Mental Health Courts Seen Soon in Chicago
Jeff Coen, Chicago Tribune- 3/25/2004

After two years of planning, mental health courts designed to better link non-violent criminals to treatment could be established within weeks at the Criminal Courts Building, Cook County's chief judge confirmed Wednesday. Chief Judge Timothy C. Evans said final discussions are under way, but the new effort is expected to start this spring. "It's my hope we can break this cycle of dependency and make our communities safer," Evans said, adding that a formal announcement is imminent.
      Officials said cases would be funneled to two judges at the courthouse, where defendants with easily identifiable histories of mental health problems would be monitored and linked to treatment as a condition of probation. Estimates are that about 10 percent of inmates at Cook County Jail have mental health problems, making it one of the state's largest facilities dealing with the mentally ill.
      The courts would be modeled on the narcotics courts common at the Criminal Courts Building, where drug treatment becomes part of probation requirements, Evans said. The mental health courts would address underlying mental health issues that can contribute to criminal behavior, planners said, potentially reducing the number of former criminals who revert back to crime. "It's something that we feel strongly about, and it's something that's been in the planning stage for some time," Evans said.
      The program would run at its start with a limited number of cases and without additional money from the court's budget or outside funding, county officials said. The two judges who would handle the cases would continue to carry a regular criminal caseload. The Cook County public defender's office already has shuffled lawyers to the courtrooms to take on the cases.
      Evans said the courts would be unique, because non-violent felony cases would be involved. Most similar programs in the U.S. deal with misdemeanor defendants. The effort would involve increased coordination between the Cook County state's attorney's office, the public defender's office, the Cook County Adult Probation Department, the social service agency Treatment Alternatives for Safe Communities, the state's Office of Mental Health and Cermak Health Services, the caregiver for jail inmates.



Parents and Specialists Help Boy Deal with Dyslexia
Claudia Feldman, Houston Chronicle- 3/26/2004

