chances that he's going to be involved in crime and drugs, our perspective is that you take mental health resources and devote them to building a positive family environment around him, whether it's school or family," Henggler said.

Judge Approves Treatment for Boy With Attachment Disorder
Associated Press, 5/30/2003

WEST OLIVE, Mich. -- An adopted Romanian boy who has an emotional disorder and allegedly molested a child will undergo a costly two-year treatment program, a judge has ruled. The 9-year-old boy was diagnosed with severe reactive-attachment disorder, in which a child resists forming loving relationships and can become unmanageable and violent.   Experts say attachment disorders are a common thread among serial killers and suspect that prisons are filled with people who have the disorder. They say children adopted out of Romanian orphanages, where they received little attention from adults, are particularly susceptible.
    After spending the first year of his life in a hospital, the boy stayed in a state-run orphanage and foster homes in Romania until David and Holly Meyers adopted him as a 7-year-old. The Grand Rapids Press reported Friday that, during counseling sessions and police interviews, the boy allegedly threatened to torture and kill family members. In a plea agreement reached with Judy Mulder, an assistant prosecutor in Ottawa County, the boy pleaded guilty to a charge of gross indecency, reduced from first-degree criminal sexual conduct.
    Mulder agreed to recommend placement in Villa Santa Maria, a 16-patient residential facility in New Mexico. The treatment center charges the county and state a combined total of about $219,000 for the two-year program. During a disposition hearing held Thursday, Judge Mark Feyen of Ottawa County Family Court was not required to follow the terms of the plea agreement. While several therapists recommended that the boy be placed in Villa Santa Maria, a county resource team that studied the case recommended a two-week intensive program in Colorado followed by placement in a foster home.
    Judge Feyen said he looked hard at the money issue before reaching a decision "but sometimes you spend some money on an individual child." "He could have taken the easy way out, but he chose what was right and honorable," Holly Meyers said afterward.

Psychiatrists Rebuke China for Blocking Inspection Visit
Erik Eckholm, New York Times- 5/31/2003

BEIJING— In an unusual public rebuke, the World Psychiatric Association has called on China to fulfill its promise to let international experts examine charges that psychiatry has been misused in China as a political tool. China's psychiatric practices have been criticized in recent years since hundreds of members of the outlawed Falun Gong spiritual movement were declared delusional and were forcibly hospitalized. The forcible psychiatric commitment of political or labor dissidents on dubious medical grounds — commonplace during the Maoist fervor of the 1960's — is also still reported from time to time.
    In August 2002, the world association, to which China's government-controlled psychiatric society belongs, voted to send an expert team to investigate the charges. Officials of the group said the Chinese had agreed to cooperate, though ground rules for a visit were not spelled out. In subsequent months, the Chinese provided written responses to inquires about many individual cases involving Falun Gong members, but these only raised further questions, Western experts said, making a direct visit to China's psychiatric facilities all the more necessary.
    Starting late last year, even the written responses stopped coming. Plans for a site visit "have been delayed during the past eight months by the limited collaboration on the part of the Chinese health authorities, in spite of the efforts of the Chinese Society of Psychiatry, which are gratefully recognized," the world association said in a statement issued this month. A committee chairman of the world association, Harold I. Eist, said in a telephone interview: "Over the recent period they have not responded to requests for information or gone forward with what had seemed to be a clear willingness to have a visit. It began dragging on to the point where we felt we had fulfilled our responsibility to be collegial to a member organization, and so we issued this statement."
    Western experts have debated whether political abuses of psychiatry in China at this point are systematic or, as some leading experts contend, an infrequent result of poor training and facilities, especially at the hospitals run by the Public Security Ministry. The Chinese professional society has worked over the last two decades to bring psychiatry in line with world standards, and has generally cooperated with the recent inquiries, Western experts said. But the political authorities of the Ministry of Health have apparently blocked further action.

