New Drug Promises Shift in Treatment for Heroin Addicts
Richard Perez-Pena, New York Times- 8/11/2003

Alex is still a 34-year-old recovering addict, trying to measure what he lost to heroin. He is still building a new life in Manhattan, repairing frayed relationships and an interrupted career in the entertainment industry. He is still reliant on a substitute drug to get him through the day. But three months ago, he switched substitutes, and his life changed for the better. Alex — he told his story on the condition that his full name not be used — stopped taking methadone, since the 1960's the standard treatment for people trying to quit heroin. Instead, he takes buprenorphine, a drug newly approved by federal regulators to treat addiction to heroin and other opiates, including prescription drugs.
    For many addicts, though not all, buprenorphine does what methadone does, blocking the addict's craving for a high, but experts and addicts say it has several advantages over the older drug, and the most important may be that a patient can get a supply, not merely a dose, with a visit to a doctor and pharmacy. Like methadone, buprenorphine (pronounced byoo-pre-NOR-feen) is addictive, but the risk of overdose is much lower. Unlike methadone, buprenorphine will not give an addict more than a mild high no matter how large the dose, and it cannot be combined with opiates or other narcotics to get higher still. Users suffer fewer unpleasant side effects, and milder withdrawal symptoms when they stop taking it.
    Alex said methadone, which he took for five years, allowed him to finish college and resume working, but that buprenorphine was a big improvement. "I'm more clear-headed than I've been in years," he said. "I feel better physically. For the first time in a long time, I can see myself getting off everything in a way that's not going to rip a hole in my life and leave me only partially functioning."
    The relative ease with which a supply of buprenorphine can be obtained is a radical departure from the use of methadone, which is tightly controlled by federal law and can be given only one daily dose at a time, in licensed clinics where space is limited. Experts say the advent of buprenorphine could triple the number of people in serious treatment for heroin addiction.
    "My hope and my expectation is that buprenorphine will revolutionize heroin treatment in the United States," said Dr. Herbert D. Kleber, a professor at Columbia University's College of Physicians and Surgeons and a leading authority on heroin and buprenorphine, who was deputy director of the Office of National Drug Control Policy in the first Bush administration.
Other experts see the change as more evolutionary than revolutionary, warning that much remains to be learned about buprenorphine, and that methadone, too, was once seen as a wonder drug. But they are enthusiastic, saying that since doctors began prescribing buprenorphine in October, the experience has been overwhelmingly positive. "Buprenorphine is no panacea," said Dr. Lawrence Brown Jr., president of the American Society of Addiction Medicine, and an associate professor at Weill Medical College of Cornell University. "But it is a fantastic opportunity for us. We need to encourage more physicians who are outside addiction medicine to take up this treatment."
    For many addicts, merely not having to go to a methadone clinic is an enormous advantage. "A lot of middle-class people are just not going to walk into a methadone clinic and stand in line every day," Alex said. "You're standing in line there with the same group of addicts every day, a lot of them talking about how they're going to get high. It's not a good head to be in if you're serious about quitting." He said he lived with constant worry that the methadone would jeopardize his job: the fuzzy-headed feeling it often induced might overtake him in the afternoon, his reliance on the clinic's hours might interfere with his work, a colleague might discover his routine. "With bupe, all of that's gone."
    New York City has an estimated 200,000 heroin addicts, and only 38,000 methadone program slots. Nationally, there are 800,000 to one million heroin addicts and about 180,000 methadone clinic spaces, and addicts outside major cities often live nowhere near clinics. Experts say that for every heroin addict, there are two people addicted to prescription opiates, drugs like oxycodone, hydrocodone, codeine and morphine, and that buprenorphine can be effective for them, as well. New York City's Department of Health and Mental Hygiene has embraced buprenorphine, urging doctors to learn about it and begin prescribing it. "We're looking at being able to increase the number of people in treatment to 100,000 by 2010," said Dr. Lloyd I. Sederer, executive deputy commissioner for mental hygiene.
    Last week, the department and the federal Center for Substance Abuse Treatment, part of the Department of Health and Human Services, held a forum in Manhattan to educate about 150 doctors and drug counselors about buprenorphine. Speakers included New York and New Jersey state officials, who spoke approvingly of the new treatment.
    Buprenorphine will not work for all addicts, and will not completely replace methadone. Some people simply will not respond well to it, which is true of almost any drug. Dr. Kleber said that half the people on methadone take such large doses that they could not change to buprenorphine without going through painful withdrawal. Some will be able to wean themselves to moderate doses and then switch, he said, and some will not. He said heroin users should be able to switch to buprenorphine, regardless of their doses.
    Jerry, 39, an addict living in Brooklyn, said he lowered his methadone dose by almost half, then moved to buprenorphine in June, transitions he described as "a little rocky, but not bad." Like Alex, Jerry, a building maintenance worker who insisted that his last name not be used, said he found that low doses of methadone lasted a little less than 24 hours, so he would awake every morning nauseous from the early stages of withdrawal. "On bupe, my head's good and my stomach's good," he said.
    Buprenorphine has been used as a painkiller for many years, and a few researchers, including Dr. Kleber, were permitted to make limited use of it for addiction treatment. In general, though, for decades federal law has prohibited use of any drug but methadone for heroin addiction. After a long lobbying campaign by treatment advocates, Congress loosened the law in 2000, and last October, the Food and Drug Administration ruled that doctors could prescribe buprenorphine in their offices for addiction treatment. To prescribe it, a doctor must first take an eight-hour course and register with the federal Drug Enforcement Administration. Because buprenorphine is addictive and has a potential black market, federal law prohibits a doctor from prescribing to more than 30 patients at a time. Still, even with those limits, in theory there are more than enough family doctors and psychiatrists in the country to treat all those who seek treatment.
    Since October, about 2,000 doctors nationally have been cleared to prescribe buprenorphine for drug treatment, including 218 in New York State and 62 in New Jersey, according to Dr. H. Westley Clark, director of the federal substance abuse center. People in the drug treatment field say there are no more than a few thousand people around the country taking buprenorphine.
    New York State has decided that Medicaid, the health plan for the poor, will cover buprenorphine, but most states and most private insurance plans do not. Doctors say the retail cost is $5 to $10 a day. Advocates say buprenorphine should be given as part of a wider array of support services, including counseling. Dr. Kleber said Columbia planned to open the nation's first center to help addicts make the transition from methadone to buprenorphine, and then refer them to doctors for long-term maintenance. France allowed general practitioners to prescribe buprenorphine in 1996, and has reported a sharp drop in fatal overdoses. New York City alone has about 200 heroin overdose deaths each year.
    Buprenorphine latches onto the same receptors in the brain as heroin, methadone and other opiates, but more aggressively and effectively. A person already on buprenorphine who took another opiate would feel no effect, because the second drug would be unable to push the buprenorphine out of the way and latch on. Buprenorphine stays in the system longer, so many people can take it every other day, rather than every day. Buprenorphine is also unlike the others in having a "ceiling effect;" that is, beyond a certain dosage, taking more does not make the person any higher, or depress breathing any more. That reduces the risk of both abuse and overdose. There is another advantage. "The withdrawal from bupe is much easier and faster than that from either methadone or heroin, so it's easier to get off it," Dr. Kleber said. "I think it's going to become the preferred drug not only for getting people off heroin, but for withdrawing them from drugs entirely."

