Teens Are Abusing Over-the-Counter Cold Pills
John Stossel, ABC News- 1/11/2003

     Parents have their hands full trying to keep kids away from alcohol, smoking and drugs. Now there's yet another substance that teens are using to get high -- legally. They're taking big doses of ordinary cold medicine. A group of kids who spoke to ABC News said they were using Coricidin HBP Cough and Cold Pills to get stoned. The ingredient that gives kids a high is dextromethorphan, or DXM. It suppresses coughs safely, but in large amounts it produces a chemical imbalance in the brain that allows the kids to get high.
     Dextromethorphan is in more than 100 cold medicines, not just Coricidin, but one type of Coricidin has the particular cocktail of ingredients that the kids prefer. This week, the American Association of Poison Control reported teen abuse of these types of over-the-counter cold medications has doubled in the last four years.

'It Tastes Just Like Candy'
     Molly, 17, described how taking a large dose of the pills made her feel, "You turn your head and everything went in slow motion. It was like you were in The Matrix or something." The abuse of Coricidin is so appealing, kids say, because it's easy to get, it's legal, and parents and teachers usually don't have any idea they're taking it. "As far as drugs go, you don't need to know a dealer, you know. If you can find a Walgreen's or a grocery store, you're set," said Jeff Helgeson, a 20-year-old from Minneapolis. Helgeson says he's been getting high on Coricidin for four years.
     Some kids call the habit "skittling," because the pills look like the popular candy Skittles. "It's just like pot, except it's better and it tastes just like candy and your parents won't know if you get high cause your eyes won't be red," said Ashley, 16. Jason, a 15-year-old from Seattle, said he liked the feeling so much he took the pills every day for five months. Another teen, Kevin, said he took Coricidin for a year and a half.

Parents, Teachers Often Unaware of Abuse
     When parents see that their kids have cold pills, they don't think twice. It's just cold medicine, after all; it seems innocent enough. School principal Judi Hanson says she's finding that Coricidin is becoming kids' drug of choice. It's easier to conceal. There's no smell, there's no dealing with a dealer. It makes it hard to detect. But Jason's father, Pat, noticed his son seemed stoned when he came home with friends and he confronted him. Jason finally admitted to abusing the medicine. Like many parents, Pat didn't know kids could get high on cold pills.
     Often the kids don't even buy the Coricidin -- they steal it. Helgeson said he stole it. "I'd wear my coat in there or stuff it in my underwear." The shoplifting has led some stores to move that type of Coricidin behind the counter. James Holm, a pharmacist at a Hopkins, Minn., store, said they had no choice. "These kids just seem to find it, zero in on it, and believe me, if you have it on the shelf, it's going to be gone," he said. "They'll steal it right out from underneath your nose. … They just grab it and go."
     As the kids talked about getting stoned, there was a lot of laughter, even when they talked about accidents and injuries they suffered while taking the pills. Helgeson laughed as he talked about breaking his elbow and ankle while snowboarding and skateboarding when he was high on Coricidin. Sometimes they laughed about not getting caught. Helgeson said he drag-raced a police car, and thought it was funny the officers couldn't tell he was high when they pulled him over. "They gave me a Breathalyzer. I hadn't been drinking. I didn't have any drugs on me. So they didn't know," he said.
     Helgeson was the oldest among the group of young people who talked with ABC News about their experiences. As the younger kids continued to laugh about their experiences, we noticed that Helgeson seemed sort of separate from them. Helgeson says it's still fun when he takes Coricidin, but he says it's wrecked his life. His mom has to drive him places because he'll lose his license if he gets another ticket. He dropped out of school and now lives at home, spending most of his time playing his guitar or just sitting. "Living in the household with Jeff the past few years has been like living with somebody who's sick and they never get well," said his mom, Merrilly Helgeson.
     Jeff Helgeson has a twin brother, John, a junior at the University of Wisconsin, whose life is good. His mom says Jeff "always has a reminder right in front of him of where he would be right now if he were not doing Coricidin." And Jeff doesn't seem happy with himself. "My brain has gone and I'm just wasted. It took all my friends away from me. I threw my life away." Yet he keeps using.

Abuse on the Rise
Failing grades or a trip to the hospital is sometimes what it takes to alert kids and their parents to the danger. Doctors say they're seeing more and more kids in emergency rooms who've taken too much Coricidin. Over the last three years, there's been approximately a 300 percent increase in calls to poison control centers about dextramethorphan, said Dr. Edward Boyer, an emergency room physician in Massachusetts. Boyer says the kids who come in to the emergency room are agitated, difficult to control, sweating and unresponsive when you try to speak to them.
     Molly and Ashley had a recent close call. They told Ashley's mom they were going to bed. Instead they took Coricidin, sneaked out of their house, and went to a party where they took more Coricidin. "My fingers were so numb that I couldn't open the package. So me and Molly were literally trying to rip the package open with our teeth," Ashley said. They went to a boy's house where Ashley may have had sex, but she doesn't know. "He took me in a bedroom and I guess he tried to have sex with me. … He was on top of me. But I fell asleep." Later, a hospital test revealed she and the boy had not had sex. She and Molly did get home and later went to sleep. But by morning, they were still very high. The Coricidin high can last a day. Ashley's mom called the poison control center and was told to get the girls to the hospital.

