Study: Mental Illnesses Are Under-Treated
Associated Press, 6/1/2004

CHICAGO -- Mental illnesses including anxiety disorders and depression are common and under-treated in many developed and developing countries, with the highest rate found in the United States, according to a study of 14 countries. Based on face-to-face diagnostic surveys in the homes of 60,463 adults, the study found that mental ailments affect more than 10 percent of people queried in more than half the countries surveyed. Rates ranged from 26.4 percent of people in the United States to 8.2 percent of people in Italy. While Nigerians appeared to have the lowest prevalence of mental illness -- 4.7 percent -- the researchers think the actual number is likely much higher since residents of the violence-prone West African nation may be hesitant to confide in strangers. ``In some countries there just is not this tradition of public opinion and speaking your mind,'' said Ronald Kessler, a Harvard Medical School researcher who led the study.
     Interviewers who were not psychiatrists spent about two hours asking questions, using a mental health survey that has been shown to be an effective diagnostic tool. Psychiatrists are re-interviewing some participants in every country to verify the results, Kessler said. The study was done in 2001-2003 in Belgium, China, Colombia, France, Germany, Italy, Japan, Lebanon, Mexico, the Netherlands, Nigeria, Spain, Ukraine and the United States. Results appear in Wednesday's Journal of the American Medical Association.
     The most common ailments everywhere except Ukraine were anxiety disorders, which include panic attacks, phobias and post-traumatic stress disorder. In Ukraine, where unemployment is rampant as the country struggles with westernization, mood disorders including depression topped the list, Kessler said. Questions on some disorders, including bulimia and attention deficit disorders, were not asked in every country, at least partly because they were thought to be relatively uncommon. The researchers said that limitation and relying on people to be truthful about their health may have led to underestimates. ``In every country there is a hidden or unhidden stigma,'' said co-researcher Dr. T. Bedirhan Ustun of the World Health Organization. ``People are reluctant to admit that they have mental problems.'' This may be slightly less true in the United States, where mental illness has been highly publicized in recent years, so the U.S. rate may not be that much higher than in other countries surveyed, Ustun said. Kessler said it's plausible that the U.S. rate would be higher because of ``higher expectations'' of success that can lead to frustration when people can't live up to them.
     According to the researchers, ``Substantial proportions of serious cases receive no treatment'' in every country studied. In developed countries, about 36 percent to 50 percent of people with serious symptoms were untreated in the previous year. In developing nations, between 76 percent and 85 percent of serious cases were untreated. In all countries, a substantial proportion of people with less severe cases received treatment, suggesting a ``misallocation of treatment resources,'' the researchers said.
     Kessler said reasons for under-treatment include lack of access to health care in many regions. Also, Ustun said, in many countries insurance doesn't adequately cover mental health treatment and doctors who fail to detect it are not considered as neglectful as those who fail to diagnose physical ailments such as high blood pressure. ``Better health care systems and training'' are needed to address the problem, Ustun said.



How Household Junk Can Grow Into Mountains
Anahad O'Connor, New York Times- 6/1/2004

People who compulsively hoard objects have singular patterns of brain activity that distinguish them from other patients with obsessive compulsive disorder, a new study finds. Researchers say the study, based on brain scans of compulsive hoarders, provides the first solid evidence that hoarding defines a distinct subset of patients. The research might also open a door to new treatments for the illness, which is often unaffected by standard drugs. "This adds to the evidence that O.C.D. is a heterogeneous disorder, not a single entity," said Dr. Sanjaya Saxena, director of the research program on the condition at the Neuropsychiatric Institute at the University of California, Los Angeles. "More specifically, it shows that compulsive hoarding may be a variant or subtype that requires its own type of treatment."
      Scientists have long been puzzled by pathological hoarding, which afflicts up to 40 percent of the seven million to eight million Americans with obsessive compulsive disorder. As a group, studies show, excessive hoarders, who fill their houses with accumulations of junk, usually newspapers, bags of old clothing and lists, experience more anxiety, depression and social disability than obsessive compulsive patients with other symptoms. The hoarders are also less likely to seek help. Experts say eviction notices or social workers often bring to light compulsive hoarders' problems.
      The new study, in The American Journal of Psychiatry today, compared 45 obsessive compulsive adults, including 12 hoarders, with 17 healthy participants. Compulsive hoarders, compared with people with other compulsive symptoms, had decreased activity in the anterior cingulate, a brain structure involved in decision making and problem solving. The hoarders also showed less activation than the healthy subjects in the posterior cingulate, an area involved in spatial orientation, memory and emotion.. The findings, said Dr. Dennis L. Murphy of the National Institute of Mental Health, who was not involved with the study, are the first step toward defining "hoarding as not just a phenomenon, but as something that might have a different basis in brain activity."
      Dr. Saxena said the study might explain why hoarders are so attached to their possessions. Deciding what to keep and what to discard is often a struggle. They are tormented by fears of throwing out items that may be needed one day. Often, the objects are kept in the open, stacked to the ceiling in the living room, the kitchen or even on the bed, Dr. Saxena said. That may result from the lower activity levels in brain regions that govern memory and spatial orientation. "It may have to do with the difficulty they have in their visual spatial processing," he said. "And they may have some trouble remembering where things are and feel that they need to have them in sight."
      Hoarders rarely respond to serotonin enhancers like Prozac, Luvox or other standard drugs used to treat obsessive compulsive disorder. The researchers said they were looking into the effectiveness of newer drugs, including one that can increase activity in the anterior cingulate.