Overweight Teens Are More Likely to Consider Suicide
Andrew Sterns, Reuters News Service- 8/11/2003

C H I C A G O— Overweight teenagers may have fewer friends than their normal-weight peers and suffer higher rates of depression and suicide if teased about being fat, a pair of studies said today. The prevalence of obesity among children has reached epidemic proportions in many developed nations, with an estimated 15 percent of U.S. adolescents considered obese. Diets containing too many fatty snack foods and a lack of exercise are usually blamed by researchers, though genetic factors can play a role.
    A University of Minnesota study published in a theme issue on obesity in The Archives of Pediatrics and Adolescent Medicine found a strong association between the teasing endured by overweight teenagers and rates of depression, low body satisfaction, low self-esteem and eating disorders. "Of particular concern are the alarming rates of suicidal ideation and attempts associated with weight-based teasing, which are two to three times as high among those who were teased compared with those not teased," study author Marla Eisenberg wrote.
    The recent study of nearly 5,000 teenagers in the Minneapolis area found 26 percent of teens who were teased at school and at home reported they had considering suicide and 9 percent had attempted to kill themselves. Thirty-six percent of the teased girls reported being depressed, and 19 percent of the boys.
    Eisenberg said that toning down teasing would require educating peers and family members about the impact of their derogatory comments on sensitive adolescents, while trying to help overweight children learn to better deal with it.
    Another problem for overweight teenagers is that they have fewer friends than their normal-weight peers, though they may not realize their lack of popularity, a second study in the journal said. "Overweight adolescents were more likely to be socially isolated and to be peripheral to social networks than were normal-weight adolescents," wrote Richard Strauss of the University of Medicine and Dentistry of New Jersey and Harold Pollack of the University of Michigan.
    Among the 17,500 adolescents aged 13 to 18 surveyed, those who were overweight listed similar numbers of friends as their normal-weight peers, but they were picked as friends by an average of 3.4 others compared to an average 4.8 nominations received by normal-weight peers. Fewer friends translates into reduced "social capital," the researchers said, which in turn can shape a person's "economic status, educational attainment, job seeking, mental health and general well-being."

Risks and Remedies: Gambling and Parkinson's Drug
John O'Neil, New York Times- 8/12/2003

Brain researchers have found that the thrill gamblers feel involves the release of the same chemicals whose workings go awry in patients with Parkinson's disease. Now a small study being published today reports a link between Parkinson's patients with gambling problems and their medication.
    A survey of 1,884 patients seen at the Muhammad Ali Parkinson Research Center in Phoenix turned up nine who said their gambling had caused financial hardship. All were taking high doses of medicines that block the workings of the brain chemical dopamine.
    In seven of the nine cases, the gambling began within one month of a decision to increase the level of medication, according to the study, which was published in the journal Neurology. Six of the patients stopped gambling after they were switched to a different form of drug, while another improved after the dose of the original medicine was reduced. One patient withdrew from treatment and committed suicide.
    The study's lead researcher, Dr. Mark Stacy, the center's director, noted that the availability of casino gambling in the Southwest, where many retirees live, could make the potential for drug-induced gambling something doctors should warn their patients against.

