Scientists Say They ID Bipolar Gene
Malcolm Ritter, Associated Press- 6/15/2003

Scientists say they've identified a flawed gene that appears to promote manic-depression, or bipolar disorder, a finding that could eventually help guide scientists to new treatments. A particular variant of the gene was associated with only about 3 percent of cases in a study, but researchers said other variants might be involved with more. Follow-up research might help reveal the mysterious underlying biology that makes some people susceptible to the disorder, and so help scientists devise new treatments, said the study's senior author, Dr. John Kelsoe of the University of California, San Diego. The work is reported in Monday's issue of the journal Molecular Psychiatry.
    Previous studies have suggested that other genes are involved in manic-depression. But one expert, Dr. Melvin McInnis of Johns Hopkins University in Baltimore, said in an interview that he thinks Kelsoe's new work and another recent study provide the strongest evidence for involvement of particular genes in the disease. Manic-depression, which affects about 2.3 million American adults, involves episodes of depression and mania, states of abnormally high mood or irritability. While effective treatment is available, scientists would like to find better medications.
    Genetics clearly play a role. Kelsoe's work focused on a gene called GRK3, which influences the brain's sensitivity to chemical messages brain cells send each other. Defects in the gene might promote manic-depression by making people oversensitive to these messages, which are carried by dopamine and other substances, he said.
    Kelsoe and colleagues found statistical evidence tying a particular variant of the GRK3 gene to the disease. They tracked the inheritance of this variant from parent to child in families with a history of bipolar disorder. Overall, the variant was passed along more often than one would expect by chance to a child who later developed the disease. That suggests the variant promotes susceptibility to bipolar disorder.
    The association between the variant gene and the disorder appeared in one group of 153 families and a second group of 275 families. That association is only statistical, and Kelsoe said researchers now are looking for biological evidence that this variant of the gene acts abnormally. In any case, Kelsoe said other investigators will need to confirm his study's finding in other families to build the case that GRK3 is truly related to manic-depression. "It's likely only one of many genes involved in the disease," Kelsoe said. "Who knows how many such genes there are? It's likely in the dozens."
    On the Net: National Institute of Mental Health: www.nimh.nih.gov/publicat/bipolarmenu.cfm

Michigan Senate Considering Requiring Equity in Mental Health Coverage
Associated Press, 6/15/2003

LANSING, Mich. -- If you break a leg or get really sick, your health insurance usually will help pay your medical expenses. But if you're seriously depressed, a victim of panic attacks or schizophrenic, it may not pay for psychiatric counseling or other mental health treatment. Such discrepancies have led state Sen. Beverly Hammerstrom to push legislation that would require that benefits for mental health services match benefits for medical services.
    Her efforts have prompted an outcry among Michigan business leaders. They warn such a law will drive up insurance costs and threaten the financial health of businesses that provide insurance coverage for their workers. Hammerstrom, who heads the Senate Health Policy Committee that is reviewing the bills, disagrees with such critics. "I don't think it's a mandate. It's an end to discrimination," the Temperance, MI Republican said.
    She said insurance companies now provide a higher level of coverage for a physical illness than a mental illness. "If somebody has cardiovascular problems, we don't limit them to a certain number of visits. In mental health issues, they are limited to a certain number of visits. ... All we're saying is we want parity so they're treated the same," she said. The bills are strongly supported by mental health activists, Gov. Jennifer Granholm and patients who have experienced the difference in insurance rules firsthand.
    Carole Ann Heller of Westland, whose 30-year-old son has been diagnosed as manic-depressive, calls the difference in coverage "absolutely shameful." "A chronic disease of the brain is no different than diabetes or heart disease," she said. "It is shameful that people who are suffering mental illness are treated differently than people with any other chronic illness." She said her son will need expensive treatment for the rest of his life. "There's so many people like him," Heller said. "They have a choice of remaining dependent on the state or getting a job and contributing to society. But they need that cushion of knowing that when they need treatment, it's going to be there."
    The legislation is attracting more attention than it might because of a recent national report that gave Michigan poor grades for its mental health system. Michigan was the only state in the nation to receive all failing grades in the study. The National Mental Health Association said Michigan provides inadequate services for the mentally ill in the three categories analyzed by the group. The categories included: parity with physical coverage in services provided by private insurance plans and government programs; access to medications; and protection against declining services that may result from managed care.
    While Michigan received all failing grades, the association considered no state's performance to be satisfactory. "No state has prioritized community-based mental health enough, but Michigan is definitely a state that has failed in its support for the mentally ill," said Chuck Ingoglia, NMHA vice president for research and information services. "We think the report should be a call for action."
    Spokeswomen for both Gov. Jennifer Granholm and Department of Community Health Director Janet Olszewski said the new administration is working to address the deficiencies. Granholm also has pledged to support the requirement that mental health coverage be no more restrictive than coverage for physical ailments.
    But that hasn't stopped business groups from strongly opposing Hammerstrom's legislation. "Even supporters acknowledge the bills will increase the cost of employer-supplied health care by one or two percent," said Rich Studley, Michigan Chamber of Commerce vice president. "Our members feel these questions should be decided in the workplace by labor and management." Studley said the mental health parity legislation is entirely at odds with other GOP policies in the Senate.
    An insurance company representative echoed Studley's remarks. Insurance companies "are opposed to any mandates and these are a huge mandate," said George Carr, an attorney and lobbyist for American Community Mutual Insurance Co. of Livonia, the largest Michigan-based health insurer. "The cost will go up, no question about it."
    But Mark Reinstein, president and CEO of the Mental Health Association in Michigan, said the legislation is "vitally important." "We support it and desperately need it," he said. "We have tremendous insurance discrimination in Michigan."
    Neither insurance groups nor Hammerstrom could say how much the proposed parity would cost or how many people might use such insurance coverage, although the Mental Health Association in Michigan said it might affect 2 million to 3 million people. Hammerstrom said data indicate one of every five people may need mental treatment over their lifetime. Thirty-seven other states have addressed the parity issue, she added, leaving Michigan in the minority of states that have not. "That was one of the reasons they ranked us so poorly" in the national report, she said. "If we address the parity issue, it would go a long way to make our mental health system better."
    On the Net:
Michigan Legislature, http://www.michiganlegislature.org
Michigan Department of Community Health, http://michigan.gov/mdch

Gay Canadians' Quest for Marriage Seems Near Victory
Clifford Krauss, New York Times- 6/15/2003

