Panel Says Zoloft and Cousins Don't Increase Suicide Risk
Gardiner Harris, New York Times- 1/22/2004

     Adding to the debate over using antidepressant drugs for depressed teenagers and children, a group of prominent researchers issued a report yesterday saying that Zoloft and similar medicines did not increase children's suicide risk. The group, drawn from members of the American College of Neuro- psychopharmacology, also found that the drugs were effective in treating children's depression. "Depression in children and adults is the major illness that underlies suicide, and we believe that the S.S.R.I. class represents the medication with the greatest efficacy against this very serious condition," said Dr. J. John Mann, a professor of psychiatry at Columbia University who was co-chairman of the reporting panel.
     Those conclusions are hotly contested, and the report does not settle the debate on giving children the medicines, selective serotonin reuptake inhibitors, or S.S.R.I.'s. Citing associations between antidepressants and suicidal thoughts or tendencies in children, British drug regulators told doctors last month not to prescribe those drugs for children, with the exception of Prozac. The Food and Drug Administration plans hearings on the question on Feb. 2.
     In the new report, the panel reviewed 15 clinical trials, some unpublished, that included more than 2,000 teenagers and children as subjects. The trials used varying methods and had disparate outcomes, but showed that S.S.R.I.'s -- Effexor, Paxil, Prozac, Zoloft and others -- "are effective in treating depression in children and adolescents," the report said. It recommended that clinicians continue to use the drugs for depressed youths, although it said clinicians should "ask depressed patients about suicide, suicidal thinking and plans for suicide."
     Dr. Jeffrey Lieberman, professor of psychiatry at the University of North Carolina, said he found the report persuasive. "What the report said is that the risks of not treating patients with severe depressive illness outweighs the risk of treating them with S.S.R.I.'s," Dr. Lieberman said. Dr. Richard Harrington, professor of child and adolescent psychiatry at the University of Manchester in England, said he was not sure that drugs were effective for teenagers and children. "Maybe they work," Dr. Harrington said. "But if so, they don't work very well. And I'm still troubled by the suicidality."
     Critics pointed to weaknesses in the report. The panel did not have access to some information that British regulators used to come up with opposite conclusions. The report did not undertake a sophisticated and difficult meta-analysis, in which figures from many studies are pooled for examination. Other researchers are conducting that analysis. Critics of the medicines noted that 9 of the 10 task force members had significant financial ties to the pharmaceutical industry, although such ties are common among prominent researchers. The panel said no industry money financed the report. "Of course they concluded that these drugs are safe," said Tom Woodward, who said he believed the drugs led his daughter, 17, to commit suicide. "All these guys are tied to the pharmaceutical industry."
     Worries that they might cause a small number of patients to become intensely suicidal have swirled about the drugs since shortly after Prozac was introduced. The question seemed to have been put to rest in 1991, after a Food and Drug Administration panel said there was no convincing evidence to link the drugs to increased suicide risk. Millions of people have taken the medicines. Although sporadic complaints continued to link drugs to suicides, those reports were widely dismissed as anecdotal, isolated events that could not be relied on to assess the medicines. But later studies raised new questions.

Psychiatrist's Testimony Could Get Yates a New Trial
Claudia Feldman, Houston Chronicle1/25/2004

Incorrect testimony about a nonexistent episode of a popular TV drama -- and new questions about the innocence of the mistake -- may be grounds for a new trial for Andrea Yates. California psychiatrist Park Dietz erred when he testified in the highly publicized 2002 trial that an episode of Law & Order featured a mother who drowned her children. In the TV plot, the woman schemed to escape a confining marriage, Dietz said. She claimed she suffered from postpartum depression and was acquitted. No such Law & Order episode ever aired, but an e-mail from a teacher to the Harris County district attorney's office alerted them that a TV drama dating back to the 1980s, L.A. Law, did run a similar episode -- and gave the defense what they hope will be ammunition for a new trial.
     Dietz's error might not have been caught, but Suzanne O'Malley, a writer for Law & Order and an investigative journalist, was in the courtroom when he testified. She suspected Dietz was wrong, then called the show's producers to be sure. After some legal wrangling before the sentencing, jurors were alerted to the mistake. Or was it a mistake?
     Public records in the 1st Court of Appeals refer to the e-mail that was sent by the schoolteacher to the district attorney's office shortly after the Yates murders in 2001. The teacher had just seen a rerun of the old L.A. Law episode and realized the plot bore some resemblance to the Yates case, and she thought the prosecutors ought to know. Today, the teacher asks not to be named and will not comment on her e-mail. But her laywer, Philip Hilder, said the staff at the district attorney's office -- he won't say who -- took increasing interest in the e-mail as the trial date approached. They called the teacher several times to talk about it, Hilder said. "My client doesn't understand how the prosecution could confuse L.A. Law and Law & Order. She has some question as to the truth, the veracity of Dr. Dietz." Dietz has not returned Chronicle calls.
     To complicate matters, prosecutors Joe Owmby and Kaylynn Williford were required by law to share the teacher's e-mail with the defense if they knew Dietz's testimony was either a mistake or a lie. Defense attorney George Parnham says prosecutors shared nothing, though they should have known or did know the testimony was false. Owmby says he can't comment on the e-mail but noted that he did not ask the question that prompted the discussion of Law & Order -- Parnham did. Owmby said he had no idea Dietz's testimony was false when he presented it, and Williford said she was unaware, too. Not only that, Williford says, Dietz's testimony was inconsequential. She didn't refer to it, she said, because there was so much more relevant material to discuss.
     Hilder disagrees. He says the mistake, perhaps the compounded mistakes, are grounds for a new trial. "At minimum, aw, geez, it's inexcusable. It goes to the very heart of the integrity of the judicial system." A Harris County grand jury also considered the e-mail and a possible aggravated perjury charge this past summer. Jury foreman Jim Brooks explained, "We were looking into the (Houston Police Department) crime lab, and we had requested some paperwork, and this e-mail just popped up. We were really surprised to see it. It staggered the imagination." Grand jurors considered indicting three individuals involved in the Yates trial, Brooks said. Park Dietz was one, but Brooks wouldn't name the other two. In the end, grand jurors didn't have the required nine votes, Brooks said. Dietz was no-billed.