Sometimes Deadly Consequences
At least five people have died after taking Coricidin, but even death doesn't seem to scare the kids. Jason had heard about a boy who died, but said he knows that the boy took the type of Coricidin that contains acetaminophen. And he knows not to take that type. "It tends to cause you to die," he said. He's right, because acetaminophen can cause liver damage or death when taken in large doses.
Boyer said, "If you talk to kids, they know they should take the stuff that doesn't have acetaminophen in it."
     It's hard to believe the kids know which type of medicine is going to hurt them less. But Boyer says he believes they do, and he says they can get a lot of information from an online drug encyclopedia called Erowid. While Erowid warns that high doses of acetaminophen can be fatal, the Web site appears to have been written by drug users. They describe first-time experiences, and suggest dosages -- and in the case of Coricidin, warn of its dangers. In fact, you can get more information from these than you get from the government's drug-abuse Web site, Boyer said. "If I need information on a drug of abuse, I go to this Web site," he said.

Easy Access Makes Drug a Greater Threat
Some parents say Coricidin, because it's so accessible, is worse than other drugs. They want it taken off store shelves. But the company that makes Coricidin, Schering-Plough HealthCare Products, said removing it from the shelves would deny cold sufferers access to a helpful medication. "We want to minimize abuse by warning people and changing the package so it's harder to shoplift, but Coricidin HBP is a valuable cold medicine, the safest and most effective product for patients with high blood pressure," the company said in a statement. It also said putting it behind the counter would deprive those who need it.
Wal-Mart's policy is to sell it only to customers 18 or older, and the chain limits the number of boxes people can buy to three. Still, kids who want to abuse the medicine can still find it in stores or buy it over the Internet. Ultimately, making the decision not to abuse the medicine will be up to the kids.
     Ashley said it's difficult to stop taking it once you get started. "It's addictive," she said. "here's some ingredient in those pills that makes you want to take it again no matter what." That's not correct. Dextromethorphan is not physically addictive. Ashley and Molly have now stopped taking it. People do quit. Jason has been clean since June, and Kevin for almost a year. But Jeff Helgeson still uses. "I know that the right answer is for me to never do it again. Or drugs in general," he said. "But once you've been down that road, it's really difficult to get on a different path and stay on that path."

How to Get Emotional Eating Under Control
ABC News, 1/12/2004

Have you ever had a bad day at the office and headed straight home to retreat to the couch with a tub of ice cream? Does chocolate get you through those stressful relationship moments? For some, eating can be more about filling an emotional need rather than true hunger. Since June, trainer Jorge Cruise, author of Eight Minutes in the Morning, has been helping two San Diego mothers get their weight -- and their emotional eating -- under control, and charting their progress on Good Morning America.
     The women felt that emotional eating, as opposed to eating when they were hungry, had prevented them from being their personal best. Karen Dunn, a mother of two, who often ate while watching TV late at night, lost 20 pounds at the August check-in, and has now lost a total of 32 pounds. She has gone from a size 24 to a size 16/18. Lori Brown, a mother of three young children who reached for chocolate when she was stressed or upset, lost 22 pounds at the August check-in, and has now lost 47 pounds. She has shrunk from a size 14 to a size 6, and now enjoys shopping in trendy stores. "I didn't need a diet," Brown said. "I needed a lifestyle change. Jorge helped me address issues from my childhood which caused me to medicate myself with food. Now, my heart is open." She interacts with other people on Cruise's Web site (Jorgecruise.com), serving as a mentor.
     Dunn admits she had some trouble changing her eating habits. "I had trouble eating every three hours because I work two jobs," Dunn said. "I get up at 4 a.m. and light a candle and work out. When I need support, I call Lori or even call Jorge or I'll go online and talk to other people."
Here are Cruise's tips that helped Dunn and Brown stop emotional eating:
1. Use mantra: Is this what I really need? Use a mantra to get you through moments of difficulty. Dunn and Brown wrote down their mantra in the palm of their hands. It is the question: "Is this what I really need?" You can ask yourself the same question whenever you are tempted to use food for a fix, when you are tempted to eat for an emotional reason and not because you are hungry.
2. Create a power photo collage. Make a collage of images and pictures which inspire you. Brown, for instance, included a photo of herself at her heaviest weight, and at her lightest. She also used magazine pictures of fit, healthy women. The collages help you to visually commit to losing weight.
3. Use reminder beeper to remind yourself to eat every three hours. You can use a beeper, a stopwatch, anything to teach you when to eat. Lori used a beeper to remind herself to eat every three hours. If she follows it, she knows she's on track. If she's eating at other times, she knows it is emotional eating.
4. Review your motivation daily. People doing the best have a specific motivation for losing weight. It might be an upcoming occasion, or the desire to be fit enough to play with your grandchildren. Remind yourself daily about this reason, whatever it is. Brown had a bikini hanging on a hanger to inspire her, and that was a powerful reminder of why she wanted to lose weight.
Below are tips for emotional eaters just starting out on a weight loss program.