Large Study on Mental Illness Finds Global Prevalence
Donald G. McNeil, Jr., New York Times- 6/2/2004

Preliminary results from the world's largest survey on mental health indicate that mental illness is widespread and undertreated, and that wealthy people with mild illness receive more and better treatment than poor people with severe illness. From 1 to 5 percent of the populations of most of the countries surveyed had serious mental illness, according to the findings, being published today in The Journal of the American Medical Association. And in most of the countries, 9 to 17 percent of those interviewed had had some episode of mental illness in the last year, whether serious or less severe, said the study, by researchers from the World Health Organization and Harvard Medical School.
      Around the world, the authors found, mental illness causes as many lost days of work as any physical problem like cancer, heart attack or back pain."The level of role impairment we found to be associated with serious mental disorders was staggering: more than a month in the past year when the respondents reported being totally unable to work," said one chief author, Dr. Ronald C. Kessler, a professor of health care policy at Harvard.
      In poor countries, about 80 percent of serious cases went untreated, but even in richer countries 35 to 50 percent of cases had not been treated in the last year. The surveys asked about treatment not just by psychiatrists and psychologists but by family practitioners, members of the clergy, shamans and herbalists.
      Earlier efforts to assess mental health across the globe have been frustrating, experts said. Those efforts either tried to match disparate national surveys or relied on the "global judgments of clinicians," said Dr. Robert L. Spitzer of the New York State Psychiatric Institute, who was not involved in the new study and who praised Dr. Kessler's work. Dr. Ronald W. Manderscheid, chief of the Department of Health and Human Services division that does national mental health surveys, said, "It's fantastic and wonderful that data has been collected cross-nationally using a common methodology.''
      The findings were based on 60,643 face-to-face interviews with adults in 14 countries. Eight countries were defined as rich: the United States, Germany, France, Italy, Belgium, Spain, the Netherlands and Japan; six were deemed poor or nearly poor: Mexico, Colombia, Ukraine, China, Lebanon and Nigeria. Within each country, whether rich or poor, the study took into account the economic status of respondents. The 90-minute interviews assessed a wide range of ills, including agoraphobia, obsessive-compulsive and panic disorders, post-traumatic stress syndrome, bipolar disorders, bulimia, major depression, and alcohol and drug abuse.
      The study did not try to diagnose schizophrenia, because that requires a psychiatrist, said one of its authors, Dr. Bedirhan Ustun of the Global Program on Evidence for Health Policy at the World Health Organization. "If an interviewer knocks on your door and asks if you are hearing voices," Dr. Ustun explained, "you are likely to answer no.''
      Dr. Kessler acknowledged that his methodology needed refinement. Although some general trends were clear, there were wide unexplained disparities. For example, about 26 percent of Americans were judged to have mental illness, compared with only 4 percent of the residents of Shanghai and 5 percent of Nigerians. The differences were even more extreme in smaller categories. The Dutch were found to have 30 times the drinking problems that Italians had, and 4 times the problem of the French. About 18 percent of Americans had anxiety disorders, versus 12 percent of the French, 11 percent of Lebanese and 10 percent of Colombians. Europeans other than the French were in the 7 percent range, while Nigerians and Chinese were the calmest, at about 3 percent. "I'm sorry it's so fuzzy, but that's the way it is," Dr. Kessler said. "It sounds like Nigeria is a paradise, but I know there are camps there where lots of people have P.T.S.D.," a reference to refugee camps where people fleeing ethnic violence have post-traumatic stress disorder.
      Embarrassment about disclosing mental illness varies from country to country, Dr. Kessler explained. For example, in Nigeria, he said, women were reluctant to admit being depressed, but might say their mother had been, a response that gave interviewers a clue about truer rates. In addition, he said, "sometimes the language we use doesn't ring a bell in the countries we're in." In China, for instance, no word distinguishes depression from sadness, he said.

Antidepressant Seen as Effective in Treatment of Adolescents
Gardiner Harris, New York Times- 6/2/2004