TORONTO— A decision this week by an Ontario appeals court to extend full marriage rights immediately to gay and lesbian couples, after two similar though less sweeping recent rulings in Quebec and British Columbia, appears to have given decisive impetus to efforts to make same-sex marriage a reality across Canada. Dozens of gay and lesbian couples have already rushed to municipal buildings in Toronto, Ottawa and Hamilton to marry without waiting for a decision by Justice Minister Martin Cauchon on whether he will appeal the Ontario court decision to the Supreme Court. "The trend of court decisions is overwhelmingly in the direction of recognizing an entitlement for gays and lesbians to be married," said Patrick Monahan, incoming dean of the Osgoode Hall Law School at York University here.
    The Netherlands and Belgium are currently the only countries that extend full marriage rights to same-sex couples. France, Germany, Finland, Sweden, Norway, Denmark and Iceland allow gays and lesbians to enter into legal partnerships that award many of the same protections and responsibilities that marriage does. Quebec and the state of Vermont have also enacted legislation enabling such unions in recent years. In the case of the Quebec law, enacted last year, gay and lesbian couples gained the same full parental rights and obligations once given only to heterosexual couples, along with sweeping pension, health insurance, inheritance and other benefits. Six of Canada's 10 provinces extend some parental rights to same-sex couples, as do many states in the United States.
Legislation to grant legal status to same-sex couples was introduced in Chile's congress on Wednesday, suggesting that the issue is emerging at least for debate in even socially conservative countries. Last December, lawmakers in Buenos Aires granted legal status to gay and lesbian couples, allowing benefits like pensions and hospital visits. The law encompasses insurance policies and health benefits covered by local government only, and it does not permit same-sex couples to adopt children or marry.
    In Ottawa, some members of the House of Commons have argued that the issue of whether marriage rights should be broadened to apply to gays and lesbians should be decided by Parliament or the Supreme Court, to ensure that there is a national policy rather than practices that differ from province to province. Leaders of the two national conservative parties and Premier Ralph Klein of Alberta have objected to tampering with marriage traditions. But political resistance appears to be subsiding as polls indicate that a majority of Canadians accept the premise that gays and lesbians should have the right to marry.
    All three candidates for leader of the governing Liberal Party who are vying to replace the retiring prime minister, Jean Chrétien, in February have expressed support for allowing same-sex marriage. A House of Commons committee on Thursday voted narrowly in favor of extending marriage rights to gay and lesbian couples, the first time that an elected body in Canada had done so.
    Some legal scholars have suggested that Parliament may leave the final decision on the matter to the courts, but that it will eventually enact legislation enabling religious institutions that view marriage as valid only between men and women to refuse to marry same-sex couples. "Same-sex couples are capable of forming long, lasting, loving and intimate relationships," the Ontario court ruled unanimously. The three appeals judges said the extension of marriage rights was obligatory under the Charter of Rights and Freedoms, Canada's version of the Bill of Rights, and would cause no harm to the general community. The decision retroactively recognized the 2001 marriage of a gay Toronto couple that were married in a church ceremony but were refused a license by the city.
    Since the Ontario court's decision on Tuesday, daily images of gay and lesbian couples kissing before their relatives and friends have appeared on newspaper front pages and have been broadcast on television news programs across Canada. On Wednesday alone, the city issued 26 marriage licenses. "It means an awful lot," said Brian Rolfes, a 38-year-old personnel director of a consulting firm, while he and his partner, Bradley Berg, a 35-year-old lawyer, filled out a marriage license application at Toronto city hall on Thursday. "To be able to go anywhere in the world and be able to say, `Well, actually, we're a married couple,' " he said, adding, "It's the final piece of the puzzle. It's true equality."
    The celebrating has stretched across the border, where American gay rights advocates say the extension of marriage rights in Canada will have an enormous effect in the United States. "Americans will be able to look across the border to a country that speaks the same language and is also committed to democracy and pluralism and see that the sky does not fall when gay couples are allowed all the protections and status of marriage," said Evan Wolfson, executive director of Freedom to Marry, a New York-based group that supports the right to marriage between people of the same sex.
    Only a few American same-sex couples have married in the Netherlands because that country has a long residency requirement for foreigners seeking to marry, and Belgium only allows same-sex couples to marry if they are eligible to do so in their home countries. But since Canada has no residency requirements for marriage, gay and lesbian Americans can be expected to marry here in great numbers. Brad Ross, a spokesman for the city, jokingly predicted that Toronto could become "the new Las Vegas."
    Whether a Canadian marriage certificate granted to a same-sex American couple will be recognized in the United States remains uncertain. "There will be a period of uncertainty and discrimination," Mr. Wolfson predicted, "but they are going to come here married and be married just like anyone else on the planet."
    The extension of marriage rights to gay and lesbian couples in Ontario was built on a string of recent Supreme Court precedents. In one 1998 case, the high court unanimously ordered Alberta to include the term "sexual orientation" in provincial human-rights legislation protecting against discrimination. Based on that ruling Julius Grey, a prominent human rights lawyer in Montreal, said, "the recognition of marriage between people of the same sex looks inevitable."
    Last month, a lower British Columbia court ordered the federal Parliament to rewrite the definition of marriage by July 2004, or it would do so itself as "the lawful union of two persons." In the United States, similar cases are now before courts in New Jersey and Massachusetts. Lawyers for seven gay and lesbian couples have already made oral arguments before the Supreme Judicial Court of Massachusetts, and a decision is expected later this summer.

Supreme Court Limits Drugging of Defendants
Charles Lane, Washington Post- 6/16/2003

The Supreme Court placed new limits today on the government's authority to involuntarily medicate nonviolent defendants so that they can stand trial, a decision that could force prosecutors and courts to revisit what has, until now, been a fairly common practice in criminal trials. By a vote of 6-3, the court ruled that lower courts had mistakenly determined that federal prison officials could require St. Louis dentist Charles T. Sell to take antipsychotic drugs so he could face charges of Medicaid fraud. Sell insisted that he had a constitutional right to keep what he called "mind-altering" substances out of his body.
    Acknowledging that an individual's personal autonomy must be weighed against the public interest in prosecuting crime, the court ordered a review of Sell's case to determine whether involuntary medication will "significantly further" an "important" government objective, whether there is no alternative, and whether it would be "medically appropriate." "This standard will permit involuntary administration of drugs solely for trial competence purposes in certain instances," Justice Stephen G. Breyer wrote for the court majority. "But those instances may be rare."
    For the past five years, Sell, a St. Louis dentist, has been sitting in a federal prison hospital in Springfield, Mo., while doctors and lawyers try to figure out what to do with him. The U.S. government indicted him on charges of Medicaid fraud in 1997, but courts have found him to be so mentally ill that he is not competent to stand trial. Those courts have agreed with government doctors who say the only hope of rendering him competent is to administer anti-psychotic drugs -- by force, if necessary -- but Sell, citing the drugs' sometimes debilitating side effects and his own constitutional rights, has refused.
    The Supreme Court has ruled in the past that the government may forcibly medicate a prison inmate -- already convicted of a crime -- who would otherwise be dangerous to others and who would be helped by the treatment. But it has also said the government cannot forcibly medicate a defendant during trial unless it shows that the person is dangerous and needs the drugs to improve.
    In 2001, the justices declined to review a ruling by the U.S. Court of Appeals for the D.C. Circuit, upholding an order to medicate Russell Weston, a schizophrenic accused of killing two Capitol Police officers, so he would be competent for trial.  Sell's case is novel because he has been charged with nonviolent offenses and the courts have not ruled him a danger to others. It is also somewhat unrealistically framed in the Supreme Court, because the federal government has also charged him with trying to intimidate a witness and hire a hit man to kill an FBI agent -- but neither of those charges is technically part of this appeal. During the arguments on in March , Justice John Paul Stevens noted that Sell has already been confined longer than he would have been if convicted on all counts of the Medicaid fraud indictment.
    But Deputy Solicitor General Michael R. Dreeben, arguing for the government, told the court that Sell has himself to blame for his extended stay behind bars, since he is one of only a handful of people who have ever litigated their refusal to be medicated to such an extent. "Most individuals accept the fact . . . that medication is the appropriate, medically sanctioned way" to get better for trial, Dreeben said. The case is Sell v. U.S., 02-5664.

How to Be the Perfect Parent (and Drown Yourself in Guilt)
Howard Markel, New York Times- 6/16/2003