Yates' Husband Says Trial Was Unnecessary
Associated Press, 1/25/2004

HOUSTON- Nearly two years after Andrea Yates' conviction for drowning her children in the family's bathtub, her husband maintains his mentally ill wife never should have been prosecuted. Yates, a diagnosed schizophrenic, was sentenced to life in prison after a jury rejected her insanity defense in March 2002. "Why do we even have insanity laws if they are not based on medical insanity?" Russell Yates asked. To be found innocent by reason of insanity, defendants must prove they have a severe mental disease and did not know their actions were wrong.
     Police discovered the lifeless, wet bodies of Yates' four youngest children under a sheet on her bed after she called 911 on June 20, 2001. The oldest child, Noah, 7, was found floating face down in the tub. Yates was found guilty of murdering three of her children, but was not tried for the other two deaths. Andrea Yates is now jailed at a psychiatric prison in Rusk, where she works in an outdoor flower garden. But her husband says she should have received treatment at a mental health facility, not a life term. "The prisons are set up for security, they are not set up for treatment," he said. "She needs fairly intensive care from a team of psychiatrists. She is not getting that type of treatment at all."
     On a Web site he created shortly after the deaths, www.yateskids.org., Russell Yates blames a doctor who treated his wife before her children's deaths, prosecutors, and the judge. "Most people in Texas believe if someone is brought up on charges they are guilty. In Harris County, it is guilty until proven innocent," Yates told The Associated Press in an interview Tuesday. Defense attorneys have until next month to file an appeal. Judge Belinda Hill said she could not comment because the case is still pending. Prosecutor Chuck Rosenthal said he did not want to "dignify anything (Russell Yates) has to say."
     Russell Yates visits his wife every other weekend, trading off with other family members. "It's tough," he said. "It's tough because I look back on the family we had and the happiness we had. "It is very hard to see the woman I married and the woman who bore my children suffering. I hate it. I enjoy visiting with her but I hate to see where she is."

Pain, Work Relentless in Yates Case
Claudia Feldman, Houston Chronicle- 1/25/2004