Study Looks at Loss, Its Role in Depression
Ellen Barry, Boston Globe- 8/13/2003

In their search for the roots of depression, psychiatrists have long focused on the experience of loss -- the jarring loss of a loved one, the lost haven of a relationship, or the more primal feelings of loss that can be traced back to the mother's breast. But a new study of more than 7,000 adult twins calls into question assumptions about depression that date to Sigmund Freud. The events that send people into major depression, the authors found, are not merely losses, but humiliating ones that drive at a person's self-esteem -- most typically, being abandoned by a romantic partner.
    The classic experience of pure loss -- the death of a family member -- is only about half as likely to lead to depression, according to the study, published this week in Archives of General Psychiatry. "When your father dies, it doesn't directly address who you are. You can still love yourself after your dad dies," said Dr. Kenneth Kendler, a psychiatric geneticist at Virginia Commonwealth University and the study's lead author. Blows to a person's status, like the experience of marital abandonment, "hit you at a more basic level. Boy, this is a vulnerable part of our psychological anatomy. So much of human life is built around this."
    Depression affects nearly one in 10 Americans in a given year, and scientists contend that many people inherit a biological vulnerability to the disorder. But relatively few studies have examined the triggering events that can mark the beginning of a long slide into major depression.
    Kendler followed 7,322 adult twins -- whose genetic similarities made the environmental differences stand out -- and noted the major difficulties they faced, such as the loss of a loved one, major financial trouble, serious illness or injury, job loss, legal problems, or divorce. When he divided the events into categories, his conclusion called into question time-honored psychiatric theories: While the experience of loss put a twin at a higher risk for depression -- about 10 times the risk of one who had not experienced loss -- being humiliated was about as important. The two experiences together were by far the most dangerous kind, increasing the risk of major depression by a factor of 20. In one out of five cases, these individuals showed signs of major depression within a month. A good example of such an experience, he said, is if a lover "leaves you, but he doesn't move out of the neighborhood and parades his new girlfriend, who may be more attractive than you, up and down the street."
    Kendler suggests that depression has evolutionary roots: It is a survival mechanism for an individual whose status has dropped dramatically. Depression suppresses a person's desire for food, companionship, or other basic needs -- an accommodation that makes sense for someone with a low social status. "You are less demanding of your environment when you are in a low-status position," Kendler said. "You become nonthreatening, more pathetic, so that instead of incurring greater hostility," others will care for you.
    In 1917, Freud began searching for the seeds of depression in a landmark essay, "Mourning and Melancholia," which distinguished between normal grieving at the loss of a loved one and a sustained sickness in which anger at the loved one is redirected toward the self. Thirty years later, John Bowlby observed the pain of children separated from their mothers and developed his "attachment theory," which held that the loss of the affectionate infant-mother relationship is the root cause of most adult mental illness.
    Today, researchers have been closing in on the mysterious interactions between the neurobiology of the brain and the powerful human experiences that can throw it out of balance. In a study published last month in the journal Science, researchers Terrie Moffitt and Avshalom Caspi identified a gene that, depending on its shape, can make people especially vulnerable to depression when a traumatic event occurs -- or especially resilient.
    Kendler said his study's main contribution is the idea that humiliation, not pure loss, is a triggering event. The need to maintain one's self-respect may be more central to the personality than widely believed. "We are built to be status-protecting organisms," he said. With a better understanding of genetic predisposition and environmental triggers, doctors hope to apply preventive medicine to mental illness. "We puzzle about these things: What does it mean to have bad things happen to you? . . . You have some kind of risk determined by your genes, and then you ask yourself what it is in the environment," said Dr. Bruce Cohen, who is president and psychiatrist in chief at McLean Hospital in Belmont.

Movies Make Patients' Day, Some Therapists Find
Dan Nephin, Associated Press- 8/17/2003

ERIE, Pa. — When psychiatrist Fuat Ulus meets with patients, there's a chance that Clint Eastwood will be there too. Not as a patient, but as a therapist of sorts. Ulus has used Eastwood's Dirty Harry character to help patients address chronic anxiety. After all, there probably aren't many more anxious situations than when Inspector Harry Callahan is confronted with a thug holding a gun to a human shield and threatening to shoot. Ulus doesn't advise patients to deal with their anxiety by brandishing a .44-caliber Magnum and declaring, "Go ahead, make my day." But watching the scene can spark discussion on coping with anxiety. He has also used "The Deer Hunter" to help Vietnam veterans open up about post-traumatic stress disorder.
    Ulus is among a handful of therapists who find movies or clips from movies helpful in treating patients. "Patients are more receptive to discussing issues that are somewhat removed from them, played out by characters on a screen, rather than directly confronting those issues from their own lives," Ulus said. He recently wrote "Movie Therapy, Moving Therapy!", a guide for therapists interested in using movies, and is developing a weekly movie therapy program that would be open to the public.
    "Therapists have used movies for a long time, but in an informal way," said Birgit Wolz, an Oakland therapist who's been using movies in group therapy sessions for nearly a decade. In movie therapy, therapists won't simply advise depressed patients to rent, say, "It's a Wonderful Life." "A good comedy is always nice when I don't feel good, but it's not going to have much therapeutic value," Ulus said.
    The assumption that movies can be prescribed to treat a problem can backfire, Wolz said. "If you're renting a happy movie when you're sad, it can have the opposite effect" and make a sad person more depressed, she said. Instead, therapists might use a movie or segment that illustrates a situation that a patient is experiencing — whether the patient realizes it or not. The patient might find it easier to confront his own issue after seeing how someone in a movie handles a similar situation. "The movies really go to the deeper layers of the consciousness," Wolz said. "The movies are a catalyst for the experiences people go through."
John W. Hesley, a Dallas-Fort Worth area therapist who along with his wife, Jan G. Hesley, wrote the 1998 book, "Rent Two Films and Let's Talk in the Morning: Using Popular Movies in Psychotherapy," has a theory on why a problem that seems overwhelming might be less burdensome after movie therapy. "You can talk about it sometimes easier if it's happening to someone else," he said.
    Ulus and Wolz say movie therapy is gaining in popularity, but no one has concrete numbers on its use. A couple dozen people participate in Ulus' Internet movie therapy mailing list.  Pam Willenz, spokeswoman with the American Psychological Assn., said the association doesn't take positions on treatment types, but recognizes film's use in therapy. The organization also doesn't track practitioners.
    Therapists stress that movie therapy isn't a treatment in itself. Rather, they say, it's a tool that can be used with other treatments in individual and group settings. Movies "are metaphors that have emotional truths for people," said Bernie Wooder, a London psychotherapist who's used movies for about seven years.
The melding of movies and therapy was natural for Ulus, 60, a self-described movie buff who estimates that he's seen thousands of films. He immigrated to America in 1971 from Turkey, where he said his mother would take him to see several movies a week when he was growing up in the 1950s and 1960s, and they helped him learn American culture. Now, in a given month, he might see 50 or 60 movies, some theater releases and other movies that he's already seen, but from which he hopes to glean a lesson.
    Although movie therapy may not be widely known, its roots can be traced to bibliotherapy, which uses books in much the same way and was developed in the early part of the 1900s. "I think movie therapy is a little more colorful and fascinating than bibliotherapy," Ulus said. There's another benefit too. "It's a whole lot easier to have a patient watch a movie than to read a book," John Hesley said.

