Experts: Male Eating Disorders on Rise
Associated Press, 5/11/2004

In an era of diet fixation, chiseled underwear models and ``a culture of muscularity,'' some researchers say eating problems among men are getting worse -- even as sufferers face a lingering stigma about having a ``women's disorder.'' Intentional starvation, cookie binges, vomiting, hospitalization. The details were typical for an eating disorder. But Jeff Everts might not seem like a typical sufferer. ``We're able to hide it much better,'' said Everts, a 43-year-old Albuquerque, N.M., resident recovering from anorexia and bulimia. ``We don't talk about it, where women would.''
      Women are more likely to have eating disorders than men. But men can also suffer from bulimia, binge eating and, to a lesser extent, anorexia, according to researchers. Leigh Cohn, co-author of ``Making Weight,'' believes such disorders afflict about 2 percent of men versus 4 percent to 5 percent of women, and he is convinced the rate for men is on the rise. Other researchers have differing estimates, but there are no definitive studies. ``It's hard to know because men have been so reluctant to seek treatment,'' Cohn said. ``And men, in many cases, are unaware that they have an eating disorder. For example, they may exercise obsessively and just think that's regular guy exercise behavior.''
      Athletes whose weight is crucial to their performance -- jockeys, wrestlers, distance runners and gymnasts -- have a higher incidence of eating disorders. Cohn said they can develop bad habits when weight loss is seen as a requirement of the sport. The root causes can be similar for men and women: genetics, low self-esteem, trauma and cultural influences. Just as women feel pressured to look like stick-thin magazine models, men can be swayed by images of pumped-up hunks with broad shoulders, six-pack abs and narrow waists. Pictures of perfect bodies can reinforce the belief that ``normal'' bodies are not OK, researchers say. And those perfect male images -- think muscle-bound movie heroes, magazine cover boys and shirtless rappers -- can be hard to ignore. ``I don't know what's on 'NYPD Blue' tonight,'' Cohn said, ``but I'm assuming that we'll see some male skin, because we almost always do.''
      Researchers at the University of Central Florida released a study this month saying men who watched TV commercials of muscular actors felt unhappy about their own physiques. This ``culture of muscularity'' can be linked to eating disorders or steroid abuse, the researchers said. The book ``The Adonis Complex'' tracks the evolution of boys' action figures from the average GI Joe in the '60s to the absurdly pumped-up toys of today. Scaled to human size, the authors say one Wolverine action figure would have 32-inch biceps. ``Basically they're marketing to men in the same way they marketed to women,'' said Roberto Olivardia, co-author of the book. ``And I think men and young boys have responded to that.''
      Dr. Theodore Weltzin of Rogers Memorial Hospital in Oconomowoc, Wis., said one study showed 70 percent of high school males dieting. The hospital offers residential treatment for males, and Weltzin says he sees a fair number of dieting men who are ``carbohydrate-phobic,'' as opposed to women sufferers who tend to be fat-phobic. ``More males are engaged in really abnormal eating behavior in terms of skipping meals, in terms of engaging in purging after eating, and laxative use,'' Weltzin said.
      Everts said his disorder became evident in high school in the late '70s when he began eating less and exercising more to become a better athlete. The 5-foot-10 football player got all the way down to 96 pounds, a hospital room and eventually, a psychiatric ward. ``They just basically said, 'If you eat, you'll get out,''' he said. That triggered a new problem: binge eating. Everts eventually found help, though he still considers himself recovering. He now weighs around 134 pounds -- within the normal weight range for a man his height.
      Researchers say people are becoming more aware of male eating disorders and more men are starting to come forward. But not all. ``My male patients also have to struggle with this layer of, `Well, does this make me less of a man? Am I gay? What is all of this about?''' Olivardia said. While there is a stereotype that eating disorders are more prevalent among gay men, Olivardia believes that perception is because gay men are more likely to seek treatment. He said he has patients in their 40s, meaning they have struggled with eating disorders for up to three decades before getting help. Weltzin expects to see more male eating disorder cases in the future: ``I don't see where percentages are going to go anywhere but up.''
      On the Net:
National Association of Anorexia Nervosa & Associated Disorders: www.anad.org/site/anadweb/
National Eating Disorders Association: www.nationaleatingdisorders.org



Pfizer to Pay $430 Million to Settle Drug Marketing Case
Associated Press, 5/13/ 2004

BOSTON -- Pfizer Inc. will plead guilty to criminal charges and pay $430 million in fines to settle charges that a company it bought four years ago illegally promoted non-approved uses for a drug by flying doctors to lavish resorts and paying them hefty speakers' fees to tout it. The settlement with the world's largest pharmaceutical company over the company it bought, Warner-Lambert, includes a $240 million criminal fine -- the second-largest criminal fine ever imposed in a health care fraud prosecution, the Justice Department said. Michigan's share of the settlement will be more than $2 million, Attorney General Mike Cox said Thursday.
     Whistleblower David Franklin, the scientist who reported the marketing abuses to authorities, will receive $26.6 million as part of the settlement. "This is a standard industry practice," Franklin told The Associated Press in an interview. "Hopefully, real change will happen now, and this will be the start of something and not the end."
     Under the agreement announced Thursday by federal prosecutors, the company acknowledged spending hundreds of thousands of dollars to promote non-approved uses for the anti-seizure drug Neurontin. Pfizer will plead guilty to violating the Food, Drug and Cosmetic Act. Besides the $240 million criminal fine, the company will pay $152 million in civil fines to be shared among state and federal Medicaid agencies. Another $38 million would go to state consumer-protection agencies.
The company said the activity occurred years before it bought Warner-Lambert in 2000.
"Pfizer is committed to compliance with all health care laws and FDA requirements and to high ethical standards in all aspects of its business practices," the company said in a statement.
     The case began in 1996, when Franklin filed a whistleblower lawsuit against drug maker Parke-Davis and its parent company Warner-Lambert, alleging it used an illegal marketing plan to drive up Neurontin sales in the 1990s. The lawsuit alleged that while Neurontin was approved only as an epilepsy drug, the company promoted it for relieving pain, headaches, bipolar disorder and other psychiatric illnesses. While doctors can prescribe drugs for any use, the promotion of drugs for these so-called "off-label uses" is prohibited by the Food and Drug Cosmetic Act. Last May, federal prosecutors in Boston filed a brief in support of Franklin's lawsuit, and have since been in settlement negotiations with New York-based Pfizer to recover money the Medicaid program spent on Neurontin.
     Franklin's lawsuit alleged that the company's publicity plan included paying doctors to put their names on ghostwritten articles about Neurontin and to induce them to prescribe the drug for various uses by giving them tickets to sporting events, trips to golf resorts and speakers fees. One doctor received almost $308,000 to speak at conferences about the drug. Neurontin's sales soared from $97.5 million in 1995 to nearly $2.7 billion in 2003.
     "We believe we have exposed an illegal practice in the pharmaceutical industry that caused the Medicaid program to pay tens of millions of dollars for off-label prescriptions that were not eligible for reimbursement under the Medicaid program," said Franklin's attorney, Thomas Greene.
Franklin, 42, said Warner-Lambert had conducted a clinical trial that showed Neurontin was less effective than a placebo for treating bipolar disorder, but it never published those findings and told doctors the drug was highly effective for treating the psychological condition. "Patients every day are still taking this drug hoping it's effective, and there's really no evidence for that," Franklin said. He said he and other medical liaisons were instructed to lie about or exaggerate Neurontin's effectiveness for non-approved uses, including showing doctors one case study on a patient who used Neurontin and then telling doctors there were thousands of similar cases.
     "I couldn't be more supportive of doctors using drugs for off-label uses. Doctors have to use their best judgment -- sound medical judgment -- to treat their patients," Franklin said "But what this company chose to do was to use that intense desire by doctors for information about drugs and pollute it with false information," he said. "The primary victims here are the patients whose doctors might have made another decision if they had the right information."
     Franklin filed his lawsuit under the U.S. False Claims Act, which allows private citizens to sue on behalf of the government and receive a portion of awards in cases where companies are defrauding the government. "This illegal and fraudulent promotion scheme corrupted the information process relied upon by doctors in their medical decision-making, thereby putting patients at risk," said U.S. Attorney Michael Sullivan, who joined senior Justice Department officials in Washington to announce the settlement Thursday. Pfizer shares fell 31 cents to close at $35.40 Thursday on the New York Stock Exchange.