For more than a century, millions of American parents have relied on a library of advice books written by experts on virtually every aspect of their children's health, safety and behavior. Child-rearing problems and solutions, of course, have changed considerably over this period. But one thing has not: in each era, the baby experts have inadvertently inspired a great deal of anxiety among parents already uncertain about their ability to be parents.
    Ann Hulbert, a parent and freelance journalist, describes these insecurities in a new book, "Raising America: Experts, Parents, and a Century of Advice About Children." "I assumed that anxiety over raising the perfect child was a baby boomer affliction, but I discovered that it has been a centerpiece and a trademark of enlightened parenting in this country for over a century," she said.
    Mothers and fathers at the beginning of the 20th century were motivated to seek expert advice mainly to avoid life-and-death consequences from their poor child-raising skills or their bad decisions. Dr. Richard Meckel, who wrote "Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929," said that infant death in this era was a strong possibility — one that most families today could not fathom. "The writers of these early baby care manuals offered their readers something that was still not readily available to most American parents: scientifically informed and detailed information on infant care and the means to avoid serious, deadly illnesses," added Dr. Meckel, a historian at Brown.
    As medicine advanced in the 20th century with the development of vaccines and antibiotics, the menu of problems that parents focused on gradually shifted from the deadly to what sociologists call "low-morbidity, low-mortality issues." These include uneven sleeping patterns, finicky eating, learning disabilities, attention disorders and an expanding list of behavioral syndromes. Not surprisingly, Ms. Hulbert said, the focus of child care books shifted.
    It was not until the end of the 1890's that baby care manuals became staples in the middle-class American nursery. One of the most successful was written by Dr. L. Emmett Holt, a New York City physician who divided his time between running Babies Hospital, developing intricate modifications of cows' milk to resemble breast milk (hence the term formula) and being the pediatrician to the family of John D. Rockefeller Jr. and other wealthy New Yorkers.
    In 1894, Holt published "The Care and Feeding of Children," a perennial best seller that went through 12 editions and 75 printings. In it, he prescribed a strict regimen of feeding that resembled a railway schedule, issued warnings not to kiss or cuddle infants and urged toilet training by age of 4 months. "Holt's prescriptions for absolute control over the baby's daily routine and the scrupulous prevention of deadly infections attracted legions of readers," Dr. Meckel said.
    As pediatricians began to conquer many of the contagious scourges of childhood, they evolved into family counselors. From 1920 to the late 1940's, psychologists and child study experts produced a flurry of contradictory and often dogmatic treatises on child-rearing and behavior. One was Dr. John B. Watson, the censorious psychologist and best-selling author of "Psychological Care of Infant and Child." "He rarely missed an opportunity to tell mothers that they did not know what they were doing and sorely needed his help," Ms. Hulbert said.
    The job of calming the apprehensions of post-World War II parents fell to Dr. Benjamin Spock, a pediatrician whose mother raised him on the precepts of Dr. Holt. Throughout the pages of his "Baby and Child Care," first published in 1946 and second in sales only to the Bible, Dr. Spock told parents: "Trust yourself. You know more than you think you do." Dr. Spock's beautifully written blend of medicine and psychology emphasized a partnership between the child and parent, but it also reminded parents they were, ultimately, in control. Yet Dr. Spock was often misinterpreted and eventually derided as being too soft. As the journalist Stewart Alsop said after Dr. Spock had spoken out passionately against the Vietnam War, many older Americans believed that the era of social unrest that began in the 60's had its roots in children who were "Spocked when they should have been spanked."
    In the years since Dr. Spock's eclipse, child-rearing advice has splintered further along lines of specific problems, developmental stages, philosophies and even political ideologies. Still, the frantic search by American parents for the singularly correct way to rear children has only intensified. Several scholars who have studied child-raising in the United States over the last century have complained that the guidebooks themselves can make mothers feel inadequate, especially if the parents are unable to follow the advice or choose not to. Dr. Steven Shelov, editor in chief of the American Academy of Pediatrics' "Caring for Your Baby and Young Child," which has sold more than five million copies, observed that parental anxiety might be increasing because "people today are having fewer children, later in their lives and, because of long-distance families, cannot always consult their own parents for advice."
    Dr. T. Berry Brazelton, the famously genial pediatrician whose 30-plus books have sold in the tens of millions, said: "I never really wanted to give advice. I do not believe that is the way to learn how to parent. My books are aimed at helping mothers and fathers look into a child's mind." He acknowledges the obsession with being a perfect parent and the guilt that can arise from the inevitable failure. "It's a reflection of how passionate parents are about raising children, and I admire that," he said. "The trouble is that most parents don't realize that failure is really the best way to learn how to parent."
    In her book "Baby and Child Care," Dr. Penelope Leach, a child psychologist, stresses the importance of understanding children's changing stages. She sighed when asked about the unintended guilt that her book and those of her colleagues might provoke. "Some readers have told me that my book makes them feel guilty and yet these same people seem to know the whole book by heart," Dr. Leach said. "I always ask, `Why didn't you just recycle it?' If an advice book doesn't empower you, there's no reason to use it. When writing a book, you have to have a point of view unless you want it to resemble a bowl of porridge." Ms. Hulbert said reading advice books by those with differing opinions could be valuable. "Sometimes," she said, "it is good to listen to an expert tell you something that you are not willing to tell yourself."
    Heidi E. Murkoff, co-author of the successful "What to Expect" series of baby care manuals that have sold more than 21 million copies, proudly wears the mantle of a nonexpert who offers nonjudgmental advice. But she, too, receives letters from readers who feel anxious when they do not precisely follow her suggestions. "We offer suggestions and encourage parents to try them all," Ms. Murkoff said. "Every baby is different and every parent is different. We need to be flexible in how we give advice and parents need to be flexible in how they take it. Parents need to trust their instincts, and too much conflicting advice can get in the way of that." Of her credentials, she says, "I have an M-O-M degree." Dr. William Sears, a pediatrician, emphasizes a philosophy called the seven B's — birth-bonding, breast-feeding, baby-wearing, bed-sharing, belief in the communication value of a baby's cry, beware of the baby experts and balance — in his popular baby care manuals "The Baby Book" and "The Discipline Book."
   Most parents today, he says, know that expert advice is constantly changing. "Don't take any experts' philosophy too seriously," Dr. Sears said. "Even mine." Dr. Brazelton, the pediatrician and writer, added: "Asking parents to relax is kind of silly. I don't think any parent is relaxed. But things can go smoother if you learn to watch your baby. He or she will tell you when you are on the right track and when you are not." Ms. Hulbert takes a historically informed approach. "It's no wonder, really, that the experts suspect mothers of often failing to follow their advice with consistency," she said. "How could they? Perhaps that's the saving grace of the genre. "A century of dizzying advice may well have helped parents to keep their heads. After all, when expert counsel tugs at you from opposite directions, it's hard to get too carried away."

Study Finds a Large Depressed Population, With Many Untreated
Daniel Ling, ABC News- 6/17/2003

As many as one in every six Americans experience major depression at some point in their lives, but the vast majority never obtain adequate treatment, according to a study published today in the Journal of the American Medical Association. While researchers found some 33 million or more Americans suffer from the debilitating condition, in line with past estimates, only 22 percent of those surveyed with major depression in the past year were receiving sufficient care.  The study used trained research clinicians to diagnose patients, answering critics who maintain past figures were inflated by a large proportion of mild cases and unreliable diagnostic procedures. The clinicians classified 90 percent of patients as moderate to extremely severe cases.
    The findings carry both health and economic implications, suggest experts. "Persons with a major depressive disorder were taken out of their productive role for an average of 35 days," noted Dr. Joshua Straus, director of consultation-liaison psychiatry at the Stone Institute of Psychiatry in Chicago. "The plain fact is that depression is highly disabling." Straus also cited the ripple effect on other aspects of health: "Having major depression is associated with increased death due to heart disease and stroke." In addition, patients who are not adequately treated tend to use inpatient hospital care excessively, driving up overall health-care costs.

Treatment Not Forthcoming
The study found that almost half of the subjects did not receive any care at all. And some doctors believe the numbers may be even worse. Dr. Paul Appelbaum, chair of the department of psychiatry at the University of Massachusetts Medical School in Worcester, Mass, and past president of the American Psychiatric Association, said that the study's definition of "adequate treatment" — a 30-day drug or psychotherapy regimen — was too lenient. "It's likely that an even smaller percentage of persons than the 22 percent figure given really had their depression treated adequately," he added. "If anything, the study overstates the degree of treatment in the community," concurred Dr. Alec Bodkin, chief of the clinical psychopharmacology research program at McLean Hospital in Belmont, Mass. "Their definition of adequacy may include some energetic but ineffective treatment." Physicians pointed to ignorance, social stigma, and lack of insurance coverage as the primary causes of inadequate treatment.
    Dr. William McKinney, director of the Asher Center for the Study and Treatment of Depressive Disorders in Chicago, emphasized the need for people to be proactive. "Depression is clearly underdiagnosed and therefore many people will not get the treatment they need. … The public needs to be aware and seek treatment or recommend evaluation for others."

How Doctors Are Responding
Appelbaum called for increased efforts to dispel the social stigma of mental disorders with "public education that emphasizes that depression is an illness like other illnesses." He also stressed the importance of increased health coverage for mental illnesses, noting the disparity between the United States and other nations. "Most other major industrialized countries have national health insurance programs & in which psychiatric illnesses tend to be treated as other illnesses," said Appelbaum. "In America, most health insurance policies currently discriminate against mental disorders by limiting coverage."
    Insurance companies counter that expanding coverage could increase health insurance costs by hundreds of millions of dollars, causing many to lose their insurance completely. Nevertheless, many doctors continue to work to break down these barriers to mental-health treatment. Appelbaum highlighted the effectiveness of adequate treatment in helping patients as one reason, noting that roughly 60 percent of patients respond to the first medication taken. Added Appelbaum, "Patients who respond to the medication can in the course of several weeks see a complete recovery."
    Bodkin summed up the growing sentiment that there is an urgent need to deal with the problem of major depression. "The symptoms of depression substantially impair the quality of life and capacity for role function. The predominant lack of effective treatment for people suffering from depressive illnesses should not be tolerated by our society."