Smoking Issue a Quandary for Psychiatric Facilities
Catherine Saillant, Los Angeles Times- 8/18/2003

Long after cigarettes have been snuffed out in other public facilities, administrators in California's psychiatric hospitals are still debating how to keep work sites smoke-free when many of the people they care for are heavy smokers. Their quandary is complicated by emerging evidence that smoking may help calm patients with major mental disorders such as schizophrenia.
    In schizophrenics, nicotine appears to reduce anxiety and the adverse effects of antipsychotic medication while increasing concentration, studies report. But for doctors, tolerance of smoking is clearly a double-edged sword. Although offering temporary relief, the habit may end up killing patients. Hospital administrators, meanwhile, must respond to employee demands for a workplace free of secondhand smoke. California banned smoking in nearly all businesses and public places beginning in 1995.
    Many psychiatric hospitals have struck a compromise, allowing patients to smoke on outdoor patios during supervised breaks. A few have created well-ventilated smoking rooms that are closely monitored by staff. But a growing number are considering, or have already imposed, outright bans on lighting up. That has brought protests from advocates for the mentally ill, who say such a measure is too harsh for critically ill patients. "When people are agitated and disoriented and they go the hospital, that is no time to take away their smoking privileges," said Karyn Bates, an advocate and former patient from Ventura.
    The latest battleground is in Ventura County, where administrators at the county hospital were considering a complete ban — even in the outdoor courtyard where psychiatric patients now gather hourly for a cigarette break. Los Angeles County's mental health department tried a smoking ban, but dropped it after patient advocates filed a discrimination lawsuit. St. Helena Psychiatric Hospital in Napa County also imposed a ban, but changed direction after four years.
    Julia Graham, supervisor of the inpatient unit at Napa, said staff members pushed for a resumption of smoking privileges after seeing the effect the ban had on patients. Many are admitted involuntarily and cannot leave for at least three days, she said. Denied cigarettes, some attempted to go AWOL and others became combative, she said. The biggest problem, though, was that patients were so irritated by the ban that they could think of little else, she said. That was true even when they were offered patches to relieve nicotine withdrawal, she said. "If all they can talk about is that they want a cigarette and why can't they have a cigarette, they are not focusing on the problems that brought them into the hospital," Graham said. "It was a hard decision, because smoking is harmful to your health. We all recognize that. We just felt this crisis time was the wrong time to intervene."
    But bans have apparently worked in other locations. Humboldt County imposed a no-smoking rule several years ago with few problems, said Dr. Michael Ferguson, former director of that county's mental health division. "There were some patients glad to leave so they could resume their addictive behavior," Ferguson said. "But it did not raise significant complaints. Once it was clear that's the way it is, it was a relatively minor issue."
    In Ventura County, officials agreed to back off from a ban for now, after mental health advocates protested. Next month, though, Ventura County Medical Center will begin offering a voluntary smoking-cessation program for psychiatric patients. Patients will be offered counseling and nicotine patches when admitted, said operations manager Curtis Ohashi. They can also take stress-reduction classes to find ways other than grabbing a cigarette to deal with anxiety. Ohashi and others know they face an uphill battle. Studies estimate that nearly half of those with mental illness are smokers. Doctors have long noticed that schizophrenics, in particular, are attracted to smoking. Nearly 90% of them take up the habit, studies report.
    Now there is some evidence that smoking could be a form of self-medication. A study conducted at Thomas Jefferson University in Philadelphia found that schizophrenics who smoke could pay attention and control impulses better than those who did not. Other studies have come to similar conclusions, although scientists caution that more research is needed. Some attention is being paid to the issue at medical schools around the nation.
    On a recent day at Ventura's hospital, two dozen patients headed to an outdoor courtyard as soon as the break was announced over a PA system. There, surrounded by 22-foot-high block walls, they stood single file in lines to be handed a cigarette by a staff member. "Lighter's over here!" shouted another staff member, holding the flame as patients then lined up to get their smokes lighted. One man paced the courtyard, ignoring everyone as he took deep drags. Others sat on a shaded picnic table and chatted.
    Longtime mental health practitioners say the tight control over tobacco today contrasts sharply with the psych wards of even two decades ago. Back then, patients chain-smoked in large dayrooms, said Hedda Markham, a psychologist who worked at Camarillo State Hospital before it closed. Camarillo even had a cigarette lighter built into the wall, she said. Dr. Ronald Shaner, medical director of the Los Angeles County Department of Mental Health, recalls that smoking was perfectly acceptable in the 1970s and early '80s. "There was a time when cigarette companies gave free cartons of cigarettes to hospital wards," Shaner said. "It was just compliments of the company. We have, for obvious reasons, come a long way."

A Scientist's Lifetime of Study Into the Mysteries of Addiction
Mary Duenwald, New York Times- 8/19/2003

