On Sept. 1, the city of Ann Arbor's 15th District Court launched a Sobriety Court, a separate docket that targets drivers charged with drunken-driving offenses for the second time. Drivers who enter the program agree to court-supervised treatment, including a 12-step program, weekly drug tests and random visits by probation agents and police officers, in exchange for no jail time. The first court session was Sept. 10.
Q. What is Sobriety Court?
A. Sobriety Court is an intensive probation supervision program that involves the bench (judge) as well as the probation department and it targets repeat drunken-driving offenders.
Q. Why create a court for people with multiple drunken-driving offenses?
A. Drug courts, in general, have been remarkably able to reduce recidivism. Drug courts started in Miami in the 1990s and in the last five or six years, there's been an expansion into drinking and driving offenses. I learned about Sobriety Court from a colleague in the Boston area where one was started. It just seemed to fit the need here. Anecdotally, we're seeing higher breath scores (indicating higher blood-alcohol content) at the time of arrest and we're seeing an increase in repeat offenders. In 2003, we had between 100-120 cases filed of second offenses. ... If we can prevent the majority of second-time offenders from becoming third-time offenders, we can make Ann Arbor a safer place and make those people's lives richer.
Q. Is Sobriety Court in a separate building?
A. It's a separate docket, but not in a separate building.
Q. Do offenders choose to enter Sobriety Court, or do you decide whether defenders should enter?
A. Repeat offenders can either choose Sobriety Court or choose a period of jail time. If you're a repeat offender, you're automatically in unless you opt out.
Q. How will you track the court's effectiveness?
A. With the city's assistance, we're investing in a database program that's been used in drug courts throughout the country. The database will collect a minutia of details that we can turn into reports.
Q. What's the difference between a traditional court that handles drunken-driving offenses and a Sobriety Court?
A. In a traditional court appearance, the defense attorney has interaction with the judge. In Sobriety Court, a Sobriety Court team meets a day before the court hearings and we discuss each case and what we think should happen to the person. I have the final say because that's where the law says the decision rests. But it's wonderful to get everyone's input. Also, the dialogue in the courtroom is between the defendants and the judge and it's a different kind of dialogue. I want to know how they're doing, how it feels to be sober, (and if they relapsed) why did they relapse, and the situation in which they relapsed.
Q. Who makes up the Sobriety Court team?
A. The team is made up of the judge, an assistant city attorney, assistant county prosecutor, probation agents, private defense attorneys, the city's public defense attorney, an Ann Arbor patrol officer and a deputy chief and two treatment providers.
Q. How many cases are in Sobriety Court now?
A. We have eight people, but we expect it to increase as people go through the (four) program phases. Our target number for the program is 120 people.
Q. What's the procedure for Sobriety Court?
A. The Sobriety Court procedure is to get defendants in front of me seven days after their arrest and then sentence them within three weeks of their arrest. We want to keep it on a faster track. (However), defendants don't waive any of their Constitutional rights and they can still have a trial. The goal is to get defendants into treatment faster. Traditional cases often result in someone getting into treatment three months or longer after arrest.
Q. What happens if a defendant relapses and violates probation?
A. With an addicted population, you expect relapses and we understand that. However, each violation of probation is met with prompt and specific sanctions and they escalate in severity. The severity will be responsive to the violation. Repeat violations are treated more severely and ultimately someone will be discharged and serve a long block of (jail) time.
Q. Is there anything planned for people who successfully complete Sobriety Court?
A. As part of the Sobriety Court docket, there will be a ceremony and they'll get a certificate of completion. ... We have a Wednesday drunk-driving docket (in traditional court) and we've had people over the years that we've spent extra time with. Some of them come in with horrible attitudes and some of them are resentful that you forced them to do things. But you see changes in them over time. That's what we hope will happen in Sobriety Court. We're expecting honesty and no whining. We're expecting people to show up and meet the requirements. In exchange, we'll be as committed to their sobriety as they need to be.

'Terrible 2s' Might Need Dose of Toddler Talk
Anne Rueter, Ann Arbor News- 10/24/2004

Infants have crying jags, and toddlers have tantrums: Most moms and dads dread these moments, but think they come with the turf of parenthood. Not so, says, Los Angeles pediatrician Harvey Karp. In two popular advice books, he describes ways parents can tap "a virtual off switch for (infant) crying" and turn habitual tantrum-throwers into happy, cooperative youngsters.
      Karp, an assistant professor at the UCLA School of Medicine, describes these methods in his second book, "The Happiest Toddler on the Block: The New Way to Stop the Daily Battle of Wills and Raise a Secure and Well-Behaved-One-To-Four-Year-Old," written with Paula Spencer and published in March. "The most important thing for parents to understand is a new way of seeing how their child sees the world," Karp says. His two books, as well as his DVD learning aids, urge parents to do things that seem counterintuitive, but work.
      For instance, he believes parents need to speak to an upset toddler not in a calm, rational manner, but in "toddler-ese" - using short, repeated phrases, body language and a voice tone that echoes the frustrated child's. Parents find it embarrassing and unnatural to speak this way, but are impressed when they see 50 percent to 75 percent of tantrums disappear within a couple of weeks, he says. Toddlers "want to know that you get it. They can live without getting what they want."
      Karp likens the stages of a child's development to the stages of emotional and mental development in prehistoric humans and their forebears. In the book, he categorizes a child's stages as the "Charming Chimp-Child" (12 to 18 months), the "Knee-High Neanderthal (18 to 24 months), the "Clever Cave-Kid" (24 to 36 months) and the "Versatile Villager" (36 to 48 months).
      In his 2002 book, "The Happiest Baby on the Block: The New Way to Calm Crying and Help Your Newborn Baby Sleep Longer," Karp describes "Five S's" - techniques such as swaddling a newborn, loudly shushing in its ear to imitate the loud noise level experienced in the womb, and giving frequent chances to suckle. He believes that infants age 0 - 3 months need to exist in a protected "fourth trimester" world similar to the womb, in which they can most easily tap their innate "calming reflex."
      Karp decided to write his first book after he attended a lecture on the !Kung San people of Botswana, whose infants are nursed frequently and more or less constantly held. "!Kung San babies cry for under 60 seconds," he says. "In our culture, the definition of colic is when an infant cries and fusses for three hours or more a day." Wondering why, he drew on the practices of other cultures and on infant and child research to develop his ideas. For more on his aids for parents, visit thehappiestbaby.com

More Funds, Intervention Key to Curing MI Ailing System
Laura Potts, Detroit Free Press- 10/26/2004