Tips for Emotional Eaters
Cruise has three key tips for emotional eaters just starting out on a weight loss program.
Tip No. 1: Get Moving in the Morning. Exercise should be done before eating breakfast, or even having coffee, so that whatever else happens that day, you have it in your head that you have accomplished something. "It's the greatest thing to do each day," Cruise said. "Just 8 minutes of exercise right when you get out of bed. Start the day with an endorphin rush, knowing that you are on the right path."
Tip No. 2: Find Three Supportive Teammates. If you want to lose weight, enlist support. "It's a lonely job, losing weight," Cruise said. "People often find comfort in food. Well, they should find comfort in friends and family. They need support. They should have three people that they touch base with every day in order to maintain a regimen of support."
Tip No. 3: Eat Every Three hours. The third tip is to limit yourself to only eating every three hours, without in-between meal snacks. "It's all about regimen and routine," Cruise said. "Don't get off the routine. It sounds so simple but it is really very hard. They have to know that there is a time and a place for food, and the other parts of the day should be food free. Again, all part of maintaining and sticking to routine."

Dealing With Depression and the Perils of Pregnancy
Laurie Tarkan, New York Times- 1/13/2004

     When Jennifer Klein, a 32-year-old social worker in Los Angeles, discovered that she was pregnant, she immediately stopped taking her antidepressant to avoid exposing her baby to it. She had made the same choice with her first child and experienced only the normal ups and downs of pregnancy. This time was drastically different. Several weeks after going off the drug Zoloft she slid into a major depression, which left her crying all day, feeling overwhelmed by simple tasks like going to the supermarket, feeling too tired to move, and extremely anxious, worrying about the pregnancy, her 2-year-old son and her job.
     "I'd spend all day crying and I couldn't stop," Ms. Klein said. "I hated that my son saw me like that." When she was feeling the most overwhelmed, she said, she thought of giving away the new baby to her sister. In her 15th week of pregnancy, she broke down in tears in front of her obstetrician, who recommended that she go back on Zoloft. The doctor told her that the risk of not taking it was greater than the risk of taking it. "I was still worried about the effects of the medication on my baby, but I knew I needed to do something," Ms. Klein said. "I couldn't function anymore the way I was going."  She took a lower dosage of Zoloft to minimize exposure to the baby. It was just enough to keep her functioning, but not quite enough to alleviate the depression completely. After her son was born, she resumed her full dose and now says she feels much happier.
     For some women, especially those with a history of significant depression, the risks of abandoning antidepressants during pregnancy may be far greater to the mother and the fetus than taking the drugs themselves. Those who abruptly stop taking their medications, often on the advice of their obstetricians, put themselves in danger of a relapse. Others who switch to lower dosages may still suffer depressive symptoms.
     Although there are known risks to taking antidepressants in pregnancy, and there may be unknown risks, mental health experts do not advise all pregnant women or those planning to conceive to stop their drug regimens. "Most physicians would say we don't know what the risks of these medications are, so the safest thing to do is to go off them," said Dr. Lori Altshuler, a professor of psychiatry at the University of California, Los Angeles and the director of the Mood Disorders Research Program there. "The fact is, there are tremendous risks to the mother when she goes off antidepressants, and I don't think there's an appreciation on the part of the physician or the patient just how serious these are."
     About 75 to 80 percent of women who go off antidepressants will relapse during the pregnancy, said Dr. Lee Cohen, director of the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital. Some pregnant women with major depression have reported having suicidal thoughts or were unable to function at work or take care of their older children. Depression in pregnancy is associated with poor eating, missing prenatal appointments and use of substances like tobacco and alcohol, Dr. Cohen said. Missing prenatal visits alone is a strong predictor of problems, among them premature babies and low birth weights.
     Depressed women also have a higher rate of obstetrical complications and preterm deliveries, and a review of 11 studies has shown that they have 45 percent more miscarriages, said Dr. Gideon Koren, a pediatrician and the director of the Motherisk program at the University of Toronto, a risk-counseling service for pregnant women. In addition, being depressed during pregnancy is a strong predictor of postpartum depression, which can lead to poor mother-infant bonding and has been linked to emotional, behavioral and learning problems in the child.
     In one study, Dr. Koren's group followed women who called the Motherisk hot line, which receives about 5,000 calls a year regarding the use of psychiatric drugs. Of 34 women who called and said they had stopped taking an antidepressant, a benzodiazepine (used to treat anxiety) or both, all reported withdrawal symptoms and psychological problems. Eleven reported suicidal thoughts, and four of them were admitted to hospitals.
     Estimates from various studies indicate that about about 12 percent to 20 percent of pregnant women are depressed, yet the diagnosis may go undetected. About 12 percent of women in the general population suffer a depressive disorder each year. According to one recent study published in The Journal of Women's Health, 20 percent of women screened in the waiting rooms of obstetrical clinics scored in the depression range, with fewer than 15 percent of those in that category indicating that they had received any formal treatment for depression, like psychotherapy, medication or counseling.
     Some mental health experts believe that doctors set a much higher threshold to medicate pregnant women suffering depression than they do for pregnant women suffering other diseases like high blood pressure, peptic ulcer disease, bronchitis and other infections. "I think the categorical belief is that depression is something you get over rather than something you take medication for," said Dr. Zachary N. Stowe, director of the Women's Mental Health Program at Emory University in Atlanta. "We have more research on the safety of antidepressants in pregnant women than any other class of drugs in the world," Dr. Stowe said.
     A number of studies have confirmed that neither the older tricyclic antidepressants nor the newer and more popular selective serotonin reuptake inhibitors, or S.S.R.I.'s, are associated with an increased risk of malformations in newborns. "We have over 2,000 cases of women who have been exposed to Prozac during the first trimester, 400 cases of women exposed to Celexa, and several hundred cases for other S.S.R.I.'s like Zoloft and Paxil," Dr. Altshuler said. No study has shown an increased risk of congenital malformations, experts agree. One study from Stanford, published in The Journal of Pediatrics, however, did find an increase in minor anomalies like delays in fine motor skills and increased tremors in babies 6 to 40 months old, though these findings did not show up in several longer-term studies.
     Dr. Victoria Hendrick, associate professor in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, said the findings "show that it is important not to assume these medications are safe simply because they do not seem to produce birth defects."
There is also concern about the long-term effects of antidepressants on a child's brain development.
Again, only a few studies have followed babies into childhood, the longest being up to age 6. These have found no association between exposure and a child's learning and behavioral development.
"Even though the data are very limited," Dr. Altshuler said, "it's encouraging that there aren't any studies that find that exposure in utero leads to any behavioral changes, lower I.Q. or failure to reach normal development or milestones."
     Recent studies, however, are finding that babies exposed to antidepressants in the third trimester of pregnancy have a higher rate of newborn complications, like respiratory distress, shivering, hypoglycemia and jaundice. One study by Dr. Koren's group looked at 55 newborns exposed to paroxetine, known as Paxil, during the third trimester. Twelve exposed newborns had complications requiring intensive treatment and prolonged hospitalization, compared with three in a control group. These symptoms, though worrisome, are transient, disappearing in one or two weeks. Paroxetine appears to take a larger toll on newborns than other S.S.R.I.'s.
      "It's such a hard decision," Dr. Altshuler said. "The evidence we have to date doesn't show any compelling risk to the developing fetus, but we have very limited data." "I think it's really a question of accepting that there is no risk-free decision here," she said. "You have to weigh the risk of the mother relapsing by going off medication, and the potential risk that the fetus may have some long-term effects from this medication." Most experts agree there is some risk to taking antidepressants. Dr. Stowe noted, "I don't use the word safe, but if the woman is depressed or anxious to the point that she needs to be treated, then an antidepressant is better than leaving her untreated." Dr. Hendrick added, "My threshold for treating depression in pregnancy is certainly much higher than in a woman who is not pregnant."
     People who choose to go off antidepressants can instead be treated with psychotherapy during pregnancy, but experts say that this may not be effective in women with major depression. If women go off antidepressants, it is important to taper off the drugs gradually over a period of a couple of weeks, to avoid withdrawal symptoms. Some women choose to stay off antidepressants during the first trimester, the period of fetal organ formation, although many will relapse before the end of the trimester. Others go off antidepressants toward the end of the third trimester to avoid newborn complications.
     There is not enough data to recommend one drug over the other, but most experts believe women are safer with drugs that have been studied the most, like the tricyclics or Prozac. Some doctors do not recommend that women switch during pregnancy because the drug they switch to may not be effective for them.
     A lesser but not insignificant problem is that many depressed women who are breast-feeding will not take antidepressants, or they will go back on the drugs but choose not to breast-feed their infants. Most experts believe that the risk to the nursing infant is minimal. "Most of these drugs get into the breast milk in very small amounts, and it's not considered a risk," said Adrienne Einarson, assistant director of the Motherisk program. "If a woman needs to be treated for depression, it's certainly not a reason to stop breast-feeding," she said.

