Often, Time Beats Therapy for Treating Grief
Jane Brody, New York Times- 1/27/2004

It is commonly assumed in this therapy-oriented world that nearly every grieving person can benefit from bereavement counseling or therapy. But both the experience of psychologists who provide bereavement services and a thorough review of the literature on the results of grief therapy suggest otherwise. Rather, the findings suggest, a majority of people who suffer the loss of a loved one neither need nor benefit from participation in a bereavement group or from more formal grief therapy. These people experience what might be called a normal grief reaction, and the symptoms of it gradually diminish over 6 to 18 months. "Feeling grief is the burden we face because we're capable of becoming attached and loving people," said Dr. Robert Hansson, a psychologist and student of grief at the University of Tulsa. "It's a natural process. It hurts, but most people can work through it and go on."
      A major new "Report on Bereavement and Grief Research" prepared by the Center for the Advancement of Health concluded, "A growing body of evidence indicates that interventions with adults who are not experiencing complicated grief cannot be regarded as beneficial in terms of diminishing grief-related symptoms." The report adds that there is very little evidence for the effectiveness of interventions like crisis teams that visit family members within hours of a loss, self-help groups that seek to foster friendships, efforts to show the bereaved ways to work through grief and a host of other therapeutic approaches believed to help the bereaved.
      In fact, the studies indicate, grief counseling may sometimes make matters worse for those who lost people they loved, regardless of whether the death was traumatic or occurred after a long illness, according to Dr. John Jordan, director of the Family Loss Project in the Boston area. Such people may include the only man in a group of women, a young person in a group of older people, or someone recently bereaved in a group that includes a person still suffering intensely a year or more after the loved one's death. Further, the research suggests, bereavement counseling is least needed in the immediate aftermath of a loss. Yet it is then that most grieving people are invited to take part in the offered services. A more appropriate time is 6 to 18 months later, if the person is still suffering intensely.
      Even when bereavement therapy is needed, however, the benefit may depend on the approach used. For example, most bereavement groups focus on emotional issues. These are most helpful to women. But men tend to grieve differently, and they are more likely to benefit from an approach that focuses on their processes of thinking.
      Caring friends and relatives often coax those who have just suffered the loss of a loved one to seek professional help, either by taking part in a bereavement group or through individual psychotherapy. But Dr. Robert A. Neimeyer, professor of psychology at the University of Memphis, editor of the scientific journal Death Studies and chairman of the committee that prepared the new report, said in an interview: "Not everyone requires the same thing. Dealing with grief is not a `one size fits all' proposition."

Fresh Approaches
Dr. George Bonanno, psychologist at Columbia's Teachers College, has found that the bereaved who naturally avoid emotions should not be forced to confront grief. Even three years later, such people show no traumatic consequences as a result of suppressing it, he reported. In more than half the cases, Dr. Neimeyer explained, far more useful than therapy to the bereaved are the empathy and emotional and physical support that friends, relatives and caring people in the neighborhood and at work can provide in the first weeks and months after a death. Only when grieving is "complicated" — intense and protracted, associated with deep unrelieved depression and interfering with normal enjoyments, life tasks or an ability to work — is there a clear-cut need for grief therapy, Dr. Neimeyer said.
      Dr. Hansson of Tulsa observes that many people who experience complicated grief have neither faced their losses nor allowed themselves to work through the emotions that naturally ensue.
If, months down the road, a bereaved person is still grieving intensely, therapy should be sought, Dr. Neimeyer said. Among the hallmarks of complicated grief he listed are "intrusive thoughts about the deceased, recurrent images of how the person died, a continual quest to reconnect with the deceased, corrosive loneliness, feeling purposeless and empty, difficulty believing the death ever happened and feeling that the world cannot be trusted. Treating people with these symptoms is important because their unresolved grief can have serious, even life-threatening health consequences, including high blood pressure, stroke, heart attack, substance abuse and suicide. "Such people can literally die of a broken heart," Dr. Neimeyer said.
      Perhaps the most revealing study of the varying courses of bereavement was undertaken by Dr. Bonanno, Dr. Camille B. Wortman, a psychologist at the State University of New York at Stony Brook, and six co-authors. They evaluated 1,532 people (all married, with at least one partner of each couple over age 65), then followed them for up to eight years. When a spouse died, they assessed the bereavement experiences of the widow or widower over time. This is what they found: Forty-six percent of the survivors were "resilient." They experienced transitory distress, but scored low in depression both before the death and at 6 and 18 months after losing their spouses. Eleven percent followed a common grief course, with rather severe depression at 6 months that had largely disappeared by 18 months. Sixteen percent, who were not initially depressed, nonetheless were devastated afterward, experiencing prolonged depression. Eight percent were chronically depressed beforehand, with the depression worsened by the death. But 10 percent who had been depressed before the death did very well afterward, perhaps because they had been in bad marriages or were relieved from the burdens of taking care of ill spouses. The remaining 9 percent did not fit into any category.

No Single Pathway
"Clearly," Dr. Neimeyer said, "the five stages of grief — denial, anger, bargaining, depression and acceptance — don't necessarily fit. There is no one pathway through grief. Depending on their grief reaction, people may require very different therapy or no therapy at all." Also new are professional beliefs about the goals of resolving one's grief, which traditionally focused on forgetting the loss and moving on. "We are less wedded to seeking closure, to the idea of saying goodbye to the one who died," Dr. Neimeyer said. "We now recognize the importance of finding healthy ways to sustain a relationship with a deceased loved one, to maintain continuing healthy bonds, for example, by carrying forth their projects. "Closure is for bank accounts, not for love accounts. Love is potentially boundless. The fact that we love one person doesn't mean we have to withdraw love from another."

'Overlooked' No Longer
John Langone, New York Times- 1/27/2004

The Complete Guide to Mental Health for Women," edited by Dr. Lauren Slater, Dr. Jessica Henderson Daniel and Dr. Amy Elizabeth Banks. Beacon Press, $24.95.
      Why women's mental health? Why not just general mental health? The answer, the authors of this home reference conclude, is that men and women are different, in mind, body and psyche. "They are different in hormonal development, in brain development, in physiological development and in social development," they say. Add to that the fact that models of female psychological development are for the most part male, and the authors' contention that "we have been overlooked" appears to be well founded.
      The book is a collection of observations by psychologists and psychiatrists. Among the many topics covered are postpartum depression, menopause, aging and its effects on mood and memory, why women are at greater risk for developing schizophrenia in midlife or old age, issues of sexuality, women of color and relationships, domestic violence, and afflictions from addiction to eating disorders. We learn that little is known about what a "normal" female sexual response is, that women exposed to trauma develop later problems at rates higher than men, and that depression in women strikes earlier than in men. The book provides valuable advice on drug and other treatment options, exercise and physical activity, how to find and choose a therapist, and what questions to ask a psychiatrist.