Supreme Court Sets Guidelines For Forced Medication
Charles Lane, Washington Post- 6/17/2003

The Supreme Court yesterday laid out demanding guidelines for forcibly medicating defendants who are too mentally ill to stand trial, a decision that could alter the balance between government and individual in a small but significant category of cases. By a vote of 6 to 3, the court ruled that lower federal courts had mistakenly authorized prosecutors to require St. Louis dentist Charles T. Sell to take antipsychotic drugs so he could face charges of Medicaid fraud, mail fraud and money laundering. Sell insisted that he had a constitutional right to keep what he called "mind-altering" substances out of his body. Recognizing that the public interest in prosecuting crime must be weighed against an individual's autonomy, the court ordered lower courts to review Sell's case and imposed a checklist of conditions that the government must apply in cases involving defendants who are not dangerous.
    Involuntary medication must "significantly further" an "important" government objective, Justice Stephen G. Breyer wrote for the majority. The drugs must be "substantially likely" to render the defendant competent and "substantially unlikely" to produce side effects that interfere with the defendant's ability to receive a fair trial, he wrote. There must be no alternative to medication. And it must be "medically appropriate," his opinion said. "This standard will permit involuntary administration of drugs solely for trial-competence purposes in certain instances," Breyer wrote. "But those instances may be rare."
    Breyer also noted that courts should try to determine first if medication is required to prevent defendants from endangering themselves or others. If it is, he wrote, then the need to consider forced medication to ensure competence for trial "will likely disappear." If, on the other hand, a defendant is not dangerous, the burden on the government to show a need for forced medication could grow.
    "They have set a rather high bar for the government when it's seeking to medicate persons who are accused of serious nonviolent crimes," said Sell's attorney, Barry A. Short. "And I don't think it's a bar they can get over with Dr. Sell." But Paul Appelbaum, president of the American Psychiatric Association, which supported the government in the case, said that "the decision leaves more work for the courts to do. In outlining these criteria, the court has not said how to balance them."
    Issues of mental competence to stand trial arise in a significant number of both state and federal cases. In a recent 12-month period, the U.S. Bureau of Prisons medicated 285 federal defendants who otherwise would have been too mentally ill to understand the proceedings against them or to assist their lawyers. Of those, 226 agreed to treatment and 59 were medicated involuntarily, according to Justice Department figures.
    Those statistics do not distinguish between those charged with violent crimes -- such as Russell E. Weston Jr., the schizophrenic man charged with killing two Capitol Police officers who has been ordered to take medication while in custody -- and those charged with nonviolent crimes. That Sell was charged with a nonviolent offense and had been found not dangerous by the courts made his case a novel one. It is also unusual for a defendant to fight an order to take medication.
    The decision will have no impact on the capital murder trial of Gregory D. Murphy, the Alexandria man charged in the April 19, 2000, knife attack on 8-year-old Kevin Shifflett, both prosecution and defense lawyers said yesterday. However, Murphy's lawyers continue to fight the forced medication of their client, who suffers from paranoid schizophrenia and has been found incompetent to stand trial in Shifflett's slaying. They have a petition pending before the high court.
    In the past, the court had ruled that the government may forcibly medicate a prison inmate -- already convicted of a crime -- who would otherwise be dangerous and who would be helped by the treatment. And in another case, it had left open the possibility that the government could forcibly medicate a murder defendant to make him competent to stand trial. Breyer's opinion yesterday synthesized principles from those cases, developing a rule that would apply to trial-competency determinations "whether the offense is a serious crime against the person or a serious crime against property."
    Sell, 53, who was indicted on 63 counts of fraud and money laundering in 1997, has been diagnosed as suffering from "delusional disorder, persecutory type." The lower federal courts have agreed with government doctors who say the only way to render him fit for a trial is to administer antipsychotic drugs. But Sell, citing a contrary opinion from his own medical expert, says the drugs would not help him and could have debilitating side effects. The Fifth Amendment guarantee against being deprived of liberty without due process of law gives him the right to say no, he says. As a result, his case has remained in legal limbo and he has spent most of the past five years in a federal prison hospital in Springfield, Mo., where he has had frequent run-ins with guards and spent months in solitary confinement.
    The time Sell has spent in custody exceeds the maximum sentence he would have received if tried and convicted on the fraud charges. However, he has also been indicted on charges of trying to intimidate a witness and hire a hit man to kill an FBI agent -- charges that, for technical reasons, were not part of his Supreme Court appeal and which the justices were thus obliged to ignore.
    Justice Antonin Scalia, joined by Justices Sandra Day O'Connor and Clarence Thomas, dissented from yesterday's ruling. Scalia said that the court lacked jurisdiction to hear Sell's appeal since the lower court's order to medicate him was not a final judgment of his guilt. The case is Sell v. United States, No. 02-5664.

In Missouri, an Uphill Battle Against 'Meth'
Robert E. Pierre, Washington Post- 6/17/2003

ST. CLAIR, Mo. -- For five hours, the two men escaped notice as they bought up blister packs of decongestant pills, two at a time, at stores across suburban St. Louis. But at their last stop -- the 19th of the day -- a suspicious security guard alerted police. Pulled over 30 miles later in this town of 4,500, the men were soon in handcuffs for having enough pills to make about an ounce of methamphetamine, the illegal and highly addictive stimulant that is better known as crank, crystal or just plain meth.
    Their ages, 63 and 50, didn't surprise Detective Travis Blankenship. The drug has ravaged the state for more than a decade, ensnaring young and old, businessmen, housewives and entire families. "It used to be big news to find a meth cook," said Blankenship of the Franklin County police as he sifted through the shopping bag filled with 38 boxes of pills. "Now everybody is cooking meth."
    Missouri has led the country for the past two years in the number of clandestine labs shut down by police. The state also is renewing efforts to clamp down on access to Sudafed and other pseudoephedrine-based products, which are prized by meth cooks because they can be easily transformed into the illicit street drug. Three communities since December have ordered that stores keep all decongestants with pseudoephedrine as the sole active ingredient behind the counter or in locked cases. And the Missouri legislature last month passed the nation's most stringent such law, limiting sales of the medicine to two packages per person and requiring that the packages be placed near the checkout counter to prevent theft.
    Drug companies protested that the laws are a hardship on chronic allergy sufferers. Convenience store owners balked at the government's telling them how to allocate prime retail space. But with jails clogged and the meth problem as bad as ever, lawmakers said drug company profits and convenience had to take a back seat. "It's just a terrible drug," said state Sen. Anita Yeckel (R), who got involved with the issue a few years ago after meeting a young sheriff whose lungs were damaged after he accidentally inhaled toxic fumes from a discarded lab. "I don't know of any drug that's as addictive. There are a lot of parents who think this is like cocaine or marijuana. This is worse."
    First imported to the region by truckers from large West Coast labs, meth took off in the Midwest and later the Southeast in the mid-1990s when locals began making their own. Illicit manufacturers using home recipes could make the drug cheaply and did not need a middleman to sell to users. That left police without a big boss or a cohesive organization to target. Instead, they had to hunt down dealers and users one at a time. "It literally spread like contact dermatitis," said Dwayne Nichols, a 30-year veteran of the Bureau of Alcohol, Tobacco, Firearms and Explosives, who now administers federal money that targets high-activity drug areas throughout the state. "It's like trying to fight a water balloon -- you fight it and it goes somewhere else." The state's rural areas were particularly hard hit. Cooks set up in cheap hotel rooms, back yards and deserted roadsides, and had plenty of woods in which to hide stashes. There was also easy access to anhydrous ammonia, a farm fertilizer that is a key ingredient for meth.
    The hunt can be all-consuming. If Dennis Fowler, a sheriff's deputy in Stoddard County in southeastern Missouri, isn't staking out a farm or co-op for fertilizer thieves, he's making arrests with a statewide task force or visiting local stores, reminding them to keep their eyes open. "Any pill-buying lately?" Fowler asked the clerk at Dollar Discount in Bloomfield. "Not since last week," the woman responded. "Well, give us a call if they come in, and tell us which way they're going," said Fowler, as he left for the next stop.
    A short time later, at the trailer of one of Fowler's informants, a man who said he has been a sometime user of meth for a decade explained the drug's allure. "It makes you feel like Superman," said the man, who did not want his name used. On binges, he would stay up for days or even weeks at a time, he said. While paranoia, also known as "geeking," is common, so are the cravings to get high. "If they have to steal, they'll do it," the man said, sitting next to his wife, also a meth user, in their trailer. "Women will trade sex for drugs. People do what they have to." A native of Stoddard, Fowler said few families have escaped meth's wrath. He arrested his own sister and sent his brother-in-law to jail.
    It's so destructive, said Associate Circuit Court Judge Joe Satterfield, that addicts must be protected from themselves. That is why he regularly sets bail of at least $100,000 in cash for those arrested on meth-related charges. It's the equivalent of having no bond at all because few can pay. It has prompted some legal experts to complain that he is misusing his authority and trampling on prisoners' rights, but Satterfield is unfazed by the criticism. He said he is tired of seeing people "bond out," only to be back before him the next week for the same offense. "It's a tremendous burden on the system," he said. "They forget sex. They forget their kids. When they get out, they go do it again."
    And as a result of Satterfield's tough stance, some just move to neighboring jurisdictions such as Butler County. The problem is so severe there that Poplar Bluff, the county's largest city, was named one of the state's 15 sites to dispose of hazardous waste collected from meth labs. One prominent defense attorney in Poplar Bluff said that criminal cases account for 75 percent of his practice, and 75 percent of those are meth-related charges. One in four of the divorces he handles involves a case of the husband or wife using meth.
    "Why they want to mix a bunch of poisons and inject is beyond me," said Daniel T. Moore, over a lunch of tacos with his best friend, Police Chief Danny Whiteley. Whiteley catches them; Moore attempts to get them off. While they differ on whether enforcement methods are effective, they agree that the drug is a burden. "It's taken the criminal justice system and drowned it," Moore said. And that's why the focus now is on keeping pills out of the hands of drug users.
    In St. Peters, the first city to pass a pill ordinance, the measure was taken partly in response to the death last year of a grocery security guard who was smashed against a wall by a pickup truck driven by two people suspected of stealing decongestants. The St. Louis County police department now has a full-time "pill diversion task force." It has teamed up with large retail chains and small stores to either gain access to their surveillance cameras or get clerks to tip them to suspicious purchases. The task force -- which includes officers from the state highway patrol and neighboring departments -- has arrested people from as far away as Mississippi driving five hours to try to make purchases in anonymity. Last year, conducting surveillance twice a week, the group made 118 arrests and confiscated 60,000 pills. Already this year, the task force has made 103 arrests and seized 36,000 pills and six pounds of liquid pseudoephedrine pills that were already "soaking down" in preparation to make the drug. They also seized 21 labs, typically consisting of Pyrex dishes, lithium batteries, liquid ammonia and plenty of toxic sludge from the various chemical reactions. Despite such numbers, police know they are not catching everyone. Still, they remain optimistic that something -- restricting access to pills, raiding labs, jailing cooks -- will work. "As time progresses," said St. Louis County police detective Damon Kunnermann, "we're going to put the crunch down on people."