Chicago Mental Health Court Handles First Cases
Jeff Coen, Chicago Tribune- 5/13/2004

Latina Washington stood before a judge wearing blue jail scrubs Wednesday, charged in her third prostitution case in a year. After reviewing Washington's history of mental health problems and learning that the 42-year-old South Side woman recently had lost contact with a local treatment center, Judge Lawrence Fox accepted a plea of guilty in her latest case. He then ordered her to submit to 18 months of probation "and any mental health treatment that's recommended to you."
"Yes, sir," Washington answered before walking out of the courtroom. With that move, she became the first person to pass through Cook County's new mental health court, which is designed to link non-violent felony offenders suffering from schizophrenia, bipolar disorder or severe depression to treatment as a condition of their probation.
      Players in the local criminal justice system are making a bid to siphon mentally ill defendants charged with non-violent crimes out of Cook County Jail quicker, get them back into counseling and on medication in the hopes that they will commit crimes less frequently. Fifty inmates will enter the pilot program voluntarily beginning this month. The program's planners will wait to see whether inmates can re-establish themselves in society and stop straining the jail's stretched resources.
      Mental health courts have been set up in DuPage County, Broward County, Fla., Salt Lake City, Santa Clara County, Calif., and other locations across the United States in recent years, with some reporting success. But planners said the effort in Cook County has national significance because it will affect only felonies processed at Chicago's Criminal Courts Building, one of the nation's busiest. If it can work here, they say, it might work anywhere.
      Under the new program, a social worker in the jail's Cermak Hospital will find candidates for the mental health court through a computer search. Those chosen will have been diagnosed as bipolar, schizophrenic or severely depressed, but won't need acute care or be considered unfit for trial. The office of Carl Alaimo, chief psychologist and director of mental health services for Cermak, will compare information from two databases to find inmates who fit the criteria. "We take all the open files with the Illinois Division of Mental Health Services, and crunch it with the entire daily census of people under the charge of the sheriff in the Cook County Jail," Alaimo said. "And what falls out is all the open cases that are currently living inside the jail." From there, the candidates' criminal records will be considered, along with their current charges, and those seen as a good fit will be asked for their consent. None accused of violent crimes will be part of the program, and open files with the state's mental health office will ensure the bill for the treatment of probationers will be paid by Medicaid.
      Representatives from the parties involved in the program then are expected to consider the possible entrants, including the Cook County state's attorney's office and public defender's office, the Cook County Adult Probation Department and the social service agency Treatment Alternatives for Safe Communities (TASC). The effort is taking place with the approval of Chief Judge Timothy C. Evans and Chief Criminal Court Judge Paul Biebel Jr.
      As in Washington's case, and the case of another defendant sentenced to the special probation Wednesday, 53-year-old Clarence Cobb, plea arrangements should be worked out before or on the day each defendant is arraigned. That would mean they could go from arrest back into treatment in a matter of just a few weeks. Cobb, arrested March 26 for drug possession, and Washington both were expected to enter residential treatment centers this week. Case managers from Treatment Alternatives for Safe Communities will work to ensure both Cobb and Washington, and all other incoming participants, are linked to transportation and housing and other services they might need.
      For the mentally ill, the journey through the crowded Cook County Jail begins as it would for anyone. Every day, hundreds of people who have been arrested and given bail hearings are funneled into an underground intake area at the jail near 26th Street and California Avenue. They stare out through the holding pens' chain-link walls, waiting for Cook County sheriff's deputies to shout directions as processing begins. It appears as organized chaos in an area roughly the size of two or three basketball courts. Inmates move across tile floors or lean on painted cinderblock walls. The smell of too many bodies and not enough ventilation is everywhere.
      On a recent evening, clinical psychologist Leslie Stein was moving from inmate interviews to grabbing papers from the "booking pit," to jumping in as her staff screened hundreds of new arrivals for mental health problems. "You know I'm sick, give me some medicine," said an inmate who recognized her. "You're stalking me," Stein shot back, taking no grief from any of the inmates. Her staff workers sit in a row of booths, making a preliminary decision on each inmate's mental health in just a few minutes. Is the person receiving outpatient psychiatric treatment anywhere? Have they ever been in special education? Are they feeling suicidal? "Who's crazy, and who's being manipulative? Who just wants medication?" Stein said.
      For Stein and her staff, the mental health court would be successful if it led to them seeing their regular jail visitors less often. Among the jail's roughly 10,500 inmates about 1,000 are on psychotropic medication. Removing some of the inmates the new court might handle would leave more time to work with those in acute psychiatric care and the sickest inmates, Stein said.
      When she thinks about the kind of inmate a mental health court could help, Stein said she thinks about those like an older inmate she had seen that night asking for cigarettes on Cermak's second floor. He had been booked for trespassing, and Stein's staff had found a history of mental health treatment. "He's terrified," she said. Planners said they hope that avoiding a prison sentence in a felony case through the mental health court will be enough incentive for many offenders to stay in treatment.
      Linda A. Teplin, a Northwestern University professor, is among the nation's foremost researchers on the incarcerated mentally ill. In the 1990s she learned through sampling that about 6 percent of males at the Cook County Jail and 12 percent of female inmates had a severe mental disorder. The deinstitutionalization of the mentally ill over the last few decades has led to more of them being arrested, Teplin said. "If you don't treat their mental disorder, they may be caught in a revolving door where they are in jail, and back in the community, and in jail and back in the community," she said.
      Case managers from TASC will help ensure the services offered in the program are ingrained in individual offenders. Pamela Rodriguez, executive vice president of TASC, was there during the early stages of planning and said the model seems to work. Offenders are not diverted from facing criminal penalties, which serves the interests of prosecutors, she said, and low-level offenders are not unduly criminalized, which appeals to public defenders.
      Assistant State's Atty. Mark Kammerer, who is supervising the effort for his office, said the belief is that the threat of a probation violation, as well as positive reinforcement from judges in the program, will lead defendants to stay in treatment. The combination has proven successful in the county's drug court program.
      After receiving some initial federal and state grant money for planning, the new mental health court will run with no additional funding. If money were found to expand the program to the mentally ill who don't have open cases that Medicaid will pay for, it is estimated 4 percent to 6 percent of the jail's population might be taken out of the criminal mix, Rodriguez said. "The question is, what does `not working' look like?" Rodriguez said. "It looks like what we've been doing--turning a blind eye toward mentally ill folks who cycle back through the system."