Abuse Case Revisited, Cloudier Than Ever
Peter M. Nichols, New York Times- 1/27/2004

On the cover of the DVD version of Andrew Jarecki's "Capturing the Friedmans," released today by HBO, is the question "Who do you believe?" When Mr. Jarecki's acclaimed documentary about the Friedman child molestation case of 1988 opened in theaters last May, it provided plenty of information for viewers to make their own judgments on the merits of the charges brought by prosecutors on Long Island against Arnold Friedman and his son Jesse, who both pleaded guilty and went to prison. Now the DVD, loaded with extras, comes along to reinforce or perhaps challenge previous opinions.
      DVD's routinely expand on films and their making of course, but here the DVD has a chance to step into current developments and play a part in a continuing judicial process. On Jan. 7, citing disclosures in Mr. Jarecki's documentary, a motion was filed in Nassau County Court to vacate the conviction of Jesse Friedman, who was paroled in 2001 after serving 13 years in prison. (His father died in prison in 1995.) Serving as an addendum, the DVD, with its more than 30 short segments about the original investigation and the Friedman family, has been submitted to bolster Mr. Friedman's case. "A lot of that didn't fit into the film, but it's interesting in a legal action," Mr. Jarecki said in an interview last week. In case Nassau County doesn't have a DVD player, some extras were transferred to tape for inclusion in Mr. Friedman's motion.
      Whom to believe? On one side are the police of Great Neck, N.Y., who brought charges after interviewing scores of children who took computer classes in Arnold Friedman's basement, where the assaults were said to have taken place. On the other are Arnold and especially Jesse Friedman, who in a fresh interview that is on the DVD but not in the movie further explains his guilty plea and professes his innocence.
      Many other questions came up when the movie opened. "We heard from theater managers that there was a problem," Mr. Jarecki said. "People weren't leaving after the film. They were sitting in their seats, arguing about things, so they couldn't clean the theater." Mr. Jarecki and his fellow filmmakers began interviewing those who lingered. "People had strong reactions, they wanted to know more, talk more, and we realized this could be a starting point for the DVD," he said. One segment on the second disc answers frequently asked questions about the case and the members of the Friedman family. What are their relationships today? Why did they record their lives and troubles in such detail on videotape, an extraordinary part of the movie? Another DVD segment goes into the investigation and the methods used by the sex crimes unit of the Great Neck police. It is here that most of the contention rested and still lies. Did the police coerce fictitious stories of abuse from children?
      In a commentary with the film, Mr. Jarecki and Richard Hankin, the movie's editor and co-producer, say they worked to maintain a balance between the sides and tested that impartiality with audiences in preview screenings. Nevertheless it is hard to avoid the feeling that from the movie's standpoint the charges of violent sexual assault were badly flawed. The extras on the DVD's second disc emphasize the film's doubts. Detectives directly contradict each other on the methods of questioning, with one saying that it was important to have a child say what happened without prompting and the other holding that the child must be told that the questioner knows what happened and the child had better go along with it. One segment of the DVD includes the transcript of a tape recording, secretly made by a parent, of a detective being abusive and threatening when a child denies he was molested in the Friedmans' basement.
      "The film tries to be balanced, but by the end of the day you have a group of police officers, a judge, a district attorney who took a lot of bows for prosecuting the Friedman case, and on the other side you have a decimated family and an 18-year-old kid who went to jail for 13 years," Mr. Jarecki said. "So we have to come out with some sympathetic reaction to them."
      Both the film and DVD imply an assembly-line investigation that went from the discovery of pornographic publications in the Friedman house to the assumption by investigators that the Friedmans must be generating such materials themselves by filming molestations of Arnold Friedman's computer students. A journalist who has examined this and other child-molestation cases describes what she calls a national hysteria about so-called sex rings in the late 1980's and, in Great Neck's case, an inclination to jump to conclusions because the investigation needed to produce what the community wanted to believe.
      By any standard the DVD extras heighten the drama. One segment has the detectives and the journalist in a face-to-face confrontation during a question-and-answer session after a screening of the film at the TriBeCa Film Festival last year. Another segment has an exchange between the judge who tried the case, Abbey Boklan, and Mr. Jarecki at the premiere of the movie in Great Neck. Many segments are devoted to the Friedmans and their chaotic relations with one another. More home videos catch a family in turmoil but always given to a certain amount of showmanship in front of the camera. Jesse is a likable young man, direct and optimistic even as he contemplates life as a sex offender. His older brother, David, described as New York City's leading birthday clown, is the angriest Friedman, introspective and sympathetic in his own way. "It's clear that the family has been beaten so far beyond recognition, even people who appreciate the balance of the film can say, `Well, I don't know really what happened, but at least I can agree I don't think these guys had a chance,' " Mr. Jarecki said.
      In a segment made in September, 22 months after his release from prison, Jesse Friedman shows us the locater device he wears around his ankle. "The whole purpose of this movie for David and I was to try to get my conviction overturned," he says, "set up an environment where people in the computer class would come forward and say, `I know I said certain things to the grand jury, but those things weren't true.' " Mr. Jarecki said that he went back and filmed nine such people for the current court motion but didn't include them on the DVD.