Famed Psychiatric Clinic Abandons Prairie Home
Erica Goode, New York Times- 5/31/2003

In its best years, it was a pearl on the prairie, a place where bold ideas sprouted like cornstalks under the Midwestern sun, a name that meant the best that American psychiatry had to offer. Troubled souls traveled long distances to find treatment and refuge beneath the pine trees on its grounds. Generations of healers trained in its classrooms. At 10 minutes to 4 each day — a time dictated by the 50-minute psychoanalytic hour — the staff gathered for tea and cookies in the clinic building, chatting with visitors like Margaret Mead, Aldous Huxley and Helen Keller, drawn by its intellectual aura. A highway sign outside of town proclaimed: "Welcome to Topeka, Kansas, the psychiatric capital of the world."
    But the world has changed since the Menninger Clinic opened its doors 78 years ago in a farmhouse on Sixth Street. Today is the clinic's last day in Topeka. Its 29 remaining patients are scheduled to board a chartered jet this afternoon for Houston, where Menninger will reopen, in a partnership with the Baylor College of Medicine and the Methodist Hospital.
    The clinic's move marks the symbolic end of an era of elite private hospitals, often in bucolic settings, where patients spent months or years sorting out their lives in what the psychoanalyst Erik Erikson termed a "psychosocial moratorium." Only one hospital in the United States still offers intensive long-term psychoanalytic treatment: The Austen Riggs Center in Stockbridge, Mass., which survives, experts say, as a result of its location and small size, its relatively low overhead and its dedication to narrowly defined goals.
    Like its counterparts, Menninger has been tossed and torn over the last two decades by the sea change in health care economics, the rise of managed care ending long hospital stays. At the same time, psychiatry itself has undergone great changes. Many psychiatrists now believe that staying in the hospital for years can be detrimental for patients, promoting dependency. And the intensive psychoanalytic approach that was once the clinic's specialty has been edged to the perimeter by new drug treatments, brief psychotherapies and advances in neuroscience.
    "I think historically, the time was over," said Dr. Robert Wallerstein, a former president of the American and International Psychoanalytic Associations who worked at Menninger from 1946 to 1966 and who remains a member of its board of trustees. "The idea of being able to take as much time as you need for individual people is not one that our society is collectively willing to sustain."
    But Menninger's rise and decline in Topeka, said many people familiar with the clinic's history, also reflects the dynamics of the family who founded it, a family woven together by complex bonds of love and resentment, its influence expressed as often in sibling rivalries and noisy quarrels as in innovative ideas and compassionate acts. That turbulence was most notorious in the relations between the late Dr. Karl Menninger, known to everyone as Dr. Karl, and his youngest brother, the late Dr. William Menninger — Dr. Will — who founded the clinic with their father, Dr. Charles F. Menninger. But tensions have continued, in milder form, into the next generation.
    Those moving to Houston say they regard the transition as an exciting beginning, a chance to meld the best of the Menninger tradition — an intense focus on the individual patient, and an expertise in sorting out difficult cases — with the research and scientific tools available at a major medical center. "I think what has happened is a good evolution," said Dr. Jon Allen, a psychologist and expert on trauma and depression who has been at Menninger for 27 years and will, like other staff members, become part of Baylor's new Menninger Department of Psychiatry. "I hope that we will get the best of both worlds." The clinic's new home on 14 acres in west Houston, Dr. Allen said, "is not like this with hills and deer, but it's actually quite pretty." Others are far more dubious.
    "One can no more move the Menninger that many of us came to Topeka for than you can move the London Bridge to Arizona," wrote one psychiatrist in a letter to Psychiatric News, the newsletter of the American Psychiatric Association, after the clinic's intention to relocate was announced. Dr. Roy Menninger, Dr. Will's eldest son, who served as Menninger's president from 1967 to 1993, said in an interview that he knows the move is inevitable but remains troubled by it. "I can't stand here without many more feelings than I can accommodate, much less explain," Dr. Menninger told an audience at a reception held on May 22 at the Topeka and Shawnee Public Library, which has inherited a collection of Menninger books and artifacts.
    But Roy's younger brother, Dr. Walter Menninger, who succeeded him as president in 1993, strongly backed the move, after business consultants recommended partnering with an academic medical school, in an urban center, closer to an airport. "I'm nostalgic, but I also recognize you can't live in the past," Dr. Menninger said. In fact, the institution, which in the years after World War II trained 5 to 7 percent of American psychiatrists and ran one of the nation's top psychoanalytic institutes, the Topeka Institute of Psychoanalysis, has been a ghost of its former self for nearly a decade. With its budget increasingly pressed, Menninger tried diversifying in the early 1990's, then sharply downsized several years later, angering many who worked there. There are now only 8 psychiatrists on staff, compared with 80 in the late 1980's. The psychoanalytic institute closed in 2001. Yet the clinic was lucky to have survived at all. Chestnut Lodge, a family-run psychiatric hospital in Rockville, Md., also known for its psychoanalytic treatment, was bought by a private mental health organization reportedly for $4 million in 1996, then closed in 2001.