Violence Among Girls on the Rise
Claudia Rowe, Seattle Post-Intelligencer- 5/13/2004

There are dog-eared files in every corner of Charles Lind's office, crowding out the space on his small desk, teetering in towers of police reports about teenagers who have pummeled, knifed or threatened one another. Most concern school-related attacks. Dozens of them involve girls. "Here's a young woman, 16 years old, who punched another girl in the face and ripped out a chunk of her hair," said Lind, describing an attempted robbery at a Renton school in March. "Here's a young woman at Highline who told her teacher, 'Someone's going to pop you, and you'll be sorry.' "
     Lind, coordinator of the King County School Violence Program and senior deputy prosecutor at Juvenile Court, said that of his 18 active cases, seven involve girl-on-girl attacks. Still, the effect never dulls. Reports last week that three Mount Vernon middle-school girls jumped a schoolmate and beat her senseless at a dance for honor students left him stunned. "Maybe it's sexist," he said. "Maybe girls like the ones I'm seeing are just challenging my assumptions that young women shouldn't be threatening each other with brass knuckles, but it troubles me. A lot." The Mount Vernon incident left 14-year-old Anahi Espinoza badly bruised and emotionally scarred. The three accused assailants, two of whom are sisters, have pleaded not guilty to assault charges.
     Washington state doesn't track school discipline incidents by gender, but educators around the region say they can't help noting a trend. "We have seen an uptick in violent behavior -- fighting -- among girls," said Catherine Carbone, spokeswoman for the Highline school district. "In the last five or 10 years, the same kinds of things that have always caused taunts or teasing before, now are more physical."
     While juvenile crime rates are down across the country, the gap is narrowing between boys -- who still commit the vast majority of violent offenses -- and girls, previously assumed to handle stress by withdrawing into depression. In 2001, arrests for aggravated assault among girls were up 82 percent over 1987 levels, while for boys they rose 9 percent, according to the Office of Juvenile Justice and Delinquency Prevention.
     Washington mirrors this trend. Between 1995 and 2002, violent offenses accounted for steadily increasing rates of arrest among girls; meanwhile, boys' rates dropped almost every year. "In our intake, they used to be all boys. Now it's about 50-50," said Elizabeth McCauley, interim director for children and adolescent psychiatry at Seattle's Children's Hospital and Regional Medical Center. "We are seeing more girls who are exhibiting their distress by being aggressive. I don't think we totally understand why." Experts differ on whether the upswing is due to increased aggression among adolescent girls, or simply more aggressive reporting. Either way, they agree that girl-on-girl violence is often notable for its viciousness.
     In March, a cafeteria brawl between two girls at Rainier Beach High School left one trying to staunch the blood gushing from a knife wound to her face, while the other suffered a series of blows to the head, according to police reports. A month earlier in Baltimore, 12-year-old Nicole Townes was beaten into a coma after a boy kissed her on the cheek at a birthday party, enraging the young hostess with jealousy. Last May, a "powder-puff football game" in an affluent Chicago suburb degenerated into a high school hazing so brutal that five girls were hospitalized and 32 students expelled.
     "We always say there's going to be blood when we hear about a girl fight," said Ken Wong, supervisor of the violence-intervention program at Youth Eastside Services in Bellevue, where 13,767 girls were counseled last year, more than quadruple the number from 1990. "With guys, there's a lot of posturing -- what we call the fighting dance. But girls fight to hurt the other person physically as much as they can."
     The cuts and scratches crisscrossing Anahi Espinoza's face appear to bear that out. The Mount Vernon teenager said she was kicked, scratched and bitten, grabbed by the hair and slammed to the ground at the school dance. She remembers a flurry of blows with brass knuckles. "I was just like, 'My God, these girls are going to kill me,' " Espinoza said. The ambush, like most of those described by violence-prevention experts who work with girls, appears to have been well-planned and rooted in the same kind of emotionally charged insecurities over frayed friendship familiar to anyone who has passed through adolescence.
     Marine Madesclaire, an eighth-grader at Billings, a private middle school in Seattle, recalled a former classmate who made and dropped friends so frequently there seemed to be deliberate cruelty in her actions. "It was really hard," she said "I think it would have done less damage if she had just started fighting."
     The emotional tenor Madesclaire describes is a hallmark of fights among girls, said Meda Chesney-Lind, a professor in women's studies at the University of Hawaii, who has written extensively on the subject. "Girls fight for different reasons than boys do," she said. "For boys, it's 'You have something I want and I'm going to take it.' With girls, it's usually expressive of emotional unhappiness or uncertainty. Counselors who work with girls often say they're surprised at the complexity of the relationships."
     David Stewart, a psychologist who teaches at the University of Washington and has spent 15 years working with youths in the juvenile justice system, said the new wrinkle is not girls' violence, per se, but which girls are violent. "What you're seeing now are incidents among girls where you wouldn't expect it -- like honor students and members of sports teams," he said. "These are the same girls that in years past might have said 'Let's not talk to her. Let's not invite her to the party.' "
     Explanations for the escalating intensity range from the social to the biological, said experts and educators, many of whom admit they are stymied by a dearth of long-term, detailed data on the behavior of adolescent girls. Ever-mounting desensitization to brutality in entertainment -- witness super-samurai Uma Thurman in the hit "Kill Bill" movies -- is the first, most commonly proffered reason. "What kids see, kids emulate, and if they're seeing girls take on more aggressive roles then I think it's natural that that would trickle down," said Doug Hostetter, principal at Kentwood High School, who attests to increasing aggression, mainly verbal, among female students. "I'm not one of those media bashers, but the reality is TV has changed. Girls on MTV tend to be aggressive, not so ladylike or withdrawn or submissive and I'm definitely seeing girls respond more aggressively to conflict. I don't think they see fighting as something girls don't do."
     McCauley at Children's Hospital has another take. The earlier onset of puberty among teens leaves adolescent girls looking, and sometimes sounding, far more mature than they are. "There's a tendency for parents to assume that because kids look physically mature and are at times very articulate, they have problem-solving skills that really are not on board yet," McCauley said. "Just because they're great at math doesn't mean they're able to solve an emotional problem."
     Renee Washington, a 15-year-old at Ingraham High School who leads group discussions for middle school girls about handling conflict, recalled watching a dozen of her former schoolmates jump another girl in the bathroom. "It wasn't until my eighth-grade year that I really saw girls being mean and aggressive toward each other, calling people out saying, 'She's ugly, nobody talk to her 'cause she messes with all these guys,' " Washington said. "The girls in the bathroom were talking about how this one girl stole someone's boyfriend or something like that. I think they jumped her just to show off to their friends." At least as disturbing to Washington as the group attack itself was the reaction of the boys who gathered on the periphery, cheering the girls on. "Boys thought it was funny and they egged it on. A lot," she said.
     The dynamics may be troubling to adults and business-as-usual to youths. But without more data, parents and educators are left to grasp at tip-of-the-iceberg snapshots indicating far deeper problems. "I don't think we have evidence suggesting that physical violence among girls is a national epidemic, but certainly, it shows that we need to pay more attention to girls," said Karen Bierman, a psychology professor at Pennsylvania State University and co-editor of the forthcoming book "Aggression, Anti-Social Behavior and Violence Among Girls." "There's a real need for better tracking. Girls have just not been studied very much. They've been neglected in our longitudinal studies and that's what makes it so hard to know what's happening with them."