PHOENIX, June 1 — In the midst of a worldwide debate on whether depressed children should be treated with antidepressant drugs like Prozac, a landmark government-financed study has found that Prozac helps teenagers overcome depression far better than talk therapy. But a combination of the two treatments, the study found, produced the best result. The study, sponsored by the National Institute of Mental Health, was the first to compare psychotherapy and drug treatment for depressed adolescents. Statistically, the researchers found, talk therapy — in which a patient discusses problems with a therapist — was by itself no more effective in reducing the depression than treatment with placebos. But when combined with drug treatment, psychotherapy appeared to provide added benefit and to reduce the risk of suicide. The findings are likely to reassure psychiatrists, pediatricians and others who increasingly prescribe antidepressants to teenagers and children. Millions of young people take the drugs.
      Experts said that the study was notable for its size and for the fact that it was carried out without financing by drug manufacturers. Data on the effects of antidepressants in adolescents is in short supply. Most studies of the question have been small trials sponsored by pharmaceutical companies and have failed to show that the drugs are effective for depressed teenagers. "This study should put to rest doubts about whether these drugs work in teenagers with severe depression," said Dr. Graham Emslie, a professor of psychiatry at the University of Texas Southwestern Medical Center and an author of the study, which was presented here on Tuesday at a meeting of psychiatric drug researchers.
      Still, the findings are unlikely to resolve the controversy over whether Prozac and similar drugs lead a small number of teenagers and children to become suicidal. Such concerns led the Food and Drug Administration to warn earlier this year that patients taking the drugs should be watched closely for signs of suicide or other harmful behavior in the first weeks of therapy. The agency is reanalyzing suicidal events that occurred during drug-company trials of antidepressants in children and teenagers. British drug regulators have banned the use of all but Prozac in those younger than 18.
      The government study, called the Treatment for Adolescents with Depression Study, involved 439 youths ages 12 to 17 who were suffering from moderate to severe depression. The adolescents were randomly assigned to be treated for a period of 36 weeks with either Prozac, the antidepressant drug made by Eli Lilly & Company; a form of talk therapy known as cognitive behavioral therapy; placebo pills; or a combination of Prozac and talk therapy. The researchers collected data on the subjects for a year, but have only analyzed information from the first 12 weeks so far. Of the youths recruited for the study, 378 completed the first 12 weeks of treatment. Their mean age was 15. Depression levels were measured using several common psychological scales.
      Using one measurement scale, the researchers found that after 12 weeks, 71 percent of the subjects who received Prozac and talk therapy responded well to treatment, compared with 61 percent of those who received Prozac alone, 43 percent of who received talk therapy alone and 35 percent of those who received a placebo treatment. By another measure, talk therapy alone fared no better than treatment with placebos. The researchers also found that patients became significantly less suicidal, no matter which treatment they were given. No patient committed suicide during the trial. But the risk of a suicide attempt among the patients given Prozac was twice that of those who did not, the study found. There were five suicide attempts among those given Prozac and just one among other participants.
      Dr. John March, a professor of psychiatry at Duke University and the study's lead investigator, said that the findings showed Prozac's benefits for depressed teenagers and children far outweighed its risks. "The take-home message is that these adverse events are extremely rare,'' he said. Dr. March acknowledged, however, that the controversy about suicide and antidepressant therapy was far from resolved. "We're all holding our breath to see what the F.D.A. is going to do,'' he said.
      Psychologists, who are often the providers of talk therapy and who cannot prescribe drugs, are likely to be disappointed in the finding that cognitive behavioral therapy was found to be little better than a sugar pill. A recent major trial comparing drugs with talk therapy in children with attention-deficit disorder also showed that the drugs worked better. But the findings of another study presented on Tuesday suggest that for some conditions, talk therapy may be more effective than antidepressants. That study compared cognitive behavioral therapy with Zoloft, an antidepressant similar to Prozac that is made by Pfizer, in teenagers who suffered from obsessive compulsive disorder. Those who received the talk therapy, the study found, improved more than those who were treated with the drug.
      Dr. Thomas Insel, director of the National Institute of Mental Health, said he was pleased the results of the depression study were so clear. The institute spent $17 million over six years financing the trial. "The most striking thing about the study is that, in all groups, there was a dramatic decrease in the amount of suicidal thinking,'' he said, suggesting that all the therapies were protective.
      Dr. David Brent, a professor of psychiatry at the University of Pittsburgh not involved with the study, suggested that another form of talk therapy called interpersonal therapy might have fared better than cognitive behavioral therapy. In interpersonal therapy, clinicians focus on a patient's relationships with peers and family members and the way they see themselves. In cognitive behavioral therapy, clinicians teach patients to try to think more positively and do things that make them happy. Dr. Brent said it was good news that drugs produced better results than talk therapy "because it's hard to get people into cognitive therapy anymore. They just don't want to take the time.''
      The researchers said they plan to publish the preliminary results of the study this summer, with further analyses later. Dr. Insel said that the most useful information from the study is yet to come. "We need to know which treatments work best for what kinds of kids and who may be the most vulnerable to the side effects,'' he said. Those sorts of answers would come from more data analysis, he said. "We're going to get a lot out of this study that the public really needs to know right now,'' Dr. Insel said.

Spitzer Sues Paxil Maker for Misrepresenting Use by Children
Brooke A. Masters, Washington Post- 6/2/2004

NEW YORK-- Drug maker GlaxoSmithKline misled consumers and committed fraud by suppressing clinical studies that called into question the safety and effectiveness of its top-selling antidepressant Paxil when used to treat children and adolescents, New York Attorney General Eliot L. Spitzer alleged in a lawsuit filed Wednesday. The 18-page complaint filed in New York state court alleges that Glaxo systematically withheld negative information about the drug, also known as paroxetine. While the company's representatives and sales literature drew attention to a single study that showed Paxil had some positive results, they hid four other studies, the complaint alleges. Left unmentioned were studies that that found no evidence the drug is effective in minors and that suggested the pills could increase the risk of suicidal thoughts and behavior. The complaint cited a 1998 internal Glaxo memo that said the company's "target" was to "effectively manage the dissemination of these data in order to minimize any potential negative commercial impact."
      The Food and Drug Administration has not officially approved Paxil for use in children and Glaxo is not allowed to specifically market the drug for minors. But doctors can prescribe Paxil for children as a "off-label" use, and more than 2.1 million paroxetine prescriptions for children were written in 2002, the complaint said.
      GlaxoSmithKline said in a statement that the firm "has acted responsibly in conducting clinical studies in pediatric patients and disseminating data from those studies. All pediatric studies have been made available to the FDA and regulatory agencies worldwide. We have publicly communicated data from all pediatric studies. As for the 1998 memo, it is inconsistent with the facts and does not reflect the company position."
      The unpublished studies cited by Spitzer have been under discussion in the medical world for some time now. British regulators cited them last year when they warned doctors against using Paxil and several other popular antidepressants for children, and the FDA recently urged doctors to watch patients carefully for suicidal behavior in the first weeks after prescribing the pills. Now Spitzer is arguing that Glaxo's sales representatives had a duty to discuss the negative studies along with the positive one when promoting the drug. "The manufacturer cannot rely exclusively on the positive study. . . . Where they affirmatively state this drug is 'remarkably' efficacious and safe, and they are withholding information that challenges that, that's wrong," Spitzer said in an interview.
      Like Spitzer's previous investigations of biased research on Wall Street and trading abuses in the $7.5 trillion mutual fund industry, this lawsuit makes unusual use of New York state law to take on an issue that has generally been the province of the federal government, particularly the FDA. But Spitzer argued that "off label" uses are a gray area because they are prescribed without FDA approval and that he is simply trying to make sure that doctors have the information they need. "The last thing that I should be doing is making clinical decisions about which medicines are good or bad," Spitzer said. "We don't want to discourage off-label uses, we just want more complete information."