When Peter Oathout was 5, the very thought of kindergarten made him sick. Certain activities during the day, particularly tests where he would have known the answers had he been able to decipher the questions, made him cry. And in the evenings, when he was struggling with his homework and b's looked like d's and "d-o-g" looked like "g-o-d," he'd get so frustrated he'd cuddle up to his dad and say, "I like it better when you read."
     Peter was lucky. His parents realized something was wrong, even though they couldn't pinpoint the problem. His vision was fine. He wasn't hyperactive or developmentally delayed. They talked to his teacher. She recommended a reading tutor. And the reading tutor recognized his reading disability. The Oathouts scoured the Internet for information. That's how they learned researchers at the University of Texas Medical School at Houston are experimenting with noninvasive imaging to map brain function and dysfunction, including dyslexia.
     MEG, or magnetoencephalography, allows scientists to take snapshots of brain activity every millisecond. After spending about 30 minutes with Peter, including a break for a snack, UT researchers had the data they needed to identify his problem. Most people read using the left half of their brain exclusively. Peter, like other dyslexics, was using the left and right lobes. The MEG doctors referred Peter to the Texas Reading Institute here. After hundreds of reading drills over the next 10 months, Peter's skills improved. Today the 8-year-old is a predominantly left-brain reader who enjoys second grade at Poe Elementary. He whizzes through tests required by the Houston Independent School District. He's reading above grade level. Meanwhile, researchers continue to work with MEG, hoping to unravel many more mysteries locked in the brain.
     Dr. Andrew Papanicolaou, director of the medical school's division of clinical neurosciences, hopes the machine and its ability to map brain function may one day also help those who suffer from epilepsy, attention deficit disorder, spina bifida, autism, brain injury and stroke. "We're trying to find out the brain mechanisms for all conceivable functions -- sensation, movement, speech, memory, attention, space perception. The sky is the limit," Papanicolaou says.
     Dr. Guy Clifton, a colleague of Papanicolaou's at UT, is watching the progress with both professional and personal interest. As a parent of a dyslexic child who was helped by MEG and intervention, he's glad to see that the massive machine has immediate practical applications. As a neurosurgeon and director of the $10 million project to improve function for spinal-cord and brain injury patients known as Mission Connect, he's optimistic that continued work with MEG will give scientists many more tools to help patients. Clifton says it's amazing what doctors still don't know about the brain and its functions. MEG offers a peek in.
     Papanicolaou, 53, was born in Greece, moved to the United States at 20, then threw himself into neuroscience. In the early '80s, when he was working at the UT Medical Branch at Galveston, he learned that it was possible to study the brain's magnetic waves -- and which parts of the brain handled specific tasks -- with a pioneering version of the machines used today. Papanicolaou wanted one, and he asked for financial help from Robert Moody with the Moody Foundation. The Galveston philanthropist, who was particularly interested in head injuries and rehabilitation, agreed and contributed almost $800,000.
     In 1993, when Papanicolaou moved to the UT medical school here, he got Moody's blessing to take the machine with him. Even then Papanicolaou and colleagues were focusing on basic research in neuroscience. They wanted to figure out how the brain is supposed to work, how it sometimes repairs itself and what they could do to facilitate those repairs. The machine, then based at the medical school, has been replaced by one now in use at Memorial Hermann. The hospital and UT's department of neurosurgery paid $2.5 million for the new equipment.
     A second $2.5 million machine has been installed at TIRR (The Institute for Rehabilitation and Research, which coordinates Mission Connect activities) with help from the National Science Foundation. Funds for research, space and equipment have come from the Vivian L. Smith Foundation for Neurological Research, the National Institutes of Health and Mission Connect.
"MEG is not a panacea. It's not an end-all," Papanicolaou says. "But when it comes to taking pictures of brain function, it's the best that we've got."
     In a project with almost limitless possibilities, Papanicolaou and his colleagues had to establish priorities. UT doctors were the first in the nation, for example, to use MEG to locate language centers in the brain. That essential information helps surgeons avoid damage to those centers during operations. "I did not myself discover all these things," Papanicolaou says. "Many people have worked together as a group." UT doctors also were the first, he says, to use MEG to chart the abnormal brain-activity that defines dyslexia, which affects 2 percent to 8 percent of the school-age population in North America. The cost is enormous for those who don't get help. "Our society is highly literate," Papanicolaou says. "Two hundred years ago, it wasn't that big a deal if you couldn't read. Today, it's very important, like being able to walk."
     Papanicolaou and Panagiotis Simos launched the dyslexia screening project in 1999. Shirin Sarkari is in charge of it now. All told, they have tested about 60 dyslexic children, referred them for intensive reading tutoring and seen great improvement in their left-brain reading when tested again.
Papanicolaou says he is not sure whether all dyslexic children can benefit from this kind of one-on-one training, which starts with the correspondence of letters to sounds, then moves to the correspondence of syllables to sounds and words to sounds. But, he says, he and Sarkari are heartened by their results and look forward to testing 30 more children this year. They're looking for dyslexics ages 7 to 12, particularly left-handers, who do not suffer from emotional or other neurological problems.
     Along the way, the researchers are hoping to find out whether the slow and awkward right-brain reading is halted after a single period of intervention or whether the interventions have to be repeated. They're also wondering whether adult dyslexics can be helped or whether there is a cut-off age beyond which the brain cannot be retrained. "We think even older people can profit," Papanicolaou says.
