Suicide Warning Sought for Antidepressants
Associated Press, 3/22/2004

WASHINGTON - Doctors who prescribe some popular antidepressants should monitor their patients closely for warning signs of suicide, especially when they first start the pills or change a dose, the government warned Monday. The Food and Drug Administration asked makers of 10 drugs to add or strengthen suicide-related warnings on their labels. The agency insists it's not yet clear whether the drugs actually spur suicide on occasion or whether the underlying mental illness is to blame. But FDA bowed to pressure from anguished families who, at an emotional meeting last month, blamed the pills for their loved ones' suicides and pleaded for better warnings.
     It's a difficult issue to sort out because depression itself can lead to suicide, and studies clearly show that antidepressants have helped many people recover from depression. Still, until the question is settled, FDA's own scientific advisers had urged stronger warnings that certain antidepressants may cause agitation, anxiety and hostility in a subset of patients who may be unusually prone to rare side effects. Monday, FDA followed that recommendation, stressing that the most vulnerable time is when a patient starts therapy or changes the dose. "We think this is good advice whether the drugs increase the risk or not," said FDA medical policy chief Dr. Robert Temple. "There's a reason people are put on therapy their depression is worse or somebody's worried about it. Maybe that's what drives it (reports of suicides) or maybe it's the drugs. In either case, you really need to pay attention in the early days."
     While FDA's investigation into the possible suicide link initially focused on children and teenagers, Monday's warning includes adults, too. The FDA had investigated reports of suicide among adult antidepressant users in the early 1990s and concluded there was no link but on Monday revealed that it is reanalyzing that question. The drugs of concern are newer generation antidepressants: Prozac, Paxil, Zoloft, Effexor, Celexa, Lexapro, Luvox, which are called SSRIs or SSRI-like drugs, and Remeron, Serzone and Wellbutrin, which operate differently. Manufacturers didn't immediately say if they'd comply.
     British health authorities sounded the alarm last year, saying long-suppressed research suggests serotonin-affecting antidepressants might sometimes increase the risk of suicidal behavior in children and teenagers. Excepting only one drug, Prozac, that has been proven to alleviate pediatric depression, Britain declared the other six SSRIs or SSRI-like drugs unsuitable for depressed youth. Britain didn't mention the other three drugs listed in the U.S. notice.
     FDA issued a caution on pediatric use last year but says it doesn't yet have proof the drugs are to blame. Among 25 studies of the suspect medications involving 4,000 children and teens, there were no completed suicides. Some 109 patients experienced one or more possibly suicide-related behaviors or attempts but the studies varied dramatically in what was considered suicidal behavior. For example, among 19 patients classified as cutting themselves, almost all were superficial, with little bleeding. But critics flooded an FDA meeting last month demanding stronger action and days later, the issue again made headlines when a 19-year-old woman taking part in a study of Eli Lilly & Co.'s experimental new antidepressant duloxetine hanged herself in a company-run facility.
Most antidepressant labels already contain some fine-print statement about suicide, usually that the possibility is inherent with depression.
     FDA asked Monday for explicit explanations of worrisome behavior changes to be placed in bold print under the prominent "warnings" section of those labels: agitation, anxiety, irritability and recklessness. Doctors spotting those traits should consider prescribing a lower dose or stopping the drug, FDA said. The drugs are used for many conditions other than depression; the warning applies regardless of the reason for use.
     Critics welcomed the change but said suicide complaints first were raised many years ago.
"I'm just very sorry that it so long for them to act on this issue, because there's been so much tragedy that occurred," added Jennifer Tierney of Kernersville, N.C., who describes her daughter Jame as turning from a sweet, popular honor student into a raging loner after taking Effexor for migraines at age 14. But psychiatrists caution that suicides have dropped as SSRI use has increased round the world. "We do a disservice to a population of people who could benefit from these medications" by overreacting, said Dr. Bela Sood, chair of pediatric psychiatry at Virginia Commonwealth University. Still, FDA's warning does alert doctors "who in a very lackadaisical way decide to put these kids on medications" to do a more thorough exam and to tell parents what risks to watch for, Sood said. Children in particular aren't good candidates for SSRIs if they're highly impulsive, angry or aggressive, she said. There also is a window period of risk just after pill use begins, before depression is really alleviated but when some patients experience more energy.

Increase in Students Seeking Mental Health Help
Associated Press, 3/22/2004

HARTFORD, Conn. -- The number of Connecticut college students looking for mental health help is going up, but experts do not know why. Nationally, colleges are reporting that increasing numbers of students are seeking mental health services for illnesses or conditions ranging from bipolar disorder or schizophrenia to depression, anxiety, eating disorders and stress. The Hartford Courant Monday cited a survey by the American College Health Association last spring that an estimated 38 percent of college students reported depression severe enough that they had difficulty functioning on at least one to 10 occasions in the past year. Mental health counselors at Connecticut college campuses say the numbers of troubled students seeking help have been going up.
     At Trinity College in Hartford, counselors are seeing nearly 20 percent of the student body at any given time, Randolph Lee, director of the counseling center at Trinity College said.
Counselors at the University of Connecticut have been getting so many requests that they have had to limit to eight the number of therapy sessions each student can attend each year. "We're downsized and have no more resources with a greater number of students and a greater severity of mental health problems," Michael Kurland, health services director at UConn, said. Last year, UConn logged 7,000 visits, including repeat trips, to the university's mental health clinic. The clinic recently added weekend hours.
     Yale University counselors report a gradual increase in the number of students seeking services over the past five to 10 years and have hired staff to keep up with the demand. Researchers and counselors say it's hard to tell what's causing the increase, but there are many theories. One reason might be an increased awareness of mental health issues and improved treatment options.