Rusty Yates shifted his inscrutable gaze from an empty patch of grass to the children at play. His four boys used to love this Clear Lake Park, he said. They would jump on playground equipment over there, he said, pointing, and run staggered races over there. The NASA engineer worked it so that Luke, 2; Paul, 3; John, 5; and Noah, 7, arrived at the finish line at the same time. "It was cute," Yates said, his voice trailing off. It's been almost three years since his wife, Andrea, drowned the boys and 6-month-old Mary in the bathtub in their home. Interviews with people close to the convicted murderer reveal that her life has become a hazy blend of grief, tedium, mental illness. Rusty says he feels as if he's imprisoned, too.
     Supporters say she should be detained in a psychiatric hospital, not a prison. Those are fighting words in Houston, usually comfortable with its Wild West approach to crime and criminals. The Yates case, however, is different. Defense lawyers are pushing for a new trial, the case still is a cause célèbre among mental health advocates, and local debate is as divisive as ever. One camp sees Andrea, 39, as a cold-blooded murderer. What could be worse, they ask, than a mother who holds her children, one by one, facedown in a tub until they quit struggling? She deserves her life sentence, they say. Kaylynn Williford, one of the assistant district attorneys who prosecuted the case, thinks Yates deserves to be executed. "If Andrea Yates had been a man, the public reaction would have been very different. Here were five beautiful children who didn't get a chance to grow up, five beautiful children who didn't want to die. Think about the fear those children went through at the hands of their mother -- the one person they expected to defend them."
     The other camp is equally impassioned. They don't have enough fingers to count the people and systems who failed the Clear Lake mom before she killed the children. She tried to commit suicide twice, they note, and she was hospitalized for psychiatric problems four times. Supporters ask, how crazy did she need to be for a verdict of not guilty by reason of insanity? They're not trying to free Yates, they say, but confine her in an appropriate psychiatric setting. Wendell Odom, one of Yates' attorneys, summed up his feelings when she was found guilty, then dealt a life sentence. "I may never get over it," he said.
     Prosecutors say it's time to let all this go. They say the system did work, and Yates is where she needs to be. Defense attorneys, now working for free, vow they will keep working until justice is done. In mid-February, they'll file the appeal for a new trial. Andrea's lead attorney, George Parnham, is one of those lawyers who almost always has something to say. But one rainy day in early January, he was painfully silent. He'd just been to the Skyview Unit of the Texas Department of Criminal Justice to visit Yates. She still was so vulnerable and sick, he said, it took his breath away. He turned his back on the ugliness -- the beige stucco prison, the double coils of razor wire atop 10-foot fences, the ochre-colored guard towers receding in the background -- and ticked off his reasons for the visit.
     Most important, Parnham wanted to update Andrea on the appeal. But then he stopped. Yates is a bright woman, a former cancer nurse. But these days, her short-term memory is poor. She seems to understand what she is told, then she forgets. She isn't agitating to leave her prison home, Parnham said. For her, for now, there is a nightmarish past and no future. That sense of futility is another reason Parnham tries to make the six-hour round trip to Rusk to see Yates every month or two. He wants to support her, whether she is able to discuss the finer points of her case or just chit-chat about prison gardening projects or his old dog. "She's the sweetest," he said. "She always wants to talk about me."
     Parnham is well aware there's a high incidence of suicide among mothers who murder their children. During one prison visit, he thought she was actually telling him goodbye. Another reason to visit, he said. He wants to give her a reason to live. He tells her the entire community shares her blame. That possibility, that all Houstonians bear some responsibility for Yates' crimes, is discussed in Suzanne O'Malley's new book, Are You There Alone? -- The Unspeakable Crime of Andrea Yates. The book was a sore point with some of Andrea's family members. Rusty Yates said he has found a few errors but generally is satisfied with O'Malley's work. Small wonder, Andrea's immediate family thinks. Rusty, 39, is painted in a flattering light -- devoted husband, devoted father, devoted nurse to Andrea.
     The Kennedy family believes Rusty and his decisions about how they would live are at least partly responsible for Andrea's downfall. Rusty was the one who met traveling evangelist Michael Woroniecki, admired his message and introduced him to Andrea. Though the two men have had a falling out, it's widely believed that the itinerant preacher inadvertently supplied Andrea with the framework for her psychotic delusions. She told her doctors she believed Satan lived within her, her children were going to hell and she had to kill them while they were young so God would accept them in heaven. Rusty, the leader and authority figure in the Yates household, is commonly blamed for other decisions -- such as to home-school the children or live in a converted bus -- that made life more difficult for Andrea.
     At times Rusty is bitter about the criticism he has received from near and far. He was a devoted nurse. He desperately wanted his wife to get well. Early on, he was ignorant about her mental health problems, but most Americans are slow to recognize the signs and symptoms. He tried to work and juggle his responsibilities to Andrea and the children. That he couldn't do everything and be everywhere was no surprise. Incompetent doctors, insurance companies more concerned about the size of the bill than the quality of treatment, a legal system seeking an eye for an eye -- those are the villains in the Andrea Yates story, he said, not him. Publicly, the Kennedy and Yates families try to maintain a united front for Andrea's sake.
     Skyview is the prison system's version of a psychiatric hospital. The prison staff makes sure their most infamous prisoner takes her medicine, attends group therapy sessions and sees a psychiatrist. All those events take place regularly, says senior warden Todd Foxworth, but he won't say how regularly. What Foxworth can say: Yates lives in a 10-by-12-foot cell that is painted white. She has a metal door, not bars, and two narrow windows. She wears prison whites. She is allowed a few books, magazines and photos in her cell. Meals are served starting at 4 a.m., 10 a.m., and 3:30 p.m. Foxworth said his job would be easy if all inmates were as docile as Yates. He didn't mention the three or four times she was off her anti-psychotic medication. Off the drugs, she was hearing things, seeing things, and refusing to eat or drink.
     Over the years Yates has had numerous diagnoses -- everything from postpartum depression to schizophrenia. The diagnosis at Skyview at the moment is bipolar disorder. "I don't believe that for a second," said Dr. George Ringholz, who testified during the trial that Yates is schizophrenic.
Ringholz, chief of the section of behavioral neurology and neuropsychology at Baylor College of Medicine, spent considerable time testing Yates. He said all indicators -- the abnormalities in the frontal lobe of her brain, her visual and auditory hallucinations, the postpartum psychosis after the births of Luke and Mary, and interviews with her and her family -- all point to schizophrenia.
Dr. Lucy Puryear, also an expert witness for the defense, thinks Yates may have schizo-affective disorder. But the precise diagnosis really doesn't matter, said the psychiatrist and expert on women's mental health issues. "What's important are the symptoms," Puryear said. And that they be treated correctly.
     "The medical system failed her," Ringholz said. "There was an overemphasis on calling this postpartum depression. People saw her problems as isolated events, as opposed to a disease unfolding." Had Yates been helped before she killed the children, Ringholz said, her prognosis would be fairly good today. But she wasn't. And it isn't. "It's horrid," Ringholz said. It may be impossible to save Andrea Yates, Puryear said. "My guess is she'll stay in prison the rest of her life. The day she killed her children, her life was effectively over."
     Rusty visits his wife at Skyview every two weeks. Four out of five visits, they are allowed to hug hello and goodbye and hold hands while they talk. "What Andrea needs to recover is a good psychiatrist," he said. "A marriage needs certain things, too, like time together. And two hours every two weeks is not much time. We've talked, you know, about where we're going to go from here. We both love each other. But we're not together. It's difficult."
     About a year ago, Rusty quit wearing his wedding ring. Is he dating? None of your business, he said. "But no." Does he think about having more children? His life once was filled with children. He misses them horribly. Yes, he might want to try again. So, is he married or single? Neither, he said. Both, he said.
     He says he is caught, like the Israelites in the Old Testament, between the Egyptian army and the Red Sea. The Israelites waited on God's help, and God parted the Red Sea. "I'm at that point," Yates said. "I'm waiting for God to show me the way. I don't like either of the options that I see."
While Rusty throws himself into his job at NASA, he ponders what to do with his personal life. He tries to get organized. He works on his Web site, www.yateskids.org. A while back, Yates sold the family Suburban and bought a Suburu. He moved into an apartment and fixed up the family home on Beachcomber to sell. It's still on the market. He says, wistfully, that another family may buy it and establish happy memories there. He wants to be involved in the Yates Children Memorial Fund for Women's Mental Health Education, launched by the Mental Health Association of Houston and Parnham after the trial. The idea, Rusty said, is to educate new mothers about postpartum illnesses and to make sure his babies didn't die in vain. "What happened in my family will always be with me and associated with me," Rusty said. "But I would like people to know we had a great family. I'd like people to know something good can come from all this, and I want to be a part of it."
     He's sitting at a table in the Clear Lake Park. It's Sunday, family day. He takes one more look at the children playing. He has been described as enigmatic, smooth, unfeeling. But on the way out of the park, the face of the man who has lost everything is full of feeling. "I'm desperately lonely," he said.