     It's not known what causes dyslexia, though there are some indications it runs in families. It's also unclear whether dyslexics are born with the condition. Dyslexia first shows itself, Papanicolaou says, when little ones start to read. Not all of the UT experiments have gone as well as the dyslexia studies, he says. He hopes one day researchers will unravel the mysteries of depression, anxiety and other affective disorders. But that area of brain dysfunction has been harder to decipher. "We put on the front burner what is of most immediate urgency and what we can do something about," Papanicolaou says.
     Today, interest and money are concentrated in dyscalculia, which is a math learning disability, in aspects of bilingualism -- researchers want to know whether different languages require different brain circuitry -- and in brain injury and stroke. The question, Papanicolaou says, is why some patients recover from brain damage and others don't. "When brain tissue is destroyed, there is no regeneration," he says. "But we've found that if one part of the brain is invaded by a malformation or tumor, the function is likely to be relegated to another area. Some other area of the brain will pick it up. "That's the meaning of the reorganization," Papanicolaou says. "The neurons are reprogrammed."
     On a recent rainy afternoon at the Oathout home, Patrick, 12, is brimming with news about middle school. Grace, 10, is reminding her mom about a field trip. In the midst of the hustle and bustle sits Peter, whizzing through his homework at the kitchen table. Occasionally he smiles beatifically at his mom and dad, lawyers who are sharing painful stories about Peter's kindergarten year. "We thought he was just having problems adjusting to school," Monica says. "We thought he just had to buck up. Looking back, we realize he was trying to tell us something. We just missed it. He was so frustrated by the dyslexia."
     Peter also was frustrated by the reading therapy, which lasted two hours a pop, twice a week, for 10 months. In addition, he had to do reading drills at home. His dad, Mark, coaxed him through. When the child did well, he earned coins from a bottle filled with spare change. He also earned $100 to $150 per visit to TIRR. Because the dyslexia project is still considered experimental and is largely funded by grants, all clients accepted into the program are paid for their time and contribution to research.
     Monica is not sure exactly how much Peter has saved, but she knows where a bit of the money is going. Later this week, her mother is treating Peter to a trip to New York. It's a tradition the grandmother has celebrated with each of her other seven grandchildren when they turned 8. "It's a welcome to the world of traveling," says Monica, who gets to go, too. She is not sure what all they will see and do on their trip. But Peter has vowed he's taking his mother and grandmother to dinner while they're in New York. "We'll have to find someplace Peter thinks is really spectacular," she says.
     There are fewer and fewer reading drills going on at the Oathout house. Instead, they simply read. The other night, Peter read his mom a story about ancient Egypt. "He knows so much," she says. "What a great kid."

About 250 Set to Leave Massachusetts Psychiatric Hospitals
Raja Mishra, Boston Globe- 3/27/2004

State psychiatric hospitals will move more than 250 patients back into the community this year as part of an effort to care for those with mental illnesses in group homes and in the general population rather than in hospital mental wards, according to a report released to lawmakers yesterday. The Department of Mental Health report proposes the permanent elimination of 160 of the state's 900 long-term adult mental health beds, with the estimated $17 million in savings being used to care for those shifted into community settings. None of the state's eight psychiatric hospitals would be closed under the plan. However, the report recommends the construction of a state-of-the-art hospital in Central Massachusetts to replace psychiatric hospitals in Worcester and Westborough. "This is the last step in the deinstitutionalization process in Massachusetts," said state mental health commissioner Elizabeth Childs. "We clearly have not been discharging as many people as we could."
     Though the state faces considerable budgetary pressure, the plan would not save money in the short term. Rather, mental health officials in the Romney administration view it as a much-delayed final push to deinstitutionalize, a movement in mental health care that began in the late 1970s. Administration officials also worried that inaction could leave the state vulnerable to litigation: A 1999 US Supreme Court decision said that unnecessary institutionalizations were violations of federal disability laws. But the report also marks a slightly more cautious approach to the process than state mental health officials proposed last year. In 2003, they recommended shuttering the 156-bed Worcester State Hospital. Lawmakers from Central and Western Massachusetts opposed the move, and the Legislature ordered a reevaluation.
     The 31-page study, eight months in the making, calls for the quick discharge of 268 long-term psychiatric patients who state officials say have recovered enough to reenter mainstream life. These long-term patients suffer from severe delusions, emotional imbalances, and social pathologies that require months, often years, of care. But powerful medicines have improved the success rate of treatments. A review of the state caseload found that the 268 patients were ready to live in small group homes or even on their own with periodic supervision. "They would be safe, to themselves and others," said Childs. "Most of our patients tell us that they want to be out in the community."
     Childs estimated it would cost about $17 million to provide community care for these men and women. The money would come from permanently eliminating 160 long-term care beds at various facilities around the state. State analysts found the system could easily tolerate the bed reduction.
The state has had recent experience with such patient shifting: In April 2003, it closed Medfield State Hospital, moving 255 patients into community care, and using the $17 million in savings from the closure to provide community care for them. Only 17 have returned to institutionalized care, according to state figures.
     The report was heavily critical of the continued operation of psychiatric hospitals in Worcester and nearby Westborough, both of which serve the central part of the state. The two combine for almost 350 beds, where state analysts found only 250 are needed. And both facilities are old.
"We don't need both Worcester and Westborough. And neither hospital is adequate," said state health and human services secretary Ronald Preston. "What we've concluded is the best option is to build a new hospital." The report recommends an unspecified amount of money be spent on planning for the proposed new hospital. "We haven't figured that out yet . . . it's in the millions," said Preston. "It's a very reasonable report and we think the Legislature will support us."