Dreams Ride on Freud's Royal Road, Study Finds
Anahad O'Connor, New York Times- 3/23/2004

More than a century ago, Freud proposed that dreams concealed subconscious wishes and desires, a theory that has in recent decades fallen from scientific favor. A new study, however, may add weight to the idea that what people suppress during the day returns when they close their eyes at night. Deliberately blocking thoughts about someone before going to sleep, the researchers found, made it more likely that the person would appear in a dream that night.
      In the study, by scientists at Harvard and the University of Texas at San Antonio, college students were asked to choose someone they knew and then either concentrate on or suppress thoughts about that person five minutes before bedtime. Another group of students was told simply to pick a person and then to think about anything at all.
      Psychologists have argued about thought suppression and dream interpretation for decades, though few researchers have put the theories to the test. "Not surprisingly, any kind of thinking about something increases the likelihood that it will show up in a dream," said Dr. Daniel M. Wegner, a professor of psychology at Harvard and the lead author of the study. "But trying to suppress something increases the chances even more, indicating that the meanings of our dreams involve things we've tried to sweep under the rug." The study is being published in the April issue of the journal Psychological Science.
      The findings seem to fall in line with the idea that dreams express complicated desires and unfulfilled wishes, as Freud, who called dreams the "royal road to the unconscious," noted long ago. But Dr. Wegner does not completely agree with that assertion. In the study, he asked some of the students to picture people they were attracted to but not involved with, assuming that emotions like desire and longing would color the results. But whether the students focused on someone they had strong feelings about or someone they regarded neutrally made little difference, Dr. Wegner found. More likely, he said, the subjects were merely incorporating into their dreams what Freud described as the daytime residue of thoughts and events. Much of that residue is processed by the prefrontal cortex, which governs thought processes.
      During sleep, Dr. Wegner said, the cortex loosens its grip on distractions tuned out earlier in the day. As a result, studies show, people who try to quit smoking have dreams about cigarettes, or an actor who is gearing up for a big show has nightmares about going blank on stage. Going to bed lifts the lid on all the thoughts that the mind keeps under wraps. "A lot of the things we dream about tend to be negative, because they're the things we're most likely to deliberately keep out of our minds," Dr. Wegner said. "It's often the most awful things we can think about that we crowd into our dreams."
      Concerted efforts to block things, experts say, give them special value and can have the unintended effect of making them more memorable. In a study several years ago, for example, Dr. Wegner showed somewhat paradoxically that telling people not to think about a white bear made them obsessed with that very thought. In the courtroom, other researchers have found, telling a jury to disregard a witness's testimony can actually increase its influence. "If you're suppressing thoughts about someone, you're telling your brain it's more important than the shirt you wore or what you had for lunch," said Dr. Robert A. Stickgold, an assistant professor of psychiatry at the Harvard Medical School, who was not involved in the study. "It's probably one of a hundred ways that material gets tagged for dreams."
      Dr. Stickgold has shown that people with amnesia can have vivid dreams about something that they did the day before, despite having no conscious recollection of an event. After praising the new findings, he cautioned that interpreting them as scientific evidence of Freudian repression would be a stretch. Unlike repressed thoughts that might be unknowingly buried in the subconscious, he said, the memories looked at in Dr. Wegner's study were still fully available. "This helps to tease apart what the brain's rules are for memory," Dr. Stickgold said. "It doesn't really give Freud another leg up. But I'm sure it'll cause a tempest in the teapot."

A Wife Learns to See With Alzheimer's Eyes
Claudia Dreifus, New York Times- 3/23/2004