Michigan's mental health system needs to undergo a sweeping overhaul, including better funding and earlier intervention for people with mental health problems, the Michigan Health Commission told Gov. Jennifer Granholm on Monday. The 33-member commission presented its recommendations in Lansing to Granholm, who appointed the group to suggest improvements to Michigan's beleaguered mental health system. She has shared the report with Michigan Department of Community Health (DCH) Director Janet Olszewski, who will help determine which "short-term solutions and long-term challenges" can be implemented, said DCH spokesman T.J. Bucholz. "Reviewing the recommendations will take some time, but we are committed to improving the mental health system in Michigan using this report as the framework," Bucholz said.
      The panel was made up of lawmakers, advocates, medical professionals and other experts. The 71 recommendations range from funding and structure issues to reducing stigma. Panel chairman Patrick Babcock said hours of public testimony and expert opinions were heavily debated as the commissioners worked out the final report. "I think overall we took on some tough questions and presented a report that could dramatically change and improve the quality of mental health services in the state if these recommendations are adopted," he said.
      The report suggests establishing a new mental health fund to support services, created in part by revenue from federal grants and the sale of state mental health facilities. Other possibilities, such as consolidating regional services, also could help save money, said Mark Reinstein, president and chief executive officer of the Mental Health Association in Michigan, and a commission member. "There's no way to get around that to implement some of these recommendations. Some funding increases will be necessary," he said. "Fixing it will require some money but it will save other areas of health care, human services and society money in the long run."
      To decrease the number of adults and children with mental illness who end up in the justice system, the report urges the state to increase early intervention and community treatment options. Also, multiple state agencies need to work together to provide better housing, easier access to services and consistent, current treatment programs, the report said. It also said the state Office of Recipient Rights should have more authority, and said more uniform standards of eligibility and care are needed around the state.
      Babcock, who ran what was the Michigan Department of Mental Health during the 1980s, said "this was the first major commission in mental health since 1979 ... and this was much broader in scope." The commission, which held meetings around the state at least once a month starting in February, will now dissolve. The DCH will determine which recommendations can be put in place, and how to do so, though it has not set a timeline.
      Michigan's mental health system, once a model for other states, has been criticized in national reports and public outcry has risen over budget cuts and service reductions.
      On the Net: Michigan Department of Community Health: www.michigan.gov/mdch

The Dorms May Be Great, but How's the Counseling?
Mary Duenwald, New York Times- 10/26/2004

A few weeks ago, the parents of a Harvard student told Dr. Richard Kadison, the chief of the university's mental health service, that they suspected their daughter had a serious drug problem. "The student in question argued that, although she needed some help, her problem was not substance abuse," Dr. Kadison said. "From my standpoint, the problem was not who's right and who's wrong or what's the diagnosis, but whether she is getting the right help."
      The college campus can be a stressful place. Surveys show that the number of college students with mental health problems of all types is steadily increasing. And some students find themselves emotionally at sea, struggling with problems from homesickness and relationship breakups to drug or alcohol abuse, severe depression or even thoughts of suicide. Experts say that, given the prevalence of emotional difficulties on campus, it pays to find out, before choosing a college, what mental health services are available. "Since each student has roughly a 50-50 chance of having some symptoms of depression or other problems, I think it has to be part of the consideration in choosing a college," said Dr. Kadison, who is also the author of "College of the Overwhelmed: The Campus Mental Health Crisis and What to Do About It."
      Most universities offer counseling and other psychiatric care, but that care varies widely in range and quality. Some mental health services may be covered by a student's tuition, fees or health insurance. Others -- visits to a psychotherapist or medication specialist in the community, for example -- may not.
      A good strategy, experts say, is to find out how large a staff of mental health professionals the campus health center retains, what kind of services are offered, and what the school's policies are in severe cases, when a student needs long-term treatment or hospitalization. Entering students who are already being treated for depression or another mental illness may want to make arrangements ahead of time to continue that care once they arrive on campus.
      Nearly half of all students at some point find themselves feeling so depressed they have trouble functioning, and 15 percent meet the criteria for clinical depression, according to a 2004 survey by the American College Health Association. Among students seen at campus counseling centers, the number taking psychiatric medications rose to 24.5 percent in 2003-2004, from 17 percent in 2000 and just 9 percent in 1994, according to the National Survey of Counseling Center Directors, conducted annually by Dr. Robert P. Gallagher of the University of Pittsburgh.

     
      Most college mental health counselors, surveys show, also have noticed a sharp rise in the number of students with severe crises, like major depression, bipolar disorder and eating disorders and drug and alcohol problems severe enough to require hospitalization. The seven apparent suicides last year by students at New York University illustrated what a grave threat some students' psychological troubles can present. "There's this illusion that the university is a safe haven in a stable setting," said Dr. Dennis Heitzmann, director of psychological services for Penn State. "But for many students, it's not a carefree environment at all."
      Although competition for college admission is stiffer than ever and workloads have never been heavier, experts say the rise in mental health treatment among college students has many causes. New medications for depression, bipolar disorder and other problems are enabling many people to go to college who would not have been able to in the past. Though some students resist getting treatment, the general awareness of mental disorders like depression has grown, and seeking help is more acceptable. And some college counselors say the wider world that today's students live in is more frightening and anxiety-provoking than it was a decade or two ago.
      Dr. Mark M. Harris, assistant director of counseling services at the University of Iowa, said his service saw 20 percent more students last month than in September 2003. And his colleagues at other universities are reporting similar increases. "What I'm picking up on the national list serve is that this has been the worst fall for emergencies in two decades," Dr. Harris said. "We're seeing a lot more anxiety disorders and panic attacks. With the global war on terrorism and terror alert codes, the world has become a pervasively more frightening place to live in." Less severe problems, like homesickness or roommate squabbles, can also be troubling enough to need treatment.
      Very large public universities and wealthy private colleges typically offer the most comprehensive mental health services. But campus counseling centers of all kinds are finding themselves stretched to capacity. The typical campus mental health center includes some number of psychologists, social workers and nurse practitioners and often at least one psychiatrist, who may be a part-time consultant. "Some campuses are so small that the counseling center may be just one professional," said Dr. Jaquie Liss Resnick, director of counseling at the University of Florida and president of the Association for University and College Counseling Directors. But large institutions not only employ several counselors but can also draw upon the services of postgraduate residents in psychiatry.
      The counseling center at Penn State, for example, where there are 43,000 students, has 12 full-time senior staff members, plus eight full-time equivalent positions staffed by interns and graduate assistants. Students who come in for help are usually interviewed so that counselors can assess the severity of their problems. A student with significant depression, for example, might be scheduled for counseling sessions weekly or every other week, and in some cases antidepressants might be prescribed. Someone whose problem is not so severe might be offered a spot in group therapy. "For broader groups, we'll offer workshops or even Internet chat lines," Dr. Heitzmann said. Penn State offers a chat line on homesickness, for example.
      Therapy at university health centers is often very brief, lasting only four to six sessions. This is partly because many students are resilient enough to bounce back after receiving a little help, and partly because students often do not come in until midsemester and receive counseling only until the end of the term, Dr. Resnick said. The midpoint of the fall semester tends to bring peak use of counseling services because increasing academic pressure and decreasing daylight spur depression and anxiety in more students. As a result, many campus counseling centers end up with waiting lists for counseling. "We try to get them in as fast as possible for an initial assessment and to take care of immediate issues," Dr. Harris said. "We sort people out, and get a sense of who can wait and who can't."
      Students who need long-term therapy, may be referred to a mental health professional in the community, Dr. Heitzmann said. "It's actually bad practice to see a patient when you know that you're going to have to limit the sessions," he said. But if students do not have health insurance, or the community lacks adequate psychiatric services, outside referrals can be a challenge. Universities with medical schools may be better equipped to steer students to outside professionals. But in some cases, parents may have to undertake their own research to find a qualified therapist - and pay for the treatment out of their pockets. Dr. Gregory Snodgrass, director of the counseling center at Texas State University in San Marcos, said he had been unable to persuade state mental health service agencies to treat students. "They won't see students, because they figure that we're there," he said. When students without insurance have needed medications, he said, university psychiatrists have distributed office samples.
      At Harvard, students who arrive at college with problems that require continuing treatment are placed under the temporary care of campus or community doctors, Dr. Kadison said. He added that Harvard students are also required to carry the university's health insurance, which includes coverage for psychiatric medications. Sometimes, students who suffered an episode of mental illness in high school or earlier will experience a recurrence in college. The college years are also a time when serious mental disorders like schizophrenia first make their appearance. "Late adolescence and early 20's is the time when you'll see the onset of various mental health difficulties," Dr. Harris said. "We'll see a lot of first-episode schizophrenia. And that's often in the emergency-room category because thought disorders can make people vulnerable to self-harm."
      Students' mental health problems can raise questions about how much parental involvement is appropriate. Some students who seek counseling prefer to keep their parents out of the loop altogether, and normally campus counselors will oblige. Students who have turned 18 are legally independent of their parents. But most college mental health counselors consider it permissible to notify parents if students are hospitalized, as long as the students are still financially dependent on the parents, according to Dr. Gallagher's survey.
      Counselors usually encourage students whom they believe are at risk for suicide to let their parents know, and most of the time, the students do so, the survey found. The issue has become especially sensitive since the widely publicized suicide of Elizabeth Shin, a student at the Massachusetts Institute of Technology, in 2000. Ms. Shin had visited the university's counseling center before her death. Her parents are now suing the university for not keeping them informed.
      In other cases, however, parents face the opposite problem: they know, or suspect, that their children are suffering but are not sure how to persuade them to make use of the college's services. But counselors say that they do not, as a rule, urge students to seek treatment at the request of parents. "One of the things we abide by is the belief that the students, having reached majority age, are independent operators, and they are free to choose treatment or not," Dr. Heitzmann said. But counselors can coach parents on how to approach their children -- by listening more carefully, by avoiding lecturing and by staying in close contact.
      Parents who feel that their child is in trouble might suggest at least one visit to the counseling center. If the student complies but then refuses further treatment, as often happens, parents may have no choice but to let it go. "One thing I have to accept as a clinician, which is painful, and it would be more painful for the parent," said Dr. Kadison, "is that you can lead a horse to water but you can't make it drink."