Alcohol Is Behind Many ER Visits, Study Finds
ABC News, 3/27/2004

The number of people in the United States who go to hospital emergency rooms for treatment of alcohol-related illnesses or injuries is about three times greater than previously estimated, says a recent Massachusetts General Hospital study.
     Researchers examined data from the National Hospital Ambulatory Medical Care Survey for 1992 through 2000 and identified an estimated 68.6 million alcohol-related emergency department, or ED, visits. That's an average of 7.6 million alcohol-related ED visits per year.
From 1992 to 2000, alcohol-related visits accounted for 7.6 percent of the total 866.5 million ED visits.
     People aged 30 to 49 had twice the rate of ED visits with diagnoses considered to be completely attributable to alcohol than people 50 or older or those aged 15 to 29. The visit rate for men with diagnoses completely attributable to alcohol was three times higher than for women. The visit rate for blacks with such diagnoses was twice that of whites.
     "Although U.S. public health officials recognize that EDs throughout the United States face an enormous burden from alcohol-related diseases and injuries, this study shows that the current literature significantly underestimates the magnitude of this burden," the study authors write. "Our nine-year study also reveals a rising trend in the number and rate of a widening gap between sexes and a shrinking gap between races among those seen in the ED with certain alcohol-related diagnoses," they write. The authors suggest that "improving the frequency of ED screening may lead to more appropriate referrals and interventions during alcohol-related ED visits, with a reduction in subsequent illness and additional visits to the ED."

Why Test Animals to Cure Human Depression?
Gina Kolata, New York Times- 3/28/2004

You might think if questions were raised about whether antidepressant drugs can make patients suicidal during the first few weeks of treatment, that scientists would turn to animal testing for further investigation. After all, suicides are rare enough that there are no firm human data on whether the drugs can cause them. But you can do experiments with animals -- examining their brains, giving them high doses of drugs -- that you could never do with people.
     That might seem like a reasonable course of action, especially after the Food and Drug Administration announced last week that it was so concerned about a possible, though very slight, suicide risk that it wants antidepressant drugs to carry warnings on their labels. But it turns out that animal experiments are not an option. The reason, said Dr. Alan Schatzberg, chairman of the department of psychiatry and behavioral science at Stanford University's School of Medicine, is that "we don't have an animal model of depression."
     Instead, he and other experts say, the first generation of antidepressants was discovered by accident. Though a few came on the market based on clinical tests showing they could help patients, animal tests were later developed to speed the discovery of other drugs. The idea was for pharmaceutical companies to use animal testing to screen thousands of potential new compounds to pick out those most likely to work in clinical tests on depressed patients.
     The problem, some researchers say, is that while the animal tests work fine for identifying promising new drugs, they do not mimic anything like human depression. For one thing, animals respond to the drugs within half an hour, while depressed patients need weeks before feeling their effects. Another difference is that antidepressants affect different parts of the brain in animals and humans. "Depression has a strong emotional and cognitive component," Dr. Schatzberg said. "People feel sad, worthless, guilty." Those symptoms, he noted, involve the prefrontal cortex, a brain area not highly developed in animals. So, he asked, "How do you model it in an animal?"
     In one popular test, mice are placed in a pool of water and monitored to see how long they swim before giving up. If they are treated with an antidepressant, they swim longer. Another experiment involves hanging mice by their tails; those given antidepressants struggle longer before giving up. In a third test, mice are taught to avoid an electrical shock by pushing a lever. When the lever is inactivated, the mice continue to push it anyway, even though they still get shocked. Mice under the influence of antidepressants keep pushing it longer.
     But Dr. Robert R. Ruffolo, president of research and development at Wyeth, said it was a mistake to assume that an animal test can reflect human behavior. "The first thing we do -- and this is tough -- is we don't try to relate the behavior in an animal to a human behavior," he said. Animals like mice, he added, "don't feel happy or sad." "We didn't have someone in a lab thinking, 'Gee, if an animal swims longer, it won't be depressed,' " Dr. Ruffolo said. Instead, researchers found, by trial and error, that the same drugs that make a mouse swim longer are the ones that alleviate depression in humans. "It almost didn't matter what the behavior was," Dr. Ruffolo said. Such tests, says Dr. Solomon Snyder, director of the department of neuroscience at Johns Hopkins University Medical School, are "very, very empirical." But, he added, there is a certain rationale at work. "What's notable about depressed people is that they are hopeless. That's sort of what they are trying to model."
     Some psychologists say they can make animals exhibit signs of depression by putting them in situations where they feel helpless to control their fate. "All this stuff about animals don't feel sad or hopeless, that's some huge leap," said Dr. Martin Seligman, director of the Positive Psychology Center at the University of Pennsylvania. He said that the only sign of depression that could not be elicited in animals was suicide. What if, by chance, researchers stumbled on an animal test that predicted whether an antidepressant drug might prompt suicide as a rare side effect in people?
"We would immediately go back and test all of our drugs," Dr. Ruffolo said. If the animal tests indicated that the drugs were linked to suicide, he added, the company would use the test to search for other drugs that were not.
     Even so, animal research can be a trap, researchers say, because it forces companies to zero in on drugs that generate the same results in limited tests. That cycle produces lots of me-too drugs but little insight into how to produce better antidepressants that could help more people and perhaps even make them more cheerful and optimistic. Maybe even drugs that could alleviate concerns that some patients might commit suicide when they first start taking them. "Would you miss new classes of drugs that are antidepressants and work by completely different mechanisms?" Dr. Ruffolo asked. "The answer is absolutely yes." Dr. Schatzberg of Stanford agrees, acknowledging that "We need new theories." "We're getting closer but we're not there yet," he said.