Shyness Has a Root in Brain That Long Endures
Paul Recer, Associated Press- 6/20/2003

WASHINGTON -- A shy child may learn to be more outgoing, but a study suggests that shy temperament may be inherited and that a brain marker for it does not change with age. In the study, which appears this week in the journal Science, researchers conducted brain scans on 22-year-olds and found that those who had been classified 20 years before as inhibited or shy children had a distinctive reaction in their brains when confronted with novel images.
    People who as toddlers had been judged to be inhibited showed in the scans that the amygdala structure in the brain responded much more actively to unexpected sights than was the case with subjects who as children had been judged to be more outgoing, said Jerome Kagan, professor of psychology at Harvard University. ''That is support for the notion that the reason they were shy, timid, and reserved when they were 2 years old is because they had an excitable amygdala,'' said Kagan.
    The results suggest that shyness is a temperament that can be inherited, but Kagan said that temperament does not necessarily determine a person's eventual personality. ''They are now 22 years old,'' he said of the test subjects. ''A lot of the ones who were fearful aren't fearful anymore. They have overcome it. But the question is, did they still have a very active amygdala.'' Based on the brain scans, he said, the answer is clearly yes.
    Tests were conducted on 13 people who had been evaluated as shy at age 2. The test results were compared to those of nine people who as children had been evaluated as outgoing and bold. ''We had assumed, but never measured, that . . . the shy, inhibited group had inherited a certain chemistry'' in the amygdala, Kagan said.
    All the subjects were exposed to a series of pictures of faces with neutral expressions. After they became accustomed to those pictures, new faces were introduced, and researchers measured the reaction of the amygdala structure, using magnetic resonance imaging. The brains of those evaluated as shy in childhood were much more active than those of other subjects. Before any firm conclusions can be drawn, there needs to be a similar research using many more subjects than the 22 in the current study, Kagan said.
    Although some children are shy and others are outgoing, he said, these traits can change with time and life experiences. ''People overcome their shyness,'' Kagan said. ''You can also acquire shyness.'' Extreme shyness can be a precursor of serious disorders, such as social phobias and depression. By finding the biological basis for such shyness, it may be possible to develop drugs to treat patients whose lives are adversely affected by the condition, Kagan said. Other coauthors of the study are Dr. Carl E. Schwartz, Dr. Christopher I. Wright, Lisa M. Shin, and Dr. Scott L. Rauch, all of Harvard Medical School.

Spring's Psychological Lift Never Came, Doctors Say
Jim Fitzgerald, Associated Press 6/20/2003

WHITE PLAINS, N.Y.- Summer arrives Saturday, but the psychological lift normally provided by springtime hasn't come yet for people suffering from the winter doldrums or more serious seasonal disorders in the weather-beaten East, some doctors say. ''Many of my patients are complaining bitterly,'' says psychiatrist Norman Rosenthal, author of ''Winter Blues.'' ''Normally there are long, warm, sunny days in April, May and June, with a predictable resurgence in energy and mood. This resurgence has not occurred.   ''Just today, with the rain, a patient said to me, `I can't believe it. It's unending. I'll never get my spring cleaning done.''
    The East has had one of its coldest, wettest springs on record. More than half the days in May and June have been rainy in New York City. Alabama, Maryland, North Carolina, Ohio, Tennessee, Virginia and West Virginia have all had their second- or third-rainiest May on record. So residents are getting used to toting umbrellas and not the kind you can plunge into the sand at Cape Cod or the Jersey shore. And if the gray clouds in the sky and gray pallor in the mirror are mood-killers to the average person, they can be worse for people diagnosed with such syndromes as seasonal affective disorder.
    ''Some people more than others are sensitive to the amount and intensity of the light they're exposed to and these are people who in the winter typically have seasonal depression or seasonal affective disorder,'' said Dr. Norman Sussman, professor of psychiatry at the New York University medical school. ''For people who suffer from this condition this has been a terrible spring.'' Rosenthal, who teaches at Georgetown's medical school in Washington, said such patients often withdraw from friends and families, lack concentration and underperform at work, while oversleeping and overeating. Patients can develop a persistent sadness and a pessimistic view of the world.
    Dr. Michael Terman, who directs the winter depression program at Columbia Presbyterian Medical Center, said symptoms are usually treated with artificial light. Patients turn on extra lights when they wake up in the morning or use lighting that comes on automatically to imitate dawn. ''Usually by the end of April you don't need the lights anymore. You store them in the closet and I go out of business until October,'' he said. ''But now we've had a long string of gloomy days extending from the beginning of May so these lightboxes are still being used.''
    Still, the theory that wintertime blues are persisting isn't universally accepted. Frederick Brown, who teaches psychology at Penn State and specializes in biological rhythms, said he hasn't come across it and is doubtful. Even on the stormiest days, he said, ''It's much brighter in the morning that it is in winter. Even though the days are cloudy, they're longer by several hours and there's much more sunlight.''
    Statistics on this spring's effect on seasonal depression are hard to come by. Many people simply get the blahs, finding it a little harder to get through a day when they have to wake up in the dark. Terman said that if those people are counted, nearly half of all New Yorkers are in the doldrums during the shortest days of the year. ''These people accomplish what they have to, they persist, but they really have to push to get through the day,'' he said. Which means this year, they're still pushing even as the year's earliest sunrises arrive.
    Kelly Kim, 30, of Little Ferry, N.J., said the spring weather has curbed her plans to go out with friends after work. ''It's kind of depressing,'' she said. ''I just want to go back home and relax.'' Sophie Peresson, who came from France this summer to work as an intern at a Manhattan bank, said she's spent inordinate amounts of recreation time at museums and movies. ''I don't like rain,'' said Peresson, 22. ''I'm not in a good mood.''
    Sussman said he knows people who haven't bothered to open their vacation homes and have canceled annual fishing trips. ''There are certain psychological expectations people have with the seasons,'' he said. ''What's happened this year is we've had no spring. So people who look forward to putting their boat in the water or going to the beach or playing tennis, that's just been totally wiped out. There's been a disruption to the normal cycle or pattern of things.''
    On the Net: Questionnaire to determine ''morning type'' versus ''evening type,'' http://www.cet.org