Caution Urged on Anti-Psychotic Drugs
Associated Press, 1/27/2004

People taking certain drugs for schizophrenia, manic-depression, autism, dementia or several other psychiatric disorders should be carefully watched for signs they are developing diabetes, obesity or high cholesterol, four medical societies say. The recommendation follows recent studies that link those potential side effects to certain anti-psychotic drugs. The statement deals with six now available in the United States: Abilify, Clozaril, Geodon, Risperdal, Seroquel and Zyprexa. The recommendation, released Tuesday, comes from the American Diabetes Association, the American Psychiatric Association, the North American Association for the Study of Obesity, and the American Association of Clinical Endocrinologists. It appears in the February issue of the journal Diabetes Care.
     The medications differ in their risks of promoting the various side effects, the statement says. So a patient who develops a problem with one drug can be gradually switched over to another drug with less potential for that problem. For example, a switchover should be considered if a patient has a weight gain of 5 percent or more, the statement says. Obesity and diabetes, like high cholesterol, raise a person's risk of heart disease.
     The recommendation says doctors should screen patients before starting them on such a drug or as soon as possible afterward, noting such things as a history of obesity and diabetes in the patient and the family, and the patient's weight, blood pressure and cholesterol levels. Doctors should also monitor the patient once therapy has begun.
     Patients and family members should be informed of the potential for the side effects, and be told of signs of diabetes and especially those of a life-threatening complication called diabetic ketoacidosis, the statement says. That complication is marked by such symptoms as weight loss, nausea, vomiting, rapid breathing and dehydration. That complication has appeared in some people using anti-psychotics, and it was an early tip-off that the drugs might be linked to diabetes.

Not All Young Bullies Are Boys
Deborah Bach, Seattle Post-Intelligencer- 1/27/2004

Rachel Simmons, author of two books on female bullying, has a confession to make -- she was once a bully herself. Appearing at Seattle Girls' School yesterday during a cross-country tour promoting her new book, the 29-year-old Brooklynite came clean to a group of about 100 middle-schoolers.
     Simmons told them about her best childhood friend. The pair were inseparable until ninth grade, when Simmons joined the popular clique and, at the whim of its leader, turned on her girlfriend. Without explanation, the group stopped talking to the girl, who was devastated. "She eventually left the school and she never came back," Simmons told the roomful of girls, who listened raptly. "That's how much we hurt her."
     Simmons' second book, "Odd Girl Speaks Out: Girls Write about Bullies, Cliques, Popularity and Jealousy," was published in December. A collection of poems, songs and essays, the book sheds light on the particular brand of nastiness girls inflict on one another. Simmons contends there is a "hidden culture of girls' aggression," spawned by a society that denies girls the right to deal with conflict openly. Consequently, Simmons maintains, girls turn to covert forms of aggression: backbiting, exclusion, rumors and silence. Because anger is rarely articulated, the behavior flourishes beneath the radar of teachers and parents, making it nearly impossible to detect -- and often deeply wounding.
     Yesterday, the middle schoolers shared their stories with Simmons and a panel of high school girls from Seattle's Holy Names Academy. Simmons has been hosting similar sessions around the country, abandoning the usual promotional bookstore appearances for what she calls "Oprah for girls" -- rap sessions intended to provide younger girls with advice, comfort in the knowledge that they're not alone, and a venue to articulate what they've experienced. Audiences, she said, have been responsive.
     "I think the reason why they are so eager (to talk) is that there really just isn't, unfortunately, an opportunity for girls to ask questions about the underside of friendship, the hard parts, the awkward moments and the feelings of discomfort," Simmons said in an interview earlier in the day. "It's really hard to find advice about that and yet ironically, it's probably the subject that's closest to their hearts -- their friendships, their relationships."
     Seattle Girls' School students talked about being suddenly abandoned by friends, about being upstaged by them, about feeling devastatingly alone in a group of peers. Simmons -- an animated speaker whose talk is peppered with girlspeak like "ohmygod," and "whatever" -- empathized and offered insight. She talked about the forms of aggression girls engage in, from the social aggression that involves attacking someone's self-esteem or reputation, to the indirect aggression that might prompt a girl to "accidentally" trip and slam someone into a locker. Girls practice their aggression secretly, Simmons told the group, "because we expect girls to play by different rules than boys. Girls are not allowed in our society to be angry, to be upset. They're told that a good girl is a nice girl."
Marja Brandon, head of the private Seattle Girls' School, said that when Simmons contacted her in late summer about making a second appearance at the school, she welcomed her back. "For boys it's OK to show your emotions and be direct. For girls, somehow being direct isn't ladylike," Brandon said. "I think she does a great service by naming it, addressing it and letting us discuss some of those behaviors."
     Simmons has been on both sides of the bullying divide. The impetus for her bestseller "Odd Girl Out," published in 2002, dates back to a third-grade classmate named Abby. The girl turned Simmons' best friend against her, and soon persuaded the remainder of her friends to follow suit. Sixteen years later, as a Rhodes scholar studying at Oxford, Simmons found herself still trying to make sense of what had happened with Abby. She headed to the library, expecting to find reams of research on girl aggression. The dearth of information she encountered prompted Simmons to send an e-mail to her friends in the United States, asking for women's stories about female aggression. Within a day she was deluged with responses, and soon had a book contract.
     Simmons studied political science and women's studies at Vassar College, and was skeptical that she could break new ground on gender studies. But the response she encountered while working on her book indicated otherwise. "Everywhere I went -- checkout lines, hair salons, a long-distance operator when I was signing up for a plan -- everyone who heard what I was doing became immediately emotional and connected," she said.
     While researching "Odd Girl Out," Simmons got back in touch with the childhood friend she scorned, who was also working in Washington, D.C. They met for coffee one day, and the woman confronted Simmons about the past. Simmons, who had denied the behavior to herself, ended up apologizing. "Amazingly," she said, "now we're good friends."

Report Criticizes Mental Health Care of State's Young Inmates
Jenifer Warren, Los Angeles Times- 1/28/2004