Illinois to Change Kids' Mental Aid
Chicago Tribune, 1/26/2004

ILLINOIS -- Mental health screenings for children in crisis psychiatric situations will be merged under a single statewide program to save money and streamline services, according to a plan announced Sunday by Gov. Rod Blagojevich. The state plans to set up a hot line and consolidate the screening programs geared toward children from low-income families by July 1, said Mike Claffey, spokesman for the governor. The new system will allow Illinois to generate an additional $1.1 million in federal matching Medicaid funds and will include follow-up medical services not currently in place, he said.
      The Illinois Department of Human Services and the Illinois Department of Children and Family Services already conduct mental health screenings under two separate programs, Claffey said. Under the proposal, the two agencies, as well as the Department of Public Aid, will create a single screening process. The screenings will direct children to local community services, with a goal to "prevent unnecessary psychiatric hospitalization," Claffey said.

Maryland Deficit Limiting Options for Mental Illness Care
Christian Davenport, Washington Post- 1/26/2004

When the voices come, it's as if the air is talking to her. Persistent, genderless, they tell her that she's the greatest person alive, that the solar system is ruined, that her soul has left her. At her worst, Barbara Cecil, 50, who has had schizophrenia and bipolar disorder for most of her adult life, needs to be in a hospital with doctors, counselors and medicine working round-the-clock to keep her mind from being hijacked by thoughts that don't seem to be her own. Although she'll never be the confident young woman who grew up in Roanoke jumping horses and training lifeguards, she can, with the proper help, live in community settings and venture out on supervised trips to McDonald's or to a museum.
     But as the Maryland General Assembly debates the Ehrlich administration's plan to close Crownsville Hospital Center, a cost-saving measure first proposed last year, Cecil and her family wonder what will happen to her and the center's 200 other mentally ill patients. The shuttering of the hospital, which sits on a sprawling green campus in central Anne Arundel County, could begin as early as July. The proposal comes as the legislature is grappling with one of the most severe financial crises in decades and illustrates how Maryland's budget problems are affecting some of the state's most vulnerable residents.
     The consequences already are far-reaching. Limited funding has frozen the amount of community housing available to the mentally ill for the past three years. That means that state institutions are almost always full, with patients such as Cecil waiting to be placed in community settings. That, in turn, has forced others in need to languish in prisons, homeless shelters and hospital emergency rooms, advocates for the mentally ill said. "The whole system is backed up," said Herbert Cromwell, director of the Community Behavioral Health Association of Maryland. "The demand for public health services has never been greater. It's almost at epidemic proportions." Maryland prison officials estimate that as many as 9 percent of the state's 28,300 prisoners -- about 2,500 -- are being treated for mental illness. Meanwhile, about 1,700 patients are in the state's mental institutions.
     "Many times the money does not follow the patient into the community," said Barbara Bellack, president of the Maryland chapter of the National Alliance for the Mentally Ill. "Families are fearful that if they can't get their loved ones into the hospital, they could get arrested. We know there are more people in jails with psychiatric disorders than there are in psychiatric hospitals. It's treatment by default, and that's not treatment."
     It's a nationwide dilemma. In a report released last year, Human Rights Watch said that one in six prisoners across the country is mentally ill and that the rate of mental illness in the nation's jails and prisons is three times higher than in the general population. The problem, the nonprofit organization reported, is in large part due to a lack of funding. "Unless you are wealthy, it can be next to impossible to receive mental health services in the community," Jamie Fellner, a co-author of the report, said in a statement. "Many prisoners might never have ended up in jail if publicly funded treatment had been available."
     Mary Ervin of Crofton thinks her 25-year-old son never should have ended up in jail. Two years ago, while he was suffering a psychotic episode, he stepped in front of a bus. Acquaintances who knew that he had bipolar disorder called police to get him help, she said. But when he started knocking on the window of a parked car, the woman inside thought she was being carjacked, and he was arrested. The judge ordered him to Crownsville for an evaluation. But he remained behind bars for about two months before a spot opened up in the hospital, Ervin said. Since then, after six months at Crownsville and then a stint at a group home, her son has improved greatly. Now, he's at home and working, slowly regaining his former self. "I feel very comfortable with how he's doing now," said Lindsay Ervin, Mary's husband. "He seems happy. But there is always that fear that he could quit taking his medicine and go back to doing what he was doing before. While he's well today, tomorrow things could change."
     With Crownsville closing, families fear that a crucial safety net is being pulled from beneath them. But state health officials said that if Crownsville is eliminated, patients would be transferred to Spring Grove Hospital Center in Baltimore County and Springfield Hospital Center in Carroll County. Others would be sent to the Walter P. Carter Center in Baltimore, which, under the state's proposal, would be turned over to a private company.
     During a hearing of a Maryland Senate subcommittee last week, Health and Mental Hygiene Secretary Nelson J. Sabatini said the number of beds will stay the same if Crownsville is shut down. He vowed that "the guiding principle is first and foremost to maintain quality care." Closing the hospital, founded in 1910 as the Hospital for the Negro Insane, would save $12 million annually, he said. About $5 million of that would go toward expanding community-based treatment programs.
That move has been applauded by mental health advocates, who argue that community-based treatment is more humane and has long needed an infusion of state aid. Still, they fear that Maryland's current budget crunch could make a bad situation worse. "The cuts this year are going to be painful," Cromwell said.
     In recent years, Maryland's overburdened mental health network has routinely run deficits: $60 million in fiscal 2002 and $54 million last year. While Gov. Robert L. Ehrlich Jr. (R) has given the agency enough money to cover both of those overruns, he has made it clear that this year the Mental Hygiene Administration is going to have to live within its budget. With a deficit of $40 million and growing, that is going to mean cuts -- such as the closing of Crownsville and the scaling back of rehabilitation services, mental health officials said. "Each year, the governor has bailed us out," said Brian Hepburn, the administration's director. "He is very committed to taking care of people with mental illness. But there isn't the money to cover the deficits anymore."
     As health officials trim spending, Cecil sits in her room at Crownsville, where the door is thick and a small window allows hospital staff to check on her. It was less than a year ago that she was living in a Prince George's County group home and the voices told her that if she started a fire, she would get her soul back. She did, which is how she ended up at Crownsville. But now the voices -- which she said made it seem like "the air is talking to you, the universe, the solar system telling you about your life" -- have been muted. And her days are spent in counseling sessions, learning how to sit through a job interview and charming the hospital staff with a wide, contagious smile. She's even learning to cook her favorites: burritos, nachos and fried chicken. While her speech is sometimes slurred and the medicine makes one of her hands shake, she's improved so much that her doctors said she's ready to go back to a group home that provides 24-hour supervision. She thinks she's ready, too. "This is the best I've ever been," she said recently. In fact, she's been ready to leave the hospital since October, said Cathy Ford, her social worker. But there hasn't been any place to put her. So she waits.