Study: Talk Therapy Beats Light Box for Seasonal Depression
Cecilia Capuzzi Simon, Washington Post- 1/13/2004

For those with seasonal affective disorder -- also known as SAD, a form of depression brought on by the dark days of winter -- light therapy (LT) is the standard treatment. For at least an hour a day, patients sit in front of a box that emits white fluorescent or full-spectrum light. The treatment is believed to help compensate for a person's decreased exposure to the sun during winter's short days, yet 47 percent of patients overall and 57 percent of those with moderate or severe cases of SAD do not respond fully to it. Compliance is low and relapse is common.
      Those sad facts drove researcher Kelly Rohan, an assistant professor of medical and clinical psychology with the Uniformed Services University of the Health Sciences in Bethesda, to study the effectiveness of cognitive behavioral therapy on SAD. Cognitive behavioral therapy, or CBT, is a form of talk therapy in which patients are taught to identify and change the thoughts and behaviors that lead to their symptoms. One of the most thoroughly studied mental health therapies, it's been proven effective at reducing symptoms of anxiety, depression and other psychological problems.
      Rohan's finding? CBT alone was more effective than LT alone, and 80 percent of patients responded completely when the therapies were combined. Those who received CBT also had dramatically lower rates of relapse. Rohan says it makes sense to use CBT to treat SAD, which afflicts about 5 percent of adults in the Washington area, according to an estimate by the National Institutes of Health. Though SAD is brought on by the body's inability to adapt to seasonal changes, Rohan believes that the biological explanation alone is simplistic. A large cognitive component of the disorder is often overlooked, she says. A person's thoughts in response to those changes are also responsible for the symptoms, she says.
      For individuals with a history of becoming depressed in the winter as days shorten and circadian rhythms are disrupted, the season -- and even its approach -- "takes on a certain meaning," she says. "Many patients expect their symptoms to begin" as the fall nears. "My phone starts ringing in August," she says. "Physiologically, there is no reason for symptoms to begin that early." Many SAD patients, she explains, take cues from the environment -- changing leaves, dropping temperatures, less daylight -- and depressive symptoms and behavior become a learned response. "They go into hibernation mode in anticipation of the winter -- staying indoors, or in bed, and cutting off social interactions, activities and exercise," she says. All are symptoms of generalized depression.
      Rohan's study does not disprove the usefulness of light therapy, but she hoped it would identify an alternative or at least complementary therapy for the disorder and address LT's shortcomings. For example, even those who do respond to LT suffer what Rohan calls "residual" symptoms: LT-induced improvement is not as complete as spontaneous remission in the summer months. In addition, adhering to LT protocol is difficult. "It's hard enough to get a patient to take a pill as prescribed for depression," Rohan says. "Imagine trying to get them to sit in front of a light box up to two hours a day. Fifty-nine percent of patients discontinue use. It's a nice treatment. It's effective. But if people can't comply long-term, that's a problem."
      Rohan's study compared three groups -- those treated only with LT, those treated with CBT and those treated with both. All three groups improved, based on two depression-rating scales. But those who received CBT, either alone or with LT, were less depressed at the one-year follow-up. And in one of the depression-rating scales administered the winter following treatment, not one CBT participant -- with or without LT -- met the criteria for depression. By comparison, 62.5 percent of LT-only participants met the depression criteria the next year. "Light therapy doesn't teach people anything they can do to cope with stress and depression," Rohan says to explain the low relapse rates for those who had the talking cure. "CBT teaches skills that can be used in other areas of life."
      People in Rohan's cognitive therapy groups attended group sessions twice a week for six weeks. During those meetings, they learned about the biological origins of SAD and also about the learned behaviors and ingrained thought processes that Rohan believes contribute to their symptoms. They were taught how to alter behavioral patterns in the winter to "get them to act more like they do in the summer," Rohan says, developing interests and activities for the colder months and making efforts to maintain social contacts.
      CBT participants also were required to identify negative thoughts and write them down. This helped them develop a greater awareness of what affects their moods, Rohan says, and provided opportunities to challenge their thinking. Lastly, participants were taught to recognize SAD's early warning signs to help prevent relapse. "We got them to push themselves even when they didn't feel like it," Rohan says. "When they did, they got relief and were able to do more. That created a positive upswing so they could do even a little more the next time."

A Bully's Future, From Hard Life to Hard Time
Jane E. Brody, New York Times- 1/13/2004

The teasing started with a wisecrack about another person's sexual orientation, and escalated when the object of the remark responded with a provocative taunt of his own. The next thing anyone knew, one man had flung a metal chair, striking the other's face, shattering bones and partly severing his nose. It is the kind of bullying behavior you might expect from unruly teenagers. But in this case, the authorities say, the bully was a New York City firefighter and his victim was a colleague, who had to be hospitalized and placed on a respirator.
     According to other firefighters, an endless flow of sometimes vicious and cruel taunts is commonplace in firehouse culture, with verbal abuse most often inflicted on young firefighters to toughen them up. But, as studies of younger bullies have repeatedly shown, bullying can have disastrous effects not only on the victims but also on the bullies themselves, who often grow increasingly violent and antisocial.

A Stepping Stone
The rash of school shootings in recent years, including the massacre at Columbine, has renewed attention to the extent and potential consequences of bullying for both bully and victim. In a videotape, the young gunmen attributed their acts to retaliation for years of taunting that they said friends and relatives had inflicted on them because of an unwillingness to dress and act as others wanted.
     Bullies, researchers insist, are not born, they are made. And they can and should be unmade before the behavior becomes so ingrained that it shapes their personalities and behavior for life. In a nationwide survey of 15,686 students in sixth through 10 grade in public and private schools, Dr. Tonja R. Nansel and colleagues at the National Institute of Child Health and Human Development found that children who bullied and their victims were more likely to engage in violent behaviors than those who had never been involved in bullying. They found that children who bully are at risk for engaging in more serious violent acts, like fighting frequently and carrying weapons.
     For example, among boys surveyed who said they had bullied others at least once a week in school, 52.2 percent had carried weapons in the past month, 43.1 percent carried weapons to school, 38.7 percent fought frequently and 45.7 percent reported being injured in fights. The comparable statistics for boys who had never bullied others in school were 13.4 percent, 7.9 percent, 8.3 percent and 16.2 percent.
     The greatest risk for engaging in violence-related acts was found among boys who bullied others when they were away from school; 70.2 percent of them had carried weapons. Nor were girls exempt from potentially violent behavior. About 30 percent of girls who had bullied others in school at least once a week reported carrying weapons. The victims of bullying were also at risk for violent behavior, with weapons carried by 36 percent of boys and 15 percent of girls who had been bullied in school at least once a week.
     At greatest risk were boys and girls who both bullied others and were bullied themselves; they were 16 times as likely as youngsters not engaged in bullying behavior to carry weapons, the researchers reported last April in The Archives of Pediatric and Adolescent Medicine. "It appears that bullying is not an isolated behavior, but a sign that children may be involved in more violent behaviors," said Dr. Duane Alexander, director of the child health institute. "The implication is that children who bully other children may benefit from programs seeking to prevent not just bullying, but other violent behaviors as well."