Depression Research Finds Mental Health Experts Optimistic
David Kohn, Baltimore Sun- 5/15/2004

Husseini Manji just wants his rats to be happy. But that's not an easy thing to make happen. Many have been genetically engineered to be fretful and melancholic, to give up easily when faced with problems. But Manji is determined; he gives his disheartened rodents a range of experimental drugs, including one that lowers chemicals released during stress and another that strengthens the brain's neuronal support system.
      Manji isn't an overenthusiastic animal lover. He's a psychiatrist at the National Institute of Mental Health who knows that if he can get his rats to be more curious, or swim longer in a pool of deep water, he might eventually be able to help some of the 20 million Americans suffering from depression. Manji, 44, is part of a new wave in depression research. Using fresh insights into how this often-devastating disease harms the brain, he and others are developing innovative drugs. These new approaches go far beyond current treatments, most of which work by increasing levels of the neurotransmitter serotonin. Over the past decade, researchers have linked depression to other neurochemicals and have found evidence that structural defects in the brain might play a role. He helps oversee NIMH's extensive depression-research program. In labs on the Bethesda, Md., campus of the National Institutes of Health, Manji and his colleagues examine depression from a variety of angles. In addition to rats, they study genes, neurons, primates and humans.
      The most commonly used antidepressants are drugs such as Prozac, which increases brain levels of serotonin, a chemical that effects mood, anxiety and cognition. Introduced 17 years ago, selective serotonin reuptake inhibitors are safer than older antidepressants and have fewer side effects. But SSRIs work well for only half those who take them. And even when successful, they regularly cause gastrointestinal and sexual problems. Last month, the FDA warned that SSRIs might cause suicidal thoughts, particularly in children. A quarter of the 6 million Americans who take antidepressants aren't helped by any medicines, whether SSRIs or their predecessors. "There's a huge need for new drugs," Columbia University neurobiologist Luca Santarelli said. He is one of many scientists working on drugs that stimulate the growth of new nerve cells in key parts of the brain.
      Studies in animals and humans have shown that this neuronal sprouting, as it is called, can lift depression. Known as neurogenesis, this recently discovered phenomenon could play a crucial role in the next wave of medicines. "This could be the key to treating depression," said Princeton University psychologist Barry Jacobs, a leading proponent of the neurogenesis theory.
      Current antidepressants stimulate neurogenesis in the hippocampus -- a brain region involved in mood and anxiety -- but do so indirectly and slowly. These drugs typically take three to six weeks to improve mood, an eternity for a deeply depressed person. Santarelli and others are looking for molecules that trigger neurogenesis without such a lag. The search has spurred scientists to examine relatively overlooked neurochemicals.
      Many researchers have focused on stress hormones. Released when animals are under pressure, these chemicals help put the body and brain on alert. Many depressed people have high stress-hormone levels, and scientists think these compounds could trigger the disease. This theory has received a recent boost from studies finding that excess stress hormones can shrink the hippocampus, the opposite of neurogenesis. For some people, depression might be "a stress response that gets stuck in the `on' position," said NIMH researcher Dr. Philip Gold, who is studying a drug that lowers brain levels of the key stress chemical corticotropin-releasing hormone. Gold thinks the compound, antalarmin, might work especially well in melancholic depression, a subtype in which patients are overagitated and anxious.
      Several pharmaceutical companies are also working on anti-CRH compounds. Because these drugs and the Prozac class of medicines work by different neurochemical pathways, they aren't likely to have the sexual and digestive side effects, and might work faster, scientists say. "We think it has legs," said Jim Cassella, head of clinical research at Neurogen Corp., a Connecticut biotech company working on a CRH antagonist. The company hopes to begin human trials next year.
      Another possible target is glutamate, a neurotransmitter that sends excitatory messages, telling the brain to pay attention. Too much glutamate overstimulates and damages nerve cells, and researchers suspect that this chemical system goes awry in depression. Manji and colleagues are interested in two glutamate blockers: memantine, an Alzheimer's drug, and riluzole, used for Lou Gehrig's disease. "It's likely that depression is actually several different biological conditions," said Dr. Dennis Charney, head of depression research at NIMH. By understanding the neurochemicals that contribute to the disorder, researchers hope to delineate those differences. NIMH is trying to find genetic markers for each subtype.
      Researchers at Emory University are focusing on brain scans, trying to pinpoint specific brain circuits affected in various forms of depression. The ultimate goal is to better match drugs with patients. Now, psychiatrists must guess, trying one drug after another until they hit on one that works. While some researchers try to lower glutamate and stress hormones, others work to boost other neurochemicals that seem to soothe depression. Chief among these is brain-derived neurotrophic factor, a compound that acts as a powerful support system for neurons. Some researchers suspect that by triggering neurogenesis and improving overall neuronal health, BDNF can alleviate depression. Current antidepressants also raise BDNF, but they take weeks.
      Roche is looking at the substance and has teamed up with a small biotech company, Memory Pharmaceuticals, to study a drug that could quickly raise brain BDNF levels. The companies are testing the compound on animals.
      Manji is also trying another way to boost BDNF: sleep deprivation. Scientists have long known that lack of sleep is a potent and almost immediate antidepressant. Because sleeplessness has obvious side effects, it's not a viable treatment. So Manji and his NIMH colleagues are trying to trick certain brain regions into staying up while the rest of the brain (along with its owner) sleeps. In an experiment set to begin this spring, scientists will inject sleeping depressives with a BDNF-boosting drug during key sleep periods, when the brain is acutely responsive. If the method works, it could literally cure depression overnight.
      Not all of these ideas will pan out. Antidepressant research is notoriously frustrating. What cheers up rats -- even those bred for despair -- doesn't always revive unhappy humans. And, because depression is so complex and subjective, what works with one group of humans often fails with another. But most scientists are confident that some of the research will end up helping patients.