SACRAMENTO - Juvenile convicts suffering mental illnesses are often over-medicated and improperly punished and cared for by inadequately trained clinicians who tend to intervene only when crisis strikes, a state-funded report on the California Youth Authority concludes. The report, obtained by The Times on Tuesday, described a patchwork state system of care that is inconsistent from facility to facility. It cited a failure to track the effects of mind-altering drugs and an over-reliance on punishment -- segregation in a wire-mesh cage, for example -- for youths who need therapy instead. Though acknowledging that progress had been made during their review of the juvenile penal system, the report's authors said "the California Youth Authority continues to fall short of meeting many recognized standards of care."
      The report was conducted as part of a class-action lawsuit filed by wards, as young convicts are called, alleging unconstitutional conditions within the Youth Authority, once a national model for rehabilitation of wayward juveniles. Its authors, experts on psychiatry and corrections, were jointly approved by lawyers for the wards and the state, which paid for the review.
      The findings drew attention in the Capitol on Tuesday in part because of the suicides last week of two teenagers at the Preston Youth Correctional Facility in Ione, east of Sacramento. Deon Whitfield, 17, of Los Angeles and Durrell Taddon Feaster, 18, of Stockton hanged themselves with bedsheets in the cell they shared, authorities said. "These suicides put a human face on the tragedy of what happens when we do not pay attention to the mental health needs of incarcerated teenagers," said Sen. Gloria Romero (D-Los Angeles), chairwoman of an oversight committee on corrections. "The Youth Authority has a crisis in its health-care delivery, especially when it comes to meeting mental health needs."
      In addition to reviewing mental health care within the CYA, outside experts also have produced reports on other aspects of the juvenile penal system, from education to violence, gangs and rehabilitation. Romero said those reports would provide fodder for a hearing she will convene in February on the system and what can be done to improve it.
      At the Youth and Adult Correctional Agency, a senior official called the mental health report "pretty ugly" and acknowledged problems. "We know that many of the observations are substantially correct," Assistant Secretary Tip Kindel said. "It's another thing the secretary [Roderick Q. Hickman] inherited. We realize these are things we need to get our arms around now." Kindel said Hickman -- recently appointed by Gov. Arnold Schwarzenegger -- had ordered the CYA's new director, Walter Allen III, to review the reports and devise a plan to correct the problems on a "quick timeframe." At the same time, Hickman is working with the Department of Corrections to tackle a list of woes besetting the adult system, problems that came to light during a special Senate hearing co-chaired by Romero and Sen. Jackie Speier (D-Hillsborough) last week.
      Whistle-blowers at the hearing charged that the prison system was suffering from a "code of silence" that was preventing guards from reporting wrongdoing. Also this month, a federal court investigator issued a scathing report concluding that the department had lost the ability to investigate and discipline rogue officers, in part because the guards' union held sway over decisions at the highest levels of management.
      The CYA report was based on inspections and interviews with a wide variety of staff and wards at nine juvenile facilities, including Preston, where the suicides occurred. It was written by Eric Trupin and Dr. Raymond Patterson, who have evaluated mental health care at correctional facilities across the country. Among findings that most alarmed them was the overuse of "chemical restraints," or drugs, on wards, "particularly when administered to youth who are not presenting a threat to staff or other youth and are being non-compliant." "Psychiatric evaluations are cursory and do not meet accepted professional standards," the report said, and "measurement of the effect of the medication on target symptoms is consistently missing." Overall, the report's authors expressed "grave concerns relative to the competence of the psychiatric staff." Founded in 1941, the Youth Authority houses 4,600 inmates in 11 institutions and four camps.

Soldiers Returning From Iraq Face Mandatory Counseling
Ron Claiborne, ABC News- 1/29/2004

P O P E A I R F O R C E B A S E, N.C. - For the first time, U.S. soldiers returning from Iraq are being required to undergo counseling to help them adjust to being home. The U.S. military is concerned combat experiences and being away for an extended period of time could put returning troops at risk for post-traumatic stress, domestic problems and even suicide.
Spc. Robert Hernandez of the Army's 82nd Airborne admitted being nervous about what it would be like to return to his old life after spending nearly a year on the battlefields of Iraq. "It's going to be weird and strange," said Hernandez. "Our whole lifestyle is completely different from what it used to be." When Sgt. Mike Bechtel was on leave last November, he was constantly on the lookout for roadside bombs. "They can expect some of that, I'm sure," he said. "I know I did when I was on leave. A little on edge, a little jumpy."
     Once soldiers complete two weeks of counseling, they will get 30 days of leave. They sometimes call home being "back in the world." For the 82nd Airborne's Third Platoon, Alpha Company, coming "back to the world" was no easy task. It took four days of shuttling from base to base and tent to tent, including 20 hours on a cold, crowded plane to get back to North Carolina.
They are among 125,000 troops currently being replaced by 110,000 fresh soldiers and Marines.
The 82nd Airborne flew into Southern Iraq last March. What was supposed to be a quick airstrike turned into a 10-month deployment.

Nebraska Governor Defends Mental Health Reform
Associated Press, 1/29/2004

LINCOLN, Neb. -- Saying he will have no higher priority in his remaining three years in office, Gov. Mike Johanns continues to defend and push his plan to close the Hastings and Norfolk regional mental health centers in favor of more home-based care. ``We can improve the lives of literally hundreds of Nebraska families,'' Johanns said Thursday.
     He was joined by the state's six regional mental health administrators who leant their support for the proposal. Johanns also touted a report by a health care consulting firm that said his plan is ``highly principled'' and can be done in the time and with the money proposed. Johanns said he was happy with the work being done across the state to see that the plan goes forward. ``I see a very positive spirit,'' Johanns said.
That positive spirit has yet to overcome Mike Nolan, city administrator of Norfolk. ``Warmed over, left over,'' he said when asked for his reaction to Johanns' latest comments. He called the mental health reform initiative ``conceptual puffery'' and claimed that the concerns of Hastings and Norfolk have not been adequately addressed. ``It's a real frustrating thing,'' he said. Johanns said he is listening to the concerns of the communities and understands why they would be upset about the centers closing. ``I would hope in time they will see the opportunities here,'' Johanns said.
     For now, Hastings and Norfolk are unified in their opposition. Earlier this month Hastings Mayor Rick Sheehy and Norfolk Mayor Gordon Adams signed proclamations declaring both communities ``sister cities,'' as a signal of their willingness to stand together on the issue. The communities have invested $80,000 on a television and radio ad campaign opposing the closing of the regional centers. They have also hired a lobbyist to work the issue in the Legislature. Nolan said he doesn't understand Johanns' zeal to close the regional centers. ``What is it that our two communities have done, that seems to us, to be distrust of us?'' he said.
      But Johanns, and the Legislature's Health Committee chairman Sen. Jim Jensen of Omaha, said the change has been needed for years. The viability of the plan was confirmed, Johanns said, in a report commissioned by the state's Health and Human Services System. The report by The Lewin Group, a consulting firm based in Falls Church, Va., suggests steps for closing the regional centers. It also offers a transition strategy for the communities and methods for identifying community-based care. The report, which was paid for with federal grant money, cost $62,250 to compile. Under the Johanns plan, the two regional centers would close by the end of 2005, provided there are community-based resources available to take in the patients. The Lincoln Regional Center would remain open, and a new facility in Omaha is proposed.
     The proposal has also been criticized by law enforcement officials who worry about what impact the changes will have on their communities. Specifically they are concerned about where they will take those people who currently are placed in the regional centers.
     Johanns wants to spend $12 million on his mental health reform plan, half of which would come from unused money the state receives from a tobacco settlement. The reforms include earmarking money for affordable housing for those with mental illnesses and to enhance emergency protective custody services. John McVay, administrator of the mental health region covering the Panhandle, said the Johanns plan will result in better outcomes for consumers and ensure safe communities.
Johanns faces an uphill battle to win legislative approval for his plan.
     In an Associated Press pre-session survey of Nebraska's 49 lawmakers, only eight said they supported the idea of closing the Norfolk and Hastings regional centers, while 15 were leaning that way. The bill (LB1083) implementing the plan, which was introduced by Jensen, has yet to be scheduled for a hearing before the Health Committee. Jensen said Thursday he is purposefully delaying the hearing to hold more meetings with those involved to work out concerns.
     The centers in Norfolk and Hastings employ about 600 people. In the last fiscal year, 1,375 adults and 63 youths were served in all three regional centers. The average stay was 186 days. On any given day, 260 people are served in Hastings and Norfolk.
     On the Net: State of Nebraska: http://www.state.ne.us/