Bullying Starts Early
Even preschoolers can be bullies, for example, giving other children insulting nicknames, refusing to invite particular classmates to birthday parties or excluding certain children from games. In a study published in November in the journal Child Development, Dr. James Snyder of Wichita State University and colleagues reported that many kindergarten children found themselves verbally and physically abused by their playground peers. By the time the children reached first grade, an increasing amount of harassment had focused on a smaller group of perpetual victims. In their observations of 266 students through two early grades, the Kansas researchers found that boys who experienced growing harassment were more likely to demonstrate antisocial and depressive behavior, and girls who were victimized in kindergarten were more likely to engage in antisocial behavior at home as they grew older and became more and more depressed at school if they continued to be victims. "Substantial rates of victimizations were observed," Dr. Snyder reported. "On average, children were targets of peer physical or verbal harassment about once every three to six minutes."
     Another study of bullying among young adolescents, published in Pediatrics last month, emphasized the "social plight of victims: they are not only targeted by bullies but also ostracized by many of their classmates." "Victims suffer not only emotional distress but also social marginalization (i.e., classmates avoid them and they have low social status)," Dr. Jaana Juvonen and colleagues at the University of California, Los Angeles, reported. This study, unlike others that required children to report on their own bullying actions and instances of being bullied, questioned fellow students of sixth graders from 11 schools to determine the incidence and consequences of bullying and being bullied.
     As in previous studies, they found that the most troubled group were those who were both bullies and victims. These youngsters exhibited the highest levels of social avoidance, conduct problems and school difficulties. Furthermore, the researchers said, "victims who bully others also best fit the profiles of seriously violent offenders." They analyzed 37 intended and actual school shootings and found that about two-thirds of those responsible had been bullied by their peers.

What Can Be Done?
Parents are advised to ask children about teasing as early as age 5. If a child engages in bullying, he should be taught to apologize, ask forgiveness and shake hands. Older children who are teased can be taught not to play the role of victim, either by saying to the bully: "I don't like your teasing. Stop it," or simply ignoring the bully and walking away.
     Children who are bullied should not be blamed for being victims, nor should they be told to fight back. That can only worsen the problem, encouraging bullies to become increasingly hurtful. It is also important to boost victims' self-confidence and make sure they take part in activities they enjoy and can excel at. Also, parents who see bullying should teach their children to stick up for victims whenever possible.
     Parents of bullies are advised to take the problem seriously, looking for the causes of anger or frustration, letting them know that hurtful behavior will not be tolerated, supervising their behavior more closely, "punishing" bullying with positive acts toward others and teaching nonviolent ways of solving problems.
     Experts say that schools, communities and parents must collaborate to control bullying. One effective school-based program, covering kindergarten through fifth grade, is called Take a Stand, developed by Dr. Sherryll Kraizer. A set of teaching guides and a training videotape costs $195.

Putting a Price on a Good Night's Sleep
Andrew Pollack, New York Times- 1/13/2004