Joanne Koenig Coste concedes that she is a bit of a Pollyanna. "It helps with what I do," said Ms. Coste, a consultant for institutions that treat patients with dementia and the author of "Learning to Speak Alzheimer's." Thirty years ago, when Ms. Coste was pregnant with her fourth child, her husband, Charles Koenig, then 44, began showing the symptoms of Alzheimer's disease. For four years, until he died in 1976, Ms. Coste devoted herself full time to his care.
She had no medical experience. But as his illness progressed, Ms. Coste found herself inventing her own methods, a system she now calls habilitation. In that approach, patients and those who care for them abandon any dreams of a cure, instead devoting themselves to making life as comfortable and pleasant as possible.
      Ms. Coste encourages people who take care of Alzheimer's patients to enter their worlds and, to some degree, to join the patients there. Homes, apartments, furnishings and even menus are juggled and rearranged to meet special needs, said Ms. Coste, who is 64 and has remarried. Habilitation has won praise from health care professionals. The founding director of the National Institute of Aging, Dr. Robert N. Butler, wrote the introduction to Ms. Coste's book, and she estimates that at least 100 nursing homes and assisted-living centers have adopted her methods
Q. What was your life like when Alzheimer's disease first became part of your vocabulary?
A. I was 32 years old when the first signs hit us. I was a full-time homemaker. My husband was a writer. Originally, he'd been diagnosed with depression, but that didn't seem right to me. Charles, who was such a fastidious dresser, suddenly couldn't match up his clothes anymore. And he was losing a sense of memory and reality. Once, when I was seven months pregnant, a friend asked how I was feeling. I answered, "Pretty good, considering the pregnancy." Charles said, "Why didn't you tell me you were pregnant?" This wasn't depression! Then Charles had a massive stroke. He'd been having these little strokes all along that were part of the disease. But that hadn't been noticed. Afterward, the doctors finally used the word dementia. They said it was neurological and progressive: "Just go home and live this out. Either that or institutionalize him."
Q. How did you respond to your husband's grim prognosis and the suggestion that he be put in an institution?
A. I wasn't going to institutionalize him. I realized that Charles was no longer the person I'd married. But when we'd married, I didn't promise, "I'll stay with you just so long as you can recognize me." I said "forever." So I took Charles home. And I tried to be with him, wherever he was. People talked about how sad the situation was. I said: "This is a new person. Come on over and get to know him." Nobody wanted to. Charles wasn't easy to care for. There was no Alzheimer's Association then, with group meetings for families of caregivers. So I was always inventing the wheel with him.
      A big moment came for me one day when I saw him scraping the Teflon off my brand new frying pan. He sat down with that pan for a couple of hours and scrapped every last bit of Teflon off. When he was done, he held it up in triumph and said the only word he could speak — "On!" This was a moment of choice. I saw the feeling of accomplishment he was expressing and said, "Thank you for scraping all the Teflon off the pan." In that moment, I understood how to go with his situation. Support him in his new state of mind, avoid conflict, praise him.
Q. Why did you call your system habilitation?
A. Because it's not about someone getting rehabilitated. Habilitation is about living in the patient's world, making the patient's environment safe and nonthreatening, focusing on his or her remaining skills and enriching the patient's life as much as you can. Let me give you an example of how it works. Charles once pruned rosebushes beautifully. He couldn't do that anymore. But he could dig a hole in the front yard. I let him dig holes all the way to China. The alternative was disaster. It would have been anger, resentment, instead of pleasantries. When he did something wrong, I'd laugh and make sure I had eye contact while I did it. That would just start gales of laughter. He laughed because I was.
Q. You are a big believer in the idea that caregivers need to redesign their homes to accommodate the needs of Alzheimer's patients. Why?
A. Because really small changes can make things much easier. You have to put yourself in the patient's place and figure out what they need. When Charles first started to get incontinent, it was at the same time I was potty training Jason, and I kept thinking, if only I can get Jason trained, then there'll only be one set of diapers. Well, to do that, I had this idea of painting the wall behind the toilet bright red, leaving the door open and hoping that Jason might respond to that. Well, Charles saw it and started to use the toilet again. His problem had been one of perception, I realized. He didn't see the toilet anymore, and that's why he'd become incontinent. But the red paint drew his attention. Well, physicians now know that nobody with Alzheimer's needs to be incontinent. You have to make things visible on their terms.
      There are a lot of other areas where this also is true. For instance, if a patient has trouble eating with utensils and is making a mess all over the place, you give them finger foods. Lighting is another thing one can fix. My husband's behavior tended to change when the sun went down. This is common with Alzheimer's patients. So I bought lots of lights and kept turning them up. I closed the curtains, so he couldn't see outside. That way, the sunlight was inside rather than outside. That made a difference.
Q. How did habilitation become your profession?
A. Charles died after four years. Afterward, I went to live with my parents in Wellesley. I took a job as a nurse's aide at a nursing home there. Caregiving was the one thing I knew how to do. Without support from outside authorities, the nursing home began incorporating habilitative methods with dementia patients. Then, I started going to meetings of the Alzheimer's Association in Boston, which was really getting seriously started then, and sharing my ideas. The whole thing grew. I began consulting. It's what I do today. Right now, I am working with an architect and an interior designer on how to design houses that people with Alzheimer's can successfully live in.
Q. How did you meet your second husband, Edward Coste?
A. On a blind date 15 years ago. My hairdresser thought we'd be a good match. I didn't want to go on any date, but my son Jason was about to leave for college, and he said: "You're not going to have me to take care of you. Let's find someone to take care of you." It was a lighthearted thing. Well, my hairdresser was right. It was love at first sight. Teddy has diabetes. I sometimes tell him: "You take your insulin. If anything happens to you, I am going to be angry. I'm not 32 anymore, and I'm not doing this a second time."

A Nicotine Patch to Match Your Genes
Eric Nagourney, New York Times- 3/23/2004

When it comes to quitting smoking, men and women may not be the same. A new study reports that among women, the effectiveness of nicotine patches intended to help people quit seems related to an individual's genetic makeup. In men, this does not appear to be the case. The study, which appears in the online version of the British medical journal BMJ, followed up on research on the patch conducted a decade earlier.
      This time, the researchers, led by Dr. Patricia Yudkin of Oxford University in England, drew blood samples from 752 volunteers who took part in the first study. The researchers then conducted a genetic analysis to see what kind of brain receptors the subjects had for the messenger chemical dopamine, which appears to play a role in tobacco addiction. Assessing how well the smoking cessation device worked over the course of the first study and in the years since, the researchers found that the patches were much more likely to help women with a relatively unusual variant of the receptor than women with a more common version.
      Dr. Yudkin said more research was needed to confirm the results. "If confirmed," she said, "they could affect the way practitioners help people who want to give up smoking in future." She said doctors might eventually be able to test women easily and inexpensively to see if they were genetically suited for the patch.

Driving Drunk: A Study Looks at Child Deaths
Matthew L. Wald, New York Times- 3/23/2004