Antidepressant Makers Withhold Data on Children
Shankar Vedantam, Washington Post- 1/29/2004

Makers of popular antidepressants such as Paxil, Zoloft and Effexor have refused to disclose the details of most clinical trials involving depressed children, denying doctors and parents crucial evidence as they weigh fresh fears that such medicines may cause some children to become suicidal. The companies say the studies are trade secrets. Researchers familiar with the unpublished data said the majority of secret trials show that children taking the medicines did not get any better than children taking dummy pills.
     Although the drug industry's practice of suppressing data unfavorable to its products is legal, doctors and advocates say such secrecy distorts the scientific record. "Conflicts of interest and the company control of the data have thrown out the scientific method," said Vera Hassner Sharav, a critic of the drugs and a patients' rights advocate. "If hundreds of trials don't work out, they don't publish them, they don't talk about them." "We need a journal of negative findings," agreed Darrel Regier, director of the American Psychiatric Association's division of research, who believes the drugs save children's lives. "The probability of those negative findings being published is far less than the chances of positive studies -- even journals are not interested in negative studies."
     Concerns over the safety of antidepressants among children have been heightened after a December warning by British regulators that the drugs may trigger suicidal thoughts and increase the rate of self-injury. An expert advisory panel of the Food and Drug Administration is scheduled to meet Monday to examine the issue, but the agency's full U.S. analysis of the data is not likely to be completed until summer.
     One industry executive, Philip Perera, a medical director at GlaxoSmithKline, said that his preference was to publish all trials but that negative studies could lead doctors to prematurely reject a medicine. "If you start publishing negative data, will it be concluded by practitioners and others that the drug is ineffective?" he asked, saying that genuinely effective medicines sometimes do no better than placebos, or dummy pills, in trials -- at least half of all children seem to get better on placebos.
     The U.S. psychiatric establishment largely supports the use of antidepressant medicines in children, with many arguing that abandoning the drugs would lead to more suicides in children with depression. But its critics, including consumer advocates and some psychiatrists , question whether mainstream psychiatry is biased by widespread financial ties to the pharmaceutical industry. The answer lies hidden in a maze of secret data, conflicting scientific interpretations and a corporate-funded clinical trial system that is not primarily designed to answer questions of public health. "If the companies wanted to publish negative studies they could, but companies don't like to publish negative studies," said Russell Katz, director of the neuropharmacology division at the FDA , which has access to all the data. "It's amusing so many people are making pronouncements about the data -- scientists and physicians -- . . . without seeing the data." Advocates say openness about studies is important because, apart from Prozac, no antidepressant has been approved by the FDA for treating children with depression. Doctors writing prescriptions do not have approved labeling to guide them: They must rely on their own judgment and the available scientific knowledge -- even as information is being withheld.
     The medicines under scrutiny belong to a class of drugs called selective serotonin reuptake inhibitors, or SSRIs. Led by Prozac, the first to be approved, the medicines caused a revolution in psychiatry. Recent analyses suggest that as many as 1 percent of children in the United States are treated for depression in any year, said Mark Olfson, a professor of clinical psychiatry at Columbia University. Of those, 57 percent are on antidepressants.
     The lack of information is the one issue about which advocates and critics of the medicines agree. Lawrence Diller, a Walnut Creek, Calif., pediatrician and author of "Should I Medicate My Child?," said that "as a front-line doctor dependent on research, it seems so contaminated by potential conflicts of interest. . . . The smoking gun is revelations from the British that negative studies were not published." Keeping data secret, critics said, has led to conflicting information, contradictory advice and heightened fears. For example, GlaxoSmithKline, which makes Paxil, has conducted three trials on depressed children. Company officials said all turned out negative -- the children on the drug did not do better than those on placebos -- but only one was published. Based on its data, the company warned British doctors that Paxil, sold there as Seroxat, "should not be prescribed as new therapy" to depressed children younger than 18. Its letter last June cited the risk of increased hostility, agitation, and suicidal thoughts and attempts. No such warning was issued in the United States, though Paxil is identical to Seroxat. Here, the company's official line on giving Paxil to children is "No recommendations can be made regarding the use of Paxil or Paxil CR in these patients."
     "There are differences" between the two recommendations, GlaxoSmithKline's Perera acknowledged in an interview. "They reflect the message that we receive from the respective regulatory bodies." British regulators have essentially prohibited the use of Paxil for children. The FDA is conducting a review of eight drugs, including Paxil. Perera said the company would await the FDA advisory panel's verdict before considering whether to make all its data public.
     Cathryn Clary, vice president for psychiatry and neurology at Pfizer, which makes Zoloft, said it had sponsored two trials in children. One had a negative result, but the company pooled it with a positive study and only published the combined result, which was positive. "We certainly understand the wish of academics and researchers and physicians to understand all of this data," she said. But small sample sizes in trials "run the risk of magnifying or diminishing a signal. Releasing an individual study can be as misleading as it is helpful."
     Graham Emslie, a professor of psychiatry at the University of Texas Southwestern Medical Center, who has helped conduct several trials for drug companies, counted nine recent trials of Prozac, Paxil, Zoloft and Celexa in depressed children. Results of two Prozac trials, one Paxil and the pooled Zoloft data have been published -- meaning that data from five trials, including the stand-alone Zoloft trial that was negative, have not. Emslie also counted six other studies on the related antidepressants Effexor, Serzone and Remeron -- none of which has been published, he said. Data from several of the unpublished studies have been presented at scientific meetings, and one has been submitted for publication, he said.
     Studies reported at conferences are not subject to rigorous advance "peer review" by independent researchers, as are studies published by well-regarded journals. Emslie said he would like to see all the data published but he said the research had been paid for -- and belongs to -- the companies. "They have a legitimate right to do what they want with the data," he said. But David Healy, a Welsh psychiatrist and author of "The Antidepressant Era," rejected the notion that the safety information could be treated like any other private property. Healy prescribes the medicines but has campaigned for more cautious use and more accurate labeling. "On a pressing issue like this," he said, "there is no reason these data could not be put into the public domain in their entirety."
     The FDA said it is evaluating 20 studies in all, but agency officials have declined to identify them.
In the end, some scientists believe, the only way to ensure that science is conducted in the public interest is for it to be funded with public dollars. The National Institutes of Health is therefore ramping up funding for clinical trials. "We have been dependent on the pharmaceutical industry to provide the answers," said Thomas R. Insel, director of the National Institute of Mental Health. "The questions they want answered are different than the public health questions."