Was a Tyrant Prefigured by Baby Saddam?
Elisabeth Bumiller, New York Times- 5/15/2004

WASHINGTON— It is no surprise to Jerrold M. Post, the founder of the Center for the Analysis of Personality and Political Behavior at the C.I.A., that Saddam Hussein grew up to be one of the world's most dangerous dictators and a member of President Bush's axis of evil. "Of all of the leaders I've profiled, his background is assuredly the most traumatic," Dr. Post said in an interview this week in his wood-paneled, African-artifact-filled office in Bethesda, Md., where he is a psychiatrist for patients whose personal struggles have typically not led to two American wars in the Middle East. "His troubles can really be traced back to the womb."
     As Dr. Post recounts in his new book, "Leaders and Their Followers in a Dangerous World" (Cornell University Press, $29.95), Mr. Hussein's father died, probably of cancer, in the fourth month of his mother's pregnancy with Saddam. Mr. Hussein's 12-year-old brother died, also of cancer, a few months later. The trauma left Saddam's mother, Sabha, so desperately depressed that she tried and failed to abort Saddam and kill herself. When Saddam was born, she would have nothing to do with him and sent him away to an uncle. At 3 Mr. Hussein was reunited with his mother after she had married a distant relative, but he was then physically and psychologically abused by his new stepfather. Mr. Hussein left home and returned to live with the uncle when he was 8 or 9.
      "So that would produce in psychoanalytic terms what we call `the wounded self,' " Dr. Post said. "Most people with that kind of background would be highly ineffective as adults and be faltering, insecure human beings." But there is, Dr. Post said, an alternative path that a minority of wounded selves take: "malignant narcissism," the personality disorder that Dr. Post believes fueled Mr. Hussein's rise in Iraq. Perhaps most important, Dr. Post says, is that Mr. Hussein is a "judicious political calculator," not a madman.
      Not everyone, of course, subscribes to the view that psychiatric profiles of dictators are predictive, useful or even accurate. "The study of human behavior is a very complex thing," said Walter Russell Mead, a senior fellow at the Council on Foreign Relations and the author of "Power, Terror, Peace and War: America's Grand Strategy in a World at Risk." "Sometimes I get up in the morning and I don't know why I do what I do." Studies like Dr. Post's can help, Mr. Mead said, "but you really do have to use this kind of information cautiously."
      Although Dr. Post has spent 30 years creating hundreds of political profiles of American foes (among them, Fidel Castro), he also developed the profiles of Anwar el-Sadat and Menachem Begin for Jimmy Carter's use at the Camp David talks that led to peace between Egypt and Israel in 1979. Since 9/11 his work has taken on new urgency. Understanding the minds of rogue leaders, he says, is essential to developing policies that can counteract them. "Someone who rises through a democratic process in Great Britain and the United States is really quite different from someone who has seized power," he said.
      Dr. Post, 70, the director of George Washington University's political psychology program, consults privately for the Department of Homeland Security and for Pentagon counterterrorism officials. In his view, the world's most dangerous leaders are often malignant narcissists, a category that he says he thinks includes Osama bin Laden, Kim Jong Il of North Korea and Hitler. These leaders share four qualities, Dr. Post said: extreme self-absorption, paranoia, no constraints of conscience and a willingness to use whatever means necessary to accomplish goals. They have little empathy for the pain and suffering of their own people, Dr. Post said, but they also can't empathize with their enemies, a critical vulnerability in that "it's very important as an effective leader to get into the mind of your adversaries."
      Mr. bin Laden in particular has little empathy for others, Dr. Post said, "and is really consumed with being God's prophet on earth." Mr. Kim, who Dr. Post says is consumed by self-doubt because he lives in the enormous shadow of his father, the founding leader of North Korea, once punished a subordinate who displeased him by sending him home naked. As for Mr. Hussein, Dr. Post says that he is not irrational and is in fact entirely predictable and over three decades in power "worked the international system to a fare-thee-well."
      While Dr. Post carefully shied away from any criticism of Mr. Bush, he did say that the president's failure to amass a large international coalition in the Iraq war — in contrast to the large one his father assembled against Mr. Hussein in the first Persian Gulf war — played to Mr. Hussein's strengths. "Saddam desperately wants to be seen as a major world leader," Dr. Post said. "And having both a large majority of the Arab world as well as the very broad coalition arrayed against him in 1990 had a very powerful negative impact on him." But in the Iraq war of 2003, Dr. Post said, he was "able to say defiantly to his radical Arab and moderate Arab supporters, `I have the courage to stand up to the mightiest nation on earth and its president.' "
     Dr. Post said he was not privy to the interrogation techniques used on Mr. Hussein, who was captured by American forces in December and is being held by the F.B.I. in Iraq. But he said standard interrogation techniques — at least those consistent with the Geneva Conventions — would probably not work on as strong a personality as Mr. Hussein. Although counterterrorism officials said this week that the C.I.A. had used coercive interrogation methods against a select group of high-level Al Qaeda operatives, American and British officials said this year that they were taking a gentle approach in their questioning of Mr. Hussein.
      Dr. Post said the best technique would be to play to Mr. Hussein's ego and tell him with admiration that he had managed to convince the government of the United States and much of the Western world that he had weapons of mass destruction. But if he still had some, where might they be? "Interrogation is part psychological karate," Dr. Post said, "which is going with the strengths of the individual rather than attempting to pressure him."
      Dr. Post got into the business of analyzing the world's leading bad guys more or less by accident. In 1965 as he was planning a career in academic medicine at Harvard, he was approached by an acquaintance who took him on a drive, pulled into an overlook and asked if he would sign a secrecy agreement to help start a pilot program at the C.I.A. to study the world's leaders from a distance. The information would be used to prepare for international summit meetings and crises. Dr. Post thought it would be an interesting thing to do for a few years, but he remained for more than two decades. "I spent the next 21 years in what I will only describe as an absolutely remarkable intellectual adventure because I was crafting a new form of intelligence," he said.
      Dr. Post develops his profiles from biographies, speeches and interviews with people who know the leaders. He said he did not think it would be particularly helpful to meet the subjects. "Actually, I think that can obscure," he said. "A number of these leaders are intensely charming and the facade they present can be misleading." Over the years Dr. Post has met only one of his subjects, Yasir Arafat, the Palestinian leader, who Dr. Post said "looked terrible." But "then he got up to speak, and it was very powerful, and you could sort of see some of that charismatic appeal."
      Dr. Post is working on another book, "The Mind of the Terrorist," about different kinds of terrorist groups and why they attract followers. "We've got a lot of people pontificating on what makes terrorists tick, and one of my strange notions is the best way to find out is to ask them," he said. Dr. Post has interviewed 35 incarcerated Middle Eastern terrorists, and his conclusion was that "they are really quite normal psychologically." Just like teenagers in the United States, he said, the terrorists were captivated by the celebrities of their culture. "But instead of it being N.F.L. or N.B.A. stars," Dr. Post said, "it's the latest shaheed." Shaheed is the Arabic word for holy martyrs and is also used to describe suicide bombers.