WASHINGTON— About two-thirds of child passengers who die in car crashes involving some measurable amount of alcohol are in the vehicle with the drinking driver, according to a new study of government statistics by Mothers Against Drunk Driving. The police reports on which the statistics are based do not indicate the family relationships of crash victims. But very often the driver is the child's parent, says MADD, which argues that drunken driving with a youngster in the car is a form of child abuse and should be a basis for revising custody agreements and visitation rights in divorce cases. "Where the ex-spouse is able to have visitation, if they come to pick up the child and they obviously are impaired, you've got a parent with a dilemma," said Wendy J. Hamilton, president of MADD. "They're court-ordered to hand over these children, but if they do there's a risk that child could be injured or killed."
      In its study, to be released here on Tuesday, the group asserts: "Driving impaired is not an `accident' or a mistake. It is a choice, just as blatant physical child abuse is a choice. Rather than a fist, the weapon is a motor vehicle." The report, "Every Child Deserves a Designated Driver," which uses a government definition of children as those 14 and under, contradicts the stereotype of the lone drunken driver smashing into a car in which a family is riding or running down children playing in the street. According to the National Highway Traffic Safety Administration, the vast majority of children killed by drunken drivers are in vehicles, and not pedestrians or cyclists. And of the 1,985 children who died from 1997 to 2001 as passengers in alcohol-related accidents, 1,349, or 68 percent, were in cars whose drivers had measurable levels of alcohol, government statistics show. Within that group, about three-quarters, a total of 1,016 children, were in cars whose driver's blood alcohol level was over 0.08 — that is, 0.08 gram of alcohol per deciliter of blood — the national standard for being under the influence.
      Experts say the danger to children transcends the increased risk that a driver who has been drinking will simply have an accident. Ralph W. Hingson, director of epidemiology and prevention research at the National Institute on Alcohol Abuse and Alcoholism, one of the National Institutes of Health, said the higher the blood alcohol, the less likely the driver would be wearing a seat belt. And if the driver is not buckled, Dr. Hingson said, child passengers are less likely to be using an infant seat, a booster seat or a seat belt.
      To help make its case, MADD is bringing Lt. Carl McDonald of the Wyoming Highway Patrol to Washington for the news conference where the study is to be issued Tuesday. Lieutenant McDonald's 5-year-old daughter died in January 1998 in a car driven by his intoxicated former wife; the girl's safety seat, though in the car, was not used.
      The government statistics, mostly drawn from the traffic safety agency's Fatality Analysis Reporting System, also give a glimpse of another problem: children drinking and then driving themselves. According to the statistics, 59 drivers killed from 1997 to 2001 were 14 or under and had measurable alcohol levels. Those drivers would usually be at least a year below the minimum age for licensing, depending on the state, and nationally would be at least seven years below the legal drinking age.

Patients taking antidepressants can become suicidal in the first weeks of therapy, and physicians should watch patients closely when first giving the drugs or changing dosages, federal regulators said yesterday. The warnings are part of a public health advisory issued by the Food and Drug Administration and are a reminder that antidepressants, taken by millions around the world, are not without risks. The agency is asking drug manufacturers to place detailed caveats about the drugs' side effects prominently on their labels.
     The agency's decision to issue such a broad warning was a surprise. Top F.D.A. officials have long insisted that their decisions are driven only by clear-cut evidence from well-run clinical trials. But in a conference call with reporters yesterday, agency officials said that no studies had shown a convincing link between drug therapy and suicide. Suicide is such a rare side effect that studies on the subject have been difficult to interpret, the regulators said. Still, the agency issued the advisory anyway. "It warns physicians that patients' depression may become worse," said Dr. Russell Katz, the agency's chief of neurological drugs, "that they may develop suicidal thinking or behavior after the initiation of treatment."
      A series of secret studies, which were conducted by drug companies and became public last year, seemed to show that depressed children and teenagers given antidepressants were more likely to become suicidal than those given placebos. The studies also showed that most antidepressants were not effective in treating depression in children and teenagers. Those studies are still under review at the agency.
      Nevertheless, a scientific advisory panel urged the agency last month to issue stronger warnings about the possibility that teenagers and children given the drugs could become suicidal. Studies in adults have found no link between the drugs and suicide, but the agency included adults in the warnings, in part because of anecdotal stories at advisory meetings last month. Dr. Katz said "a number of witnesses said that these were experiences that they had with adults, too." "We think this is good advice whether the drugs did it or not," said Dr. Robert Temple, associate director of medical policy at the agency. "If someone commits suicide, it doesn't really matter whether it's the drug or the underlying disease. In either case, you need to pay attention."
      Some psychiatrists said the new warnings were likely to slow sales, which amounted to about $12 billion worldwide in 2002, and would change how the drugs were prescribed. Prozac, from Eli Lilly, is one of the most widely prescribed drugs of all time. Zoloft, from Pfizer, had $3.1 billion in sales last year, making it one of the world's top-selling medicines.
      Dr. Jeffrey Lieberman, a professor of psychiatry and pharmacology at the University of North Carolina, said that the agency's action suggested that antidepressants had become too popular and physicians too casual about dispensing them. "I think the effect of these warnings will be to have physicians become a bit more conservative in using these drugs," Dr. Lieberman said. "They'll start limiting their use of them just to patients who are clearly depressed with clinically significant symptoms as opposed to those who have very mild symptoms."
      Dr. Regina Casper, a professor of psychiatry at Stanford, said that family physicians had become far too confident in the drugs' safety. Patients who are given their first prescription for an antidepressant should see their doctor at least once a week and perhaps more frequently, something family physicians rarely have time for, she said. "I think this will have a real sobering effect among family practice doctors," Dr. Casper said.
      The warnings also tell physicians to be particularly careful to evaluate whether patients have bipolar illness, also known as manic depression. Antidepressant therapy for such patients can cause a manic episode, the label states.
     While suicide is already mentioned in a rarely read portion of a sheet included with prescriptions for the antidepressants, the new discussion of suicide will be placed in the drug's warning section, the most important, widely read and prominent section of the label. To further ensure that doctors will read the material, part of it will be in boldface. The label is the primary way the F.D.A. communicates with physicians about the safety and efficacy of drugs.
     Jennifer Yoder, a spokeswoman for Lilly, said the company would comply with the agency's request. "It's important that patients keep today's announcement from the F.D.A. in perspective," Ms. Yoder said. "Depression is a serious public health issue, and it takes great courage for patients to begin treatment in the first place." Dr. Catherine Clary, a Pfizer vice president, said the company would work closely with the agency to come up with label changes for Zoloft. A spokeswoman for GlaxoSmithKline, the maker of Paxil, said the company was studying the request. The companies are almost certain to adopt the agency's proposed changes.
      While the F.D.A. does not have the power to require the changes, if the manufacturers refuse to go along, the agency can declare their drugs mislabeled and force their removal. Because every antidepressant introduced in the past 15 years is included in the warning, no company is at a disadvantage. Indeed, even drugs like the GlaxoSmithKline antidepressant Wellbutrin, also known as Zyban, that have not been linked with suicide were included. The drugs in the warning are: Prozac; Zoloft; Paxil; Wellbutrin; Luvox, from Solvay; Celexa and Lexapro, from Forest Laboratories Inc.; Effexor, from Wyeth; Serzone, from Bristol-Myers Squibb; and Remeron, from Akzo Nobel.
      The dispute about whether popular antidepressants cause some patients to become suicidal or violent has been continuing for 14 years. In 1990, a Harvard psychiatrist wrote a paper suggesting that some of his patients had become acutely suicidal after taking Prozac. More testimonials followed. But a 1991 scientific advisory panel concluded that there was no convincing evidence. The studies in children raised the issue again last year, and health authorities in Britain told physicians that with the exception of Prozac, the drugs should not be used in teenagers or children. Still, studies show that teenage suicides have declined sharply in countries where antidepressant therapy has become widespread, suggesting that the drugs prevent many more deaths than they may cause.
      Dr. Madhukar Trivedi, director of the mood disorders program at University of Texas Southwestern Medical School at Dallas, said he worried that the new warnings might make depressed patients afraid of their pills. "The consequences for not treating depression are very high," Dr. Trivedi said.
      The agency advisory says: "Health care providers should carefully monitor patients receiving antidepressants for possible worsening of depression and suicidality, especially at the beginning of therapy or when the dose either increases or decreases." Anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity and severe restlessness are also possible side effects, the advisory adds. The agency decided against following British regulators in suggesting that physicians should avoid the drugs' use in children. Only Prozac has been shown to be effective in treating depression in children, but that does not mean the other drugs do not work, officials said. "What we don't know for sure is what is the best thing to do for a child who's depressed," Dr. Temple of the F.D.A. said. "Depression has its own liabilities. It can be a fatal illness. What we don't know is whether the long-term benefits outweigh the risks."