Catering to the Refined
Like many early private psychiatric hospitals -- Austen Riggs, Chestnut Lodge, the Sheppard and Enoch Pratt Hospital in Towson, Md., McLean Hospital near Boston and others -- Memiinger built its reputation in the first half of the 20th century. Many of the hospitals catered to wealthy patients, "persons of education and social refinement," as the journalist Dwight MacDonald noted in a 1935 article in Fortune magazine. Their grounds were verdant and meticulously manicured, often with the help of patients who gardened as part of their therapy. Artists and movie stars sought treatment for alcoholism, depression or "exhaustion," as nervous breakdowns were sometimes euphemistically called. "At Craig House in the hills above Beacon, N.Y., the 50 patients were transported in chauffeur-driven limousines, enjoyed their own golf course, and drank wine from the hospital's private vineyards," wrote Dr. Lawrence J. Friedman in a 1990 biography, "Menninger: The Family and the Clinic."
    In the decades after World War II, with psychoanalysis in ascendance, the hospitals had waiting lists: in its heyday, Menninger had 280 or more patients in intensive treatment, 70 of them in psychoanalysis. Once admitted, patients might spend two or three years within the institutions' sheltering walls, building an identity, a network of friends, a way of living apart from the world outside. "If any patient came in for only a week, it was considered to be an inappropriate treatment," said Dr. Steven'S. Sharfstein, who took over the direction of Sheppard Pratt in 1981, and presided over its transformation into the Sheppard Pratt Health System. Dr. Sharfstein said in-hospital care now plays only a small role. The average hospital stay is nine days. But in its earlier incarnation, Dr. Sharfstein said, Sheppard Pratt kept patients far longer. "The hospital was the treatment and patients either got better or they ran out of insurance," he said. "That was what was happening for about 100 years." Some experts lament the loss of a time when patients could recover over time in a sheltered setting. But Dr. Sharfstein believes the shift to shorter stays, though forced by changing economics, was beneficial. "I think the data is pretty clear," he said. "The hospital is really useful for a short stay, and as you get into a longer stay, you have diminishing returns."
    Menninger, like other hospitals, evolved with the times, though its length of stay six to eight weeks -- remains longer than most hospitals. It has developed a reputation as a last-chance treatment center for patients with complicated diagnostic problems, many of whom have been hospitalized numerous times for shorter periods with little benefit. "It is really the last place you can get an intensive psychological work-up," said Dr. Stuart Twemlow, a psychoanalyst and the medical director of the clinic's Hope program, which treats adults with serious and longstanding mental disorders. The patients who come to Menninger, Dr. Twemlow said, often arrive speaking of themselves "like a bag of chemicals." "We introduce the psychology, so people can become thinking beings," he said.