Columbine: Parents of a Killer
David Brooks, New York Times- 5/15/2004

After I wrote a column a few weeks ago about the 1999 shootings at Columbine High School, I got e-mail from Tom Klebold, the father of Dylan Klebold, one of the shooters. Tom objected to the column, but the striking thing about his note was that while acknowledging the horrible crime his son had committed, Tom was still fiercely loyal toward him. Which prompts this question: If your child commits a crime like that, what do you do with the rest of your life?
      Tom and Susan Klebold have not really spoken to the press about all this. But the lawsuits against them are being settled, and they trust The New York Times, which is the paper they read every day, so they were willing to have a long conversation with me this week. They are a well-educated, reflective, highly intelligent couple (Dylan was named after Dylan Thomas). During our conversation they discussed matters between themselves, as well as answering my questions. Their son, by the way, is widely seen as the follower, who was led by Eric Harris into this nightmare.
      The Klebolds describe the day of the shootings as a natural disaster, as a "hurricane" or a "rain of fire." They say they had no intimations of Dylan's mental state. Tom, who works from home and saw his son every day, had spent part of the previous week with Dylan scoping out dorm rooms for college the next year.
      When they first heard about the shootings, it did not occur to them that Dylan could be to blame. When informed, Susan said, "we ran for our lives." They went into hiding, desperate for information. "We didn't know what had happened," she said. "We couldn't grieve for our child." That first night, their lawyer said to them, "Dylan isn't here anymore for people to hate, so people are going to hate you." Even as we spoke this week, Tom had in front of him the poll results, news stories and documents showing that 83 percent of Americans had believed the parents were partly to blame. Their lives are now pinioned to this bottomless question: Who is responsible? They feel certain of one thing. "Dylan did not do this because of the way he was raised," Susan said. "He did it in contradiction to the way he was raised."
      After the shooting, they faced a simple choice: to move away and change their names, or to go back and resume their lives. Susan thinks about leaving every day. "I won't let them win," Tom said. "You can't run from something like this." So they live in the same house and work at the same jobs. Susan works in the community college system. "It's amazing how long it took me to get up and say my name at a meeting, to say, `I'm Dylan Klebold's mother,' " Susan says. "Dylan could have killed any number of the kids of people that I work with."
      In general, Tom said, "most people have been good-hearted." Their friends rallied around. Their neighbors call to warn them if an unfamiliar car lurks in the neighborhood. There is a moment of discomfort when they hand over a credit card at a store, but there have been few bad scenes. One clerk looked at the name and remarked to Susan, "Boy, you're a survivor, aren't you." The most infuriating incident, Susan said, came when somebody said, "I forgive you for what you've done." Susan insists, "I haven't done anything for which I need forgiveness."
      When they talk about the event, they discuss it as a suicide. They acknowledge but do not emphasize the murders their son committed. They also think about the signs they missed. "He was hopeless. We didn't realize it until after the end," Tom said. Susan added: "I think he suffered horribly before he died. For not seeing that, I will never forgive myself." They believe that what they call the "toxic culture" of the school — the worship of jocks and the tolerance of bullying — is the primary force that set Dylan off. But they confess that in the main, they have no explanation. "I'm a quantitative person," said Tom, a former geophysicist. "We're not qualified to sort this out." They long for some authoritative study that will provide an answer. "People need to understand," Tom said, "this could have happened to them."

Fears of Crystal Meth Crisis Rise in NYC
Associated Press, 5/16/2004

NEW YORK -- Skeletal women surface at 12-step programs once exclusive to gay methamphetamine addicts. An aspiring fashion designer is indicted after federal agents claim he was overheard trying to collect cash from a meth deal. A disc jockey at a popular dance club makes no attempt to hide his drug of choice: meth. Barely noticed in New York outside the gay community just a year ago, meth -- and new signs of its spread -- has created a citywide scare. The highly addictive stimulant ``could be the crack (cocaine) of the 21st century if we don't do something to stop it,'' New York Democratic Sen. Charles Schumer said last month at a Manhattan news conference warning of meth's eastward march.
      The drug has been a problem for years in many parts of the country. But until recently, New York -- a city normally at epicenter of drug trends -- wasn't on the meth map, said Anthony Placido, head the Drug Enforcement Administration's New York office. ``It's ironic and sad,'' Placido said, ``but part of the reason is the widespread availability of other stimulants like coke and crack.''
      Horror stories already abound in the gay community, where meth's reputation for boosting stamina and sex drive made it too tempting for some. ``It was euphoric beyond anything I'd ever experienced,'' said Alan, a 45-year-old magazine editor who adheres to the first-names-only credo of Crystal Meth Anonymous. That euphoria soon degenerated into sleepless days and deep depression. ``We all thought we were dabbling in a party drug,'' said Eduardo, a 37-year-old publicist. It took overdoses and watching his teeth fall out -- ``I looked like a jack-o' lantern'' -- for Eduardo to clean up.
      The stories would have little shock value in states like California, Oklahoma, Missouri and Florida. Authorities there dismantle thousands of clandestine laboratories each year that serve a cross-section of ``tweakers'' who snort or smoke a drug commonly known as crank, speed or tina. Similar homemade labs have cropped up in rural upstate New York: 73 were reported last year, up from 45 in 2002.
      But in the northeast, cocaine and heroin have been far bigger problems. Between 1999 and 2003, the DEA's northeast crime lab analyzed about 52,000 pounds of cocaine and 4,500 pounds of heroin seized in investigations. Only 15 pounds of meth was tested. Local authorities say the city has now been targeted by large-scale suppliers fed by sophisticated ``super labs'' in California and Mexico. In February, agents arrested six suspects, including the fashion designer and a lawyer, and confiscated 13 pounds of the drug after discovering that it was being distributed at Manhattan nightclubs. About a month later, police raided the 30,000-square-foot Sound Factory club in midtown Manhattan and arrested the owner, alleging the nightspot condoned the sale of meth and other drugs. Court papers alleged one disk jockey kept a bag of meth ``in open view'' during all-night parties. In all, federal authorities in Manhattan have seized 25 pounds of meth -- with a street value of $2.5 million -- and charged more than 30 people in meth-related cases in the past six months, compared to 11 arrests in all of 2003. Another 28 suspects have been charged in unrelated state cases since early last year. The city's special narcotics prosecutor, Bridget Brennan, still views meth as a ``niche drug.''
      Defying meth's reputation elsewhere as ``poor man's cocaine,'' the version reaching the city is purer and pricier, Brennan said. Dealers charge about $120 a gram, versus $30 for a gram of cocaine, in private transactions with friends, Brennan said. ``But if crystal meth breaks out, it's going to be a big problem,'' she added. Overflow crowds at Crystal Meth Anonymous meetings demonstrate the threat. Four years ago, there was one daily meeting with a half dozen recovering addicts, organizers said. Today, the more than 20 meetings scheduled throughout the week can draw up to 100 people at a time.
      CMA member Amy, 35, hit bottom by smoking meth non-stop -- behind the scenes at her dot-com job in San Francisco, on camping trips, even before yoga classes. She smoked more than she ate, dropped 20 pounds and turned delusional about her haggard appearance. ``You didn't have to worry about dieting,'' she said. ``I thought I looked really good.'' She tried leaving her habit in San Francisco. But, after transferring to New York, she had the drug mailed to her. On Jan. 21, 2002 she quit, and now founds herself at recovery meetings surrounded by gay men. ``I don't feel like an outsider because it's the same issue,'' she said. ``It isn't just a gay problem.''