FDA Weighs Anti-Depressant Risk to Kids
Associated Press, 1/26/2004

WASHINGTON -- Parents of children with depression must sort through an emotionally charged controversy in deciding on treatment: Do popular adult antidepressants sometimes increase the risk of suicide when they're given to kids? British authorities last month declared a list of common antidepressants unsuitable for children, citing that possibility. Next week, U.S. health authorities open public hearings on the issue, at which parents who blame the drugs for children's deaths are expected to face families who credit the same pills for saving lives. It's a difficult question, as depression occurs in about 10 percent of youth, and depression can lead to suicide. Some 1,883 10- to 19-year-olds killed themselves in 2001, and specialists say there are 10 to 20 attempts for every suicide.
     Antidepressants called SSRIs, such as Paxil, Zoloft and Effexor, have been long used by adults, and authorities say there's no evidence of a suicide risk for them. But medicines can work differently in children, and only carefully controlled studies can prove if suicidal behavior is more common among youths taking SSRIs. The same holds for determining whether if a risk is proved, is the risk because the drug just did not alleviate the depression or had had some other effect. No suicides have occurred in studies encompassing 4,000 children. But preliminary data suggest suicidal behavior and attempts, while infrequent, might be two to three times greater among users of some SSRIs: roughly 3.2 percent among children getting the drugs compared with 1.5 percent among those given dummy pills.
     The possible risk was spotted after the U.S. Food and Drug Administration, seeing pediatric SSRI use rising, ordered research to see whether they work in children. So far, the FDA has approved just one SSRI -- Prozac -- for use in depressed patients under age 18, but the agency says none of the others are yet proven to alleviate pediatric depression.
     Lack of benefit in the face of possible risk led to Britain's warning that SSRIs other than Prozac are unsuitable for children. Here, FDA still is analyzing the research; it hopes to have recommendations by summer. ``Obviously there are many pediatric psychiatrists who believe in these drugs, but definitive advice on what to do is still pending,'' says Dr. Russell Katz, FDA's chief of neurological drugs. ``Now, we can only say use them with caution.''
     For 18-year-old Jame Tierney of Kernersville, N.C., that's not enough warning. Next Monday, Jame will tell the FDA that fury and thoughts of suicide consumed her while taking Effexor -- an experience her family wants the government to pay special heed to because Jame wasn't depressed when she started the drug at age 14. It was prescribed for migraine headaches. A year of the starting dose induced some jitteriness. But when the headaches returned and the doctor doubled the dose, Jame's parents say their daughter went from a sweet, popular honor student to a raging loner. ``I hated my family, my friends and most of all myself,'' Jame says, describing screaming fits and hard-to-control impulses such as once lightly cutting her wrist with a razor until the pain stopped her.
Effexor maker Wyeth Pharmaceuticals wrote doctors in August to warn that while a cause-and-effect isn't certain, its studies show more suicide-related thinking in children taking the drug than those given dummy pills, including a 2 percent incidence of hostility.
     The debate elicits strong emotions. ``The aim is to do no harm. Leaving it (depression) untreated is not `doing no harm,''' says Dr. Graham Emslie of the University of Texas Southwestern Medical Center. He co-chaired a task force of the American College of Neuropsychopharmacology that last week declared evidence that links SSRIs to suicide is too weak to justify not using them. The group points to evidence that suicides have dropped as SSRI use increased around the world, and to autopsy studies that show most suicides hadn't taken an anti-depressant, or the right dose, just before their deaths.
     On the other side, critics claim SSRIs sometimes cause agitation and urgent anxiety, called akathisia, that could make certain people suicidal. ``I think these drugs have a place even in these age groups, but my ability ... to use these drugs safely is going to be enhanced if they come with the right warnings,'' says Dr. David Healy, director of the North Wales Department of Psychological Medicine, who helped trigger Britain's review.
     Day-to-day, doctors and parents are caught in the middle. ``The kids are in distress at this moment, so we have to work with the information currently available,'' says Dr. Joseph Gold, director of pediatric psychiatry at McLean Hospital, affiliated with Harvard Medical School.
He's reassured at the apparent low incidence of problems and notes that older antidepressants have far more common side effects but prescribes the lowest possible dose.