The Family Business
From its inception, Menninger was filled with bigger dreams and more colorful personalities than many of its competitors. Charles Menninger, a country doctor schooled in homeopathic cures and devoted to horticulture, wanted to build a center of training, medical care and research much like the Mayo clinic. He was overjoyed when his oldest and youngest sons, Karl and Will, followed him into medicine. The Menninger family was of solid Presbyterian stock, passionate about social causes and firmly rooted in Midwestern tradition. Karl, charismatic and mercurial, impatient with stupid questions and doctors without neckties, gained fame with his 1930 book, "The Human Mind," the first volume to explain Freudian theory to the American public. Residents were spellbound by his lectures -- and fearful of his sharp tongue.
    Will, more even-tempered and socially skilled than his brother, became the Army's chief psychiatrist in the last years of World War 11 and made the cover of Time magazine in 1948, billed as "Psychiatry's U.S. Sales Manager." Together, the two men created a intellectual center so powerful that it pulled people to Kansas, even those New Yorkers, European emigres fleeing Hitler's advance -- who had previously believed nothing of importance could co-exist with rodeos and soybean fields. "It really was a place where the brightest lights in psychiatry, psychoanalysis, clinical psychology and social work gathered," said Dr. Howard Shevrin, a psychologist at the University of Michigan who worked at Menninger from 1954 to 1973.
    The hospital cared for its share of celebrities: The actress Gene Tierney was a patient there and later worked in a dress shop in town. But it also treated people suffering from schizophrenia or other severe psychoses. In the post-war years, with thousands of veterans suffering from combat stress, Menninger trained hundreds of psychiatric residents for the Veterans Administration, now the Department of Veterans Affairs. The Southard School was opened for emotionally disturbed children. "Freud and friendliness" was a Menninger slogan. New therapies grew as sturdily as the peonies that Dr. Charles Menninger planted on the campus. Patients chopped wood, grew vegetables and spoke, in quiet consulting rooms, of secrets they had never told anyone before.
    Yet if a vision bound Karl and Will Menninger together, their differences drove them apart. Karl was a lifelong Democrat, who spent every Christmas Eve visiting the prisoners at the county jail, belonged to the American Civil Liberties Union and distrusted the conventional and the pretentious. Will, too, had a social conscience: Between 1953 and 1965, he addressed 23 state legislatures, according to Menninger documents, urging the lawmakers to improve the conditions in state hospitals. He voted Republican, dined with corporate executives and knew the value of raising money.
    Despite his international renown, Karl was jealous of his younger brother, said family members and psychiatrists who knew both men. Will, for his part, was perpetually frustrated by Karl's whims and unpredictable outbursts. In an episode known in Menninger lore as the "palace revolution," Will acceded to the demands of senior staff members and removed Karl as chief of staff. Dr. Wallerstein recalled stopping into Karl's office on a visit to Menninger shortly afterward. Two calendars were on the wall, he said, both draped in black. "One said `the month they killed Jack Kennedy,' the other was `the month they killed Karl Menninger,' " Dr. Wallerstein said. After Will's death in 1966, some trustees and staff members argued that it was time for Menninger to be run by businessmen rather than family members. But, perhaps because the family's spirit still pervaded the institution so intensely, Roy Menninger followed his father into the presidency.

Transplanting to Texas
In the next 26 years, Roy had his supporters and his critics. So did his brother Walter, when he took over as president in 1993. The brothers' relationship, more peaceable that that of their father and uncle, has still had its strains, as both freely say. Karl Menninger died in 1990 at the aged 96. When the plan to move to Houston was first announced in the spring of 2000, many staff members were in shock. "Clinicians were walking around the campus crying," said Dr. Allen. In a telephone interview, Dr. Walter Menninger said he knew that some people blame him for the downsizing and the decision to relocate. "It took me a long time to figure out that this institution always likes to have two Menningers"-- one good and one bad, he said. "Right now, I'm the bad Menninger and Roy is the good Menninger."
    Once in Houston, the clinic will take in more patients and hire more staff members; 80 are moving from Topeka, according to Menninger. A board of directors, made up of representatives from Menninger, Baylor and the Methodist Hospital, will oversee the clinic's operation. Another board will preside over the Menninger Foundation. The Houston area, said Dr. Stuart Yudofsky, Baylor's chairman of psychiatry, has "great needs, from a variety of perspectives, for the services that Menninger has traditionally provided"
    In Topeka, meanwhile, strong feelings remain. "I'd rather have seen us go down swinging," sighed Dr. Irwin Rosen, a psychoanalyst who was Menninger's director of the adult outpatient department until 2001. "But we took the third strike with the bat on our shoulders." What remains is the future, "an, empirical question," as one staff member put it, Of, how a Kansas-bred institution will take to Texas soil. "This place has, I think, done its dying with dignity," said Dr. Twemlow, who is going to Houston. "And hopefully, it will be like the phoenix -- whatever comes up will be, in some way, Menninger."