Court: Women Shouldn't Lose Child Custody
Associated Press, 10/26/2004

ALBANY, N.Y. -- Women should not lose custody of their children solely because the youngsters see them being battered by abusive spouses, New York state's highest court ruled Tuesday. The Court of Appeals said the removal policy followed by New York City's Administration for Children's Services in domestic violence cases was prohibited by state laws, which require courts and child welfare officials to weigh several factors when determining whether to remove children from violent households. ``Not every child exposed to domestic violence is at risk of impairment,'' the court said in a 7-0 decision written by Chief Judge Judith Kaye. In many instances, she added, ``removal may do more harm to the child than good.'' The rights of both mothers and children are violated when custody is taken away under these circumstances, the court said.
      The decision is in line with a 2002 ruling by federal Judge Jack Weinstein, who found that routinely taking children out of homes where their mothers were being battered is ``in effect visiting upon them the sins of their mother's batterer.''
      The city appealed to the 2nd U.S. Circuit Court of Appeals, which asked the state high court about what New York law says about such cases. Tuesday's decision will now be used by the federal appeals court in its consideration of the city's appeal. The case involved three women who sued the city; lawyers for the women and for the city all claimed victory. David Lansner, a lawyer who represented the three, said the court ``ruled very clearly that removal of children should be a last resort.'' ``Judges have to make specific findings of fact based on evidence that the children are in imminent danger,'' Lansner said. ``The court also said that judges have to balance the trauma that children suffer from removal against the possible trauma of remaining at home.'' Lansner said ACS records are unclear about how many battered women have had their children taken away in such cases, but he estimated it was at least several hundred a year.
      Attorneys for New York City, however, said the ruling recognizes that Family Court has jurisdiction in such cases, and that harm from domestic violence -- or its potential -- can be used as grounds for relieving battered women of custody. ``In effect, everything the city argued to the Court of Appeals was accepted,'' said Leonard Koerner, chief of the appeals division in the New York City corporation counsel's office. Alan Krams, a senior city corporation counsel, said the city does not believe domestic violence victims should be punished. But, ``violence escalates to the point where the children in the household are put at risk and the city needs the legal authority to intervene,'' he said.

Experts Urge Care Dealing With Anorexics
Associated Press, 10/27/2004

ALBANY, N.Y. -- It's something many thousands of Americans will notice: Friends or daughters going beyond skinny to skeletal. The urge to confront loved ones showing signs of anorexia -- ``Will you please just eat?!'' -- can be powerful. But mental health professionals counsel gentle persuasion over hard lobbying.
      Friends and family need to realize that an anorexic looking in the mirror does not see the same emaciated figure they do. ``You want to avoid getting into a full frontal assault because that almost always ends badly,'' said Dr. Doug Bunnell, a clinical psychologist and board president of the National Eating Disorders Association.
      Anorexia nervosa is a psychological disorder in which the sufferer becomes exceedingly thin and still believes he or she is overweight. Some exercise obsessively; others use laxatives or force themselves to vomit. Mental health officials have estimated that 0.5 percent to 3.7 percent of females will suffer from the potentially life-threatening disorder in their lifetime. Males are also diagnosed with anorexia, but at a much lower rate.
      Lisa Roy and an anorexic who wants to remain anonymous became fast friends in college, sharing rides home and going to parties. Then, month by month, year by year, Roy noticed her friend getting thinner, alarmingly so. ``Like skin and bones,'' Roy recalled. The image haunted her so much that she mustered the courage during a semester abroad to write to her friend. ``I apologize if I'm wrong,'' she wrote, but she hoped her friend would seek help for her problem. ``That letter just woke me up,'' said the friend. The young woman did seek professional help. Six years later, she still keeps the letter.
      An excruciating feature of anorexia nervosa is that it can seem to unfold in slow motion in front of friends and family as the sufferer gets progressively thinner. Loved ones are typically tormented by the same questions: Should I say anything? What do I say? When? Dr. Gina Scarano-Osika, a psychologist in Glens Falls, N.Y., said anorexics need to be made aware there is a problem before it becomes severe. But she offers a crucial warning to friends: Do not try to ``save'' someone on your own. ``A lot of kids think they can save the person themselves; if they just meet and have sleep-overs and talk about this and teach them how to eat, it will be OK,'' Scarano-Osika said. ``It's not true.''
      Instead, she suggests talking to friends and family to organize an intervention in a comfortable place. Friends should involve adults such as parents, counselors, teachers -- someone the person trusts, Scarano-Osika said. Bunnell advises having a folder at the ready with names of medical professionals and helpful Web addresses. Small groups are better, Scarano-Osika said, because the person may be sheepish, embarrassed or defensive.
      The eating disorders association cautions not to worsen the situation with admonitions like ``You just need to eat!'' or ``You are acting irresponsibly.'' Try a softer tack, with phrases like ``I'm concerned about you.'' Be supportive. ``One of the hallmarks of the illness is denial of the illness,'' Bunnell said. ``So if you go at someone really harshly or in a confrontational way, you're just going to evoke a real defensive reaction.'' Lisa Roy tried to stay non-confrontational in her letter to her old college friend. Other friends helped her find professional help.
      An intervention does not always work the first time. Hard as it may be to do so, Bunnell said, friends and family have to accept that they are powerless. All they can do, he said, is keep speaking honestly about their concerns. ``You cannot personally put yourself on the hook for it,'' he said.
      On the Net: National Eating Disorders Association: www.nationaleatingdisorders.org