Study Examines Teen Summer Marijuana Use
Martha Irvine, Associated Press- 6/4/2004

CHICAGO -- Summer's almost here and that means teens will have more time on their hands to pick up bad habits -- such as smoking marijuana and drinking alcohol, a new federal survey says. The National Survey on Drug Use and Health found that June and July were the most popular time for teens to try marijuana, with about 6,300 new users a day during those months. That compares with about 4,700 new users a day during other times of the year. Additionally, the survey found that first-time use of alcohol and cigarettes also increases during the summer, when many teens are less supervised and, particularly in this economy, having trouble finding jobs.
     At a Friday news conference in Chicago, White House drug czar John Walters challenged teens and parents to quell marijuana use this summer, noting that the drug has been developed to become much more potent and addictive over the last 20 years. "You are going to be on the front line of those influences," said Walters, who heads the Office of National Drug Control Policy, addressing a group of Chicago high school students. "But we need adults to stand with you."
     Several teens who were present said they understood the risks of drug use, which they learned in their health classes. Still, they know other teens who use marijuana, which they and surveys say is the most common illegal drug taken by high-schoolers. Some said they even know elementary school students who've been caught using it. "It's definitely a problem," said Julissa Santoy, a freshman at Whitney Young High School, a public magnet school. "We should say something. We shouldn't just mind our own business." But Maribel Davila, another freshman, also placed responsibility on parents. "A lot of kids are pushed because there's a lot of stuff going on at home," she said, referring such things as divorce, adults' own addiction issues and other family discord. None of the students were surprised by the findings. Nor was at least one researcher not involved with this survey who tracks teen drug use.
     While its helpful to know when young people are most likely to start taking drugs "the real question is 'What should they do based on that information?'" said Lloyd Johnston, who heads the University of Michigan's Institute for Social Research and oversees an annual national survey of teens called "Monitoring the Future." The most recent University of Michigan survey, released late last year, found an 11 percent drop in illegal drug use in the past two years. But it also found that, while marijuana use had dropped, nearly half of 12th-graders surveyed said they had tried it at least once -- and about a third said they had used it in the last year.
     Walters agreed with Johnston that the best way to deter marijuana use is not just to say "Don't do drugs." To that end, federal officials have begun running advertisements directed at teens that urge them to take a stand with friends who use marijuana and other drugs. The government has also begun a campaign titled "School's Out -- Don't let your teen's summer go to pot," which maps out basic tactics for parents such as setting rules, monitoring a teen's activity and scheduling family time.
     At Friday's news conference, YMCA executive director Ken Gladish called the suggestions "fundamental common sense." He referred to a recent YMCA survey that found 14.3 million young people are unsupervised outside school -- a number that triples in the summertime. Meanwhile, he said, more than half of those teens surveyed said they wished they had access to more supervised programs in their neighborhoods.
     On the Net: http://www.whitehousedrugpolicy.gov/

Medication vs. Talking
Bryan Robinson, ABC News- 6/7/2004

When Chad Taylor noticed his son was apparently experiencing serious side effects from Ritalin prescribed for attention deficit hyperactivity disorder, he decided to take the boy off the medication. Now, he says he may be accused of child abuse. In February, 12-year-old Daniel began displaying some symptoms that his father suspected were related to the use of Ritalin. "He was losing weight, wasn't sleeping, wasn't eating," Taylor told ABC News affiliate KOAT-TV in New Mexico. "He just wasn't Daniel."
      So Taylor took Daniel off Ritalin, against his doctor's wishes. And though Taylor noticed Daniel was sleeping better and his appetite had returned, his teachers complained about the return of his disruptive behavior. Daniel seemed unable to sit still and was inattentive. His teachers ultimately learned that he was no longer taking Ritalin. School officials reported Daniel's parents to New Mexico's Department of Children, Youth and Families.Then a detective and social worker made a home visit. "The detective told me if I did not medicate my son, I would be arrested for child abuse and neglect," Taylor said.
      A spokesman for New Mexico's Department of Children, Youth and Families told KOAT-TV that they could not comment on the case because of state confidentiality laws. John Francis, a detective for the Rio Rancho Department of Public Safety, said that Taylor was not threatened but told KOAT-TV that parents could be charged in situations like his. "People can be charged with child abuse, child neglect or various other crimes involving a child," he said.

More Kids on Antidepressants
Taylor is among many parents facing a dilemma over whether to medicate children who suffer from mental disorders. A recent study by Express Scripts Inc., a medical benefits management company, found antidepressant use increased 49 percent among consumers younger than 18 between 1998 and 2002. Preschoolers up to age 5, the study found, were the fastest-growing users of prescription antidepressants.
      Some parents have been concerned about overmedicating their children and the potential short- and long-term effects of the drugs. Some have wondered whether their children would receive the most benefit from medication or talk therapy. Despite these concerns, experts say parents should never take their children off medication without checking with the child's doctor. "I would never recommend that anyone take themselves or their children off prescribed medication without first consulting their doctor, particularly if they're taking multiple medications," said Jay Reeve, senior psychologist at the Children's Inpatient Unit at Bradley Hospital in East Providence, R.I.