As Autism Cases Rise, Parents Run Frenzied Race to Get Help
Jane Gross, New York Times- 1/30/2004

ARDSLEY, N.Y. - When Phyllis Lombardi lets her 6-year-old son, Joey, play in her yard here, she cannot take her eyes off him because he is autistic, barely speaks and might bolt into traffic. But a fence costs more than the Lombardis can afford since they moved to this Westchester County village last year. Ardsley has state-of-the-art autism programs, but also real estate prices that have forced the family into a rental just a block from the Saw Mill River Parkway. It was desperation that brought the family here from Rockland County, when Mrs. Lombardi joined an army of parents, their frustration growing as their numbers increased, facing a crisis of supply and demand when their autistic children reach school age. "I can't fix him, so my only peace of mind is to get him the best services I can," Mrs. Lombardi said, echoing mothers from Palo Alto, Calif., to Princeton, N.J. "That's what I have to do to sleep at night."
     The mismatch between needs and services is widening, experts say, despite many start-up programs for autistic children. But new schools and additional classrooms have not kept pace with skyrocketing caseloads and growing sophistication among parents about what sort of educational techniques work. Education -- highly structured, virtually one-on-one and thus astronomically expensive -- is the one proven treatment for autism, experts say. But it is no guarantee. Examples of exceptional success -- and a narrow window of opportunity -- have frantic parents trolling the Internet, visiting any school that sounds promising, winding up on waiting lists and often moving or suing their school district to get what they want.
     Dr. Catherine Lord, primary author of a 2001 federal report on teaching techniques for autism, estimated at the time that only 10 percent of affected children had access to the proven labor-intensive pedagogy, which can cost a school district as much as $60,000 a year per child. Dr. Lord says there are many indications that the situation is worse today, when schools nationwide are dealing with 120,000 autistic students, up from 20,000 a decade ago. Some private schools that accommodate a mere 25 children have waiting lists with hundreds of names on them. The best public school programs are besieged. There are not enough certified behavioral therapists, so promising aides are trained in the classroom and then fought over, like prized nannies, by parents seeking after-school and weekend help. Dr. Fred R. Volkmar, an autism researcher and diagnostician at Yale University who has a three-year waiting list to see new patients, said even the wealthy are not protected. "I see mega-mega millionaires and movie star folks who can't find anything to tap into," he said.
     A few states -- notably North Carolina and Delaware -- provide coordinated, seamless services from preschool until the age of 21. But more common is an incomprehensible jumble that parents must decode amid the fog of learning their child's grim prognosis. New York State has exemplary services for preschoolers, paid for by county departments of health, and a dearth of services for students in kindergarten through age 21, whose education is paid for by local school districts. New Jersey is just the reverse. Connecticut, alone in the metropolitan region, offers no Medicaid benefits for the disability. "It's an appalling jumble," Dr. Lord said.
     It took three years for Mrs. Lombardi to find Concord Road Elementary School here. She called hundreds of strangers seeking advice. She sent bouquets to school secretaries who parted with nuggets of information about teaching methods and staffing ratios. She sneaked into back-to-school nights to see if the special education students were hidden in the basement. Eventually, Mrs. Lombardi decided that Ardsley had the best programs around, so good that districts from New York City to Rye Neck pay tens of thousands of dollars a year to place severely autistic children here. Joey would have his own aide to help him sit still, a classroom partitioned into quiet learning spaces with 10 adults supervising 11 children, private speech therapy four times a week and exposure to ordinary kindergartners at lunch and recess. But to make it work, Joey's father, Nicholas, is working 15-hour days as a ticket broker and Mrs. Lombardi has had to take a part-time job as a receptionist. In addition to the costs of living here, there is Joey's out-of-school therapy, which sustains his fragile progress and can cost a family $20,000 to $40,000 a year.
     Some school systems are scurrying to catch up with Ardsley. But parents resist being part of a pilot program. Dr. Lord understands their reluctance, yet she believes that these start-ups, serving two or three autistic children at first, are essential to an eventual expansion of services. Mrs. Lombardi was impressed by the charismatic teacher in the one autism classroom in Pearl River's elementary school, in Rockland County, where the family had its home and where Joey had attended an excellent preschool program. But the situation was "too fragile for my liking," Mrs. Lombardi said. "What if the teacher broke her leg, or took a maternity leave?" In Westchester, tiny programs were starting in Ossining, which would have been more affordable, and Briarcliff, where her sister-in-law lives. "But once I heard `new' that was it," Mrs. Lombardi said. "I can't waste time for my kid while they're learning."
     Moving to a district with a long-standing program is a popular strategy for families like the Lombardis, creating what seem like autism clusters in places like Ardsley; Guilford, Conn.; and Naperville, Ill. Placement in a district where a family does not live, or in a private school, requires the home district to agree that its educational programs are not "appropriate" as mandated by federal law. In that case, a district must pay for the disabled child's education elsewhere. If the home district insists that it has adequate programs, well-to-do families often threaten to sue. Generally they get what they want, without going to court, because the district cannot afford legal fees or lost working hours for professionals who would have to testify.
     New York City has few private schools for autistic children once they are 5 years old, and several efforts to start them have foundered because of real estate costs. The public school system serves 3,000 autistic students, adding additional classrooms as the need arises. Some of its programs are highly regarded by special education experts statewide and prompt families to move from one borough to another. But some upper-middle-class New Yorkers, especially those whose nondisabled children are in private school, fear that the programs are not good enough.
     Ilene Lainer, for instance, never looked at a public school for her autistic son Ari, now 7. Instead, she set up a home program for him, which was supposed to be supervised by an agency under contract to the city. Nobody ever came to observe the parade of therapists working with Ari, Ms. Lainer said, so she hired a home supervisor from the private Alpine School in Paramus, N.J. When the city refused to pay Alpine's fee, Ms. Lainer threatened a lawsuit and prevailed at a hearing before an administrative law judge. Meanwhile, she searched for a private school in New Jersey. One asked for a video of her son for diagnostic purposes and never acknowledged its delivery. Another never called her back about an interview, despite weekly phone messages. "You have no idea how cruel these people can be," said Ms. Lainer, who practiced law until her son's diagnosis.
     Ari was eventually accepted at a New Jersey private school. Ms. Lainer, despite one legal victory, doubted that New York City would pay for her son's education in another state and so she began house hunting across the river in districts she was told were most likely to agree to pay for private school. But, she simultaneously retained a lawyer for a second hearing with the city. To Ms. Lainer's surprise, the city settled and reimbursed the $58,000 in annual tuition she had already paid. For now, she is driving Ari to Bergen County every day and is a founding member of an advocacy organization exploring ways to open comparable schools in Manhattan.
     In the suburbs, parents also hire lawyers to get extra services or an out-of-district placement. Here, too, special education committees generally give in. Some of the guest students in Ardsley came with the full support of their home districts and others because the parents threatened a legal battle.
     Mrs. Lombardi is not inclined to fight. And she wonders what happens to parents who do, and then must face their antagonists for the annual review and revision of a child's Individual Educational Plan, which is essentially a contract for services. In Joey's case, this means deciding each year if his one-on-one aide is still necessary or if four sessions of private speech therapy a week can replace five. Mrs. Lombardi wishes Concord Road had speech therapists trained in a particular method that has helped Joey elsewhere. She has written letters to the Board of Education and put it on the agenda of the special education committee of the P.T.A. But she accepts that the training is too expensive. "Every parent thinks more is better," Mrs. Lombardi said. Mrs. Lombardi's persuasion depends on food, not fisticuffs. She puts boxes of candy in Joey's backpack with a note to his teacher saying "Happy Monday." She bakes corn muffins for the bus driver, who encourages the boy to imitate his chirpy "Good morning!" When things are particularly difficult, like when Joey had problems with toilet-training or tried a weighted vest to calm his frequent thrashing, Mrs. Lombardi turns to chocolate. "I go with my brownies," she said. "And if they see frosting, it's `Oh, Mrs. Lombardi, what can we do for you?' "