District of Columbia Failed to Check on Patients
Carol D. Leonnig, Washington Post- 6/20/2003

The D.C. Department of Mental Health received more than 500 reports of serious incidents affecting the city's mentally ill population over a 12-month period but cannot document that any were investigated, as required, according to a report released yesterday by the D.C. inspector general. The audit, requested almost two years ago by Mayor Anthony A. Williams to ensure that the city's 8,000 mentally ill patients were being cared for, examined 508 incidents from June 2001 to June 2002. Among them were 46 unexpected or unexplained deaths, 128 allegations of abuse or assaults and 28 suicide attempts.
    The report also shows that the District has lost track of 20 mentally ill patients who were charged with crimes and committed to St. Elizabeths Hospital and who later were allowed to leave the hospital and did not return. Some of them have been missing a few months, the audit said, others as long as 20 years. The failure to investigate the incidents occurred as the city was working to take over an agency that had been under court-ordered supervision since 1997. Officials at the Mental Health Department acknowledge that the city did not have a policy to investigate incidents until October 2001 and that the staff needed was not in place until January 2002.
    Martha Knisley, who took over the Department of Mental Health in April 2001 -- a year before the city assumed full control -- is on extended leave and could not be reached for comment yesterday. But in the official response included as part of the report, Knisley concurred with the report's recommendations for improvements. The department, Knisley wrote, "readily admits that the incident investigation process has been a challenge to develop and implement."
    Officials challenged the sweep of the report yesterday, saying the department looked into some incidents that were not already being investigated by other agencies. They could not specify how many. "We're not saying we conducted full-blown investigations into 508 incidents," said the department's acting general counsel, David Norman. "But there were some cases where we initiated an investigation."
    The mayor's spokesman, Tony Bullock, said there appeared to be a significant difference of opinion between the Mental Health Department and the inspector general over how thoroughly incidents were investigated and what constituted an investigation. "It seems very hard to imagine 500 incidents occurred and none of them were investigated," Bullock said. "Obviously, the mayor wants to be sure that matters of this gravity are being properly investigated. Obviously, we have to get to the bottom of this."
    Advocates for the city's vulnerable residents said they were amazed that the city failed to investigate reported incidents. "This is a bare-minimum requirement -- that the city at least investigate when someone says something terrible happens," said Kelly Bagby, senior attorney at University Legal Services, an advocacy group for the mentally ill.
    The report said the department also failed to follow up on serious incidents, citing several examples. The audit describes one incident in February 2002, when a group home resident was found dead with a laceration on his head. The death was ruled a homicide, and an employee at the home was indicted in connection with the death. But the Mental Health Department had no record that it took action against the group home for failure to report previous injuries, the audit found.
    In August 2001, the roommate of a 48-year-old woman left a voice mail with the department saying her roommate had locked herself in her bedroom for three weeks. Three days later, the audit said, a health care supervisor found the woman unconscious in her room. She died on her way to the hospital. The medical examiner concluded from bruises on the woman's back that she had been hit several times with a pipe. The department had no record of having investigated the incident or having obtained a cause of death from the medical examiner.
    The city has been cited for failing to investigate and monitor the care of the mentally retarded population, which is under the D.C. Department of Human Services. In fall 2000, the agency said it was investigating 46 reports and had a backlog of 419. Knisley has said it will take years for the Mental Health Department to recover from decades of mismanagement and dysfunction. She has pledged to aggressively monitor group homes and last year reported that new inspectors had visited 114 of the 167 homes for the mentally ill, issuing deficiency notices to 104 and moving to deny one license renewal.   Advocates applauded Knisley's efforts at reform but stressed that the city needs to devote more resources.  The Mental Health Department's Office of Accountability is responsible for investigating incidents, monitoring all District patients placed in out-of-state facilities, licensing group homes in the city and monitoring Medicaid administration. It had a staff of eight in February, and Knisley said she would hire more.
    D.C. Council member Sandy Allen (D-Ward 8), whose committee oversees the Mental Health Department, questioned the timing of the report. The council is trying to oust the inspector general, Charles C. Maddox, and the resulting legal battle is in D.C. Superior Court. "We're getting more reports now from the inspector general than we have in the past," Allen said. Maddox said the audit was in the works for more than a year. "This report is just an example of the work we've been doing -- before and after the controversy began with the council," he said. "In the last four years, we've issued more than 375 reports . . . and in the last three years alone, we've recouped at least $17.5 million."

FDA Warns Against Giving Children Paxil
Reuters News Service, 6/20/2003

The Food and Drug Administration warned yesterday that patients younger than 18 should not take the antidepressant Paxil because of a possible increased risk of suicidal impulses associated with the drug. The statement from the FDA comes nine days after British regulators issued similar precautions for children and adolescents. The drug, one of GlaxoSmithKline's top sellers, is known as Seroxat in Britain. The drug generated global sales of about $3.4 billion last year, but it is facing the prospect of generic competition in the United States within the next 18 months. The medicine has been the subject of increased public concern because of reports of adverse reactions, prompting Britain to set up an expert panel to investigate.
    Although Paxil is officially approved for adults only and companies are allowed to promote and market drugs only for approved uses, doctors have had discretion to prescribe Paxil or Seroxat to young people on an "off-label" basis. Children account for a small portion of patients taking the antidepressant. A total of 4 million prescriptions were written for Seroxat in Britain last year, with 8,000 patients younger than 18 receiving treatment. New data from clinical trials showed episodes of self-harm and potentially suicidal behavior were 1.5 to 3.2 times higher in patients younger than 18 taking the drug than in those getting a placebo.

54,000 Prescriptions Draw Law's Notice; Clinic Is Raided
Lisa Falkenberg, Associated Press- 6/22/2003

DALLAS — Dr. Daniel Maynard took no appointments. Instead, hundreds of patients would wait for hours in the parking lot in a line that began forming the night before. "When you've got 300 people ahead of you, you know a production line is what he's doing," said former patient Walter Shearin, 53, who would wait eight to 10 hours to see Maynard and get his prescription for narcotics renewed. "It's a red flag." Maynard's practice was a red flag to state and federal authorities too. They raided his clinic, home and bank this month, and seized thousands of documents and computer equipment in an investigation into the deaths of 11 patients, several of whom died of drug overdoses or toxic combinations of drugs.
    Investigators alleged in court papers that Maynard prescribed narcotics without a valid medical purpose. No charges have been filed. But the 57-year-old doctor could face manslaughter or criminal negligent homicide charges, investigators said. The investigation involves far more deaths than similar cases brought recently against doctors in Florida, Georgia and New Mexico, officials said. The doctor still holds his medical license. But the district attorney's office has asked the federal Drug Enforcement Administration to revoke his license to prescribe narcotics. And the state canceled Medicaid reimbursement payments to the clinic.  The investigation has come as a relief to relatives of patients who died under Maynard's care. But the news was met with shock and frustration by lines of patients who took turns knocking on the locked door of the South Dallas clinic in the days after the raids, waiting to be escorted in.
    The doctor has not spoken publicly about the investigation. But his attorney, Jim Rolfe, said Maynard is "completely innocent." "He did not prescribe anything to anyone that was not medically necessary, medically sound or medically OK to do so," Rolfe said, adding that the number of deaths — 11 people, ages 29 to 62, over the past three years — is "really not abnormal" considering the number of patients that Maynard has.
    Records show that in 2002, Maynard wrote more prescriptions for the sedative diazepam (also known by the brand name Valium) than any other doctor in Texas. And he wrote the second-most prescriptions for Tylenol with codeine. In all, he wrote 54,748 prescriptions last year, according to the records. If Maynard worked an average 270 days a year, eight hours a day, that would work out to about 200 prescriptions per day. "When we say 25 per hour, there's no way you could see the patient and write the prescriptions, much less document the whole situation," said Dale L. Austin, chief operating officer for the Federation of State Medical Boards.
    Sandra Blackburn, 47, a teacher, lost her two older brothers after years of pleading with them to stop seeing Maynard. "I personally believe he's a drug dealer," she said. "He's a legal drug dealer. That's the sad thing." Her brother Cecil Armitage, 62, died in March, surrounded by dozens of prescription bottles. Court records show Maynard had written him 23 prescriptions for such drugs as the pain reliever and cough suppressant hydrocodone, Viagra, diazepam and cough syrup with codeine. Blackburn's other brother, Harold Armitage, 52, who suffered from high blood pressure, hepatitis C and kidney failure, was killed in a traffic accident after going to Maynard for pain medication. He had been prescribed such drugs as diazepam, hydrocodone, the muscle relaxant carisoprodol and Viagra, according to court records.
    Patients waiting outside Maynard's clinic defended him as a kindhearted doctor who hands out cash to hungry people so that they can buy fried chicken down the street. He has become an institution in a part of town where haggard men ask strangers for bus fare and sirens wail incessantly. "There's a lot of pain in this neighborhood and this is his specialty, treating pain," said patient Lawrence Stephenson, 58. He said he takes a narcotic for back pain. Rebecca Martinez said Maynard is "the one who keeps my mom and dad alive." Dist. Atty. Bill Hill said support from patients is to be expected: "That's where they're getting their dope."      The district attorney and five other agencies, including the FBI and the DEA, began investigating Maynard after complaints by family members of patients who died from drug overdoses. Hill said it could take months to go through the seized evidence to determine whether Maynard, a doctor of osteopathy and a Texas general practitioner since 1973, will face charges. Meanwhile, Rolfe said the doctor is still seeing patients. "He's been in the community of South Dallas for 24 years," Rolfe said. "He's going to continue to practice as long as he possibly can."