What Is the Best Approach?
There has been debate over whether medication is more effective than psychotherapy in treating children and adolescents with serious mental illness. A study sponsored by the National Institute of Mental Health found the antidepressant Prozac helps teenagers battle depression better than talk therapy. But the study also found a combination of the two methods produces the best results.
      Experts agree that a combined medical and psychotherapeutical approach could be the best way to battling depression in teens and adolescents. But the approach depends on the severity of the illness. "Medication can be a very helpful component of treatment for children and adolescents with depression, but medication alone is rarely an adequate or sufficient intervention," said Dr. David Fassler, clinical associate professor of psychiatry at the University of Vermont's College of Medicine. "It should only be used as part of a comprehensive treatment plan, individualized to the needs of the child and family," he said. "Most children and adolescents tolerate medication well, with minimal side effects. But all children taking medication need to be monitored closely to make sure the symptoms are improving and to identify any potential problems or reactions."

The Children’s Challenge
Doctors say treating depression in children — especially young children — is difficult because they generally are not able to explain their feelings or give sophisticated answers to questions about their moods. Unlike teenagers and adults, they sometimes cannot link events in their lives to their feelings — or at least eloquently explain how an experience affected them. Most often, children lash out, showing signs of trouble either through various kinds of misbehavior or through drawings at school. "Generally speaking, the younger a child is, the more difficult it is to diagnose the illness," said Reeve. "It's safe to say the younger you go, the more difficult it is to distinguish one disorder from another."
      Children's general lack of sophistication plays a role in the difficulty in determining whether they suffer from a mental illness and whether they would benefit from medication, psychotherapy or both. Some critics argue that many primary care physicians are not adequately trained in diagnosing illnesses in children. "There are so many providers that are dispensing antidepressants to children and teens without appropriate knowledge and skills to administer these medications, as well as without accompanying cognitive-behavior therapy, which is critical in the improvement of depressive symptoms," said Bernadette Melnyk, founder and chairwoman of the National Association of Pediatric Nurse Practictioners' Keep Your Children/Yourself Safe and Secure Campaign. She said many doctors do not evaluate children for depression. "In a recent survey of over 600 providers from 24 states across the country, we found that many providers are not screening routinely for depression in children."
      Doctors also sometimes misinterpret behavior that stems from depression as a symptom of attention deficit disorder. "Many children with depression also are being misdiagnosed with attention deficit disorder," Melnyk said. "Younger children with depression often present differently than older children. That is, they are most likely hyperactive and restless, versus sad and depressed."

Do Your Homework
For parents, mental illness in kids can be frightening, especially if their children are having suicidal thoughts or showing suicidal behavior. In severe cases like these, immediate medical intervention can save lives and a subsequent combined medical and talk therapy could be the best remedy. Still, every case is unique and treatment strategies should fit a child or teen's individual needs. But sometimes parents panic when they see what they believe are adverse side effects in their children after they begin taking medication. To avoid any misunderstandings or rash decisions, experts recommend that parents do their homework. Thoroughly research mental diseases and treatments and consult the child's physician about the disease and potential side effects of medication. It also helps to know the qualifications of the child's doctor. "Parents need to be advocates for their children," Fassler said. "They need to ask lots of questions, and they need to get as much information as possible about both the diagnosis and the treatment options."
      Meanwhile, Chad Taylor remains convinced that he has made the right decision for Daniel. He says his son is acting like himself again, but officials are continuing to monitor Daniel's case.
Taylor told KOAT-TV he is not putting Daniel back on Ritalin, no matter what the consequences for himself may be. "Yeah, I'll go to jail for it," he said. "I'll go as long as I have to go."