Antidepressant Use Early On Affects Mice
Alan Zarembo, Los Angeles Times- 10/27/2004

In an experiment in mice, researchers have found that treatment with an antidepressant early in life increases the appearance of depression and anxiety-like symptoms in adulthood. The researchers gave daily doses of fluoxetine, better known by the brand name Prozac, to mice from four days after birth until their normal weaning age of 3 weeks — a period that roughly corresponds in humans to a fetus in the third trimester of pregnancy up to early childhood. At 12 weeks — adulthood for mice — the test animals showed signs of abnormal behavior.
      The study, which will be published this week in the journal Science, is seen as a starting point for determining the long-term effects of prescribing antidepressants for pregnant mothers and young children. "It underscores that there is really very little known about how medications that affect the central nervous system affect child development," said Dr. Victoria Hendrick, a professor of psychiatry at UCLA who treats and studies depression in pregnant women.
      Prozac, a widely prescribed antidepressant, is part of a class of drugs that enhance the action of the brain chemical serotonin, which is known for its role in regulating mood. Serotonin also serves as a growth factor, helping organize neural circuitry in a maturing brain.
      The researchers suggest in the study that manipulating serotonin levels in the young mice altered normal brain development. One place that might have been affected was the prefrontal cortex, an area that helps regulate emotions and continues developing into early adulthood. The drugs could be "altering the maturation of brain areas that are responsible for dealing with novelty and stress," said Dr. Jay Gingrich, a psychiatrist and the paper's senior author.
      Diagnosing depression and anxiety in mice requires some creativity. Compared with a control group, the adult mice that received Prozac early on waited longer to enter a brightly illuminated area for a food pellet. They also took more time to flee from a chamber that delivered intermittent electric shocks through the floor. And they explored less when placed in a simple maze.
      Experts cautioned that mice were at best an imperfect model for studying human brain chemistry. "The mouse has a rudimentary prefrontal cortex," said Paul Plotsky, a neuroscientist at Emory University in Atlanta. "It is not nearly as complex as what you see in a rhesus monkey or a human." In addition, a mouse metabolizes drugs much faster than a human does. But using human subjects to study the long-term effects of antidepressants in children would be difficult, since a controlled study would require following the participants for a decade or more. More likely, epidemiological studies will be used to gather data.
      Currently, antidepressants such as Prozac, which belong to a class of drugs known as selective serotonin reuptake inhibitors, are regularly prescribed to pregnant women. Studies of their use have focused on short-term safety.
      No evidence has turned up linking the drugs to birth defects. One study concluded that certain SSRIs, taken by mothers in the third trimester, increase the risk of perinatal complications such as respiratory distress. Another found motor skills slightly deficient in the young children of mothers who had taken the drugs during pregnancy. Those risks, however, are often minor compared with the risk an unstable mother poses to a fetus or infant. One study showed that anxiety in pregnant women could increase levels of a hormone that has been linked to premature birth.
      Some psychiatrists require pregnant women and their partners to sign a release form before using antidepressants. "I inform them about the risk — the unknown risks and what we know," said Dr. Regina Casper, a psychiatrist at Stanford University. "I say: 'I cannot give you a recommendation. You need to decide for yourself.' " This study is unlikely to affect clinical practice, Casper and others said.
      Prescriptions of SSRIs for children are already under fire, with the Food and Drug Administration recently requiring "black box" labels on antidepressants warning of an increased risk of suicide in minors. In addition, there are few efficacy studies showing that SSRIs work in children. In 2002, U.S. doctors wrote 2.7 million antidepressant prescriptions for children up to 11 years old and 8.1 million for children between the ages of 12 and 17, according to the FDA.

Sports Psychology: Dealing With the Invisible Injuries
Pete Thamel, New York Times- 10/27/2004

NORMAN, Okla. - In a collegiate track career that spanned six and a half years, Nicki Moore won races, endured injuries and felt insecure about her body while wearing a skimpy track uniform. After achieving unexpected success in her freshman season at the University of Missouri, Moore had to deal with the physical and mental hardships that came with a leg injury so severe that her doctors told her she might never walk again. She battled back to compete, though not at the same level, and ultimately retired. By experiencing the gamut of emotions inherent in college athletics, Moore unknowingly got the ideal experience for her current job.
      These days, Dr. Nicki Moore works for the University of Oklahoma's athletic department, offering counseling and sport psychology services for athletes. Oklahoma officials say Moore's position is the first of its kind in an athletic department. She offers psychological services and helps athletes enhance their performances.
      "I view this as a proactive move," Dr. Gerald Gurney, an associate athletic director at Oklahoma, said. "This is by no means a place where our student-athletes aren't having a positive experience. We want them to have a better experience. These are problems athletic departments are dealing with everywhere across the country."
      Moore's training, which includes a master's and a doctorate in counseling psychology, enables her to help students with problems like depression, eating disorders or stress from the demands they face. At the same time, her training in sport psychology helps her when a wrestler needs to stay focused, when a golfer wants to overcome the yips or a when a shooting guard struggles at the free-throw line. Since her hiring last July, Moore, 30, has already seen about 60 student-athletes for both kinds of counseling, she said.
      College sports are becoming so specialized that athletic departments like Oklahoma's have a staff physical therapist and a chief financial officer. The addition of Moore as an assistant director of athletic academic affairs for psychological services represents a trend of attending to the mental health of student-athletes.
      The N.C.A.A.'s assistant director of education research, Mary Wilfert, said there was a steady flow of anecdotal evidence from members showing concern for the mental health of student-athletes. Some universities have sport psychologists on retainer who are available through the campus medical center. What makes Moore unique is her ability to provide services from within the athletic department. "The stand-alone psychology, getting people ready to handle the rigors of competition and performance and everything that comes with it, that's the next horizon where you're going to see a lot of people make a move to," Notre Dame Athletic Director Kevin White said.
      Oklahoma hired Moore for a variety of reasons. The athletic department discovered a demand for psychological services by surveying student-athletes. Gurney was not certain, however, if student-athletes wanted and needed help to enhance their performances or merely with day-to-day stress. The Student-Athlete Advisory Council expressed two concerns: the daily stress of being a student-athlete and eating disorders. "We needed someone to help us with the everyday issues of life that an athlete faces," said the council president, Kris Glenn, a fifth-year senior on the track team. "The ups and downs of athletics takes a toll on your mental state. We decided it'd be really good to have someone in-house and on staff that the door is always open to talk to."
      Oklahoma Athletic Director Joe Castiglione decided to hire Moore, whom he knew from Missouri. There, they had been exposed to the track coach Rick McGuire, who has a Ph.D. in sport psychology and who showed them how useful sport psychology could be for members of a team. "For me, when things were going poorly in athletics, the whole world was bad," Moore said. "He helped me gain a more balanced perspective on things and helped train me to become a leader."
      What she learned from McGuire helped push Moore into her current field. And through her training and experiences, she has been able to help student-athletes at Oklahoma. "I understand the process of going through injury and retirement and struggles," Moore said. "I've had some unfulfilled dreams. You have a lot of kids that desire and want to compete beyond college, but most of them won't. That fuels my passion for what I do. I want to help them develop as people and develop other interests and skills."
      Moore has spent her first few months at Oklahoma introducing herself to the athletic community and educating teams and coaches about what she has to offer. Patient confidentiality prevents Moore from speaking about specific cases, but Oklahoma coaches say they are pleased she was hired. Jack Spates, the wrestling coach, said he recently became aware that one of his wrestlers was struggling because of a death in his immediate family. Spates said he was going to recommend that he visit Moore. "Sometimes you need someone other than your coach to speak to," Spates said. "They need an outside voice, someone they can confide in things that they'd be reluctant to share with a coach." Kelvin Sampson, the men's basketball coach, said: "Sometimes you feel unqualified. I've had kids where I've said, 'I wish that I knew how to help them.' But I didn't feel qualified to help."
      Dr. Christopher Carr is a part-time sport psychological consultant at Purdue. He starts seeing student-athletes at 7:30 a.m. and finishes at 6 p.m. when he is in West Lafayette, Ind. It is that type of schedule that makes the people in the sport psychology field believe they and their services are needed. Twenty years ago, Carr says, coaches were the ones taping ankles, not athletic trainers. He sees mental health care for student-athletes following the same track. "I hope that other athletic departments will follow suit," Moore said. "Just the enormous demand for these services that has already been expressed since I've been here is proof enough for me that the issues are here. Absolutely, I think it's a need. It's been a need for a while."