'Opening Skinner's Box': Adventures of the White Coat People
Peter Singer, New York Times Book Review- 3/28/2004

The idea behind Lauren Slater's book is simple but ingenious: pluck 10 leading experiments in 20th-century psychology from the pages of the scientific journals in which they were first published, dust off the painfully academic style in which they were written up, add some personal details about the experimenters and retell them as intellectual adventures that help us to understand who we are and what our minds are like.
      How to select the experiments? Some select themselves. Slater starts, as her title suggests, with B. F. Skinner's animals in boxes, their behavior modified by food rewards to press levers, peck at a particular spot and behave in various bizarre ways. Then comes Stanley Milgram's research on obedience to authority. Milgram proved that people who have volunteered to take part in an experiment in learning will give what they believe to be severe electric shocks to others, if they are told by someone in a white coat that the experiment requires them to do so. Another classic is the research undertaken by John Darley and Bibb Latane in the wake of the 1964 murder of Kitty Genovese, a young Queens woman who was brutally attacked while 38 people, in different apartments, saw or heard what was happening, but did nothing to aid her. People are more likely to come to the aid of others, Daley and Latane found, when they are alone than in a group. Also included is Leon Festinger's research into ''cognitive dissonance,'' or how we deal with apparently irreconcilable facts and ideas -- research that led Festinger to infiltrate a cult that had set a date when the world would end.
      Some of Slater's selections seem influenced by her own experiences. (The author of ''Prozac Diary,'' ''Lying: A Metaphorical Memoir'' and ''Welcome to My Country,'' Slater is herself both a psychologist and someone with first-person experience of mental illness.) That may have led her to include David Rosenhan's 1970's experiment on how easy it is to get admitted to a psychiatric institution, and how hard it is to get out again. In the book's final chapter Slater gives a largely sympathetic account of psychosurgery. Though Slater is well aware of the ethical questions posed by the application of experimental techniques to patients, she wants us to see the issue as gray, rather than black-and-white. She reminds us that we tend to criticize yesterday's treatment too harshly, and to accept too easily our current practices. We readily assume that taking antidepressants is safer than psychosurgery, because cutting into the brain is irreversible. But Slater points out that we really don't know the long-term effects of taking drugs like Prozac. Psychosurgery today is far more precise than it was in the crude days of the lobotomies that gave it a bad reputation, and it does not turn people into zombies.
      Ethical issues run through the book. Milgram's experiments on obedience have made us more aware of the dangers of uncritically accepting authority, but they would be unlikely to get through one of today's institutional ethics committees. Milgram certainly misled his subjects about the nature of the experiment in which they were participating. Most of them were forced to confront the fact that they were capable of giving severe shocks to innocent people. But does the deception, or the discovery, make his research wrong? Slater interviews one of Milgram's obedient subjects and finds him crediting his involvement with Milgram's research with helping him to become a better person, by confronting his moral weakness. And Milgram apparently received many letters from other subjects saying the same thing. So Slater raises the question whether today's ethics committees have tilted too far in the direction of protecting human subjects.
      In another chapter, Slater describes the work of Elizabeth Loftus, a psychologist who has sought to disprove the idea of ''repressed memory.'' Juries that trust the reliability of a recovered memory of sexual abuse or incest that supposedly occurred decades ago can put people living utterly respectable lives into prison for many years. Loftus has found it hard to carry out research into the reliability of such memory because, she asserts, ''you can't get ANYTHING'' past a human ethics committee anymore. Nevertheless, in the end Loftus did, with some ingenuity, manage to set up an experiment that didn't violate ethical guidelines but still demonstrated how easy it is to get people to ''remember'' an entirely fictitious occurrence.
      Slater's most ethically troubling chapter, however, is about research not on humans but on animals. Slater describes how Harry Harlow deprived infant monkeys of their mothers to study the effects of maternal deprivation. Then, because he wanted to know what the effect of an ''evil mother'' might be, he designed a mechanical surrogate mother that he called the Iron Maiden. When the infant monkeys tried to cling to it, this mechanical monster would, on command, shoot out sharp spikes or blast the babies with cold air that threw them back against the bars of their cages. In his later years Harlow -- who at this time was, in the words of one of his research assistants, ''a terrible drunk'' and ''always, always intoxicated'' -- devised new ways of tormenting monkeys. Since the maternally deprived female infants grew up into neurotic adults who would not allow a male to mate with them, he constructed a ''rape rack'' -- his term -- so that he could tie them down while males mated with them. Then, Slater tells us, he constructed an isolation chamber ''in which an animal was hung upside down for up to two years, unable to move or see the world, fed through a grid at the bottom of the V-shaped device.'' This he called ''the well of despair.'' Roger Fouts, who has done research with chimpanzees, feels strongly, Slater reports, that what Harlow learned from these experiments was ''not only obvious but derivative.''
      At this Slater, to her credit, draws a clear moral line. She thinks what Harlow did, and all the monkey research he spawned, is wrong. When she tells her husband this, he predictably responds by asking her if she'd choose a monkey's life over that of their child. Her response is that as she is 99 percent monkey herself, she would of course choose her child. But that is just animal instinct, or mammalian love. The other 1 percent, which may be her reason, tells her that it is ''rarely defensible to cause suffering to sentient beings.''
      Slater makes some errors that made me wonder about her accuracy in areas with which I am not familiar. Some of these are minor slips, like placing Roger Fouts in Oregon, not Washington, and misspelling the names of his chimpanzee friend, Washoe, and of the animal rights activist Alex Pacheco. Others are more troubling. When Linda Santo tells her that the Roman Catholic Church is formally investigating her daughter Audrey for possible sainthood, Slater tells her readers that ''the last time the Catholic Church considered naming someone a saint was in 1983.'' She obviously hasn't been paying attention to Pope John Paul II's canonization binge -- he has named more than 400 saints since that year. To link Milgram's research with Nazism, Slater writes of ''Hannah Arendt's thesis on the banality of evil, the bureaucratic Eichmann blindly taking orders, propelled by forces external to him.'' This misdescribes Arendt's thesis. In ''Eichmann in Jerusalem'' she emphasizes his statement that his obedience was justified by Kant's definition of duty, and that he was able to give a broadly correct account of Kant's categorical imperative. In Arendt's view it was Eichmann's considered decision that he ought to obey orders. He was not ''propelled'' to do so by anything external to him.
      Though careful readers may want to check some of Slater's assertions, ''Opening Skinner's Box'' is a very readable, if highly personal, account of what we know, and don't know, about human nature, and of the ethical issues raised by our efforts to find out more.