Seeking Origins of Alzheimer's
Ronald Kotulak, Chicago Tribune- 6/7/2004

Ronald Reagan's death, caused in part by Alzheimer's disease, comes as researchers are beginning to discover that the illness likely has its start long before old age, possibly even in childhood. As scientists uncover the roots of the brain-destroying malady, which affects 4.5 million Americans and is expected to reach three times that number by mid-century, they also are pointing the way to new opportunities to prevent or greatly delay the disease's onset. "The picture that's emerging is that there are a lot of environmental factors that contribute to your risk of getting dementia later in life," said Dr. Robert Wilson of Rush University Medical Center's Alzheimer's Disease Center in Chicago. "We're focusing on mental activity and its protective effect, but we're also finding that physical activity and social activity seem to be somewhat protective."
      Many of the lifestyle changes and medical treatments that reduce the risk of heart attack and stroke--lowering cholesterol, exercise, weight loss, anti-inflammatory drugs--also may work to control Alzheimer's. "We need to shift the thinking away from treating Alzheimer's disease as a disease of late life," said neuropsychologist Paul Nussbaum of the University of Pittsburgh School of Medicine. Alzheimer's appears to follow a pattern similar to that of heart disease, he said. In heart disease, bad diet, lack of exercise and unhealthy lifestyles can lead to the formation of deposits in the arteries of youngsters, which may grow over time until they cause chest pains or heart attacks in middle age or beyond.
      Bad lifestyles also can set the stage for Alzheimer's very early, especially in young people who have a genetic predisposition to the disorder, Nussbaum said. Cholesterol deposits in brain arteries, for example, can trigger inflammation and other biological processes that have been linked to Alzheimer's. "Alzheimer's is a childhood disorder," Nussbaum said. "It's an invasion of our brain very early in life and across our life span, and it tends to show up clinically late in life."
      Preliminary evidence appears to support the early-onset hypothesis. Autopsy studies of people who died young and who were mentally intact found that many already had the characteristic plaques and tangles and dead brain cells characteristic of Alzheimer's. Some of the signs showed up in people in their 20s and 30s.
      Until now, autopsies were the only way to definitely show a person's brain was riddled by amyloid plaques and neurofibrillary tangles, the two hallmarks of Alzheimer's. But research teams at the Mayo Clinic and the University of Pittsburgh have developed techniques that for the first time may make it possible to accurately diagnose Alzheimer's disease early in living patients. Currently, a presumptive diagnosis is made based on a patient's behavior. "A simple [magnetic resonance imaging] evaluation for Alzheimer's disease would ease the suffering of so many families and, hopefully, vastly improve patient care options," said the Mayo's Dr. Joseph Poduslo.
      By giving patients special compounds that stick to amyloid plaques, Mayo and Pittsburgh scientists use MRI and positron emission tomography (PET) scans to identify amyloid deposits in the brain, possibly enabling doctors to detect the disease early and to monitor how anti-Alzheimer's drugs are working to eliminate amyloid plaques. "We're learning more about how to help the brain help itself," said Marcelle Morrison-Bogorad, associate director of the National Institute on Aging's neuroscience and neuropsychology of aging program. "A huge amount of research has moved from late-stage Alzheimer's disease to earlier and earlier stages where protective measures are more likely to be effective," she said.
      The institute and drug companies are testing at least 30 compounds for their ability to delay or prevent the onslaught of dementia. A recent study showed that using two drugs in tandem--donepezil, which increases levels of the memory-enhancing chemical acetylcholine, and memantine, which prevents a deadly overproduction of another neurotransmitter--significantly slows the progress of Alzheimer's.
      Another new study found that people who regularly take vitamins E and C, potent antioxidants, have a significantly reduced risk of developing Alzheimer's disease. Antioxidants neutralize free radicals, destructive molecular residue from metabolism and disease processes, which are thought to destroy brain cells. Much more effective drugs are expected to become available within 10 years.
      In recent years, former First Lady Nancy Reagan has been campaigning for embryonic stem cell research as a potential scientific avenue leading to cures for such illnesses as Alzheimer's. Such studies are generally opposed by conservatives and anti-abortion groups because they involve the destruction of human embryos.
      In the meantime, researchers say there is much people can do on their own. There's a growing conviction among scientists that a lifestyle that is good for your heart and your overall health can also considerably reduce your risk of Alzheimer's, said Bill Thies, vice president for medical and scientific affairs of the Chicago-based Alzheimer's Association. Among them are:
- Know your medical numbers--blood pressure, cholesterol and blood sugar--and get them treated. All three have been linked to an increased risk of dementia. Diabetes may increase the risk of Alzheimer's by 65 percent, according to a recent study.
- Get some physical exercise. Studies show that active older people have a lower risk of Alzheimer's. A University of California, Los Angeles, study found that walking about 1 mile a day cut the risk of cognitive decline by 13 percent. The Canadian Health Study also found that regular walking reduced the risk of cognitive decline and dementia.
- Eat a diet that favors fish and vegetables and avoids fats. Martha Clare Morris of Rush University Medical Center found that people who eat more fish and vitamin E-rich foods have a lower chance of developing cognitive impairment and dementia.
- Stay connected to society. This is a particular problem for older people who have lost relatives and friends. Their risk of dementia increases.
- Stay mentally active. A recent study in the New England Journal of Medicine found that people 75 years and older who read, danced or played board games or musical instruments had a reduced risk of dementia. Crossword puzzles also appear to help.
- Avoid toxins, such as cigarette smoke and excessive alcohol.
- Keep your weight within normal limits. Studies show that overweight people are more prone to Alzheimer's.
- Reduce psychological distress, especially depression, through exercise, meditation or medication. Rush's Wilson found that depression may be an Alzheimer's risk factor.
      "All of these things will be good for your health, no matter what," Thies said. "My grandfather retired at 65, and like everyone else he just sat around because the next thing you did was die. "People who are 65 now are saying, `Well, I'm ready to start my next career.' The only way you're going to be able to do that is if you remain functional, and that's a combination of the mental and physical abilities that you've preserved."
      People who live to be 100 and older usually don't have Alzheimer's, heart disease or any of the other chronic disorders associated with aging, said Dr. Thomas Perls of the Boston University School of Medicine and director of the New England Centenarian Study. They have really good genes in addition to healthy lifestyles, he said. "There's a lot of evidence to show that for the rest of us, we have an average set of genes to get us to our mid- to late 80s in very good health," Perls said. "The reason that many of us develop age-related diseases at younger ages has much to do with what we do with our bodies," he said. "We live on average about 10 years less in this country than what our genes are capable of achieving for us."
      Brainteasers may be one of the most potent weapons against Alzheimer's. Growing evidence indicates that mental gymnastics that stimulate the construction of new connections between brain cells may buffer the destructive effects of the disease. Muscles grow stronger through physical exercise, but the brain's exercise is learning, which sparks the construction of new connections, said Pittsburgh's Nussbaum. Scientists refer to the formation of new synaptic connections as building "brain reserves." The idea is that as brain reserves increase, they make many more connections than a person can afford to lose to disease before memory loss occurs.
      The gradual destruction of connections and the subsequent death of brain cells mark Alzheimer's. "Learning things that are a challenge can certainly delay the onset of Alzheimer's disease by years," Nussbaum said. "You can slow the course once it's started, and it's never too late to start. The final question is going to be how much of an impact will this have in maybe stopping it altogether. We don't know that yet."