BETHESDA, Md. — The road from Dr. Nora Volkow's childhood home in Mexico to the director's office at the National Institute on Drug Abuse here was surprisingly short and straight. From the time she entered medical school, at 18, Dr. Volkow devoted herself to the study of addiction. A research psychiatrist known for her brain-imaging studies, she has published hundreds of papers, including many that demonstrate how dopamine, a brain chemical linked to pleasure and motivation, plays a major role in addictions of all kinds: to drugs, to alcohol and even, some say, to food. Two oversize computer screens, perfect for viewing PET scan images, stand on the desk in her office; even with her new leadership role, she intends to continue her own research.
    Dr. Volkow (pronounced VOHL-kahf), 47, grew up in Mexico City, the daughter of a fashion designer and a pharmaceutical chemist. Her father, the chemist, had come to Mexico as a boy with his grandfather Leon Trotsky, the Bolshevik leader expelled from the Soviet Union by Stalin. She never met her famous great-grandfather, but she was raised in the house where he lived and died, assassinated in 1940 by a Stalinist agent. On weekends as a teenager, Nora Volkow and her three sisters led visitors on tours of the house, which is now a museum. Now, as the first woman to lead the drug abuse agency, Dr. Volkow will direct the spending of government money on drug addiction research. On a rainy morning in June, she discussed her new challenge.
Q. What got you interested in drug abuse?
A. It always fascinated me, the ability of a drug to take over the process of what we call free will. I don't know of any other situation where an individual will give up their family, their profession, their money because of an addiction they cannot control. I wanted to know what drugs do to the brain.
Q. How can a drug change a person's motivation?
A. People say that addicts take drugs because the drug is pleasurable. And that is where the whole stigmatization of the drug-addicted person as being morally weak comes across. I don't like the whole concept of pleasure because it gets oversimplified. It's motivation and drive. Drug addiction actually becomes a need. There's tremendous variability in predisposition for addiction. We know that genetics are a key element. Why? Because you can genetically engineer animals that will not become addicted no matter how much of a drug you give them. We also know that environment can be protective or can favor vulnerabilities.
Q. How does drug abuse affect free will?
A. People say the addict loses control. But that is not complete. A drug-addicted person is motivated by the procurement of a drug. They may care for their family very much. It's just that the motivation to procure the drug becomes much more powerful than the motivation to be responsive to their family.
Q. What kind of environment is likely to protect people from addiction?
A. Parenting plays a key role. If you take nonhuman primates and rear them with peers they are much more likely to abuse alcohol than those that were reared by parents. Having parents creates in them a sense of self-security. Whereas those that are reared by peers become very timid. And then they are much more likely to engage in aggressive acts and taking drugs. Parenting has very subtle effects that you couldn't have predicted.
Q. Do you consider drug addiction to be, in part, a biological problem?
A. People say if you consider drug addiction a disease, you are taking the responsibility away from the drug addict. But that's wrong. If we say a person has heart disease, are we eliminating their responsibility? No. We're having them exercise. We want them to eat less, stop smoking. The fact that we have a disease recognizes that there are changes, in this case, in the brain. Drug addiction also has an impact on a wide variety of illnesses. Smoking and alcohol are linked with a higher incidence and prevalence of certain cancers. Marijuana too. The co-morbidity of depression and smoking is close to 90 percent. Do you know what percentage of schizophrenic patients take cigarettes or take drugs? Eighty-five. Look at heart disease, the No. 1 killer. What is one of the highest risk factors? Smoking.
Q. Drug abuse usually begins in adolescence. Do adolescents have a kind of predisposition to drug addiction?
A. We don't know. Our studies have been very much targeted in adults. We know certainly that the brain dopamine system changes dramatically during childhood and adolescence. But what is unique about the brain of adolescents that makes them particularly vulnerable to drugs? People have said, Well, maybe it's just a stage in their lives where they want to try everything. But why would they want to try everything? Obviously, it reflects something in the way that the brain is working.
Q. Is there any priority among the various drugs of abuse that need special attention?
A. If you look at it in sheer numbers, of course, cigarette smoking is an overwhelming priority. Cigarette smoking may also facilitate consumption of other drugs. Still nicotine is not like other drugs. For example, when animals have free availability of cocaine, the animals stop eating, they stop sleeping, and 100 percent of them die. If they have free availability of nicotine or, for the same matter, heroin, the animals survive.
Q. Is marijuana as dangerous as other drugs?
A. There's data that shows it's damaging to learning and memory, but then there's data that shows it's not. I've used imaging, and clearly we have shown that marijuana abusers have changes in certain areas of the brain involved with memory and motor coordination. So the idea that it is a benign drug, I don't think that it is so straightforward. We all know marijuana users that are so apathetic. But nobody has done the studies to document the amotivational syndrome. If people are smoking marijuana, they should know what marijuana is doing to their brain. We need to do the work.
Q. How do you try to prevent drug abuse?
A. Providing access to knowledge definitely helps. A lot of people, and certainly adolescents, do not realize the consequences of being addicted to other things. People who are addicted are at the higher risk for suicide. They are at the higher risk for depressive disorders. Many of these drugs are toxic. Take methamphetamine. When we look at the brains of young methamphetamine abusers, they look like the brains of people 40 to 50 years older. So what drugs are inducing in your brain is aging. Do you want to be a 20-year-old with the brain of a 70-year-old? I think that message is very, very powerful.
Q. As the great-granddaughter of Leon Trotsky, did you grow up in a political household?
A. No. My father was so traumatized by what had happened to his family, he wanted to protect us from anything political. When I left Mexico to go to Paris — I did one year in Paris as a medical student — I was exposed to it because there's a lot of Trotsky's group in France. It was a very interesting experience. But I've never become politically involved. If you want to be a scientist, you cannot allow politics to get in the way of your objectivity.

Study: Fish Oil Helps Treat Depression
John McKenzie, ABC News- 8/19/2003

For years, researchers have been searching the seas, collecting rare sponges, coral and algae in the hope that the chemicals they contain might become potent medications. Now some researchers say they've found an effective antidepressant below the waves: Fish, or more specifically, fish oil containing so-called omega-3 fatty acids. "We've been very impressed by the response rates we've observed," said Dr. David Mischoulon, a psychiatrist at Massachusetts General Hospital who has overseen an omega-3 clinical trial. "We believe there is definitely something to these treatments."
    Scientists first became interested when they noticed that countries with the highest fish consumption had the lowest rates of depression. They also observed that mothers in England who ate very little fish during pregnancy doubled their risk of developing postpartum depression compared to women who ate fish regularly. So scientists began a series of studies to see why.

Omega-3 Fatty Acids Found to Have Same Effect
Researchers found that omega-3 fatty acids, when fed to piglets, had the same effect on the brain as the antidepressant Prozac: They raised levels of a critical neurotransmitter, serotonin. "After only 18 days, those animals that were fed the enriched formula had double the level of serotonin in their frontal cortex, in the part of the brain that regulates depression and impulsivity," said Dr. Joseph Hibbeln, a senior clinical investigator at the National Institutes of Health.
    Omega-3 fatty acids are polyunsaturated oils that cannot be made by the body and are derived primarily from seafood. The fatty acid with most direct influence on brain development and function is DHA. "The DHA is highly concentrated in the brain," Hibbeln told ABCNEWS, "and it's concentrated in the brain right where the neurons communicate with each other and all the signals pass back and forth." The DHA from omega-3 makes up the walls of neurons, Hibbeln said. "The body cannot manufacture DHA so it has to get it from our diet."
    At Sheffield University in England, Dr. Malcolm Peet gave omega-3 fatty acids to 70 depressed patients who had not been helped by drugs such as Prozac. After 12 weeks, 69 percent of the patients showed marked improvement compared with 25 percent given placebos.