Americans are about to be reminded again how much they need sleep - and sleeping pills.
A new effort appears to be developing to expand the use of sleeping pills, which because of their potential for abuse have long had a reputation as being in some ways more dangerous than the insomnia they are meant to treat.
     Some sleep experts say newer pills are safer than the ones that once caused deaths from overdose. Moreover, some say, there is growing evidence that insomnia is a serious medical condition, not just a nuisance. "Slowly, we are beginning to identify that insomnia does have some risks associated with it, and when that happens there will be more press to treat it aggressively," said Dr. Michael H. Bonnet, director of the sleep laboratory at the Veterans Affairs Medical Center in Dayton, Ohio.
     But part of the new push is driven by drug company marketing. Two new sleeping pills are expected to be available by the end of next year and their manufacturers hope to have them approved for broader and longer-term use than recommended for previous pills. And the companies are expected to advertise their products, and the problem of insomnia, heavily.
     Sepracor, which makes one of the new drugs, recently financed a press seminar on insomnia. The other drug will be marketed by Pfizer, whose vast sales force and ample advertising have helped make best sellers of drugs like Viagra, the cholesterol fighter Lipitor and the painkiller Celebrex. "What Pfizer sees here is a wonderful opportunity for what they've done" with those drugs, said Gary A. Lyons, president and chief executive of Neurocrine Biosciences, which developed the drug, indiplon, and licensed it to Pfizer. Only a small fraction of insomniacs now take prescription sleep-inducing drugs, Mr. Lyons said. "This is unquestionably one of the largest potential pharmaceutical markets in the world," he added.
     As a hint of what might come, a public relations campaign was mounted a decade ago when Ambien, now the best-selling sleeping pill, was introduced. "With a public fearful of sleep medications and reluctant to admit having insomnia, Edelman and client Searle teamed up with the National Sleep Foundation and leading academic institutions to address `Sleep in America,' " Edelman, a public relations agency, recounted in a history of its first 50 years. By emphasizing the safety problem of driving and working while sleepy, "Edelman helped Searle revitalize a flagging sleep market," the company wrote.
     Dr. Daniel F. Kripke, professor of psychiatry at the University of California at San Diego, said that drug companies and some sleep doctors, many of them consultants for drug companies, were exaggerating the seriousness of insomnia. "Frankly, worrying people about sleep is good for the drug companies, it's good for the sleep clinics and maybe it helps people get research funding too," said Dr. Kripke, who runs a Web site, the Dark Side of Sleeping Pills, at www.darksideofsleepingpills.com. There is little evidence that sleeping pills meaningfully improve sleep over the long run, he said. There is even evidence from a survey in the 1980's that regular users of sleeping pills tend to die younger than non-users.
     But most experts dismiss that evidence. "He's about the only person I know of who supports that view," said Dr. Andrew D. Krystal, associate professor of psychiatry and director of the sleep research laboratory at Duke who has consulted for Sepracor. He said the consensus was that insomnia is a serious condition and that pills were becoming safer. "I believe we'll see a shift toward people having effective treatments available that doctors are willing to prescribe and patients are willing to take," Dr. Krystal said.
     Estimates of the number of people with insomnia vary widely. About 40 percent of adult Americans have at least occasional trouble sleeping, according to the National Sleep Foundation, which promotes understanding of sleep disorders and research on them. Some insomnia is temporary, caused by job worries, for instance. But an estimated 10 to 15 percent of adults have severe or chronic insomnia. Many cases appear to be caused by an underlying condition like depression or painful arthritis, and the best approach is to treat that underlying condition. But for perhaps 15 to 30 percent of those with chronic insomnia, no known underlying disorder can be found.
     Several studies have shown that people with insomnia are more likely than others to become depressed. Lack of sleep, though not always caused by insomnia, can interfere with social life, job performance and driving. At least one study has shown that sleep deprivation results in poor glucose metabolism, a hallmark of diabetes. Still, scientists cannot yet point to any study showing that treating insomnia with sleeping pills staves off depression or other diseases. Yet some experts say understanding the dangers of insomnia is only a matter of time. "Some day we'll see that like smoking, this isn't good for you," said Dr. Michael L. Perlis, associate professor of psychiatry and director of the sleep research laboratory at the University of Rochester.
     Sleeping pills, technically called hypnotics, have gone through several generations. Decades ago, the common pills were barbiturates, which were addictive and led to many deaths from accidental or deliberate overdoses. By the 1970's, they were largely displaced by drugs called benzodiazepines, which included the sleeping pills Halcion and Restoril and the tranquilizer Valium.
With these drugs it was much more difficult to die from an overdose, though they could still be dangerous if paired with alcohol. Halcion was taken off the market in some European countries and the recommended dose in the United States was reduced after some users suffered amnesia, hallucinations and other side effects. There is evidence that benzodiazepines can be addictive and that people develop a tolerance, so the pills eventually lose effectiveness.
     In 1983, the National Institutes of Health issued a consensus statement from experts urging doctors not to prescribe such pills for more than three or four months. The Drug Enforcement Administration considers the drugs Schedule IV controlled substances because of a limited potential for abuse.