Hinckley Still Patient in Mental Hospital
Associated Press, 6/7/2004

WASHINGTON -- Seventy days into his presidency, Ronald Reagan was shot by John W. Hinckley Jr. in an attempt to impress a young actress. Hinckley, 49, has been a patient at St. Elizabeths psychiatric hospital here since he was acquitted by reason of insanity in the shooting of Reagan and three others outside a Washington hotel in March 1981. Reagan was nearly killed and press secretary James Brady was permanently disabled. The shooting was said to be an attempt by Hinckley to impress actress Jodie Foster. At the time of the assassination attempt, Hinckley was a college dropout who moved from job to job and city to city. His parents said he had been under psychiatric care before the shooting.
      Late last year, Hinckley's psychiatrists said he was no longer a threat, and Hinckley was granted six unsupervised visits in the Washington area with his elderly parents. The Reagan family and others strongly objected. Until that Dec. 17 ruling, Hinckley had been allowed dozens of visits off hospital grounds, supervised by medical staff, and always under the watchful eye of Secret Service agents. He took trips to theaters, bowling alleys, beaches and bookstores.
     The decision by U.S. District Judge Paul L. Friedman to grant the unsupervised visits drew a sharp rebuke from the Reagans. Calling it an outrage, Reagan's son, Michael, asked, "Can we trust two 80-year-old parents, if he gets off of his drugs, to do the right thing and get him back into a hospital where he belongs or stop him from hurting himself or hurting others?"
      The judge did set some restrictions on the trips away from St. Elizabeths, such as limiting them to the Washington area. Hinckley had asked the judge to allow visits to his parents' home in Williamsburg, Va., about three hours south of the capital. Each of the unsupervised visits may last up to 12 hours. And if all goes well, Hinckley may be allowed two 32-hour overnight trips with his parents within 50 miles of Washington.
      Government lawyers who fought Hinckley's request insisted that he remained a threat. They said he had stopped reading and writing -- two activities that helped professionals determine Hinckley's mental health. Even so, the Justice Department decided against an appeal of Friedman's ruling.

Pills or Talk Therapy? If You're Confused, No Wonder
Benedict Carey, New York Times- 6/8/2004