A New Era in Treating Imaginary Ills
Mary Duenwald, New York Times- 3/30/2004

Every doctor recognizes them. The man who discovers a bruise on his thigh and becomes convinced that it is leukemia. The woman who examines her breasts so frequently that she makes them tender, then decides that the soreness means she has cancer. The man who has suffered from heartburn all his life but after reading about esophageal cancer has no question that he has it. They make frequent doctors' appointments, demand unnecessary tests and can drive their friends and relatives — not to mention their physicians — to distraction with a seemingly endless search for reassurance. By some estimates, they may be responsible for 10 to 20 percent of the nation's staggering annual health care costs.
      Yet how to deal with hypochondria, a disorder that afflicts one of every 20 Americans who visit doctors, has been one of the most stubborn puzzles in medicine. Where the patient sees physical illness, the doctor sees a psychological problem, and frustration rules on both sides of the examining room. Recently, however, there has been a break in the impasse. New treatment strategies are offering the first hope since the ancient Greeks recognized hypochondria 24 centuries ago. Cognitive therapy, researchers reported last week, helps hypochondriacal patients evaluate and change their distorted thoughts about illness. After six 90-minute therapy sessions, the study found, 55 percent of the 102 participants were better able to do errands, drive and engage in social activities. Antidepressant medications, other studies indicate, are also proving effective. "The hope is that with effective treatments, a diagnosis of hypochondriasis will become a more acceptable diagnosis and less a laughing matter or a cause for embarrassment," said Dr. Arthur J. Barsky, director of psychiatric research at Brigham and Women's Hospital in Boston and the lead author of the study on cognitive therapy, which appeared in the March 24 issue of The Journal of the American Medical Association.
      Almost everyone has inexplicable physical symptoms from time to time, and many people experience a moment of worry that their odd rashes, bumps or pains are signs of real trouble. But an official diagnosis of hypochondria, according to the American Psychiatric Association, is reserved for patients whose fears that they have a serious disease persist for at least six months and continue even after doctors have reassured them that they are healthy. In patients with hypochondria, experts say, ordinary discomforts appear to register more intensely than they do for other people. "The person's nervous system is like a radio whose volume has been turned up so high, the background static becomes intolerable," Dr. Barsky said.
      Researchers have found that hypochondria, which affects men and women equally, seems more likely to develop in people who have certain personality traits. The neurotic, the self-critical, the introverted and the narcissistic appear particularly prone to hypochondriacal fears, said Dr. Michael Hollifield, an associate professor of psychiatry at the University of New Mexico. As many as two-thirds of hypochondriacs also have other psychiatric disorders. Studies suggest that 40 percent suffer from major depression, 10 to 20 percent have panic disorder, 5 to 10 percent have obsessive-compulsive disorder, and some have generalized anxiety disorder.
      The fear of illness comes in varying degrees of intensity. Hypochondria may be mild, a faint background noise, or so intense it drowns out all other thoughts. "It can be hard to sleep or think of anything else other than your hypochondriacal fears," said Dr. Brian Fallon, an associate professor of clinical psychiatry at Columbia. In some cases, patients become so fearful about their imagined illness that they make the symptoms worse. "A headache that you believe is due to a brain tumor is a lot worse than a headache you believe is due to eyestrain," Dr. Barsky said.
      For the hypochondriac, a nagging worry often becomes panic, which then leads to further symptoms. "Because patients are anxious, their heart starts to race and they become dizzy," said Dr. Jonathan S. Abramowitz, a clinical psychologist at the Mayo Clinic in Rochester, Minn., who treats patients with hypochondria. The new symptoms cause further anxiety, and the cycle continues. In the most extreme cases, patients can worry to the point that they develop delusions or become almost entirely disabled by fear. "They become so afraid of what is going on with their body, they become shut-ins," said Dr. Hollifield of the University of New Mexico. "They think that anything they do is going to rile their body." Yet hypochondria does not typically lead to suicidal thoughts, said Dr. Don R. Lipsitt, a professor of psychiatry at Harvard, if only because people who fear illness also fear death. "These people have a tendency to live out a pretty healthy life," he said. "They nurse themselves. They mother themselves in a sense."
      Hypochondria has a long and colorful history. In the 18th century, Boswell wrote a weekly magazine column, "The Hypochondriack," describing his obsession with personal health. In the 19th century, Darwin worried over unexplained palpitations, fatigue and trembling in his fingers, which flared up when he had to discuss his new theory of evolution. Proust was so protective of his health that he kept himself wrapped in layers of overcoats and mufflers. The ancient Greeks used the word hypochondria to describe symptoms of digestive discomfort, combined with melancholy, that they thought arose from the spleen and other organs in the hypochondrium, the region under the rib cage. The disorder was thought to occur only in men. In women, unexplained symptoms were attributed to hysteria, a dislocation of the uterus.
      This view prevailed for 2,000 years, until physicians in the 17th century realized that hypochondriacal fears probably originated in the brain, not the body. Yet doctors could offer little in the way of treatment beyond the traditional strategies of bleeding, sweating and inducing vomiting. In the 20th century, Freud recognized that hypochondria had both psychological and physical properties. But because the disorder was not relevant to his theories, he had little interest in it. Other doctors held that the suffering of hypochondriacs must be "all in their heads."
      But many experts now say that discounting patients' symptoms only makes matters worse. "When you think about it, it's the ultimate hubris for a physician to proclaim that a patient's symptoms are not real," Dr. Fallon of Columbia said. "If a person is experiencing something, it is real, whether or not you can explain it physiologically."
      Still, it is psychiatry that offers patients the best hope of getting control of their anxiety. That often leads general practice doctors into a delicate dance, as they try to find ways to refer patients to psychiatrists without offending them. Just mentioning the word hypochondria to a patient, Dr. Barsky said, can cause trouble. "That comes across as, you're telling me I'm a faker, the malingerer, that it's all in my head," he said. "It's tremendously pejorative." As a result, some experts have suggested that doctors drop the word altogether, substituting the term health anxiety, which has fewer negative connotations.
      If a name change can allow more patients to accept their problem, the logic goes, perhaps more patients will seek treatment. Cognitive therapy, as demonstrated by Dr. Barsky's study, has proved surprisingly effective in helping patients who read into every ache and pain a portent of disaster. In the study, the patients, whose fixation on illness had greatly interfered with their daily lives, did not see their symptoms disappear. But they did learn to pay much less attention to them. The therapy taught the patients to re-examine their assumptions about the symptoms. "We talk with patients about other possible explanations for their headaches, their tension or their lack of sleep," Dr. Barsky said.
      The therapists, who included psychologists, social workers and nurses, also coaxed patients to temporarily suspend some of the usual ways they reassured themselves, like checking the Internet for health information, taking their pulse or blood pressure and scheduling appointments with doctors. The researchers also sent letters to the patients' primary doctors, advising them about ways to help. The doctors were told to see the patients for regularly scheduled appointments only, not for emergency visits when their symptoms flared up; to be conservative about providing treatment or ordering tests; and to aim to help patients cope with symptoms rather than eliminate them. "You have to work with the primary care doctors," Dr. Barsky said, "because hypochondria affects the doctor, too."
      The patients who received cognitive therapy continued to improve for as long as 12 months after treatment, the study showed. Of the 80 patients in the control group who saw their regular doctors as usual, 29 percent also improved during the year, Dr. Barsky said. He added that because the subjects were screened over a short period, some in both groups might have had only temporary hypochondria.
      Other experts said the study's findings were an encouraging sign that hypochondria was not as intractable as people had thought. "The study highlights the cognitive distortions that the patients engage in," Dr. Fallon said. "And it gives them a practical tool with which to confront their fears and their physical sensations."
      Early research into medication as a form of treatment is also promising. Dr. Fallon, for example, has found that two antidepressants, Prozac and Luvox, can ease hypochondriacal fears and fixations in as many as 70 to 80 percent of patients. The drugs appear to be most effective in patients who believe they are afflicted with a specific illness, Dr. Fallon said, and less effective in those troubled by symptoms like headaches, joint pain or vision problems but do not know what may be causing them. Dr. Russell Noyes, an emeritus professor of psychiatry at the University of Iowa, is exploring whether interpersonal therapy, which encourages patients to examine their social and family relationships for clues to their problems, is effective.
      Inevitably, some patients will stand by their hypochondriacal convictions in the face of any effort to dislodge them. "There will always be someone who says, `What I really need is for somebody to biopsy my liver,' " Dr. Barsky said.