Possible Closure of State Hospitals Prompts Worry
Rosanna Ruiz, Houston Chronicle- 10/28/2004

Closing Houston area state hospitals and schools for the mentally ill and mentally retarded could force patients into facilities where they risk inadequate care or none at all, parents and advocates said Wednesday. "Nothing scares me more than seeing my son leave Richmond and be forced to go to a group home. We need the Richmond State School," said Louise Abt, whose son has lived in state schools since he was 4. Abt's remarks came during the first of nine statewide public forums regarding the possible consolidation and closure of 21 state schools and hospitals. Wednesday's forum, conducted by the Texas Health and Human Services Commission, was the only hearing scheduled for Houston.
      The commission is under a mandate from the Texas Legislature to study the merging or shutting down of state hospitals and schools. The commission will make its recommendations for closures in a report to be considered by the Legislature next year. Most of the 60 people attending Wednesday's meeting opposed the closing of any schools or hospitals.
      Texas has 11 state schools — residential facilities providing 24-hour supervision, treatment and programs for mentally retarded clients. The closest to Houston is in Richmond. There are 10 state hospitals providing psychiatric treatment and care for mentally ill patients, including Rusk State Hospital, which serves East Texas.
      El Campo resident Mary Rosenfield, 94, said the commission has failed to consider the impact or "human cost" of moving mentally retarded patients from one school into another. Her daughter, Rita, has lived at the Richmond State School for 30 years and wishes to remain there the rest of her life, she said.
      Dennis Drew said he has to travel two hours to visit his daughter at the Richmond school each week. He said he might be unable to visit her as frequently at another facility if the school is closed. "Anyone who votes for a bill that closes Richmond State School will not get my vote," he said, choking back tears.
      State Reps. Charles Howard, R-Sugar Land, and Dora Olivo, D-Rosenberg, voiced opposition to closing the Richmond school. "The bottom line is we have to take care of these people who can't take care of themselves," Howard said. "And we will find the dollars to make that happen." Advocates say any savings the state achieves with facility consolidations or closures should be pumped back into services for the mentally ill and mentally retarded.

Mental Illness on Stage for Cops
Kevin Pang, Chicago Tribune- 10/29/2004

The man is cursing at the police outside. He is screaming about invisible bugs dirtying his home and won't let officers come in. Officer Tonita Jones isn't yelling back at the actor playing the mentally unstable man during this training session. She uses a comforting tone to assure the man that everything is OK and that the police are here to help. The man finally agrees to let the officers inside, on the condition that their hands are clean. He is clutching a broomstick, sweeping nervously at all the germs, yelling at them. Jones and her two partners believe the man is off his medication. She maintains a comfortable distance, speaking in slow, soothing tones. She persuades the man to put the broom down and come to the hospital with them. She tells him: "I'll make sure you don't see the bugs." He replies: "You sure?"
      Through classroom sessions and role-playing with professional actors, the Chicago Police Department unveiled a pilot program Thursday that trains officers to deal with situations involving people with mental illnesses. Nearly 80 members of the Englewood and Town Hall Districts took part in the program this week at the Police Academy's West Loop campus. Officials said they hope the experimental program will eventually be available to all 13,500 officers. "Our officers don't have the level of knowledge about what mental health is and what it looks like," program coordinator Lt. Jeff Murphy said. "We're not doing this because we have to, we're doing it because it's a better way of doing it."
      If the program is approved, the Police Department will be one of eight mental health crisis intervention teams statewide. Since the Illinois Law Enforcement Training and Standards Board introduced the program in May 2003, more than 300 officers have been certified. Suzanne Andriukaitis, executive director of the National Alliance for the Mentally Ill of Greater Chicago, said the program would direct people with mental illnesses to medical help instead of jail cells. "This is truly win-win-win," she said. "This decreases hospitalization and incarceration days; the officers are much better informed; and it saves human suffering."
      Chicago's program would be one of the nation's largest initiatives undertaken by a police force. The goal, Murphy said, is to have at least one trained sergeant and two trained officers on call at all times in each of the city's 25 police districts.
      At the role-playing exercises Thursday, teams of three officers worked with actors who threw curveball situations at them. David Inglis, who portrayed the man holding the broomstick, said he was impressed with the officers who responded, especially Jones. "She was caring, spatial and knew who was in charge. I was suckered with that sweetness," Inglis said. Officer Vincent Allen, who also appeared in the scene, said, "Patience is number one....we need to build a sense of trust."