If Sanity Is Forced on a Defendant, Who Is on Trial?
Daphne Eviatar, New York Times- 6/22/2003

Charles Thomas Sell has a long history of mental illness. He has told doctors that his gold fillings were contaminated by Communists, and he once called the police to report that a leopard was boarding a bus outside his office. When he appeared at a bail hearing after his indictment for Medicaid fraud five years ago, he screamed, cursed and spat in the judge's face when she tried to tell him his rights. After a diagnosis of "delusional disorder, persecutory type," Dr. Sell was deemed incompetent to stand trial in April 1999 and was imprisoned in a psychiatric institution.
    But could the government make him take antipsychotic medication so he could be tried? On Monday the Supreme Court said it was possible, but only in special circumstances. After setting out a list of relevant factors, including the probable effects of the drugs and the importance of trying the case, the court sent it back to the trial court to apply the standards.
    While the court's ruling settled some legal issues, it did little to resolve the larger philosophical questions in the case: how does one define free thought and individual identity in an age when technology has provided the tools to radically alter them? What is the dividing line between the mind and body? What is the nature of personal autonomy?
    To many, the idea of forcing someone like Dr. Sell -- who has been deemed neither dangerous nor incompetent to determine his own medical treatment -- to take mind-altering drugs solely for a government proceeding raises the specter of Orwellian "thought police" or a Brave New World of drug-induced complacency. "Over himself, over his own body and mind, the individual is sovereign," John Stuart Mill wrote in his celebrated 1889 essay, "On Liberty."
    In their brief to the Supreme Court, Dr. Sell's lawyers argued, "The right to be free from unwanted physical and mental intrusions has long been recognized as an integral part of an individual's constitutional freedom." Ethan Nadelmann, the executive director of the Drug Policy Alliance, which submitted a brief in the Sell case, agreed. "If you think about the most fundamental freedoms in this country," it said, "those freedoms are ultimately meaningless unless we assume some underlying freedom of consciousness."
    But defining freedom of consciousness for someone who is mentally ill is tricky. Do psychotropic drugs distort the individual's personality, the existential self? Or do they do the opposite, as the government argued, and, restore a delusional mind to its pristine state? Not even mental health experts agree on this. The American Psychiatric Association, which supported the government, argued that mental illness is a physical disease that should be treated like any other. "The brain is an organ just like the liver is an organ and the heart is an organ," said Dr. Renee Leslie Binder, a psychiatrist who advised the association on its court brief. "If someone has an infection, you don't tell them to breathe deeply. You give them antibiotics to fight the infection. When someone has a brain disease, the main form of treatment is medication." The American Psychological Association, though, emphasized the importance of seeking alternatives. Its brief supporting Dr. Sell said these drugs "operate on the individual's thought processes and thus implicate fundamental issues of personhood and individuality."
    The conflict has essentially come up against the age-old mind-body problem. If the mind is fundamentally different from the rest of the body, the government's and psychiatric association's purely medical view of the issue misses the point. "The American Psychiatric Association has embraced a somewhat reductionist approach to understanding human life," said Christian Perring, chairman of the philosophy department, at Dowling College, whose research focuses on the philosophy of psychiatry. "If you understand a person simply in terms of brain functions, you miss a lot. A large number of philosophers and even psychiatrists feel that loses sight of understanding a person as a whole person and in the context of a larger community."
    The notion of autonomy is also critical to philosophical discussions of the right to refuse treatment. Although the idea originally referred to political governance of states, it is now often applied to individuals and understood as "acting on one's own considered or reflective desires," explained William Ruddick, professor of philosophy and adjunct professor of psychiatry at New York University. Philosophers generally agree that "autonomy can be overridden when its exercise harms others," Mr. Ruddick said. Although Dr. Sell's crime arguably harmed others, his refusal of medication, Mr. Ruddick notes, does not. Therefore "it would be a clear violation of his autonomy to override his refusal in order to adjudicate the admittedly serious charges against him."
    That's also the view of the Center for Cognitive Liberty and Ethics, a California-based organization whose mission is to defend mental autonomy in the face of modern technology. To the center, the forcible injection of mind-altering drugs is nothing less than government mind-control. Richard Glen Boire, counsel for the center, said the government is claiming "the right to make you think a certain way or not be able to think certain thoughts." He added: "Dr. Sell's case is exactly that. He's posing no harm. They want to use one of these drugs to make him think differently." Dr. Sell's lawyers made the same point. "The content of Dr. Sell's thoughts is precisely the reason the government seeks to medicate him," Dr. Sell's lawyers wrote to the court. "The very purpose of the government's efforts is to change Dr. Sell's thought and speech so that he does not evidence persecutory delusions." Dr. Sell has said that the F.B.I. is plotting to kill him, that the Branch Davidian Compoynd at Waco, Tex., was intentionally burned by government agents, and that the F.B.I. fabricated the criminal charges against him and sent him to Alaska to silence him. "While Dr. Sell's view of the world and political beliefs may seem unusual in these respects," his lawyers wrote, "until Dr. Sell is adjudged incompetent to make medical decisions, he must be permitted to think his thoughts and speak his mind even if the government does not like what he thinks or says."
    Indeed, not only should someone be free to be mentally ill, but there may even be social benefits to such "diverse thinking," Dr. Sell's lawyers argue. As they wrote to the court, Ludwig van Beethoven, Isaac Newton and. Ernest Hemingway all suffered from mental illness. They quoted Emily Dickinson:
Much madness is divinest sense To a discerning eye;
Much sense the starkest madness. 'Tis the majority
In this, as all, prevails. Assent, and you are sane; Demur, you're straightway dangerous,
And handled with a chain."
    Yet even if the government succeeds in convincing a lower court that Dr. Sell should be brought to trial, that creates a conundrum: what if Dr. Sell was deluded when he supposedly bilked the government of Medicaid money? In other words, if Dr. Sell's mind is chemically altered for his trial, is the government trying the same person?
    "You are trying a different defendant in the sense that the medications can often have a transforming effect on personality," said M. Gregg Bloche, a psychiatrist and law professor at Georgetown University. Indeed, whether psychotropic drugs change a person's identity is vexing scholars, who debated the issue at the annual conference of the Association for the Advancement of Philosophy and Psychiatry last month in Sari Francisco.
    Dr. Lester Grinspoon, emeritus associate professor of psychiatry at Harvard Medical School and editor of the Harvard Mental Health Letter, is disturbed by the implications in this case. "It says in effect that whatever his disorder is, we can get rid of that for the moment and it's clear that this man is responsible for the crime. But even if you are treating this man's paranoid delusions, he is still a paranoid person. His behavior, to the extent it came out of that paranoia, can't be treated in retrospect. It just doesn't make sense to make somebody competent to stand trial for a crime he committed while he suffered from the disorder."
    Paradoxically, Dr. Sell is probably more likely to go free if he does consent to the drugs. He has already been locked up for more than five years while his objection to the government's forced medication plan has wound its way to the Supreme Court. That's longer than he would have served if he had been convicted of all fraud charges.