Doctors, Too, Have Fears; They Just Go Underground
Abigail Zuger, New York Times, 3/30/2004

If stereotypes are to be believed, one of the best ways to develop hypochondria is to enroll in medical school, and one of the best ways to recover is to graduate. Medical students are notorious hypochondriacs. So commonly do they scuttle into university health services with self-made diagnoses of terminal illness (usually the one they are reading about at the time) that the phrase "medical student syndrome" was coined several decades ago to describe their behavior. Among doctors, though, hypochondria seems to disappear. Instead, doctors are notorious for avoiding medical attention at all costs, even when they are clearly ill.
      What psychic winds propel the medical mind from Point A to Point B are completely unexamined: no one has systematically studied how doctors' beliefs about their own vulnerability to illness evolve over the years. Even the few researchers who have tried to pin down how common medical student syndrome is have come up with contradictory results. Two small studies from the 1960's found that 70 percent to 80 percent of medical students had unfounded medical fears at some point in their training. Two other studies found true hypochondria in only a small fraction of medical students, no more than among other graduate students.
      Some researchers reconcile these findings by suggesting that while episodes of hypochondria are pervasive among medical students, they are so short-lived that at any single moment, most students are free of them. In other words, after a lecture on Hodgkin's disease, a kind of lymphoma that typically affects young adults, most students surreptitiously feel their necks for the swollen lymph nodes that signal early disease. Some find them and head off in a panic to the doctor, only to learn that everyone has enlarged nodes in the neck once in a while: they are transient and normal. A few weeks later, when the class stops studying lymphoma, and the suspect lymph nodes have, as predicted, vanished, the students leave that particular fear behind and head on to others.
      Experts think they understand why medical students behave this way. They are being bombarded by information without any context. Immersed in the arcane details of serious illness, they seldom hear much about health. Most are young and healthy, and for the first time in their lives are confronting the enormity and randomness of human illness, leaving them fearful and vulnerable. Then they graduate. No one is quite certain what happens next.
      Common wisdom holds that doctors are too busy and too experienced with the vagaries of the human body to be hypochondriacs. Instead, although no studies back up this impression, they often ignore their own illnesses. The medical care they do seek tends to be less than optimal, often a casual conversation with a colleague in a hallway or parking lot. Their adherence to treatment plans is miserable, and medication tends to consist of whatever free samples are available on office shelves.
      Does this behavior indicate they are suffering from what might be termed the opposite of hypochondria — delusions of immortality? Many accuse doctors of just that, citing the cumulative intoxicating effects of years spent fully dressed, vigorous and vertical, ministering to the undressed and miserably horizontal. It is possible, though, that a different process is at work. The medical student syndrome may never really go away; it may just go underground, muzzled by an increasingly jaundiced view of medical care. While a medical student who fears lymphoma may hasten to the hospital, a practicing doctor knows exactly what lies in wait there: sleepless nights, endless tests, errors and complications of all stripes, and the need to surrender autonomy to colleagues whose flaws one often knows too well.
      "When Doctors Get Sick," a collection of essays written by physicians with serious illness, yields a spectrum of attitudes toward falling ill, from "it can't happen to me" to "I always knew it would." But virtually every author confesses continuing misgivings about submitting to the known indignities of patienthood. It may be that doctors' hypochondriacal tendencies persist even with increasing age and experience. But once fear of medical care joins fear of illness, the only option is to worry and wait in silence.

Learning From Prozac: Will New Caution Shift Old Views?
Tanya Luhrmann, New York Times- 3/30/2004

After the federal advisory issued last week, the most popular antidepressant drugs may soon carry boldface warnings that patients who take them may become suicidal in the first weeks of therapy. Although the science behind the move is murky, the effects of the warning may be beneficial. The Food and Drug Administration asked drug companies to add the warnings to their labels. But agency officials conceded that no studies had clearly established a link between antidepressants and suicide.
      The F.D.A. acted on the basis of unpublished studies that suggested that suicidal thinking and behavior occurred more often among depressed children and adolescents who were given newer antidepressants like Paxil and Effexor. Yet suicidal impulses are also symptoms of depression, making the data difficult to interpret. One estimate suggests that one person in six with severe depression eventually commits suicide. Antidepressants typically take three weeks or longer to begin working. Patients who think about suicide or make suicidal gestures in those first weeks may have done so because they were depressed, not because the medications caused the suicidal impulses. Moreover, it is a psychiatric commonplace that profoundly depressed patients may be at higher risk for suicide when antidepressants begin to take effect, simply because the medication gives them the energy to carry out plans that they were previously too depressed to enact. It is also difficult, as F.D.A. officials have observed, to determine the reliability of the reports of suicidal thinking or behavior in the studies. In one study, a girl was reportedly described as suicidal because she had slapped herself.
      Yet even if it turns out that the antidepressants do increase suicidal thoughts or actions in some people, that pales as a public health problem beside the challenge of treating depression in the general population. Most people with serious depression — an illness that affects one of 10 Americans at some point — never seek treatment.
      Antidepressants, whatever their side effects, work for many people and have undoubtedly prevented countless suicides. Still, most experts agree that the drugs do not work well enough. Many people improve but do not recover completely. About a third of depressed patients do not respond to any medication at all. In this sense, the drug agency's action may have salutary consequences. Studies have made it increasingly clear that the best treatment for most psychiatric difficulties is a combination of medication and psychotherapy, or at least continuing contact with a mental health professional. That is true for schizophrenia, for borderline personality disorder, for anorexia, for trauma. It is true in spades for depression. Some studies have found psychotherapy alone to be as effective for mild to moderate depression as medication. Used in tandem, the two forms of treatment are more effective than either alone. A pragmatic effect of the federal advisory may be that prescriptions for antidepressants are more frequently accompanied by psychotherapy or, at least, by regular visits to doctors. The agency recommended that patients be closely monitored when they started on antidepressants and when the doses were altered.
      Prozac and its successors changed the way Americans thought about psychiatry and psychiatric illness. When they first entered the market, the drugs seemed to offer a risk-free solution to everything from serious mental illness to everyday blues. They appeared not only to alleviate depression, but also to make people more alert and more focused, less shy, more assertive and more self-confident. "Better than well," as Dr. Peter D. Kramer put it in "Listening to Prozac." Even better, the newer drugs seemed free of the unpleasant side effects of older antidepressants, which caused, among other problems, constipation, weight gain and cardiac difficulties. And they were safer. Unlike older drugs, the newer generation was almost never fatal in overdose. Prozac became one of the most widely prescribed medications of all time.
      Yet the honeymoon has been ending for a while. Over the last decade, it has become clear that Prozac and its cousins have side effects of their own, not least, sexual problems that many people find unacceptable. Some people report feeling emotionally deadened on the antidepressants. Others gain weight. Stopping the drugs is, in some cases, also a problem. With the exception of Prozac, they must be slowly tapered off to avoid withdrawal effects. The F.D.A. advisory is likely to temper the public's view of the drugs even further. Perhaps they will eventually be viewed simply as useful tools rather than magic bullets, and they will be less likely to be dispensed irresponsibly or with tolerant shrugs.
      Since the ascendancy of the biological approach to psychiatry in the 1980's, Americans have tended to view psychiatric illness as something that should always be treated with drugs and to believe that medication is the only intervention needed. But the real story of 20th-century psychiatry is how complex mental illness is and how difficult it is to treat. If there is are lessons to be learned from this controversy, they are that antidepressants should not be dispensed like candy, that depression is a serious problem and treating it a serious enterprise, that therapy should always be considered as an option and that, at the least, patients who are given medication should be carefully followed by people who ask them how they feel.
      Tanya Luhrmann is a professor at the University of Chicago and the author of "Of Two Minds: An Anthropologist Looks at Modern Psychiatry."