A Death in the Box
Mary Beth Pfeiffer, New York Times Magazine- 10/31/2004

By the time Jessica Lee Roger was discovered on the floor of her prison cell on Aug. 17, 2002, it was too late. In the 24 minutes since guards had last checked her, she had tied a bed sheet around her neck and, after many attempts over three years in prison, finally strangled herself. When word of Roger's suicide spread through the cellblocks of the Bedford Hills Correctional Facility that sultry weekend, two correction officers cried. Fellow inmates were angry. The superintendent, who was away for a few days, was devastated. A mentally ill young woman had died, and she had died in the most stressful and isolating place in the New York state prison system. Jessica Roger, 21, killed herself in the ''box,'' and many thought she didn't belong there.
      For more than a third of Roger's 1,200 days at the prison in Westchester County, she was, as she said in a letter to her mother, ''locked up and locked in'' as punishment for her fits of rage and resistance. For 250 days, she was confined to her cell, unable to participate in programs or communal meals. She spent another 160 days in the ''special housing unit,'' what inmates call the box. The box is the most severe punishment in prison: the final threat, the ultimate time out. It is a small barren chamber set apart from the general population with a concrete floor, a steel door and no clock to mark the time. The essential quality of the box is isolation -- a gloved hand passes food through a slot in the door; a caseworker's muffled voice filters through the holes in a small Plexiglas window. Inmates are allowed few personal possessions. Lights are never fully extinguished. It is four walls for 23 hours a day -- a psychologically punishing experience by design. For people like Jessica Roger, it can also be an incubator of psychosis.
      Forty years ago, America's seriously mentally ill were housed in psychiatric hospitals that kept them too long and often without good cause. As those hospitals closed, a promise to provide care in communities went unfulfilled. At the same time, America's prison capacity grew; it has quadrupled since 1980. People with untreated mental illness are often poor and homeless. Many commit petty crimes, creating arrest records that often lead to harsh sentences. Today some 250,000 Americans with mental illness live in prisons, the nation's primary supplier of mental-health services.
      Mentally ill inmates do not do well in the tense and rulebound world of prison. They create scenes, lash out unpredictably and cannot or will not obey orders. Special housing units are intended for the most violent inmates, but they also tend to collect those who are troublesome and mentally ill. More than 800 of the 4,300 inmates in New York's special housing units suffer from mental illnesses like schizophrenia, major depression or personality or trauma disorders. They may talk to voices only they can hear. They may see conspiracies in simple routines. They may have little emotional control or be obsessed by inexplicable fears. For these people, prolonged confinement to a cubicle-size room is a grueling psychological test that many fail. About 6 percent of inmates in New York have been housed in the box since 1998. Yet 34 percent of suicides, 26 in all, have occurred there.
      This isn't news to prison officials, who have been sued over special housing units in at least 10 states. In California, a federal judge said that placing the seriously mentally ill in such confinement was ''the mental equivalent of putting an asthmatic in a place with little air to breathe.'' Over the years, advocates in New York have challenged conditions in the box at four state prisons. Those lawsuits resulted in incremental but largely isolated changes -- increasing the mental-health staff at one prison, providing inmate counseling at another. But the underlying problem remains: when people with mental illness end up in prison, the need to treat them collides with the need to keep prison order, and everything about the system favors the latter.
      Consider Attica, the infamous New York prison, where in 1998, after 18 years of fighting in court, officials settled a lawsuit on behalf of mentally ill inmates in its special housing unit. The prison promised to monitor inmates closely, provide better mental-health care and do a better job of training staff members. Nineteen months later, a court expert found that little had changed: the symptoms of ill and psychotic inmates were routinely written off as ''malingering.'' Men who broke down were hospitalized and inexplicably returned to the box afterward, only to break down again. Since the settlement, there have been seven suicides at Attica, among New York's highest. Frustration with this slow pace of change led advocates for mentally ill inmates to file a suit against the entire state prison system in 2002. The suit, for which witnesses are now being deposed, asserts that mentally ill inmates are punished for exhibiting symptoms of illness that the system has failed to treat. Relegated to the box, they become sicker from the ''near total lack of human contact.''
      Roger had attempted suicide in the box at least four times before she succeeded. Once, she tied a sheet around her neck during a 100-day sentence, which was meted out after she refused orders and overturned furniture. She left a note with the outline of her hand spattered with blood: ''This is how I feel.'' She was sent to a prison psychiatric hospital for a month, where she was counseled, medicated and treated. Then, although she received a diagnosis of bipolar disorder, borderline personality disorder and other mental illnesses, Jessica was returned to complete her punishment in the small airless cell that had broken her. Within days, she again attempted suicide.
      Jessica Roger was a large young woman with hazel eyes and a ponytail of dark blond hair. She was needy, bright and emotionally so much a child that in the visiting room she would cling to her mother, head on her shoulder, arms wrapped around her. Born and raised in Poughkeepsie, N.Y., Roger had been in and out of mental hospitals 17 times since she was 11; she had gotten only as far as the fifth grade. When she was 16 years and 4 days old, just past the threshold at which children become adults under New York criminal law, Roger was arrested for the relatively minor offense of biting her sister's arm in a fight. But while in custody, the explosive teenager kicked a jail guard who was trying to refasten the handcuffs that had slipped from her wrists. She was convicted of second-degree assault of a correction officer.
      Dutchess County Court Judge George Marlow tried hard to avoid sentencing Roger to prison. He approved a plea deal to send her to an intensive program for emotionally troubled juveniles, one of few suited to her. But while she waited in the hospital for a bed to become available, she set fire to a mattress. The deal collapsed. ''When someone has a documented history of mental illness, as this defendant does,'' the judge said at her 1999 sentencing, ''there ought to be a place where there could be both isolation and treatment. That is the only humane response.'' Lacking that place, Marlow made what he called one of the most painful decisions in a 32-year career: sentencing Jessica Roger to 3 1/2 to 7 years in prison. It was her first foray into the criminal-justice system.
      New York is one of more than 30 states that operate 23-hour confinement units and prisons, sometimes called ''supermax'' facilities. Many of these were built in the 1990's in a frenzy of construction; there are now more than 20,000 inmates nationwide in these units. The resurgence of isolated confinement is often dated to the 1984 lock-down at the federal penitentiary at Marion, Ill., after rising violence led to the murder of two guards. But it was also fed by America's incarceration binge: prisons crowded with gang members, the drug-addicted and the mentally ill presented a daunting management challenge. And in an era when the rehabilitative ideal had long been waning, punitive forces took another step forward. ''The supermax,'' said Gov. Tommy Thompson of Wisconsin in 1996, ''will be a criminal's worst nightmare.'' In New York and elsewhere, there was little public debate about the effect that the units would have on the people confined there.
      Between 1998 and 2000, New York built special housing units for 3,000 inmates, almost doubling capacity in the belief that completely shutting off troublemakers would make prisons safer. Under the state's disciplinary system, rule-breaking inmates face escalating sanctions. Smoking or failing to carry an ID card, for example, could mean a loss of phone, recreation or commissary privileges. Harassing staff members or refusing an order could mean cell confinement, called ''keeplock.'' A sentence to the box was meant for the worst offenses, which is how Glenn S. Goord, commissioner of the New York State Department of Correctional Services, has defended the units. (Goord declined to be interviewed for this article, citing the pending litigation.) In a November 2000 report on prison safety, he described some of the offenses by those in the box: Anthony Burton punched and stabbed an officer with a pen; Carlos Rodriguez stabbed another inmate to death; Claudio Cuadrado cut an officer with a razor. ''The inmates confined in disciplinary housing,'' he said in a press release last fall, ''are 'the worst of the worst.'''