More and More Autism Cases, Yet Causes Are Much Debated
Erica Goode, New York Times- 1/26/2004

No one disputes it. Cases of autism, the baffling and often devastating neurological disorder that strikes in early childhood, are rising sharply. In California alone, the number of children receiving special services for autism tripled from 1987 to 1998 and doubled in the four years after that. National figures tell a similar story.
     The upsurge has lent urgency to calls for more research on autism and more government spending to educate autistic children and has inspired federal officials, who late last year held an "autism summit" meeting in Washington, where they presented a 10-year plan of action.
     But what lies behind the increase in cases is sharply debated. To some, the upswing has all the hallmarks of an epidemic and indicates that autism itself is increasing rapidly. To others, the rise can in large part be explained by increased public awareness of autism in recent years, changes in the way the disorder is diagnosed and the incentive of tapping into federally mandated services for autistic children. Neither side can prove its argument, because the types of studies that could tease out a true increase have not been done. But the question is crucial, experts say, because its answer has significant implications for how federal money is spent, how afraid parents should be and how much effort scientists should devote to tracking down environmental factors in addition to genetic influences.
     Advocacy groups, many of them founded by parents of autistic children, have tended to line up on the side of an epidemic. And some autism experts also believe the illness is increasing. "To me, it's a huge public health emergency, a crisis," said Portia Iversen, a founder of Cure Autism Now, an organization based in Los Angeles that finances research. Ms. Iversen said she was certain that the number of children with autism was rising sharply.
     But epidemiologists cluster on the other side of the debate. They do not rule out the possibility of a true increase in autism. But they point to flaws in the way that the rising numbers -- especially those in California -- have been presented to the public. And they say the small size and widely varying findings of epidemiological studies of autism make it impossible to say what is going on. For example, Dr. Eric Fombonne, an epidemiologist and a professor of child and adolescent psychiatry at McGill University, said most of the increase was probably a result of diagnostic changes and statistical anomalies.
     What everyone agrees on is that autism is being diagnosed more frequently than in the past. The disorder, which is believed to be strongly influenced by genes, is marked by a profound impairment in the ability to relate to other people, a delay in language development, or repetitive behaviors.
Before the mid-1980's, most studies estimated the prevalence of autism at fewer than 5 cases for every 10,000 children. Over the last decade, epidemiological studies have come up with wildly disparate estimates, from 5.2 cases per 10,000 (in a large Norwegian study) to 72.6 per 10,000 (in a small Swedish study). But the trend has been upward, with most experts agreeing that at least 10 children out of every 10,000 are autistic.
     Last year, in a review of all available studies of autism rates, Dr. Fombonne concluded that the findings "point toward an increase in prevalence over the last 15 years." But predictions for the future differ along with views of what is responsible for the increase. If autism itself is increasing rapidly, the rates can be expected to keep rising, and with them, the projections of how much money will be required for services. But if most of the increase reflects more accurate diagnosis, then rates should level off as the number of previously overlooked children diminishes.
     The different interpretations also point researchers in different directions. "If you accept the fact that the numbers have increased, you must seek an environmental cause," said Mark Blaxill, of Cambridge, Mass., a member of the board of SafeMinds, one of several advocacy groups that view some vaccines given to toddlers as a likely cause of the increase in autism. Over the years, a host of other environmental factors have also been nominated as culprits, including a variety of infections, like German measles in pregnant mothers; the sedative drug thalidomide; the drug Pitocin, used to induce labor; synthetic compounds like plastics and PCB's; and food additives.
     Yet so far, said Dr. Fred R. Volkmar, an autism expert and professor of psychiatry at the Yale Child Study Center, "hard scientific evidence to support any specific environmental cause has been lacking." "Many of the purported environmental causes," Dr. Volkmar went on, "have been proposed on the basis of a single case, or a handful of cases, and the observations have not held up in larger samples."
     A number of studies, including a large Danish trial, have found no link between autism and the so-called MMR vaccine for measles, mumps and rubella, though some advocates remain unconvinced. The possible role of a mercury-based vaccine preservative, thimerosal, is still being investigated. But many investigators express skepticism for such a connection. For the last few years, vaccines sold in the United States for the routine immunization of children either have not contained thimerosal or contain only a trace, according to the Centers for Disease Control and Prevention. The agency and the American Academy of Pediatrics have stated that no credible scientific evidence connects thimerosal with autism or other childhood neurological disorders.
If autism itself is not increasing markedly, the role of environmental influences diminishes.      Epidemiologists say the wide variance in estimates from the prevalence studies that do exist support the idea that the disorder has not increased hugely. In 2000 and 2001 alone, various published studies in the United States, Britain and Scandinavia put autism rates per 10,000 children at 30.8, 7.8, 12.2, 40.5, 26.1, 13.2 and 16.8. A study in Brick Township, N.J., published in 2001, found 36 cases among 8,896 children studied, a rate of 40.5 per 10,000. Each study uses different methods and defines autism slightly differently. Complicating matters further, some studies include what are called autism spectrum disorders, a category that includes conditions like Asperger's syndrome.
     Another reason for caution, the epidemiologists say, is that the numbers that have received the most publicity -- the California findings, for instance, reported by the state's Department of Developmental Services -- are not based on scientific studies. Instead, such reports are simply tallies of the number of children enrolled in state programs who carry an autism diagnosis. They do not take into account changes in methods of diagnosis or shifts in population over time.
     Even so, the scientific support that would clinch the skeptics' arguments is lacking. "We don't have a lot of evidence one way or another, sadly," said Dr. Craig Newschaffer, an associate professor of epidemiology and mental health at Johns Hopkins University. Dr. Newschaffer said he believed "a large chunk" of the increase was a result of heightened public awareness and other such factors. "The devil is in how big a chunk is that big chunk," he said.
     Dr. Robert S. Byrd, an associate professor of clinical pediatrics at the University of California at Davis, has tried to clarify the issue by examining the California data to see whether methods of diagnosis or other statistical anomalies could account for the increase. Joined by colleagues at the university's MIND Institute, Dr. Byrd scrutinized 684 children enrolled in 21 regional centers for developmental disorders, including autism and mental retardation. About half were born from 1983 to 1985, the other half a decade later. The study was based on questionnaires given to the children's parents. It concluded that the same proportion of children in each age group - about 88 percent - met the diagnostic criteria for autism, suggesting that changes in diagnosis did not explain the increase in cases. The researchers also say they excluded two other possibilities: that parents were moving to California to obtain autism services and that some children with autism were in the past labeled as mentally retarded.
      In a report to the California Legislature in 2002, Dr. Byrd and his colleagues concluded that "some, if not all, of the observed increase represents a true increase in cases of autism in California."
Yet their study, which has not been published in a peer-reviewed journal, itself became an immediate magnet for controversy. Critics found serious flaws in it, including the small sample of responses. They also cited a variety of other factors, including public awareness, that were not examined in the study and so could not be ruled out.
      The Centers for Disease Control, which in 2000 began a surveillance program to track autism cases in 18 states, may have a better chance of deciphering the issue. Dr. Marshalyn Yeargin-Allsop, the medical epidemiologist who is overseeing the effort, said the agency was studying the prevalence of autism, demographic factors like race and ethnicity, an array of possible causes of the disorder and whether autism increases over time. In the meantime, if the numbers keep rising, the debate over what they mean will continue. "When do you say some of it has to be real?" Dr. Newschaffer asked. "I don't think anybody knows the answer to that question."