Vermont Mental Health Agency Threatens Cuts
Associated Press, 3/30/2004

BURLINGTON, Vt. -- The executive director of Vermont's largest community mental health agency says large cuts in staff and services will be needed if a proposed 1 percent budget increase becomes law. The Howard Center for Human Services in Burlington and other mental health care providers are calling for a 5 percent budget increase to retain staff and to continue to provide services.
     Howard Center Executive Director Todd Centybear said the Douglas administration's proposal would result in a $1.9 million budget shortfall for his agency. If implemented, Centybear said at least 200 people would lose services, hospitalization rates would increase and demands on emergency services would increase. The cuts would also keep Howard Center for providing full services in the areas of developmental disability services, emergency services, community rehabilitation and children and family services.
     Statewide, mental health advocates estimate the 1 percent increase will cost between 200 and 230 jobs and the cuts will affect between 3,800 and 4,300 clients and their families. The Howard Center has 727 regular employees and another 100 contract employees. Last year it served 15,057 children.



Habits: A Smoke Much Sweeter
Eric Nagourney, New York Times- 3/30/2004

Sometimes when former smokers go out drinking, by the end of the evening they are hooked on cigarettes again. Why? Researchers say that in part, it may come down to simple brain chemistry. A new study has found that alcohol, even in very small amounts, appears to enhance the pleasurable effects of nicotine. At the same time, the researchers say, nicotine may counteract some of the effects of alcohol, like drowsiness. "It may be kind of a balancing act in the brain -- that you're taking one substance to balance the effects of another substance," said Dr. Jed E. Rose of the Nicotine Research Program at Duke University and the lead author of the study, which appears in the current issue of Nicotine & Tobacco Research.
     The link between alcohol and tobacco is strong and complex. According to the researchers, as many as 90 percent of alcoholics smoke. And alcoholism is much more likely to occur among smokers than among nonsmokers, they said. But while there has been a longstanding cultural marriage between drinking and smoking, scientists have had trouble explaining the physiological relationship. Some have theorized that alcohol lowers the ability of nicotine receptors in the brain to respond to the drug, creating a desire for more cigarettes. While this may, in fact, occur in some receptors, the new study reports, over all, alcohol makes nicotine more pleasurable.
     The findings were based on a study of smokers who reported having four or more drinks a week. The volunteers were divided into different groups. One group got alcoholic beverages, the other got nonalcoholic drinks (with a tiny amount of alcohol drizzled on top to make them seem real). When the volunteers were asked to assess how satisfying they found their cigarettes, those who were given alcohol consistently rated them higher. The differences held true even when the volunteers were given nicotine-free cigarettes or a drug that prevents the absorption of nicotine, the researchers said. The patients who were given the drug smoked more, but they also said they were not as satisfied.



Psychiatrist: Yates Sane, East Texas Mom Not
Associated Press, 3/31/2004

TYLER -- The renowned psychiatrist who concluded that Andrea Yates knew her actions were wrong when she drowned her children testified today that an East Texas woman who bludgeoned her children to death with rocks did not know right from wrong. Dr. Park Dietz, hired by the prosecution, said Deanna Laney had a severe mental disease that caused a psychotic episode last Mother's Day weekend, during which she believed God ordered her to kill her children. Dietz said Laney didn't realize her actions were wrong, which means she was legally insane under Texas law. "She struggled over whether to obey God or to selfishly keep her children," Dietz testified.
     Laney, a 39-year-old stay-at-home mother who homeschooled her children, has pleaded innocent by reason of insanity to charges of capital murder and serious injury to a child in the deaths of 8-year-old Joshua and 6-year-old Luke and severe injury to then-14-month-old Aaron. Dietz said that Laney had a series of delusions on the day of the killings. He said she saw Aaron with a spear, then throwing a rock, then squeezing a frog and believed God was suggesting she should either stab, stone or strangle her children. Laney at first resisted, but she felt she had to do what she perceived to be God's will to prove her faith, he said. "She told me she felt as if the Lord were saying 'If you keep rejecting, it's going to keep getting worse," Dietz said.
     All five mental health experts consulted in the case, including both hired by the prosecution and one by the judge, agree Laney met the standard for legal insanity. But prosecutors wanted a jury to decide, saying expert opinions aren't facts and other evidence suggests Laney was not insane. Dietz has worked on other high-profile cases, including those of serial killer Jeffrey Dahmer, "Unabomber" Ted Kaczynski and South Carolina child killer Susan Smith.
     In Yates' case, the Clear Lake mother contended that Satan ordered her to kill her five children to save them from eternal damnation. Dietz concluded that Yates must have known murder was wrong if Satan ordered her to do it. He also saw Yates' attempts to conceal her murder plans as a sign that she knew they were wrong. Dietz testified Tuesday that Laney had delusions that she and Yates were chosen by God to be witnesses after the world ends. Laney believed Yates too had been ordered by God to kill her children and that the two would survive the end of the world to teach others about God, Dietz said. Yates, who drowned her children in the family's bathtub in 2001, was convicted of capital murder in 2002 and sentenced to life in prison after jurors rejected prosecutors' recommendation for the death penalty. She was tried in the deaths of three of her five children.
     Yates had an extensive history of mental illness. But Laney's family said she was never diagnosed with any mental disorder and that they never noticed any signs of illness or mood change before the killings. Dietz said Laney had at least one other psychotic experience several years earlier, in which she had hallucinations of smelling sulfur she believed was God's way of alerting her the devil was near. She prayed on it and it stopped, Dietz said. But in jail after the attacks on her children, she smelled sulfur again. She finally agreed to medication and the smell went away, which Dietz said was Laney's first indication that perhaps it was an illness, not God, influencing her behavior.