Trial Participant Accounts Significant Improvement
Jim LaBonte of Boston took part in another omega-3 study. LaBonte, who was diagnosed with depression four years ago, had tried Prozac but didn't like the way it made him feel. He complained the drug left him with no emotions, and so he stopped taking it. Then he enrolled in a clinical trial at Massachusetts General Hospital. "I leaned more toward the skeptical. I wanted to say, 'show me,' " LaBonte told ABCNEWS. LaBonte took the omega-3 fatty acid DHA each day. Within three weeks, he said, he noticed a significant improvement. He has now been taking DHA for eight months. "I'm fine today. Not only do I not feel as blue, but when depressed feelings do come I am able to handle it," he said. "We're confident that the results he had were positive," said Mischoulon. "We've also observed similar responses in other people. So it's pretty clear in our minds that these treatments work."
    Preliminary studies suggest 1 gram a day of omega-3 fatty acids can be an effective treatment, whether in the form of a nutritional supplement available at most health-food stores or simply by eating fish — especially salmon, sardines or tuna — several times a week. Researchers say much larger studies are now needed to follow up on the initial success of omega-3 trials, not only against depression but also in treating schizophrenia, bipolar disorder, and violent behavior.

Mental Patients Turning to ERs
Katherine Lutz, Boston Globe- 8/20/2003

Boston emergency rooms are grappling with soaring numbers of mental patients this year as cuts in insurance for the poor, coupled with slashed services at community clinics, leave patients with few options but to show up at the nearest hospital. Massachusetts General Hospital's emergency room saw a 49 percent jump in psychiatric patients from April of last year to April of this year, an increase that has held steady over the summer, and the ER at Boston Medical Center is struggling to accommodate 20 percent more psychiatric patients than it saw last year. "Instead of being with people who know how to talk to someone who is psychotic, the patient is on a cot in an emergency room, possibly restrained," said Dr. Mary Anne Badaracco, chief of psychiatry at Beth Israel Deaconess Medical Center.
    In April, 36,000 people in Massachusetts lost their insurance after cutbacks in MassHealth, the state's insurance program for the poor. According to the Massachusetts Department of Mental Health and community care providers, between 14,000 and 15,000 of those people use psychiatric care. Those patients are squeezed from both sides: At the same time they lost their insurance, the community health centers where they traditionally received their mental care lost their state funding and are now struggling themselves, often turning away patients or placing them on long waiting lists.
    Dimock Community Health Center in Roxbury, for instance, turns away about 30 to 40 patients a day seeking care, and no longer gets reimbursed from DMH to see uninsured psychiatric patients in their outpatient clinic. "The question is what is happening to these clients," said Dr. Bruce Bird, former chief executive of North Suffolk Mental Health Association, which now turns away dozens of patients every month because of budget cuts.
    Gail Lesley, a psychiatric nurse hired by Mass. General to handle uninsured patients flooding its emergency room, says she sees patients wait months for an appointment with a therapist. In the meantime, if a crisis strikes, they often have no choice but to show up at a hospital. "Sometimes clients are discharged from jail with a three-day supply of medication," said Lesley.
    Compounding the problem for hospitals, as many as 75 percent of these psychiatric patients also abuse alcohol or drugs and are often intoxicated when they come to the ER, making their underlying mental illness nearly impossible to treat. `People have to go through detox in the emergency room," said Dr. Lawrence Park, director of acute psychiatry service for Mass. General. "Alcohol withdrawal is a potentially life-threatening condition. If we can't find a place for them, we have to treat it," he said. The number of detox beds in the state dropped dramatically over the past year, from 997 to 420, and the state cut sharply back on money available to fund substance-abuse programs.
    Today, because of a drop in state reimbursement, Dimock can afford to fill just seven beds. In the emergency room, intoxicated patients can wait for days for a space to open up in a proper treatment facility. In the meantime, emergency rooms stretch their resources, often assigning nurses to monitor the patient around the clock. "It takes away services and staff from other people," said Park, whose staff recently treated a psychiatric patient in the ER for five days while trying to find a detox facility, psychiatrists, and rehabilitation for the patient.
    The Legislature pledged to partly restore the MassHealth cuts in October, but getting uninsured patients back into the mental health system can be difficult. "You go for five or six months without coverage and it's not a question of flipping the switch and all 36,000 people will come back on," said Michael Norton, director of behavioral health programs for the state Division of Medical Assistance, which administers Medicaid. "Right now we're already beginning to engage folks around strategies.' But Dr. Peter Evers, chief of behavioral health at Dimock, is skeptical. "Most of these people are homeless, and it's not just a question of picking up the phone and saying, `Good news. You're back on,' " he said. "The really sad thing is that it takes an awful lot for someone who has this disease to pick up the phone and ask for help."

Massachusetts Putting 100 Mental Patients on Street
Ellen Barry, Boston Globe- 8/20/2003

The Department of Mental Health today will order cuts in residential services to homeless people with mental illnesses like schizophrenia and bipolar disorder, cuts that providers warn could affect between 80 and 100 of the state's most severely mentally ill citizens and possibly force them back onto the street. The decision will cut $1.5 million in state money and $3.5 million in federal matching funds from a special account set up a decade ago to provide housing for the mentally ill, said Dr. Elizabeth Childs, the DMH commissioner. Between 80 and 100 DMH clients, often delusional people taking numerous psychiatric medications, could lose their housing, she said. "These are people that really can't survive out in the community," she said. "If they aren't housed . . . treatment is not realistic. They're very ill folks. We don't have any alternatives."
    Although the $22 million program was fully funded in Governor Mitt Romney's proposed budget, it was cut to $20.7 million in the Legislature's final budget in July. Childs said that she had found no way to avoid ordering the cuts, but that she hopes funding can be restored in supplemental budgets. "Obviously we are hoping the Legislature understands how serious this is," she said.
    The fund provides housing to 2,400 citizens, many of whom have spent years on the street. Lyndia Downie, executive director of Pine Street Inn, described the five-year process of bringing indoors one schizophrenic woman in her mid-50s: For months, outreach workers would leave soup in the Leather District alley where she crouched, so delusional and paranoid that she would throw cups of hot coffee in pedestrians' faces. It took three years before she would speak to the outreach workers. Now she is living in a Pine Street group home, taking medication for her illness. If the cut goes through, Downie said, one of Pine Street Inn's six group homes would probably be closed, forcing staff to release 10 such people. "Our beds are full," she said. "We may only be able to offer them a space on the floor."
    Other providers said the clients housed through the program would be vulnerable or possibly dangerous on the street. Nancy Mahan, director of residential programs for Bay Cove Human Services, which would probably eliminate between 12 and 24 beds for mentally ill clients, said, "I tried to send a person with schizophrenia to the lab to get blood drawn. He went twice to the lab, and he came back each time saying he couldn't do it. He said: `It's pretty hush-hush over there. You don't know if they're going to poison you.' " Massachusetts lawmakers took the unusual step of establishing the fund in the early 1990s, as Americans were focusing on the problem of homelessness and the fallout of emptying state psychiatric hospitals.
    Increasingly, psychiatrists are coming to understand the profound effect that housing can have on a mentally ill person, said Childs, the former chief of psychiatry at Caritas Carney Hospital. Recent studies suggest that simply providing housing can improve a patient's outcomes without any change in medical treatment, she said. "It's a roof over their heads," she said.