Panic Attacks Are Traced to Chemical In the Brain
Anahad O'Connor, New York Times- 1/27/2004

Sudden heart-pounding panic attacks are most likely caused by abnormalities in the brain, new evidence suggests, reinforcing earlier research on animals. People with panic disorder, according to scientists at the National Institutes of Health, have drastic reductions of a type of serotonin receptor, called 5-HT1A, in three areas of the brain. The findings, reported last week in The Journal of Neuroscience, lend credence to the suspicion that serotonin dysfunction plays a role in the disorder.
"This provides evidence for what we've been telling patients all along," said Dr. Dennis S. Charney, chief of the mood and anxiety disorders research program at the institutes and an author of the paper. "Panic disorder is due to a specific abnormality in the brain, not a weakness in character."
     About 2.4 million Americans have the disease, which can leave its victims living in constant fear of attacks that might plunge them into outbursts of worry and thoughts of impending death. Experts have compared it to being stalked by a lion. The episodes, often resembling a heart attack and known to strike at any time, can be so terrifying that some associate them with the place that they occurred -- the subway or the grocery store, for example -- and will refuse to go there again. Traditionally, the biological basis of the disease has been poorly understood. But some of the best drug treatments are serotonin enhancers, which have hinted at the chemical messenger's involvement for some time. Also supporting that theory is research on mice. When a gene for serotonin receptors is eliminated, the animals have a greater risk of anxiety.
     In the latest study, scientists used brain images to peer at serotonin receptors in humans. The subjects, 16 people with panic disorder and 15 who did not have the disorder were injected with small quantities of a benign radioactive tracer that latched onto the receptors, allowing the researchers to count them and pinpoint their locations. The disparity was marked. Subjects in the panic group averaged a third fewer receptors in areas known as the anterior and posterior cingulates. The group members were also deficient in the the raphe, which has connections to a region that processes emotion.
     Dr. Alexander Neumeister, a research psychiatrist at the National Institute of Mental Health and an author of the study, said there was a strong likelihood that the receptor deficiencies were genetic. But he also cautioned that he could not rule out the possibility that the depletions were actually a result, rather than a cause, of the disorder. "We don't know if this was there before these people were ill," he said. "The next step is to study people who have a history of panic disorder in their families but are asymptomatic. Then we can determine which comes first."
     The illness, which most commonly begins between late adolescence and the mid-30's, is just one in a group of anxiety-inducing ailments that are relatively widespread. About 19 million Americans are afflicted by one of the diseases; obsessive-compulsive disorder, post-traumatic stress disorder and specific phobias are among the more well known.
     One expert, Dr. Michael Liebowitz, a professor of clinical psychiatry at Columbia, who did not participate in the study, said the findings were significant but needed to be replicated. "There are still a few issues, like whether this is something that is specific to panic disorder or something in anxiety disorder in general," Dr. Liebowitz said. Still, said Jerilyn Ross, president of the Anxiety Disorders Association of America, the research sheds some light on the biological underpinnings of the disorder and may lift some of its stigma. Almost 75 percent of people with panic disorder do not receive treatment, she said. Some, she added, are dismissed by doctors who think they are hypochondriacs. "Anxiety, even in the mental health system is often overlooked," Ms. Ross said. "So a study like this reinforces the fact that it is real and should be taken seriously."

In a Mental Institute, the Call of the Outside
David Hellerstein, M.D., New York Times- 1/27/2004