Michigan Board Aiming to Fix Mental Health Woes
Laura Potts, Detroit Free Press- 1/30/2004

Marcie Lipsett said public schools in Michigan can't adequately provide for her teenage son, who has bipolar disorder, and the family's insurer only pays a fraction of the exorbitant costs for treatment and medications. Like family members of the thousands of mentally ill Michigan residents, Lipsett has learned to navigate the system, becoming well-versed in -- and frustrated with -- its complexities. But on Monday, the state has a chance to start improving mental health care for kids and adults, Lipsett said. That's when Gov. Jennifer Granholm's long-promised Mental Health Commission has its first meeting, a marathon brainstorming session in which its 33 members will present their concerns and hear from people such as Lipsett, of Franklin. "These kids are suffering on a daily basis," she said. "People can't fathom what it is like to raise children like this and the lack of quality in these kids' lives."
     The commission members -- including mental health consumers, advocates, state and local officials and service providers -- are scheduled to meet the first Monday of the month through September. At that point, the commission will present its suggestions to Granholm, said T.J. Bucholz, spokesman for the Michigan Department of Community Health. "We're hoping to come away from the first meeting with the steps to get to the overarching goal," Bucholz said, adding that Granholm is expected to attend at least part of the Monday meeting.
     Mental health advocates have criticized the state's system, arguing that a lack of adequate funding or services puts people in jeopardy and robs them of a quality life. The furor mounted last spring when a respected national advocacy group put Michigan last in the nation for mental health care, giving the state failing grades. The Michigan Legislature is considering several bills to address the state's mental health care system.
     "There were reports of real failures and that's just unacceptable because we can do better," said Elizabeth Bauer, who is a commission appointee and a State Board of Education member.
Bauer said she wants the commission to look at how services are delivered and to push for insurance parity, so that payment for mental health services is on par with coverage of physical health.

Flood of Heroin Ravaging Chicago
John Bebow, Chicago Tribune- 1/30/2004

Emilio Chavez Garcia was 50 when he called his estranged wife in Puerto Rico on Christmas Eve to say he wanted to come home. Maybe this time, she hoped, he would finally kick the heroin addiction that had ruined their family. Rafael Diaz was 36 and had dreams, too. Two months from getting off parole for peddling heroin, he carried a pledge in his day planner: "If I do not build a case against myself, all goals will be accomplished." Within 10 minutes of each other on Jan. 7--the syringes next to their bodies--the Chicago men became two exhibits of what authorities say is one of America's largest, most diverse and resilient heroin markets. Their overdoses on heroin thought to be so pure it was fatal touched off a massive police search in Humboldt Park to find the lethal supply. Less than eight hours later, two men were arrested after an undercover buy in front of a nail salon on North Avenue.
      Chicago's heroin trafficking long has been overshadowed by the more popular and violent cocaine trade. But it has enjoyed a renaissance for the last decade, investigators said, and is more dangerous today because the drug's purity increased dramatically in the late 1990s. For five consecutive years, the Chicago metropolitan area has led the nation in heroin-related emergency room visits--12,982 in 2002, an increase of 176 percent since 1995, according to the latest federal statistics available. During the last two years, the Cook County medical examiner logged 628 deaths--six a week--from heroin and other opiate-related drug abuse. A quarter of the men booked on criminal charges in Cook County test positive for opiates.
      As a transportation hub, Chicago also is the only city in the United States with a steady supply of heroin from all four global sources: Southeast Asia, Southwest Asia, Mexico and South America, according to the U.S. Drug Enforcement Administration. "The street gangs each have multiple sources of supply. All roads lead to Chicago," said Patrick O'Dea, a DEA intelligence supervisor in Chicago. That bountiful supply means street gangs can pay half as much or less per kilogram than they did in the late 1980s--for purer heroin. In the city's open-air drug markets, the traditional $10 "dime bag" is as much as 10 times more potent than it was 20 years ago. "From a heroin consumer's point of view, it's as good as it's ever been," said Dr. Westley Clark, director of the federal Center for Substance Abuse Treatment in Washington, D.C. "It's a recipe for calamity."