Battlefield Aid for Soldiers' Battered Psyches
Steven Lee Myers, New York Times- 6/22/2003

BAGHDAD, Iraq, -- It was only after the fighting stopped that Pvt. Christopher L. Labier began to feel the symptoms, though of what he did not know at the time. He became withdrawn. He lost his energy and his appetite. Worst of all were the images that flashed through his mind They were not nightmares, since to have nightmares you have to go to sleep. And he could not. "I'd be lying there for hours every night," he said. "I would see scenes. I would hear voices. I kept hearing one of the squad leaders tell my team leader to help him ID the bodies of his guys."
    Their bodies had been torn apart by a bomb packed inside a taxi. The explosion killed four soldiers from the First Brigade of the Army's Third Infantry Division at a checkpoint north of Najaf on March 29. Had Private Labier's platoon not been relieved a few minutes before, it might have been his body out there, rent beyond recognition.
    For anyone involved in it, war is an indelible experience. For Private Labier, it became a debilitating one. The psychological strain he continues to endure has had many names over the years. In World War I, it was shell shock. In World War II, it was combat fatigue, or, officially, psychoneurosis. But soldiers being soldiers, it was truncated to "psycho." Today, it is called combat stress reaction, and in Iraq hundreds of soldiers like Private Labier have suffered at least some of its symptoms, medical officials here said.
    They have also undergone treatment in what may be the American military's most aggressive effort ever to recognize and address combat stress while its soldiers are still in the field, before its effects deepen, especially when the war's veterans begin to return home. Each of the major combat units in Iraq included a team of mental health workers. In Private Labier's case, the First Brigade has a soft-spoken social worker, Capt. Ronald J. Whalen, who met with him and referred him to the 113th Medical Company, an Army Reserve unit from California now working out of a Baghdad hospital that had once been the private clinic of Saddam Hussein's most senior aides.
    How many soldiers here will ultimately suffer from protracted psychological problems, including, in the worst cases, symptoms of post-traumatic stress disorder, remains to be seen. The prospect certainly worries Private Labier, 24, a gunner with the First Brigade's Second Battalion, Seventh Armored Regiment. For now, though, he has returned to duty with his unit, which remains in Baghdad as a Reserve force. He credited the treatment he received for helping him cope, but he acknowledged the difficulties and the fears that he still faced, even as the mission has evolved from waging war to keeping peace. "I'm not going to lie to you," he said. "Every time you go out the gate, you get nervous, especially when people have been shooting at you for two months."
    Col. Robert S. Knapp, a psychiatrist with the 113th Medical Company, said it was not unexpected that soldiers would begin to experience combat stress now, after the worst fighting ended. The searing reactions to combat, the fear, exhaustion, grief and guilt, are often suppressed in the heat of battle, he said, surfacing only when the pace of operations slows. "They're told to suck it up and drive on," he said "Sooner or later, they have to work it out." Colonel Knapp's Reserve company arrived in Baghdad in April. In the last six weeks, it has treated more than 100 soldiers, sometimes only 1 or 2 a day, once as many as 18.
    Even though heavy combat has ended, the continued attacks on American soldiers, the difficulties of adjusting to a peacekeeping role and the heat and chaos of Baghdad continue to exact a psychological toll. Symptoms of combat stress or, in noncombat situations like today's, "operational stress," include anxiety and irritability, agitation and apathy and, in more severe cases, memory loss and psychotic episodes.
    Treatment is often as simple as giving soldiers time to rest for a few hours or days, to get a shower and some sleep, to talk about the feelings they have in the presence of a counselor. Only in rare cases -- twice, so far, in the case of 113th Medical Company -- are soldiers evacuated to undergo more serious psychological treatment.
    Colonel Knapp said he was reluctant to prescribe familiar stress and anxiety-reducing medicines like Prozac or Zoloft unless soldiers were taking them before they arrived "You can't make an accurate diagnosis of stress in a high stress environment," he said. Most often, treatment occurs within units, since most effective treatment is to get soldiers back to duty as quickly as possible.
    Captain Whalen, the social worker with the First Brigade, said he did not even consider it treatment at that level. Much of his job, he explained, was to anticipate the potential for stress before its symptoms became acute enough to require more serious counseling. Many soldiers have anxieties about patrols now. One gunner on an M2 Bradley fighting vehicle was so troubled by what he saw through his gun sight that he became afraid to look through it.
    Captain Whalen sets up meetings with soldiers who have endured some sort of crisis. The sessions, which are called "critical event debriefings," are like those given in the civilian world to police officers or firefighters after a shooting or death. On Saturday, he met with nine soldiers from the Third Battalion, 124th Infantry Regiment, a National Guard unit from Florida. The session itself was confidential, but three of the soldiers agreed to talk about it afterward.
    On June 5, their squad was sent to meet with the owner of the Al-Baraka Bank in eastern Baghdad. Two soldiers -- Specialist Willie T. Harris and Specialist Mark Ballou -- remained outside, sitting on the bank's stoop. A man walked up, drew a handgun from a black plastic bag and shot them both. The bullet that hit Specialist Ballou, the squad's medic, left him gravely wounded. Another bullet hit Specialist Harris in his protective vest. The vest stopped the bullet, but the force of the impact still gouged a hole in his flesh just below his clavicle. He carries the slug in his wallet now. Specialist Harris righted himself, dropped to one knee, raised his rifle and shot the man four times as he tried to run away. The man collapsed on the median of a bustling street, fatally wounded. It troubles him. "I'll probably never be able to get rid of that image," Specialist Harris, 30, a corrections officer in Florida when he is not on active duty. "Everything stopped. Me, Ballou and that guy were the only ones there. It was like slow motion."  Captain Whalen said it was a common response to a traumatic event: the images recurring over and over. Specialist Robert A. Pybus, who treated Specialist Ballou's wound on the scene, said it was "like a newsclip on CNN." "It just plays back in your head, uncontrollably, especially when you have down time," he said.
    Their squad has resumed patrols, though they said they did so apprehensively. Gunmen have shot at them three more times since then, though no one has been hurt in those instances. None of them have so far displayed explicit symptoms of combat stress, but they welcomed the chance to discuss it with Captain Whalen, who guided them through a factual recounting of what happened, which often helps create a foundation for coping with the stress. "We hadn't sat down as a squad. and just talked about it," said the squad leader, Sgt. Donald K Tibbets.
    Private Labier did not talk much about his feelings either, suffering instead from what he described as a private torment. His battalion was involved in some of the fiercest fighting of the war, as the Third Infantry Division swept through southern Iraq and captured the airport and the center of the city in early April. The most vivid images he recalls include the rocket-propelled grenade that landed but did not explode near his company in a village on the road into Baghdad's airport; the pinging of bullets hitting his Bradley, a sound he likened to that of a ball-peen hammer striking metal; the three Iraqis he knows he killed on the road west of the airport; the carnage of the taxi bombing.
    Talking on the eighth-floor balcony of Iraq's Interior Ministry, where his battalion now lives, Private Labier said he was having difficulty making the transition from war to peace, from fighting to patrolling Baghdad's streets. He is bitter that much of the Infantry Division has been ordered to stay on during the hot summer months, after having already fought for so long. He distrusts Iraqis. He fears the ever-present orange-andwhite taxis, since it was a similar one that exploded at the checkpoint north of Najaf. He said he feels guilt and a simmering rage when he realizes how close he came to being killed. "It could have been you," he said. "It could have been my kids at home without a dad." He began snapping at several of his fellow soldiers. "It got to the point I stayed by myself," he said. "It got to the point I didn't do anything. You might say I was depressed." He is a religious man, raised as a Roman Catholic and now a Pentecostal. His battalion's chaplain recommended that he meet Captain Whalen, and he ended up at the 113th Medical Company. He was given sleeping pills, but quit taking them "because I don't want to run from it.'. "They were my friends," he said of the four soldiers killed in the taxi bombing. "That's not what they'd want me to do."
    He sat through six counseling sessions, learning ways to manage what he felt. At the hospital, he washed his clothes and took a shower. Small things, he said, provided comfort. "You know, just putting clean clothes on my clean body," he $aid. There are things he never appreciated enough, things that no one who has not been in war can appreciate enough: a glass of water with ice, air-conditioning, clean clothes. He had his last appointment on Friday.  He learned that what he' was feeling was what experts like Captain Whalen call a normal response to an abnormal condition. "It helped knowing I wasn't the only one feeling that way," Private Labier said. "It helped to know there was a place to go." He grew up in Montgomery, Ala. He is married, with two sons, Kyle, 7, and Kaleb, 3. He relishes the prospect of seeing his wife, Danya, again. "Having your family there, being able to hold your wife, crying if you've got to cry, that'll help out," he said. He has few illusions, though, about what lies ahead: "It's just going to take time."