We have a power problem," said Dr. C., the chief of our general research unit. It was the fall of 2000, shortly after I started work as clinical director of a psychiatric institute in New York. At our weekly meeting of unit chiefs, we had been discussing the usual issues -- how many beds were full, who was ready for discharge -- when Dr. C. brought up a new topic, one I had never encountered in my 20 years as a psychiatrist. "A power problem?" I echoed. Was this some sort of psychological shorthand, perhaps, or a reference to hospital politics? "Yes," said Dr. C. "There aren't enough sockets up at the nursing station to plug in everyone's chargers." "Chargers for what?" I asked, even more confused. "For batteries. For the patients' cellphones and computers," Dr. C. said. "It's a real problem for the nurses. After they charge up, the patients go into their rooms to talk, but they can only stay there until their batteries run out, and they're always rushing up to the nurses' station to recharge."
     When I had last worked on an inpatient psychiatric unit, in the early 1980's, such devices were in the realm of science fiction. In the interim, I had toiled in outpatient settings. So it had been a bit of an adjustment to get settled into my new job at the institute, where I was overseeing three patient units, a total of about 60 beds. Every week there was something new. "I didn't even know that we let patients have cellphones here," I said. "Only on the general research unit," Dr. C. said. "Our patients aren't in as much of a crisis as the patients on the other floors, and some of them stay for several months. They want to stay in touch. Cellphones and laptops - well, they're just used to having them." "Why can't they just plug them in?" "Because they could use the cords to hang themselves."
     Of course. In my experience, each inpatient psychiatric unit had perhaps one or two pay phones secured to the wall near the nursing station. When a call came in, the receiver would be left dangling while the patient was summoned. Suffice it to say no one had privacy, whether to family, friends or doctors. Hence my surprise that, at least on one of our patient psychiatric units, patients could talk wirelessly to anyone. We said O.K. to the cellphones and the other wireless devices on the research unit. Dr. C. even got some power strips to allow more chargers to be plugged in. We were proud. Here, as in so many other areas, our institute was on the leading edge -- with Internet access in occupational therapy, and with all these devices on the floor. And the devices multiplied. Besides cellphones and laptops, we now had an influx of Palm Pilots and BlackBerries and pagers as well. And soon, perhaps predictably, problems arose. Some were practical. What if a device disappeared, or if one patient broke another's device? Nurses complained that they spent an inordinate amount of time untangling cords and baby-sitting delicate gizmos.
     Other issues were clinical. What if patients spent all their time on the phone and refused to go to therapy? What if substance abusers used their phones to "order in" their drugs of abuse (not a far-fetched idea in Manhattan)? Clearly, limits had to be set. On the other hand, we wanted some patients to talk on the phone: the ability to reach out to others might speed a patient's recovery from depression, or hasten the emergence from psychosis.
     We marveled at another change, in stigma. Traditionally, the last thing patients want is for their friends and neighbors to know they had checked into the "nuthouse." Now, when the phone rang, and a friend asked, "Where are you?" the answer could be, "In the psych hospital." From that perspective, bringing your cellphone seemed like a brash vote of confidence for the New Psychiatry.
     While our psychiatric institute was getting wired, in my own private practice I had gone unplugged. A few evenings a week I see patients at an office in a grand old building on Central Park West in Manhattan. After years of practicing in a busy clinic -- with a computer on my desk, and instant access to e-mail, Internet and lab results, and with fax and copy machines down the hall, I found myself in a high-ceilinged room with several comfortable chairs, a desk and little else. No computer, no copier, no scanner, no fax machine. Though I did have a phone, I kept the ringer turned off; and my beeper rarely bothered me. After a period of anxious adjustment (What if I needed to copy someone's insurance card or lab results? What if an urgent fax must get through?), I became blissfully happy. It was just the patient and I. Instead of worrying about e-mail messages popping up on my screen or faxes down the hall, I could focus entirely on what my patient was telling me. For a brief time, for both my patient and me, the external world could disappear.
So that is why I continued to wonder about the wireless world's entry into the psychiatric hospital, and whether we were losing the little that remained of asylum. The concept of asylum is a much-diminished one -- that people in psychic distress may want and need to escape from the outside world, to seek a kind of isolation and quietude.
     It is fair to say that the modern psychiatric ward may offer little of the serenity that Sylvia Plath or Robert Lowell sought 50 years ago in their stays on the leafy and bucolic grounds of McLean Hospital in Belmont, Mass., or at the old Payne Whitney Clinic on a bluff overlooking the East River. But until the advent of cellphones and wireless computers, it was fairly easy to get unplugged from the world, to find at least a few days of peace. Now, on our research unit, there was no escape. Once, the world was "here" and the asylum was "there." Now everywhere was "here." In some ways this was reassuring, but in other ways creepy. After all, if you have serious depression or a life-threatening eating disorder, maybe you do need some time away from your friends, co-workers and family. But I accepted this change as the price of progress.
     And so things went for the first three years of my work as clinical director. Until one recent meeting of unit leaders, when Dr. C. announced: "We've come to a decision. Enough is enough. No more cellphones!" I was shocked. As far as I knew, our wireless experiment had been going reasonably well. "Why?" "Because they were too disruptive." Dr. C. was uncharacteristically irate. "There was a constant ringing on the unit. All these different ring tones. Some people would put them on vibrate mode and sneak them into group and then want to walk out to answer their calls. Or they would be talking to their friends and would ignore the nurses. "Plus, patients would arrive on the unit without a cellphone and when they found out that everyone else had cellphones, they would get them."
     Internet access, e-mail, instant messaging -- that was one thing, in Dr. C.'s eyes. But cellphones brought in the world in real time. They were too "now," too intrusive. The final straw was the new camera phones: how could you ensure anyone's privacy? Clearly these devices brought in the outside world with startling and unwelcome immediacy. What about patients' rights to communicate? The other unit chiefs besieged her with questions. What about their autonomy?
Dr. C. countered: patients with cellphones interfered with the other patients' rights to peace and quiet. She would not be swayed. "There's only one exception," she said. "Patients who are looking for jobs need to have voice mail, something that doesn't indicate that they are in a psych ward. So we keep their cellphones in the nurses' station and they can retrieve them once a day to answer their calls."
     And so our experiment ended. Laptops and Palm Pilots, yes. Internet connections and e-mail, fine. But no cellphones. Two months later, things are much quieter on the unit, Dr. C. reports. Much more asylum-like again. After a certain amount of grumbling, patients are again participating in activities. Is it over? I don't know. Here at the institute, our enthusiasm for wireless connectivity has been tempered by reality. We have reclaimed a fragment of asylum. But my guess is that we will face a next challenge by the wireless world, and that we will continually have to work to define our relation to it. My guess is that the battle has just begun.