Klebold Parents Not Seeking Forgiveness
Associated Press, 5/16/2004

NEW YORK -- In their first interview since the Columbine High School massacre, the parents of one of the killers said they feel no need to be forgiven and didn't realize their son was beyond hope until after he was dead. ``Dylan (Klebold) did not do this because of the way he was raised,'' Susan Klebold told columnist David Brooks in Saturday's editions of The New York Times. ``He did it in contradiction to the way he was raised.'' Dylan Klebold and Eric Harris killed 13 people on April 20, 1999, before taking their own lives.
      The couple took issue with people who say they forgive them for what happened. ``I haven't done anything for which I need forgiveness,'' Susan Klebold said. They acknowledged they missed signs that their son was in trouble. Klebold and Harris were in a juvenile diversion program for breaking into a van and stealing tools and other items in January 1998. ``He was hopeless. We didn't realize it until after the
      Jefferson County Public Schools officials have consistently denied that bullying was tolerated or that athletes received special treatment. The Klebolds' comments was criticized late Saturday by some of the victims' parents. ``I'm horrified,'' Dawn Anna, whose daughter Lauren Townsend was killed at Columbine, told The Associated Press. ``I wanted an apology. I wanted a contribution to help us understand why it happened, so that it would never happen again. I didn't hear it.'' Brian Rohrbough, father of victim Daniel Rohrbough, said he was outraged that the Klebolds likened the day of the shootings to a natural disaster in the interview with Brooks. ``This was murder,'' he said. ``In my opinion, what went on in their home led to Columbine.''
      Brooks said the Klebolds agreed to the interview after an exchange of e-mails initiated by Tom Klebold, who was angered by Brooks' April 24 column. Brooks'column did not say when and where the interview took place. In the April 24 column, Brooks had paraphrased an article in the online publication Slate that said Harris and Klebold yearned to become the most prolific mass murders in history. The Klebolds' attorney, Gary Lozow, told The Denver Post the Klebolds had no plans to grant any other interviews.
      In a story for Sunday's editions of The Post, Lozow related the first moments after the Klebolds learned of the shooting. They had heard the gunmen may have been part of the Trench Coat Mafia, a loose group of students, including their son, who said athletes at Columbine bullied them. ``When early word came that the Trench Coat Mafia may be involved in the shooting, Tom ran downstairs to look for Dylan's trench coat, which he couldn't find,'' Lozow said. ``He was afraid Dylan might be involved. So he called me and offered to go to the school in hopes of negotiating with Dylan. It wasn't accepted.'' Harris' parents, Wayne and Kathy Harris, have never spoken to reporters. After-hours phone calls to Times officials were not returned, and Brooks did not immediately respond to an e-mail request for comment.

Liquor Sales Jump by a Third in Michigan Since 1998
Associated Press, 5/16/2004

DETROIT -- Liquor sales in Michigan have jumped more than a third since 1998 to make the state the sixth-highest consumer of liquor in the country in 2003, sales figures indicate. The increase in liquor sales appears to have offset flat sales figures for wine and beer over the past several years. Wholesale beer sales increased just 2 percent between 1998 and 2003, the Michigan Liquor Control Commission reported. "I've never heard the term 'cocktail' more than I have in the past two years," Doug Vollmer, owner of Doug's Party Time liquor store in Royal Oak, told The Detroit News for a Sunday story. "Alcohol has been so scrutinized for so long, that we now know what's good, what's bad, what's sociable and what's abuse. People have learned moderate consumption isn't not only bad for you, it's healthy."
      Accompanying the jump in liquor sales has been a 10 percent decline in the number of arrests for operating under the influence and a 30 percent decline the number of cases of alcohol treatment, to 55,227 in 2003, according to figures from the U.S. Substance Abuse and Mental Health Services Administration.
      Some see the two trends as a sign that people have learned the value of moderation, and how to control their drinking. But the increased sales worry some health officials like Kellie A. Puro. "With all the financial troubles, people are drinking more and that's not good," said Puro, president of the Horizons Treatment Center in Livonia. "People are out of work. There's no structure. There's no support. There's nothing to do but drink. It fills the void."
      The state's biggest seller is vodka, which rang up a tab of about $155 million in 2003 sales. In recent years the number of varieties of vodka have increased, to now include such flavors as orange, vanilla, lemon, raspberry and pepper. The trend holds for many kinds of liquor: in 1997, 1,700 varieties of distilled spirits were sold in Michigan, a number that jumped to more than 4,500 this year.
      Liquor Control Commission figures indicate that more liquor is purchased per capita in northern Michigan counties like Mackinac and Emmet than anywhere else, while the lowest per capita sales are in counties near Indiana, like Cass and Hillsdale, and those around Grand Rapids, like Barry and Ionia.