Psychotherapy May Help Hypochondriacs
Associated Press, 3/23/2004

CHICAGO -- A breakthrough study found that psychotherapy can help hypochondriacs deal with their fears. But the treatment has its limits: A quarter of the patients quit after being told the problem was in their heads.
     Hypochondria is a mental, not physical, illness. Getting sufferers to believe that is part of the challenge in treating them. ``Most hypochondriac people never will go to a psychiatrist,'' said study author Dr. Arthur Barsky of Harvard's Brigham and Women's Hospital. ``They'll say, `I don't need to talk about this, I need somebody to stick a biopsy needle in my liver, I need that CAT scan repeated.'''
     The study involved 102 patients assigned to receive psychotherapy and 85 who got routine medical care. Among those who completed the six therapy sessions, almost 57 percent showed significant improvement in symptoms and quality of life after a year, compared with 32 percent of the comparison group. ``It's actually a landmark study. This is an understudied and underappreciated problem,'' said Dr. Joshua Straus, medical director for consultation psychiatry at Chicago's Northwestern Memorial Hospital.
     Hypochondria involves persistent, unfounded fears about having a serious disease and affects about 5 percent of patients who seek help from primary-care doctors. Medication can help treat hypochondriacs' anxiety, but until now there has been little evidence of an effective treatment for the underlying disorder. ``Having some demonstrated way to intervene and help them is a terrific advance,'' said Straus, who was not involved in the research.
     The study, by Barsky and colleague David Ahern, appears in Wednesday's Journal of the American Medical Association. Among the 102 participants, 25 quit before completing all six sessions and almost 14 percent never attended any sessions. The treatment ``didn't fit with their belief system'' that their illnesses were real, Barsky said. Hypochondria is notoriously hard to treat, in part because patients often ``doctor-shop,'' or switch doctors repeatedly until they get tests or a diagnosis they can accept. Scientists are uncertain about what causes hypochondria, but some think it might be genetic or learned from parents who overreact to illness. Some cases are triggered when patients or someone close to them suffers a serious health scare. The ailment typically begins in childhood or early adulthood and can last a lifetime.
     Carla Cantor, a 49-year-old New Jersey writer whose book ``Phantom Illness'' details her struggles with hypochondria, said accepting mental health treatment is not easy because hypochondria has such a stigma. In fact, some psychiatrists and patients call the condition ``health anxiety'' instead. In college, Cantor was convinced her headaches were caused by brain tumors. Later on, she thought she was dying of lupus and was hospitalized for three days of tests that turned up nothing. After being told that she was depressed, Cantor finally began to believe that she had hypochondria. ``You're experiencing bodily symptoms as terrifying,'' she said. ``It's very hard for people to let it go.'' Anti-depressant medication has helped, but Cantor said she thinks treatment like Barsky's can also work.
     The study involved six 90-minute sessions where therapists encouraged patients to stop habits that worsened their symptoms, including seeking disease information on the Internet and reading newspaper obituaries. Patients were taught how to understand symptoms better and also learned distraction techniques. ``With a condition that is such a difficult one ... any improvement that is statistically significant -- we'll take it,'' said Emanuel Maidenberg, an assistant psychiatry professor at UCLA.
     Hypochondria is a psychiatric ailment featuring persistent unwarranted fears about having a serious disease. It affects about 5 percent of patients who seek help from primary-care doctors.
Patients often have real physical symptoms, but the causes are usually harmless aches and pains or normal physiologic reactions. For example, standing up quickly after bending over can momentarily interrupt adequate blood flow to the brain, causing brief but harmless dizziness. Hypochondriacs might think that dizziness was a stroke and seek out repeated medical tests even after doctors found nothing wrong.
On the Net:
JAMA: http://jama.ama-assn.org
Hypochondria support group: http://www.healthanxiety.com

Mass. Court Says Incest Statute Could Be Changed
Jonathan Saltzman, Boston Globe- 3/23/2004