`No more pain'
Emilio Chavez Garcia's family saw the end coming for years. Garcia had moved to Humboldt Park from Puerto Rico with his family as a young boy. After serving in the U.S. Army in the early 1970s, the affable man held a steady job in a Chicago plastics factory before falling into heroin's grip, family members said. For the last several years, he floated between Chicago and Puerto Rico, where his mother and brother repeatedly entered him in treatment programs. Garcia walked away from help for the last time in 2001, leaving his brother, Rafael Chavez, with a $21,000 home-equity loan taken out to pay for the treatment. "We're still paying it off," Rafael Chavez said. "Drugs were his life. I had a feeling I would get this call."
      It came on the first Wednesday of the year after a cousin who lived upstairs from Garcia's $350-a-month basement apartment on Whipple Street found him dead at 1:20 p.m. Six hours earlier, Garcia had dropped by his cousin's apartment for coffee, small talk and to pick up a $1,200 federal government benefits check. "He said he'd be back in a couple of hours to pay the rent," said his cousin, Carlos Rodriguez. "He said he wanted to go back to Puerto Rico. With his check, he could have lived like a king down there." When they gathered his belongings, Garcia had a few pairs of pants, a couple of shirts and one pair of gym shoes. He also left behind three children. "I thought, almost immediately, there's no more pain for our family," said his estranged wife, Nydia Santiago.
     At 1:30 p.m. that Wednesday, five blocks east of Garcia's apartment, staffers at the North Hotel on California Avenue opened the door of Room 404 and found Diaz on the floor with three small bags of heroin. It cost $95 a week for the 8-foot-by-12-foot room with a sink, a bent chair, a sagging mattress covered in a thin blanket, a worn yellow dresser and a wooden door to a shared bathroom. The view out of Diaz's dusty window was a new, brick six-flat promising luxury living for $249,000 for people seeking housing prices cheaper than those in Bucktown. Diaz had just returned to Chicago after several months visiting his ill father in Louisiana, where he'd worked as a management trainee at a McDonald's and hatched a plan to market Latin music on the Internet. Yvette Diaz said her brother was "a person of dreams" who had tried to overcome a criminal past, including a 1986 murder charge that was dismissed by a judge. Diaz had convictions for aggravated robbery, drug possession and, in 1999, for selling heroin to a prostitute. He was sentenced to 6 years in prison and paroled in February 2002. His sister recovered his belongings: a duffel bag of clothes, a toothbrush and $187. A calendar reminded him to "spend the day with Ralphie," his 17-year-old son, on Jan. 12. He was buried that day.

Police seek `bad batch'
The afternoon the bodies were found, police also received a 911 call from a customer at the Burger King on North Avenue between the apartments of Garcia and Diaz. The customer reported a man shaking violently, probably from a drug overdose. "We were sent on a mission," said Sgt. Ruben Ramirez, part of an eight-member narcotics task force that hit the streets. "We pretty much knew it was a bad batch." Police worked their informants and tracked down the shaking man at Norwegian-American Hospital. The 56-year-old told police he became ill after using heroin that morning and identified his dealer.
      At 9 p.m., police say, they arrested Angel Pantoja, 64, after he sold 2 grams of heroin to an undercover officer. His roommate, Adrian Ramos, 45, was arrested in their third-floor apartment above the salon. Police said they recovered 27 packets of brown heroin from Mexico. A burned seal on the bags matched a packet recovered from Garcia's apartment, police said. Toxicology tests to check for an exact match are pending. Both men are free on bail. Pantoja is back at his two-bedroom apartment, which is decorated with Britney Spears posters, pictures of Christ, and an acrylic sailing scene he is painting.
      Pantoja said he had used heroin for much of his life and acknowledged the drug was in his apartment on Jan. 7. He said it belonged to Ramos, who could not be reached for comment. Pantoja, a laborer who has a lengthy record of burglaries and other petty crimes, said he gave up heroin five years ago. Having a heroin habit "is worse than to be a slave," he said. Police say the drug was lethally pure. Wholesale purity reaches 80 percent to 90 percent, but dealers "cut" the heroin with other substances, leaving an average of 20 percent purity.

Stopping the flow
Cocaine remains the most popular drug and dominates local interdiction efforts. Federal agents in Illinois seized 1,816 kilograms of cocaine in 2002 and only 13.9 kilograms of heroin. Chicago police seized 50 kilograms of heroin in 2002. Years-long investigations have barely dented supply, O'Dea said.
      In 1985, federal agents dismantled much of the Mexican heroin supply that dominated the Chicago market. Nigerians quickly filled the void, then were replaced by Colombians after another federal investigation in the late 1990s. Unlike the cocaine trade, which is controlled by cartels, the heroin business is run mostly by small "mom and pop" operations in Colombia that are hard to crack, O'Dea said. The potential for higher profits also has drawn increased interest, O'Dea said. The wholesale price for a kilogram of cocaine in Chicago is $18,000 to $28,000. A kilogram of heroin has a wholesale price of $100,000 or more.
      Heroin metabolizes into morphine by the time autopsies are conducted. In 2000, the last year for which comparable statistics are available, "heroin/morphine" caused or contributed to 194 deaths in New York City and 499 in Chicago. The deaths of longtime needle users like Garcia and Diaz hark back to the 1960s and 1970s, when heroin mainly was the dominion of inner-city junkies. Today's users are more likely to be suburban teens or professionals. They start by snorting the drug but can quickly become as addicted as needle users, authorities said. "The cautionary tale is your risks go up the farther down the road you go," said Clark of the federal Center for Substance Abuse Treatment.