Moody teenagers who visit therapists for help often wonder how useful all that talk about feelings and emotions really is. Now, many doctors are asking the same thing. Last week, researchers presented findings from a large government-financed study showing that depressed teenagers were much more likely to improve by taking Prozac than by undergoing a standardized form of talk treatment, cognitive behavior therapy. For parents desperately trying to help a depressed teenager, the study may appear to make their choices even more confusing. Already worried by Food and Drug Administration warnings that antidepressants can be dangerous for a small number of children and adolescents, parents now face the news that the best alternative, talk therapy, may be a waste of time.
      Yet experts say the results of the study are more complicated, and less discouraging, than they might seem at first glance. The study, to be published this year, offers some reassurance that the drugs are probably helping. At the same time, it makes clear that psychotherapy does have a place. Although statistically, therapy alone was no better than a placebo, it did lift depression in 43 percent of the teenagers studied, compared with 35 percent given dummy pills. Almost three-quarters of the adolescents who combined talk and drug treatments improved significantly, and the psychotherapy appeared to reduce the risk of suicide. "It was very close to a significant effect," said Dr. Michael E. Thase, a professor of psychiatry at the University of Pittsburgh, "and the added effect the therapy had confirms for me that it's showing some benefit."
      Dr. Thase said good psychotherapies sometimes did not work in big studies. Large-scale investigations, by focusing on group averages, can also hide individual differences. Some people thrive in therapy, others do not. Therapists' skills vary widely. And people sometimes fare better with a form of psychotherapy other than the one being tested. Previous research has suggested that other techniques can help soothe teenage depression, and several forms of talk therapy have not been tested at all.
      Dr. Martin E. P. Seligman, a professor of psychology at the University of Pennsylvania who has worked with troubled adolescents, wrote in an e-mail message that the findings on cognitive therapy would have to be verified in further studies, "particularly so, because prevention of depression using C.B.T. procedures works well among adolescents at risk for depression." C.B.T. stands for cognitive behavior therapy. He also said in the e-mail that some teenagers picked up the techniques so well that they became "emotional acrobats."
      The government study, led by Dr. John S. March, a professor of psychiatry at Duke, found that Prozac had about the same effects on depression in 378 teenagers as it did in adults. After 12 weeks, 61 percent of those taking the drug reported feeling significantly better, the researchers reported. "This provides what I would consider definite, clear-cut evidence for the effectiveness of medication in a segment of the pediatric population for which very little evidence existed, and supports what many psychiatrists have been doing in practice," said Dr. Jeffrey A. Lieberman, a professor of psychiatry and pharmacology at the University of North Carolina.
      The drug effects were strong enough to prompt some rethinking about standard treatments, said Dr. Harold S. Koplewicz, director of the Child Study Center of New York University. At many clinics, depressed teenagers routinely receive some form of counseling before being prescribed drugs. "This study truly makes us rethink what the first line of attack should be, and I believe we have to share the results with parents before a teenager starts treatment," Dr. Koplewicz said.
      Psychiatrists and pediatricians emphasized the importance of regular visits for children on antidepressants, to monitor reactions. The researchers reported five suicide attempts among adolescents in the study who were given Prozac and one attempt among those given placebos. Citing suicide risk, the Food and Drug Administration cautioned doctors and families in March to pay close attention to children and adults on antidepressants, especially in the first weeks of therapy or when dosages are changed. Adolescents who become hyperactive, suddenly agitated or who act strangely out of character may be reacting badly to the drugs, experts say.
     The benefit of talk therapy has been much clearer in studies of adults. Researchers find that roughly 60 percent of depressed adults feel significantly better after completing a form of focused talk therapy like cognitive therapy, the type used in the study, or interpersonal therapy, another form that is often used in comparison trials.
      In interpersonal therapy, people work to mend the specific personal problems like a dispute, a loss or a betrayal that led them to fall into despair. The therapy may last 10 to 20 weeks or longer and usually stays focused on managing specific relationships. Cognitive therapy typically involves 8 to 12 hour-long sessions in which people learn to dispute and defuse self-degrading thoughts -- "I am an awful parent," and "I'm a failure as a student" - that feed on themselves and cause people to sink into depression. These methods are the only two that researchers have standardized well enough to study systematically, and they have generally worked as well as medication in people 21 and older. "Almost all such adult studies show similar positive results for both cognitive therapy and drugs over placebo," Dr. Seligman said.
      Experts say there are several possible reasons why cognitive therapy might fail teenage patients. The approach tends to work best for people with mild to moderate forms of depression. Those with more stubborn conditions often do better with a combination of drugs and talk therapy. The success of the techniques is highly dependent on the therapist's skill. And working with a standardized manual, as many researchers do, can limit a psychologist's flexibility in dealing with teenagers' individual problems. "You can't do cognitive therapy from a manual any more than you can to surgery from a manual," said Dr. Aaron T. Beck, a professor of psychiatry at the University of Pennsylvania and the director of the Beck Institute for Cognitive Therapy.
      Depending on the teenager, Dr. Beck said, the therapist might bring family members into sessions. "Adults are mature enough to learn most of what they need to know at the office,'' he said. "But with teenagers you really have to look at the family environment." Often, too, teenage depression is tied to trouble in relationships like a breakup with a boyfriend or a falling out with a good friend, crises best handled directly, with interpersonal therapy. Several studies show that interpersonal techniques can relieve depression in teenagers, said Dr. David A. Brent, a psychiatrist at the University of Pittsburgh. "I think we need to look at a variety of approaches before deciding" talk therapies are ineffective, Dr. Brent said.
      The underlying problem in reaching a troubled teenager is clear to just about any parent of one. Adolescence is a fog, a kind of high fever. Emotion swamps reason; rumination undermines introspection. It is not an ideal time, many psychiatrists acknowledge, to perform therapy that requires the detached moment-to-moment self-awareness crucial to cognitive therapy. "This component of the therapy, watching and monitoring your own feelings and thoughts, is notoriously difficult for some teenagers," said Dr. David Shaffer, a professor of psychiatry and pediatrics at Columbia. "The development of these skills happens during adolescence, and it happens irregularly and quite late in many kids." There is a huge difference, cognitive therapists say, between a high school junior who is emotionally scarred by mediocre SAT scores and one who can feel the same devastation but manage to say, after some work with a therapist, "Well, I had a bad day."
      Another problems is that talk therapies typically involve extensive take-home work like keeping diaries, and teenagers already have plenty of homework. "They're usually referred to treatment by their parents or teacher and simply not motivated to do the therapy," said Dr. Mark A. Reinecke, the chief of the psychology division at Northwestern University and a co-author of the government-financed adolescent study. "And it's very clear from studies that you're not going to do well if you're not motivated."
      Whether they favor talk therapy or drugs, doctors and psychologists who treat teenagers every day welcome any debate or public discussion about adolescent depression. Child and adolescent psychiatrists are overbooked. Psychologists who specialize in teenage depression are in short supply, and at least half of teenagers with symptoms get no treatment at all, many studies show. "I think, over all, some good can come out of this discussion if it convinces more and more doctors to get kids into treatment," said Dr. Marvin H. Lipkowitz, chairman of psychiatry at the Maimonides Medical Center in Brooklyn, N.Y. "And I think it calls attention to the need for psychotherapy. For if you're going to treat a child with medication, you do better when combined with therapy. The bottom line is, you need to be meeting and talking with the child on a regular basis."

As Part of Settlement, Pfizer Pleads Guilty
Associated Press, 6/8/2004

BOSTON - Pfizer Inc. formally pleaded guilty Monday to charges that its Warner-Lambert subsidiary violated federal law by promoting non-approved uses for one of its drugs. As part of a settlement with the government, Pfizer agreed last month to plead guilty to two counts of violating the Food, Drug and Cosmetic Act and to pay $430 million in fines -- the second-largest criminal fine ever imposed in a health care fraud prosecution, according to the Justice Department.
     Pfizer acknowledged that Warner-Lambert, a company it bought in 2000, spent hundreds of thousands of dollars promoting off-label uses for the antiseizure drug Neurontin. Martin Teicher, vice president of Warner-Lambert Co. LLC, entered the guilty plea on behalf of the company. James P Rouhandeh, an attorney for the company, noted that Teicher had no involvement in any of the illegal marketing activities.
     Whistleblower David Franklin, the scientist who reported the marketing abuses to authorities, will receive $26.6 million as part of the settlement.
     Pfizer has repeatedly said the activity alleged in Franklin's lawsuit and charged by prosecutors occurred years before it bought Warner-Lambert in 2000. The case began in 1996, when Franklin filed a whistleblower lawsuit against Parke-Davis and its parent company, Warner-Lambert, alleging it used an illegal marketing plan to drive up sales of Neurontin in the 1990s. At the time, Neurontin was approved only as an epilepsy drug, but 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 "offlabel uses" is prohibited by the Food, Drug and Cosmetic Act. Franklin's lawsuit alleged that the company's publicity plan for Neurontin included paying doctors to put their names on ghostwritten articles about Neurontin and flying physicians to lavish resorts.