The state Supreme Judicial Court ruled yesterday that the Massachusetts law against incest does not apply to stepparents and said it was up to the Legislature to change the law. In a 4-to-3 ruling in a case involving a 60-year-old Dorchester man accused of having sex with his teenage stepdaughter, the court said the incest statute prohibits intercourse only between people related by blood or through adoption. "This is no doubt a difficult case," the majority said, given that the ruling "will result in the dismissal of six indictments alleging that the defendant committed incest by having sexual intercourse with his stepdaughter when she was fifteen and sixteen years old." However repugnant it might seem, the majority nonetheless said words in the statute on incest "cannot be stretched beyond their fair meaning in order to relieve against what may appear to be a hard case."
     Suffolk District Attorney Daniel F. Conley said he was disappointed by the ruling. But he noted that the defendant, Dawud Rahim, who has been held since 2001 at the Nashua Street Jail, still faces numerous charges, including rape, exhibiting a nude child on videotape, and illegal wiretapping. Conley said he intends to file legislation shortly to broaden the incest statute to apply to stepparents.
     Rahim's lawyer, Robert J. Zanello, was pleased with the decision, saying that the court correctly interpreted the incest statute. "In this case, the SJC dealt with what the language of the statute was, and I believe the criminal statutes should be strictly construed," he said. Twenty other states only punish incest by blood relatives, the court noted.
     Wendy Murphy, a professor at the New England School of Law, said she appreciated the court's ruling "in a technical sense," but she questioned why the justices didn't recognize the role of stepparents in modern families -- when they have recognized the changing nature of families in other cases. Ira Mark Ellman, a professor at Arizona State University's College of Law and a specialist on family law, sounded a similar theme. Although the court may have correctly recognized a loophole in the original statute, he said that "exploitation of a minor is clearly a concern that triggers incest regulations."
     The state's highest court issued its ruling after Superior Court Judge Joseph M. Walker III responded to a request by Rahim's lawyer for the incest indictments to be dismissed. Walker posed a question of law to the state Appeals Court, and the SJC granted an application for direct appellate review. "We leave it to the Legislature to expand the incest prohibition if it so chooses," the court said in its majority opinion, written by Justice Robert Cordy.
     In a dissenting opinion, Justice John Greaney said the majority had reached a "startling result" based on "faulty analysis." "The court leaves us with a situation where this defendant will avoid prosecution for incest, and [unless the statute is changed] a stepfather can have consensual sexual intercourse with his sixteen-year-old stepdaughter without fear of criminal sanction. [But, he will not be able to marry her]," Greaney wrote in the dissent. "As a result of the court's decision, we are left with an unfortunate state of affairs that frustrates legislative intent and undermines the value and stability of the family as the core unit of society." Joining Greaney in his dissent were Chief Justice Margaret H. Marshall and Justice Francis X. Spina. Besides Cordy, the other justices in the majority were Roderick L. Ireland, Judith A. Cowin, and Martha B. Sosman.



Overprescribing Prompted Warning on Antidepressants
Denise Grady & Gardiner Harris, New York Times- 3/24/2004