Three Schizophrenia Drugs May Raise Diabetes Risk, Study Says
Erica Goode, New York Times- 8/25/2003

Three drugs commonly prescribed for schizophrenia and other psychotic illnesses increased patients' risk of developing diabetes when compared with older antipsychotic medications, researchers said yesterday, presenting the results from a long-awaited study of patients treated at veterans hospitals and clinics across the country. The drugs — Zyprexa, made by Eli Lilly, Risperdal, made by Jannsen Pharmaceutica, and Seroquel, made by AstraZeneca — were associated with higher rates of diabetes than older generation drugs for schizophrenia like Haldol, the study found. But the increased risk was statistically significant only for Zyprexa and Risperdal, the researchers said, possibly because of the smaller number of subjects who took Seroquel.
    Younger patients, under age 54, who took Zyprexa or Risperdal showed the highest risk of developing diabetes, the study, led by Francesca Cunningham of the Department of Veterans Affairs at the University of Illinois at Chicago, found. The results add to a growing number of reports linking Type 2 diabetes to some drugs in the class of antipsychotics known as atypicals. "These findings are absolutely consistent with everything we've looked at and seen," said Robert Rosenheck, a professor of psychiatry and public health at Yale and an author of an earlier study that found an increased risk of diabetes with Zyprexa, Risperdal, Seroquel and Clozaril, made by Novartis.
    Experts said the new findings underscored the need for patients who take the drugs and doctors who prescribe them to be alert for the symptoms of diabetes, including increased thirst, frequent urination, increased appetite and rapid weight gain. Atypical antipsychotics, studies indicate, are less likely than older drugs to produce side effects like tardive dyskinesia, a devastating movement disorder. The newer drugs also appear more effective in preventing relapse in patients with schizophrenia and may be more effective in treating certain aspects of the illness. More than 15 million prescriptions were written last year for Zyprexa and Risperdal, the two leading atypical antipsychotics, according to industry figures.
    Researchers in the last two years have found higher rates of diabetes and hyperglycemia, medical conditions that are usually reversible, among patients taking the newer drugs. But many of the studies have been based on case reports in medical journals or filed voluntarily by doctors with the Food and Drug Administration, making it difficult to determine the size of the problem or whether it is associated with particular drugs or with the class of drugs as a whole.
    The new study, scientists said, is important because of its careful methodology and substantial size: the researchers based their analyses on medical records from 19,878 veterans treated with an older or newer drug between October 1998 and October 2001. Of 5,981 veterans who took Zyprexa, 200, or 3.34 percent, developed diabetes, compared with 170, or 2.43 percent, of 7,009 veterans taking Haldol or another older medication. Of 5901 patients taking Risperdal, 193, or 3.27 percent, developed diabetes; 21, or 2.39 percent, of 877 veterans taking Seroquel developed the illness. All three drugs raised a patient's chances of developing the illness by about 50 percent, but the meaning of the increased risk among patients taking Seroquel was unclear because of the smaller number of subjects who took the drug, the researchers said. "We need a larger number of observations to be certain what its risk is and whether it differs from other drugs," said Bruce Lambert, an associate professor of pharmacy administration at the University of Illinois at Chicago and an author of the study.
    The study was financed in part by Bristol Myers Squibb , the maker of Abilify, an atypical that had not entered the market when the study began and has not been systematically studied for a link to diabetes. The study's findings have not been submitted for publication and have not undergone systematic peer review by other researchers. Its findings are also limited by the fact that the patients were not randomly assigned to different drugs and that the researchers did not know the patients' family history of diabetes or what other risk factors, including excess weight, they might have had.
    Laura Bradbard, a spokeswoman for the F.D.A., which has been tracking the diabetes issue, said the agency was reviewing the findings, which were presented yesterday in Philadelphia at a meeting of the International Society for Pharmacoepidemiology, along with other studies. The agency is considering whether to add or strengthen warnings in the labeling of certain drugs or on the class of drugs as a whole.
    How atypical antipsychotics might produce or uncover diabetes is unknown. Weight gain, a side effect of some drugs, may play a significant role, researchers believe. But P. Murali Doraiswamy, chief of the division of biological psychiatry at Duke University, said that in some cases the illness has come on rapidly, before patients have time to gain weight. Dr. Doraiswamy and other researchers said the only way scientists would be able to tell for certain how large the problem is and whether the risk is higher with some drugs would be to do a large study that randomly assigned patients to different drugs in advance and then followed them over time, a project that would require that the drug companies pool their resources or that the government finance the project.