Searching For The Next Prozac
Benedict Carey, Los Angeles Times- 5/31/2003

The antidepressant Prozac hit the market 15 years ago and did for depression what Valium had done for anxiety a generation earlier — made it not only easier to treat but also easier to discuss openly. Similar drugs followed, and millions got better. Yet as thousands of doctors from around the world convened last week in San Francisco at the American Association of Psychiatry's annual meeting, many were looking for news of the next big advance in depression.
    Depression affects up to 10% of Americans adults in a year and 8% of adolescents. Doctors write more than 100 million prescriptions a year for Prozac and drugs like it, called selective serotonin reuptake inhibitors. But one-third of patients do not respond to current drugs, and many who do suffer serious side effects. "Anything that works well and doesn't have side effects like weight gain and loss of sexual desire would be huge," said Dr. Elizabeth Koby, a Cleveland psychiatrist. "I think we're all hoping for that."
    The meeting featured dozens of reports on chronic low mood, including new evidence on drugs awaiting FDA approval, as well as discussions of novel theories about what causes depression and alternative approaches to treatment. But research psychiatrists said the next revolution in the treatment of depression will come from drugs that attack the cause of the disease rather than its symptoms.
    "All of the major drugs we have in psychiatry, including Prozac, grew out of accidental discoveries; we just got lucky," said Dr. Samuel Barondes, director of the Center for Neurobiology and Psychiatry at UC San Francisco and author of "Better Than Prozac" (Oxford, 2003). Barondes said the next generation of antidepressants and other psychiatric drugs will stem from a growing understanding of the genetic causes of mental disease. They will be new classes of drugs rather than fortified or refined versions of the old ones.
    One clue to the underlying source of depression, for example, comes from measures of the stress hormone cortisol. Psychiatrists have known for years that many of their depressed patients have high blood levels of cortisol, which is released when the body prepares to fight (or flee) for survival. But in many depressed people, cortisol levels are elevated even when there is no apparent reason for added tension, and some researchers believe that it's this overactive, or abnormal, stress response that may cause depression.
    Among the most promising ways to influence this stress response is through a brain chemical known among researchers as Substance P. This chemical is released when people feel pain and is highly concentrated in parts of the brain involved in stress response. In several studies of animals and in at least one study in depressed patients, an experimental drug has been able to reduce depressive symptoms by blunting the action of Substance P. Although the effect has not proved reliable yet, the drug maker, Merck, is continuing with the research, according to Barondes. "This remains one of the most promising targets" for developing a new class of antidepressants, he said.
    There is also good evidence that prolonged depression damages brain cells in the hippocampus, a part of the brain involved in memory and in regulating cortisol levels. If this is true, the disease becomes progressively harder to treat because of physical changes in brain anatomy. "What we think is happening is it's a vicious circle: When the brain is damaged, it's less likely to control this stress response, leading to more damage," said Ron Duman, a Yale University researcher.
    Researchers are investigating a protein known as brain-derived neurotrophic factor, or BDNF, which helps the brain shut down the stress response when it's time to relax, studies suggest. In a study published last year, Duman reported that rats administered BDNF preparations showed significant improvement in measures of depression. There is also evidence that the protein helps the brain regenerate cells, actually repairing areas vulnerable to cortisol-induced injury. Drug researchers are investigating several agents that would enhance BDNF and not only ease symptoms but also reverse the damage already done.
    "I think it sounds pretty bad when you hear that you have brain atrophy or some damage from depression," said Duman, "but what we're finding is that these things are reversible. We used to think of the brain as hard-wired, but it's increasingly clear that the circuits and connections are much more malleable and plastic, and it's encouraging to know that even if you've had this disease for a long time, there's hope for complete recovery."
    For now, the next depression drug expected to hit the market comes from the maker of Prozac, Eli Lilly. Well before its patent on Prozac expired in 2001, the company was pursuing a related substance that affects mood in a different way. Drugs like Prozac enhance the activity of a single brain messenger, serotonin; the new agent works on two — serotonin and norepinephrine — making it a serotonin norepinephrine reuptake inhibitor).
    At the meeting last week, researchers presented evidence that the drug could significantly relieve physical pain in depressed people, increasing their chances of responding to its effect on mood. The company expects the drug to be available by the end of the year under the name Cymbalta. Psychiatrists interviewed at the meeting said the new drug should be a welcome addition, if not a radical advance, in treatment. Another popular antidepressant, Effexor, which has been around since the early 1990s, also enhances the action of both serotonin and, to a lesser degree, norepinephrine.
"    Each drug has a kind of personality, its own quirks, and sometimes it's not clear why one catches on and others don't," said Dr. Peter Kramer, a psychiatrist and author of the 1993 bestseller, "Listening to Prozac." Drugs that look effective but not exceptional in studies can be surprise hits with patients. In the case of Prozac, Kramer said, no on expected much before it came out. "With Valium, some people reported that they liked their doctor better while taking it," he said. "Now, there's a positive feedback loop."