The government's warning on Monday that people newly taking antidepressants can become suicidal and must be closely monitored grew at least in part from a concern that the drugs were being handed out too freely and without enough follow-up, especially in children and teenagers. Dr. Wayne K. Goodman, chairman of psychiatry at the University of Florida College of Medicine and a member of an expert panel that advised the Food and Drug Administration, said, "I think many physicians, and particularly nonpsychiatrists, have been lulled into the notion that these drugs are safe." He emphasized that the drugs carried few serious physical side effects and a low risk of overdose. But, Dr. Goodman added, "I think what's been underestimated is this behavioral toxicity, which can indirectly lead to problems, including possibly suicidal behavior."
      Yesterday many doctors acknowledged that the new warning was sound advice and yet said they worried it might discourage doctors and patients from treating depression. Dr. Eva Ritvo, an associate professor of psychiatry at the University of Miami, said: "A depressed patient needs to be watched closely, particularly in the initial stages of treatment or when the dosage is raised. This is something we should be doing anyway as mental health professionals." But, she added, "Untreated depression is dangerous and takes a huge toll on people's lives, and we can only hope this warning doesn't discourage people from seeking treatment."
      Patients had mixed reactions. Some people who suffered depression in the past but shunned medication said the new warnings reinforced their wariness. Barry Owen, 51, a magazine consultant in San Francisco, refused antidepressants during an emotional crisis. He said his doctor recommended the drugs a few years ago "because at that point I was pretty severely depressed and having panic attacks and couldn't eat and sleep." Mr. Owen added: "I decided then not to take her advice. And while I don't doubt the usefulness for a lot of people, this new information gives me one more question about them."
      But patients who have done well on the drugs were not troubled by the new warnings. Paul Festa, 33, a San Francisco artist and writer, took Zoloft for about a year in 1999, and then Paxil for a year or so after the 2001 terrorist attacks. He said: "I would never hesitate to go back on these medications because I already know that I react extremely well to them. I feel like there should be a warning for people who are depressed that not taking these medications could lead to suicide. If you're depressed, you're putting yourself at risk for all sorts of self-destructive behaviors, up to and including suicide. "When I was depressed, the thought of suicide was crossing my mind more than it ought to have, and the antidepressants got me out of that loop."
      The advisory issued Monday by the drug agency asked manufacturers to put detailed warnings about a possible increased risk of suicidal behavior and the need for monitoring on the labels of 10 antidepressants: Prozac, Zoloft, Paxil, Wellbutrin, Luvox, Celexa, Lexapro, Effexor, Serzone and Remeron. The warning included both children and adults.
      Studies in children taking the antidepressants have not found an increase in suicide. But studies of some drugs have suggested that they might increase the risk of suicidal thoughts and behaviors. Research has also failed to provide convincing evidence that the drugs are effective in children, making the potential risks even less acceptable. There is no solid data linking use of the drugs to suicide in adults.
      Dr. Goodman of Florida said that panelists who met last month were troubled by reports that some doctors were giving patients samples of antidepressants and saying casually "Tell me how you do," rather than scheduling frequent follow-up appointments to make sure patients were tolerating the drugs. "That is problematic," Dr. Goodman said, "and probably reflects people becoming a little lackadaisical about the downside of these medications in children."
      Most antidepressants are now prescribed by primary care physicians, whose patients may never see a psychiatrist, because of concerns about cost or the perception of stigma attached to mental illness. Prozac, Paxil and other modern antidepressants became hugely popular in part because drug companies convinced family physicians that they were safe enough to use without a psychiatrist's intervention. Antidepressants are the third biggest selling category of drugs in the world behind cholesterol and heartburn pills.
      Some psychiatrists speculated yesterday that their family-care colleagues might lose confidence in the drugs and become reluctant to prescribe them. "We're hoping that doesn't happen, because primary care physicians have a major role to play in combating depression," said Dr. James H. Scully Jr., medical director of the American Psychiatric Association. "We hope they won't be scared off." Dr. Robert Lee, a San Francisco physician of holistic medicine who sometimes prescribes antidepressants, said: "I don't think people already taking them will be concerned. But a lot of people who I think would benefit from these meds already won't take them because of various stigma reasons, so I'm a little concerned that this will raise that barrier even higher." Dr. Lee said the new warning would not make him hesitate to prescribe the antidepressants. He said, "People can get agitated from them, but I've never seen somebody get suicidal from them."
      Dr. Joseph Gonzalez-Heydrich, chief of psychopharmacology at Children's Hospital Boston, said: "I've heard anecdotally that a lot of antidepressants were being prescribed by pediatricians without a lot of training or experience. I think the warning is appropriate. If it makes prescribers more vigilant or parents more vigilant, that's a good thing." Dr. Gonzalez-Heydrich said that a sizable minority of children became more agitated and irritable on the antidepressants in question. "If we see it, we take them off it or reduce the dose," he said. "Doing it that way there are a lot of kids we feel do benefit from these medications, especially long term. But they're not for everybody."
      Dr. Harold Koplewicz, director of New York University's Child Study Center, said, "The fear I have about this warning is that many teenagers will not get the medicine because it will build resistance among their parents, and that's really a tragic outcome." He noted that suicide rates in teenagers had gone down in the United States and Sweden as use of the drugs increased.
      Several primary care doctors said that they had prescribed antidepressants with success for so many years that it was unlikely the F.D.A.'s new warnings would lead them to stop. Still, the warnings have given them pause, they said. They may think a bit harder before prescribing them to patients who are simply stressed, they said. And they will watch how the warnings play in the legal field, some said. "We're going to continue to use these drugs pretty freely until we start seeing the ads in the newspapers from lawyers saying, `Have you or your family member been prescribed these drugs? If so, you may have a case,' " said Dr. Phillip Kennedy, a family practice physician in Augusta, Ga. "When the big L word, liability, raises its ugly head, that's when things will really change."
      Spokesmen for drug companies said that they would emphasize to physicians that the F.D.A.'s warning did not conclude that antidepressants cause suicide. "My hope is that people won't make a link with the drugs," said Jennifer Yoder, a spokeswoman for Eli Lilly & Company, maker of Prozac. "I think the message will be that suicide is an inherent part of the disease of depression, and physicians should carefully monitor their patients."
      Critics of the medicines said the F.D.A.'s warning was long overdue. "These warnings are not as strong as I would like, but they're an important first step," said Tom Woodward of North Wales, Pa. Mr. Woodward's teenage daughter, Julie, hanged herself six days after starting therapy with Zoloft.

Mothering and Its Cultural Discontents
Patricia Cohen, New York Times- 3/24/2004

A friend says that at cocktail parties she often gets the greet and turn: as soon as she mentions that she is a stay-at-home mom, her conversation partner abruptly turns his head and walks away. The assumption that mothers who don't work are boring, marginal, powerless — not even worth polite party chatter — is one that Daphne de Marneffe is passionately seeking to overturn with her book, "Maternal Desire." Mothering, she argues, is a creative, empowering and meaningful endeavor in its own right; a route to self-fulfillment and individuality rather than a detour; a moral, even aesthetic undertaking. Her book is part of a sprawling, sometimes heated conversation that women have been having for years — primarily among themselves — about family, feminism, fertility and fulfillment. Like long-standing sibling rivalry it spills out at every turn, on the park bench and in the office cafeteria, in hundreds of novels, nonfiction books and talk shows.
      By far the most remarked upon article that The New York Times Magazine published last year was by Lisa Belkin, about the razor-thin stratum of wealthy, high-powered women who quit their jobs to stay home with their kids (without having to cancel their Neiman Marcus charge cards). More recently Caitlin Flanagan inspired debates online and elsewhere among middle- and upper-class women with her Atlantic magazine cover article questioning whether professional women have built their success on the backs of third world nannies. It is a conversation in which nearly everyone feels equally expert — or clueless. Every time a mother is unable to pick up her daughter at school, or has to sneak out of work early or ask the baby sitter to vacuum the rug, she is confronting the financial, emotional and moral choices she has made.
      With three children and a part-time career as a psychologist and author, Ms. de Marneffe is a veteran of such conflicts. Although the convention is that a woman's fulfillment is at odds with her child's needs, the truth, Ms. de Marneffe argues, is the opposite: caregiving is the path to fulfillment. Feminism has championed women's choice, she writes, but it has ignored or denied the desire — not the duty, not the biological imperative, not the necessity — but the raw, profound desire to care for one's own children. Just talking about such deeply felt urges, she says, is so disdained that women are embarrassed to admit them. "It is almost as if women's desire for sex and their desire to mother have switched places in terms of taboo." This cultural taboo makes it nearly impossible for women to work out a meaningful and satisfactory balance in their lives.
      At times this well-researched book contains flashes of insight and expressions of deep sympathy, as when Ms. de Marneffe notes that our values inevitably determine what we consider to be needs. She captures the exquisite conflicts that weigh on women, and despite occasional lapses into self-helpese she writes movingly of the transfiguring effect of motherhood. Yet alongside nuanced analyses are familiar caricatures and overstatements. Mainstream feminism in this book resembles a Size 4 sweater after it has been put on a Size 16 body: so stretched to fit the argument that it is barely recognizable. I can't think of anyone who considers that asking if we're ignoring maternal desire is, as Ms. de Marneffe says, "tantamount to claiming that women are only happy if they are barefoot and pregnant." Many of the feminist tracts she cites are a dozen years old or more. And the supermom ideal that she says still tyrannizes women hasn't been taken seriously since big shoulder pads were in fashion.
      Most odd is her claim that the failure to have a good, affordable system of child care is in part because of mothers' ambivalence about having others care for their children. Really? So I guess that means part of the reason more than 43 million Americans lack health insurance is because they are ambivalent about having coverage.