Anorexia in Blacks Gets New Scrutiny
Shannah Tharp-Taylor, Chicago Tribune- 8/25/2003

In many ways, Stephanie Doswell is your regular college student in a T-shirt and flare-legged jeans. But she is also anorexic, bulimic and African-American, a combination so rare that it sometimes goes unrecognized. "If someone sees a sickly, thin white person, they automatically think that they have anorexia," said Doswell, 19. "If someone sees a sickly, thin black person, they don't think that they have anorexia." She adds sarcastically: "Because blacks don't get anorexia."
While their numbers are probably small, black anorexics face a host of unique problems, including inadequate diagnoses from doctors not expecting to find eating disorders in African-Americans. Anorexia has been thought of as a disease affecting rich, white females since the 1940s because it primarily affects girls from well-to-do Caucasian families.
    Recent studies seem to confirm that black anorexics are extremely hard to find. Last month Ruth Striegel-Moore of Wesleyan University in Connecticut reported in the American Journal of Psychiatry that although anorexia is believed to affect 1 percent to 2 percent of the general population, none of the 1,061 young black women in their study was anorexic. But many experts doubt that black anorexics are as rare as studies have suggested, though experts are left guessing at how prevalent the disease is in minorities.
    Traditionally, African-American girls have been thought to have some protection from eating disorders such as anorexia nervosa and bulimia nervosa because of a greater acceptance of larger body size in the African-American community, said Gayle Brooks, an African-American psychologist specializing in eating disorders at the Renfrew Center in Florida. But this alleged protection from eating disorders appears to weaken as blacks take on the values of the mainstream culture, Brooks says. "I think that there are a lot of African-American women who are really struggling with their sense of personal identity and self esteem that comes with being a part of this culture that does not accept who we really are," Brooks said.
    For years anorexia (characterized by refusal to eat enough) and bulimia (characterized by binge eating and purging) was only studied in white females, leaving gaps in medical knowledge about eating disorders and how they affect minorities. For example experts are not sure whether black girls from high-income families are more likely than their poorer counterparts to develop eating disorders, as is believed to be the case for white girls. Striegel-Moore acknowledges that her study may have underestimated the number of blacks with anorexia nervosa because she had too few girls from affluent black families. Similarly, psychologists typically search for anorexia in adolescents, the age group commonly found to have the disorder in white girls. However, experts question whether anorexia may develop later in African-Americans.
    Thomas Joiner, a professor of psychology at Florida State University, tested whether racial stereotypes influence the recognition of eating disorders. He asked 150 people to read a fictional diary of a 16-year-old girl named Mary and rated whether they thought the girl had an eating disorder. For some the diary was labeled "Mary, 16-year-old Caucasian." For others it was labeled "Mary, 16-year-old African-American." More people said the subject had an eating disorder when she was labeled white than when she was labeled black. "Race mattered," Joiner said. "There's the idea in people's minds that African-American girls tend not to get eating disorders. And that influenced their judgments."
    Joiner and his colleagues also found that many health care professionals were unable to recognize black anorexics. One 17-year-old African-American girl from Washington, D.C., said her doctors did not diagnose her properly, even though she has been purging since age 10 and at 5 foot 7 has weighed as little as 95 pounds. "The doctors just thought I had a stomach thing. ... They gave me antibiotics and rehydrated me and sent me home," said the girl, who replied to an e-mail request from the Tribune asking African-American anorexics to share their stories.
    Many researchers and clinicians studying anorexia nervosa say that becoming anorexic is more a consideration of one's social group. Girls from poor families face an additional risk because they are not likely to be able to afford treatment, which can cost as much as $30,000 for a month of in-patient care.
Doswell typifies some of the issues surrounding anorexia in black women. Her condition was verified through her therapist, Keitha Austin of Newport News, Va., who received written permission to confirm that Doswell is an African-American female with anorexia. She starts each day with eight melon-flavored gummy rings. "I don't want a booty like J. Lo," Doswell said. "I don't want to look like Beyonce because she is fat."
    At 5 feet 4 inches tall--about average--Doswell weighs 93 pounds, less than 97 percent of women her age. She wears a size 3, she says, because she likes her clothes baggy. Doswell said she envied her white, Hispanic and Asian friends, who were thin and preoccupied with weight.
Her roller coaster with eating disorders began in anticipation of an exchange program trip to Japan. "I didn't want to be fat on the trip," Doswell said. "So, I just stopped eating. It was that simple." Thirteen pounds later, Doswell was still not happy. So she forced her weight lower into the upper 90s. By spring 2002 she was eating only rice or fruit and exercising incessantly, stealing laxatives and throwing up the little food she consumed. But she did not know that her behaviors had a name. "I went on-line one day and found out that what I was doing was actually a disease," she said.

Web offers support
The Web has become a haven for young women with eating disorders. The issue of race and stereotypes are hot topics for members of the Colours of Ana Web site, created as a support system for girls and women of color with anorexia and other eating disorders. Many girls on the coloursofana.com site wrote that they have heard negative comments from other blacks saying that they developed anorexia because they are trying to be white. "I have an eating disorder because I am sick, not because I am wanting to be white," wrote one woman. "We need to get past this sort of exclusivity. It is just not helping."

Tennis star affected
In the mid-'80s Zina Garrison, a professional tennis star, looked around the tennis world and did not see anyone who looked like her. "I didn't really have anyone to look up to," Garrison said in an interview. "At the time it was basically myself, Jackie Joyner-Kersee and Florence Joyner who were the pivotal African-American women athletes doing something."
    At 21 years old, Garrison was ranked in the top 10 of women's tennis and had beaten Chris Evert. But still she struggled with self-image. "I was in a short skirt all of the time, and I was always told that I didn't have the figure to fit the tennis skirts," Garrison said.
In an effort to fit the mold of the all-white world of women's tennis and the emptiness she felt as an athlete and public figure, Garrison tumbled into bulimic behavior without actually knowing that she was developing an eating disorder. Purging took a toll on Garrison's health. Her hair started to fall out. Her skin became blotchy. Her nails softened. Garrison became too weak to play the game she loved. After watching a television show on bulimia and eating disorders, Garrison recognized her behavior as an illness, got help from her trainers and returned to the top of the tennis world as a winner of major tournaments. Even now, Garrison said, "Recovery goes on day by day."
    Kaelyn Carson was not as fortunate. At 5 foot 8 and 115 pounds of muscle, Kaelyn Carson, of Comstock Park, Mich., was a brown-eyed beauty with long, curly hair and dimples. But after a 14-month battle with anorexia and bulimia, Carson died at age 20. She weighed 75 pounds. Carson, who was biracial--African-American and white--exemplifies the fact that no one is immune from eating disorders because of her race. "She was everything," said her mother, Brenda Carson. But now she has only memories of her daughter, who was a member of the National Association of Collegiate Scholars, Miss Michigan American Teen, a high school cheerleader and track star.
    If you would like more information about eating disorders or need help, contact: The National Association of Anorexia Nervosa and Associated Disorders at anad20@aol.com, or call (847) 831-3438.