     In the 1990's, drugs known as non-benzodiazepines, exemplified by Ambien and Sonata, entered the market. Because many doctors perceive it as safer than the older drugs, Ambien, now sold by Sanofi-Synthelabo of France, accounts for two-thirds of prescriptions of nonbarbiturate hypnotics, according to IMS Health, a market research firm. Though chemically different from the older drugs, Ambien works in a similar way. All the drugs bind to receptors in the nervous system meant for a neurotransmitter called GABA. The binding enhances the transmitter's effects, which slow the nervous system. Though the older drugs bind to all three of the main types of GABA receptors, Ambien, known generically as zolpidem, binds mainly to the one type thought to promote sleep. Though some studies in animals have suggested that this causes fewer side effects, Ambien has never been tested in clinical trials lasting more than a few weeks. So its label recommends use for only 7 to 10 days, with prescriptions not to exceed 30 days. Like the older drugs, it is still a controlled substance and its label mentions the potential for dependence and tolerance.
     Dr. James K. Walsh, president of the National Sleep Foundation and head of a sleep research center affiliated with two hospitals in St. Louis, said newer drugs were being unfairly tarnished by "some myths and regulatory restraints that have evolved over the years." Those restraints have "led patients to be fearful of medications that they don't need to be fearful about, in my opinion," said Dr. Walsh, who is a consultant to many drug companies.
     The labeling of the drugs for only short-term use is a problem, some doctors say, because those most in need of treatment are chronic insomniacs. "There's a real logical inconsistency between what we know about insomnia and how we treat it," said Dr. Daniel J. Buysse, professor of psychiatry at the University of Pittsburgh.
     While some people do take the sleeping pills for months at a time, others use over-the-counter antihistamines or prescription antidepressants that have sedation as a side effect. But those drugs have not been approved for insomnia, Dr. Walsh said, so scientists know less about their effects on sleep than they do for sleeping pills.
     Some sleep specialists have been urging the National Institutes of Health to develop a new consensus statement about insomnia and its treatment, and that is expected to happen in the next year or two. The N.I.H. has already stamped the 1983 statement obsolete.
     The move toward longer use of sleeping pills could be spurred by the new pills coming to market, which for the first time are being tested for months instead of weeks. Sepracor, which is based in Marlborough, Mass., sponsored a clinical trial showing that its drug, Estorra, worked for six months without loss of effectiveness, providing about 35 minutes more sleep per night than a placebo. The Food and Drug Administration is expected to decide whether to approve Estorra by the end of February, after postponing its deadline of last November. Indiplon, the Neurocrine and Pfizer drug, is in the final stages of clinical trials and could reach the market next year.
     Estorra and indiplon work the same way as Ambien. Estorra, known generically as eszopiclone, is a derivative of zopiclone, a non-benzodiazepine sold outside the United States. "These are quantitative not qualitative differences," said Dr. Thomas Roth, director of the sleep center at Henry Ford Hospital in Detroit. "We're not talking about a new chemical class."
     So besides seeking approval for longer-term use, the newcomers will try to distinguish their drugs from Ambien by how long their drugs last in the body. If a drug does not last long enough, people can wake up again, a problem that has hurt sales of Sonata. If the drug lasts too long, people can feel groggy when they are supposed to be awake, a side effect that increases the risk of accidents. Estorra lasts somewhat longer than Ambien so perhaps could provide longer sleep. Sepracor says the drug does not cause hangovers.
     Neurocrine Biosciences, based in San Diego, is developing two forms of indiplon. A short-acting form would be for people who wake up in the middle of the night or too early in the morning and want to go back to sleep without oversleeping. The other version of indiplon will have a coating that releases some drug immediately to induce sleep at bedtime and a core that will release more later to keep people sleeping through the night. Sanofi-Synthelabo is developing a similar pulsed-release version of Ambien, which it hopes to have on the market by the end of 2005, to fend off not only the new rivals but also generic versions of Ambien that will be allowed in 2006.
     Some scientists say true breakthroughs will require drugs that work through new mechanisms, like adjusting the body's natural sleep-wake cycle. Takeda Chemical Industries, Japan's largest pharmaceutical company, is in late-stage trials of a drug, Ramelteon, that mimics melatonin, a hormone released in the brain in response to darkness that helps induce sleep.  Many people take nutritional supplements containing melatonin, though experts say it is not clear they are effective. Dr. Stephen M. Sainati, vice president at Takeda Global Research and Development, says that while melatonin binds to three receptors and had multiple effects, Ramelteon binds to only the one connected with sleep. He said the drug should have "absolutely no abuse liability whatsoever." Takeda hopes to file for approval by early 2005, he said.
     Drugs working through yet other mechanisms are further back in development.
Dr. Bonnet, of Dayton, who is also a professor of neurology at Wright State University, said that even with improvements in sleeping pills, doctors might be cautious about prescribing them. "We've forgotten the mistakes of the past so now we can go back and repeat them," Dr. Bonnet said. "People are going to pause and think, `Are we really beyond those problems?' "