      But attorneys, psychiatrists and legislators who have visited New York's special housing units describe the occupants in different terms. While some are violent criminals befitting the system's most extreme form of punishment, many others are mentally disturbed people consigned to the box for lesser offenses -- creating disturbances, using drugs or failing to follow orders. In fact, in 1986 assault counted for half of sentences to the box; in 2000 just 15 percent of special-housing-unit sentences were for assault.
      Prison is an inherently dangerous place, and it is easy to understand why correction officers view the box as an irresistible tool for controlling violence. Donald E. Premo Jr. has served as a correction officer and supervisor in New York prisons for 19 years. When inmates refuse orders or start fights, whether they are mentally ill is irrelevant, he said: they are a security threat, and his job is to contain them. ''It's not so much the harm to them,'' Premo said of mentally ill inmates who are sent to the box. ''But what is the harm to the facility if they are not controlled?'' The statistics in New York do show a significant drop in staff and inmate assault, but staff attacks had been dropping before the units were built. A study of facilities in three other states found little evidence of improved safety. Still, Premo and other officers say they have no doubt that the special housing units have made prisons safer.
      Among Roger's personal papers were dozens of yellow disciplinary citations, mementos from her time at Bedford Hills: she repeatedly refused to tuck in her shirt; she tossed toilet water; she smoked cigarettes in her cell and shouted obscenities at staff members; she bit an inmate. She was 280 pounds of attitude and illness who, in one profanity-laced outburst, told an officer: ''That's what I'm in here for, hitting one of you. . . . '' Roger's second sentence of 60 days in the box was for an ''unhygienic act'' -- spitting on an officer. She made it through 56 days before attempting suicide.
      "There's not a room she's not in,'' says Joan Roger, 46. Jessica's mother is sitting at the green Formica-top table of her three-room apartment in a downcast neighborhood of Poughkeepsie, a Hudson River city about 80 miles north of Manhattan. The white walls of the apartment are crowded with photographs. There's Jessica at 11 months clutching a teddy bear, and at 4, beaming and bright-eyed in matching short sets with her older sister, Cora. There's Jessica at 13 with her mother and grandmother. And in her mother's bedroom, a picture of Jessica in her casket, wearing a lavender Tasmanian Devil T-shirt and jeans, framed by a heart-shaped wreath of faded silk flowers. There's a visible bruise on her forehead that adds to her mother's questions.
      Wisps of hair fall from a tight knot and across Joan Roger's ruddy face. Her sweatshirt is stained and worn. She accepts blame, maybe too much, for what happened to her Jet, as she called her daughter. Driven by ''mood swings,'' Joan was verbally abusive to her daughters, she said -- ''fine one minute, the next minute I was off and running.'' Her ex-husband, Kevin Roger, 46, recalls Joan yelling awful things at the girls and once grabbing a knife from her hand that, she acknowledges, ''had his name on it.'' Joan left the girls with Kevin around the time Jessica turned 11. Jessica was shattered. Kevin Roger's alcohol abuse is a refrain in Jessica's letters and records. But unlike Joan, Kevin, who is suing the state prison system, does not apologize. ''I drank,'' he says. ''I still drink. It's legal.''
      ''To me,'' Jessica Roger told a psychiatrist when she was 17, ''my life has been nothing but hell.'' She spent much of her adolescence in institutions for troubled and sick children. She broke more than a dozen windows during her fits and tantrums. She first attempted suicide by overdosing on pills when she was 13. She was a regular at the local psychiatric emergency room. She might have gone on this way except that there came a point at which her behavior -- a fight with her sister -- ceased to be regarded as the acting out of a troubled adolescent and instead became a crime. This time police insisted that charges be filed, and Roger's fate was sealed.
      "Mommy these people are stressing me out again. They took my sheets, my blankets and my mattress out of my cell because I keep hiding under the bed and covering myself so they can't see me. . . . Mommy I really feel like hurting myself but I am afraid to tell these people because I don't want them to put me in a cold . . . cell with nothing but a thin mat and a gown. . . . Mommy the feeling of hurting myself is getting stronger. Why won't these feelings just stay out of my head forever? I can't deal with them anymore. My thoughts about hurting myself are racing now they are going faster than before.'' When Roger wrote to her mother in June 2001, she was serving 60 days in keeplock -- locked in her cell for all but an hour of exercise a day -- for setting fire to a book, yelling during the inmate count and other offenses. These forays into solitude were intended, a hearing officer told her, as ''an understood deterrence to future similar behavior.'' But like many ill inmates, Roger seemed inured to punishment. In a county jail, she was so uncontrollable that a stun device was used on her more than once. Another time, jail officers stripped her of her jumpsuit and bra, after she refused to do it herself, and put her in a suicide-proof gown. ''Do whatever you want to me,'' she impassively told a jail officer in 1998.
      Inmates like Roger are at the heart of a societal debate -- played out mostly in courts, academic publications and the reports of reform organizations -- over whether seriously mentally ill people belong in isolated confinement. But it's a question that is debated in prisons too, with lines sometimes drawn in unexpected ways. The Department of Correctional Services runs New York's prisons, but clinical care of the mentally ill is left to the Office of Mental Health. Bedford Hills Superintendent Elaine Lord, who retired in March, was known as an advocate for mentally ill inmates for whom harsh punishment in the box could be destructive and lead to a spiral of misbehavior. Lord, who declined to be interviewed for this article, sometimes clashed with mental-health clinicians, who advocated punishment to curb what they saw as inmate ''malingering'' or ''manipulating'' -- feigning or using illness, usually to get out of disciplinary sanctions.
      It is a classic tug of war in an overburdened system in which the corrections side is supposed to take the ''bad'' inmates and the mental-health side is supposed to take the ''mad'' -- and where both sides have limited resources, arguments ensue as to who belongs where. In a deposition taken for the lawsuit against the state, the superintendent summed up a school of thought with which she agreed. ''We need to stop arguing about whether people are mad or bad,'' testified Lord, who cried at the inquiry into Roger's death, ''and design some effective interventions.''
      Roger's borderline personality disorder marked her as willful, manipulative and, incorrectly, all but untreatable. In her time at Bedford Hills, she was sentenced to 16 terms in disciplinary confinement, mostly in keeplock, on 46 separate charges. She had two sentences to the box totaling about five months. She was luckier than others in New York. Inmates who are mentally ill spend on average about three years in special housing units, according to a Correctional Association of New York survey. They get caught in a vortex of worsening illness and behavior that leads to ever more punishment.
      The debate over the effects of isolation on even a normal human psyche is longstanding. In 1821, the New York Legislature directed its prison at Auburn to conduct an experiment: put 80 of its worst offenders into what a group promoting the idea described as ''complete solitary confinement, free from all employment, all amusement, all pleasant objects of external contemplation.'' The inmates soon became suicidal and psychotic. One leapt from a gallery when his door opened; another beat his head against the walls of his cell. The experiment was abandoned within two years. ''A degree of mental anguish and distress may be necessary to humble and reform the offender,'' the warden, Gershom Powers, wrote, ''but, carry it too far, and he will become either a savage in his temper and feelings, or he will sink in despair.''
      Modern research on prisoners of war; immobilized spinal-injury patients; solo, long-flight pilots; Antarctic dwellers and prison inmates has shown the human mind vulnerable to unraveling during periods of isolation and sensory deprivation. In 1979, Stuart Grassian, a Harvard Medical School psychiatrist, was asked to assess 14 inmates who were housed in the small, windowless cells of a solitary confinement unit at a maximum-security prison in Walpole, Mass. One inmate could not recall the days before he slashed his wrists. Another described feelings of panic and fear of suffocation. Many heard voices, were hypersensitive to sounds or obsessed over thoughts of torture and revenge on guards. Since then, Grassian has evaluated scores of inmates in New York and other states, and has no doubts about what he calls the ''toxic'' effect of isolation.