Digging Up Surprising Roots Behind a Problem Child
Anita Gates, New York Times- 3/24/2004

Robert Oliver, age 7, is a problem child. He has killed several cats and dogs, his grandmother says, and has attempted suicide. As a result he is on Ritalin for attention-deficit disorder and BuSpar for depression. Rory Kennedy and her cinematographer, Nick Doob, have come to Eupora, Miss., a tiny town with a median household income under $25,000 a year, to follow Robert's progress. Their intention is to make a film about how social services programs affect the lives of American children living in poverty. But the resulting gripping documentary, "A Boy's Life," on HBO tonight, turns out to be about a wicked witch.
     Ms. Kennedy, who dealt with Southern poverty in her first film, "American Hollow," about an extended family in Appalachia, is becoming quite a filmmaker. It is difficult to take your eyes off her subjects or their plight. It still seems important to mention that Ms. Kennedy is the youngest child of Robert F. Kennedy, and that she was born in 1968, six months after his death, but her professional reputation is growing and that fact may soon be considered incidental.
     "A Boy's Life" first visits Robert at home, where he pounds on the floor and bangs his head against the wall. When someone mentions that his little dog is adorable, he replies, "But sometimes he can be a little devil and bite you with his sharp teeth." Robert does seem hyperactive, practically bouncing off the walls, despite the Ritalin. Then the film follows Robert to school. He sings "My Country 'Tis of Thee" along with his classmates, he reads more than competently, he says "Yes, ma'am" to his teachers, and - can this be? - he makes the honor roll.
     "I think what we've got here is two Roberts," his principal, Vicky Beckham, tells Anna Threadgill, Robert's grandmother, during a home visit. Anna is not pleased by the suggestion that her grandson's teachers can control him but she cannot, and she reacts with a veiled version of her deadly modus operandi. When Ms. Beckham assures Robert that he has everything he needs for success, and specifically that he is intelligent and nice-looking, Anna responds immediately, taking on her grandson's voice: " `I'm good-looking, and all the kids are jealous of me, and they all call me ugly,' " she says. "But say, `I know I'm good-looking.' " If this is Anna's good behavior for the camera, one shudders to imagine how she treats Robert when Ms. Kennedy and Mr. Doob leave. And you don't have to have grown up on welfare to recognize and be outraged by the pain that an emotionally abusive parent or guardian can inflict. Poverty and a culture that discourages hope only magnify young victims' helplessness.
     When Anna mentions that her father was a full-blooded Comanche, Robert goes into his tough-guy act, saying: "Give me a bow and arrow. I need to shoot myself." His grandmother responds by handing him a pistol (unloaded at least) and then ridiculing him. "You can't even shoot Mamaw's gun," she says. Robert and his little brother, Benji, sleep in the same bed with Anna, although the house seems to have enough space for other arrangements. When Robert wins a race with Benji, she declares Benji the winner instead and says, "Robert, you don't know how to run." By the end of the film you have to cringe whenever Anna touches Robert. He cringes, too, thank goodness.
     Robert's mother, Robanna Fason, was 15 when she became pregnant as a result of rape. She was running with a "bad crowd," she says. "They got me on drugs and some kind of something that made me where I didn't know what my name was." Robanna doesn't take care of her children, she says, because she is sick. "I'll stand in the store for five minutes, and my legs go to hurting," she says by way of example of her condition, also mentioning pneumonia, seizures and thyroid problems. When she seeks medical attention, though, Anna ridicules and discourages it.
     Anna has problems herself. Dr. Virginia Fee, Robert's state-appointed therapist, concludes that Anna has something like Munchausen syndrome by proxy, inducing symptoms of emotional illness in Robert. The film suggests that Anna despises him because his arrival destroyed Anna's dreams for her daughter. She had planned for Robanna to be a beauty queen and a model, even though Robanna, in her early 20's, is obese and missing several front teeth.
     During the film the best thing that happens to Robert is that Anna goes into the hospital, and that leads to some changes. It is unclear exactly how ill she is or how much her mind is influencing her body, but when on her sickbed Anna promises Robert that she will see him again in heaven, it sounds like a threat.
A BOY'S LIFE
HBO, Wednesday, 3/24/2004 at 7:30, Eastern and Pacific times; 6:30, Central time
Produced and directed by Rory Kennedy; Liz Garbus, producer; Nick Doob, co-director and director of photography; Charlton McMillan, editor; Joel Goodman, original music; Mark Bailey, story editor; Nancy Abraham, supervising producer for HBO; Sheila Nevins, executive producer for HBO. A Moxie Firecracker Films production.