Kids' Behavior Drugs Get the Cash
Linda A. Johnson, Associated Press- 5/17/ 2004

TRENTON, N.J. -- As more children pop pills for attention deficit and other behavior disorders, new figures show that spending on those drugs has for the first time edged out the cost of antibiotics and asthma medications for kids. A 49 percent rise in the use of attention deficit/hyperactivity disorder drugs by children younger than 5 in the past three years contributed to a 23 percent increase in usage for all children, according to an annual analysis of drug-use trends by Medco Health Solutions Inc. "Behavioral medicines have eclipsed the other categories this year," said Dr. Robert Epstein, Medco's chief medical officer. "It certainly reflects the concern of parents that their children do as well as they can."
      Antibiotics still top the list of the most commonly used children's drugs, but parents are paying more for behavioral drugs, such as stimulants or antidepressants, according to the analysis of drug use among 300,000 children under age 19. Medco, the nation's largest prescription benefit manager, was to release the data culled from its customers' use on Monday.
      The most startling change was a 369 percent increase in spending on attention deficit drugs for children under 5. That's in part because of the popularity of newer, long-acting medicines under patent, compared with twice-a-day Ritalin and generic versions available for years. But the use of other behavioral drugs also jumped in the past three years. Antidepressant use rose 21 percent, and drugs for autism and other conduct disorders jumped 71 percent, compared with a 4.3 percent rise in antibiotics. Epstein said 17 percent of total drug spending last year for the group of children younger than 19 was for behavioral medicines, compared with 16 percent each for antibiotics and asthma drugs, 11 percent for skin conditions and 6 percent for allergy medicines.
      Use of behavior drugs has been controversial, with some experts saying parents and school officials are too eager to medicate disruptive children. Some experts say no. "It's not necessarily a bad thing that these medicines are being used more," said Dr. James McGough of the UCLA Neuropsychiatric Institute. McGough said children on attention-deficit drugs tend to avoid substance abuse and other problems and do better in school.

When Retirement Leaves an Emptiness, Some Fill It With Alcohol
Bonnie Rothman Morris, New York Times- 5/18/2004

Ed's beverage of choice was Scotch. He drank it hard for 50 years, but his drinking, he said, never interfered with his work as a securities analyst on Wall Street. Seven years ago, Ed, who insisted that his surname not be printed, retired. "There was nothing to do except for read and drink, and gradually the drinking took precedence over the reading," he said. "I got completely out of control."
      Retirement, with its promise of the good life, can often include sipping a single malt or two. But sometimes the drastic changes that come with retirement can lead to added drinking. "Older adults will tell us they led a very productive life," said Carol Colleran, national director of older adult services at the Hazelden Foundation and a co-author of "Aging and Addiction," published by the foundation in 2002. "Every day they made important decisions. Then they retire and play golf, and all of a sudden nobody is looking to them for major decisions or even minor ones." Feeling useless, some retirees turn to alcohol for relief.
      The number of older adults who are alcoholics is reportedly small. A national survey of drug use and health in 2002 found that 3.8 percent of people from 55 to 59, and 4.7 percent of people from 60 to 64, met the definition of heavy users of alcohol; 1.4 percent of adults 65 and older reported drinking heavily. But for older people, even small amounts of liquor can be a problem, experts say, and alcohol misuse is more prevalent than alcoholism per se.
      Studies suggest that two-thirds of older adults who are alcoholics have struggled with alcohol throughout their lives. Another third are categorized as late-onset alcoholics, people for whom alcohol abuse is new. Retirement, depression, a divorce, a loss of physical capabilities or the loss of a spouse may propel retirees into alcoholism, experts say. Sometimes the catalyst is not so negative. For some retired people, moving to a country-club-style retirement community, where cocktails are part of many events, can also lead to heavy drinking, said Dr. Alison A. Moore, associate professor of medicine in the geriatric medicine division at the University of California, Los Angeles. In such cases, Dr. Moore said, life may suddenly feel like a permanent vacation, with abundant leisure activity and free time. Some retirees do not have the psychological tools to negotiate these changes.
      Retirees who abuse alcohol may not even realize their problem. Because they are not working, no colleagues or supervisors are at hand to notice that something is wrong. Family members may live far away. And older drinkers tend to avoid driving while drunk, so they are not arrested as often for driving under the influence. Dr. Larry Schonfeld, a professor in the department of aging and mental health at the University of South Florida in Tampa, said retirees lacked checks and balances that could disclose their drinking as a problem and work to obtain help.
      Complicating the problem, few educational campaigns about alcohol are directed toward older adults. "There is very little education for retired people on this," said Dr. Samuel B. Bacharach, director of the Smithers Institute for Alcohol-Related Workplace Studies at the School of Industrial and Labor Relations at Cornell University in New York City. "There's a lot to do with pensions and finding where to live, but very little with things like alcohol."
      Dr. Bacharach is conducting a longterm study of retirement and drinking that follows 1,279 retired blue-collar workers. Now in its fifth year, the study has found that periodic heavy drinking increases with retirement. Even small amounts of alcohol can create problems for older people because as the body ages, the effects of alcohol are amplified. Medications can increase those effects. Conversely, alcohol may diminish the effectiveness of drugs and even worsen symptoms. For example, alcohol can increase bleeding for a patient taking a blood thinner.
      The 2002 national survey found that 6,345,000 people 55 and older said they had engaged in binge drinking in the prior 30 days. Binge drinking was defined as consuming five or more drinks on one occasion.
      Most providers of health care do not automatically think about alcohol or drug problems when treating older Americans, experts say, and they may overlook signs of trouble, like tremors, memory loss or falls, attributing them instead to aging or dementia. Experts say screening for misuse of alcohol rather than abuse is needed to spot retirees who are at risk for problem drinking. Just 2 percent of adults treated for substance abuse are older than 60, Dr. Schonfeld said. Older alcoholics may be more responsive to treatment than younger ones. Short-term counseling, for example, has been shown to be particularly effective with older groups, said Dr. Kristen L. Barry, a research associate professor in psychiatry at the University of Michigan. Three Florida counties have received $600,000 for pilot programs to treat the elderly who have problems with substance abuse. The programs include home visits and counseling.
      Treatments directed to older adults also tend to work better than approaches used with younger groups, said Ms. Colleran, who is based at the Hanley-Hazelden clinic in West Palm Beach, Fla. She said she developed a program for older adults at Hazelden after realizing that "plunking them into treatment in group therapy with 25-year-old crack-cocaine addicts and saying, `Bare your soul,' " was not an effective way to put them on a path toward sobriety.
      Four years ago, Ed entered a treatment program for older adults at the Hanley-Hazelden clinic in West Palm Beach. After 4 days in detoxification and 24 additional days at the center, Ed said, he finally had "some of my brain back, after a long time." He entered the clinic two weeks after his son, who also lives in Florida, had handed him a letter that read in part, "No one in my life shows up at gatherings drunk except you." Ed carries the letter with him every day.     "`I wish that 25 years ago I'd gotten that letter," he said. "It could have changed a lot of things for the better."