      Grassian's findings are part of a body of research that is consistent and ample but also, in the words of a recent article in The Prison Journal, ''weak methodologically.'' For one, his research was conducted in the context of a lawsuit -- often the only way to get access to the cloistered world of prisons. And it is based on observing and interviewing inmates rather than tracking them over time or comparing them with control groups. A research team in Canada tried to settle the debate in the late 1990's by comparing the mental health of 23 inmates segregated for 60 days with those who were kept with the general population. It found no harm to the isolated inmates, who were less mentally healthy than the control group. However, the study's subjects -- many of them volunteers -- had access to personal possessions, televisions and computers. In an article in the Canadian Journal of Criminology, the researchers cautioned that their findings are ''somewhat irrelevant'' to conditions in the United States, ''where prisoners can sometimes be segregated for years for disciplinary infractions with virtually no distractions, human contacts, services or programs.''
      Researchers and advocates generally do not object to short periods of confinement for ill and unruly inmates; they recognize that truly violent prisoners must be contained. But since the 1980's, the number of New York inmates serving special-housing-unit sentences of longer than six months has increased at six times the rate of the population. Inmates can, and do, spend years in the box. In 2002, New York had among the nation's highest proportion of inmates -- nearly 8 percent -- in isolated confinement, which includes the box and keeplock. ''The scale of punishment in New York State is particularly onerous,'' said Hans Toch, a prison researcher who is a professor of criminal justice at the State University at Albany. ''They think nothing of putting someone into a segregation setting for a year and a half for what is a serious but not horrendous offense.''
      Carlos Diaz, 46, had been in a special housing unit in New York for five years when he hanged himself with a shoelace in 2000. He had accumulated so many infractions that he had 10 years left in the box. Such deaths are investigated by an oversight board called the New York State Commission of Correction, which found that Diaz had been virtually abandoned. Although he was at one point ''extremely delusional,'' no one was monitoring his condition or providing mental-health care. ''It is a well-established fact,'' the commission noted pointedly, ''that inmates serving long-term sentences in S.H.U.'s are likely to decompensate due to extended periods of isolation and sensory deprivation.''
      In 2001, the commission investigated two deaths six months apart that painfully illustrate lapses in mental-health care that lead ill inmates to act out and be disciplined. In each case, severely mentally ill inmates at separate prisons died from ''decreased intake of food and water'' -- they starved, in other words -- one after announcing a hunger strike and the other while on a suicide watch. The Commission of Correction was searing in its criticism: ''In both cases, the inmates had been identified as having significant mental-health and/or medical problems and were not afforded the care and treatment that these services are required to provide.'' Significantly, the commission's findings are nonbinding; they are often rejected or ignored.
      Cases like these are symptoms of a system under strain. The number of mentally ill inmates grew by 78 percent since 1991, while mental-health staffing has grown by 57 percent. Complicating matters, jobs often go unfilled. Pedro Molina appealed for help in 2001 at a prison with chronic recruiting problems. His note in Spanish was found weeks later on a stack of 40 requests; no one had translated or triaged the request, and Molina, 27, hanged himself in the box. When another inmate, Ralph Tortorici, 31, killed himself in 1999, Goord himself expressed frustration, appealing to the Office of Mental Health for more psychiatric hospital beds. ''I am seriously concerned about the potential for unfortunate occurrences similar to the premature demise of Mr. Tortorici,'' Goord wrote. Tortorici suffered from schizophrenia and believed the government had implanted computer chips in his body; he was so ill that he had been hospitalized four times for periods of up to a year. The prison system's lone 189-bed hospital has not been expanded since opening in 1980. Since then, New York has built 38 prisons.
     Each morning at Bedford Hills, Jessica Roger would visit Andy DeMers, a correction officer she had made friends with. She would put her head, puppy-dog-like, on the high counter he manned. It was a ritual they shared: He would ''tune'' her nose, making a noise as he tweaked it. One day, she called to him as she was led to a van bound for the prison psychiatric hospital. ''Who's going to tune my nose?'' she asked. DeMers recalled that ''there was a sweetness inside her,'' a quality he said few officers saw. Officers aren't trained to connect with inmates but rather to control them, many experts told me, leading to many confrontations and failures of opportunity. ''She was reachable,'' said DeMers, who has since retired.
      Betty Guzzardi, a petite woman in her 50's, lived on Roger's cellblock in the months before her suicide. She was one of a handful of mother hens who would try to lift Roger's spirits. ''We used to tell her, 'You're a young girl; you'll be getting out,''' said Guzzardi, who has a daughter Roger's age. The women would play cards and Yahtzee with her, and Roger would laugh and enjoy the company. Guzzardi once watched Roger pull an electrical outlet cover off a wall and gouge her wrists with the broken pieces; she had often seen her cry. When told that Roger had been put into the box two days before her suicide -- in an incident that apparently began with Jessica smoking and ended with her throwing a chair -- Guzzardi was incredulous. ''Are you crazy?'' she told an officer. ''She's too depressed. ''The whole facility was like 'How could they do this knowing how she was?' It was very upsetting to us that a young girl like that took her life, and more than that, the facility helped her take her life.''
      State prisons bear the brunt of what is often called the ''criminalization'' of mental illness. In New York, the tally of mentally ill inmates has swelled to 7,500, or 11 percent of the population. Unprepared for the task, the system has tried to respond, if inadequately. Units have been built for mentally ill prisoners who cannot live with the general population. Therapy programs have even been started at a few special housing units. In the face of the systemwide lawsuit, the state is proposing to expand these services, along with measures to reduce time in the box for good behavior and for offenses that stem from mental illness. But advocates say that more in-patient hospital beds and dedicated units are needed for mentally ill inmates, along with training to help correction officers recognize the manifestations of illness. Just as important, better oversight is needed of a system with little accountability.
      Thanks to a previous lawsuit against Bedford and the 1987 settlement that was reached, the prison has among the highest levels of mental-health staff in the state and the mental-health care that Roger received was most likely far superior to that in the rest of the system. Women in the special housing unit are monitored regularly and given monthly therapy. But while the lawsuit improved care, it did not achieve what Jessica Roger needed most. It did not keep her out of the box. Facilities in at least four states preclude the seriously ill from 23-hour confinement; a proposal to do that in New York has languished in the State Legislature. Had it been law, Roger might still be alive.
      In her final tortured hours, Jessica Roger was moved from the box to a suicide observation cell and back again. She exhibited ''self-injurious behaviors'' on the way back to special housing, the Commission of Correction's report states, questioning why she wasn't returned to observation. But mental-health staff members had considered a prior gesture to be ''manipulative,'' the report asserts; Roger, they thought, was trying to get out of the box. ''The ultimate tragedy,'' writes Terry Kupers, a prison expert and psychiatrist, in an article in The Correctional Mental Health Report, ''is when overconcern about malingering leads mental-health staff to miss what would otherwise be clear signs of an impending suicide.''
      On Aug. 20, 2002, Roger's counselor closed out her file, recalling recent encounters with Jessica. ''This writer would ask inmate if she had decided if she wanted to get a new ticket yet (misbehavior report) and inmate would laugh and say she wasn't going to get locked.'' Before long, however, the inevitable happened. ''Inmate acted out after hours and was sent to S.H.U.,'' the counselor wrote. ''Writer was informed of her death yesterday morning on 8/19/02. She will be missed.''