Sleep Experts Debate Root of Insomnia: Body, Mind or a Little of Each
Andrew Pollack, New York Times- 1/13/2004

     After a night of poor sleep, what could be more enticing than a nap the following day? But for insomniacs, even napping is difficult. "Insomnia patients, when you give them a nap opportunity during the day, they can't fall asleep, even though they say they are tired," said Dr. Michael H. Bonnet, professor of neurology at Wright State University School of Medicine and director of the sleep laboratory at the Dayton Veterans Affairs Medical Center.
      The observation is one piece of evidence that it is not just everyday worries that keep people from getting a good night's sleep. Dr. Bonnet said he believed that insomnia had a physiological component and that insomniacs tended to be hyper-aroused, accounting for their difficulty in napping. Studies by him and others show that compared with sound sleepers, insomniacs have higher heart rates and body temperatures, as if they were in danger and preparing to fight or flee. "Their furnace is turned up higher than control individuals," he said.
      Dr. Bonnet simulated insomnia in healthy young sleepers by giving them the caffeine equivalent of 12 cups of coffee a day for a week. By the end of the week, they had become more anxious, as shown on a personality test. Some researchers suggested that lack of sleep caused the anxiety. But Dr. Bonnet did another experiment involving healthy sleepers who did not take caffeine but were awakened every time an insomniac in the next room woke up, so that the sleep patterns were identical. At the end of the week, the healthy sleepers had not become more anxious. And they were able to fall asleep faster than insomniacs could. Dr. Bonnet said he concluded that it was the body's arousal, from the caffeine in the first experiment, that had caused the anxiety, not the lack of sleep.
      Not everyone supports the physical cause theory, however. Some believe insomnia is caused by worries about daily life. Others, like Dr. Michael L. Perlis, an associate professor of psychiatry and director of the sleep research laboratory at the University of Rochester, say that if worry is keeping people awake, it is worry about not being able to sleep. Some people, Dr. Perlis said, "say you are awake because you are worrying." "I would say you are worrying because you are awake." Dr. Perlis said he thought insomnia was caused by a conditioned response that produces changes in the brain or central nervous system. After a while, he said, merely walking into the bedroom is enough to cause brain activation. "You're going to walk in that room and you're going to wake up," Dr. Perlis said.
      Some people undergo behavioral therapy to treat their insomnia. To make sleep more likely at night, they are told not to compensate for lost sleep by going to bed earlier or napping. To associate the bedroom with sleep only, they are told not to watch television in bed and to leave the bedroom if they wake during the night and cannot get back to sleep. Dr. Charles Morin, professor of psychology at Laval University in Quebec, found in an oft-cited study that patients getting behavioral therapy did better in the long run than those taking sleeping pills because the effects of the pills wore off after they stopped taking them. "With medication we tend to get quicker results, but with behavioral therapy we get longer-lasting benefits," Dr. Morin said. But neither therapy works that well, he added. "Very few people actually become good sleepers with treatment."