When Aaron, a 33-year-old writer from New York, decided to get help for his five-year addiction to painkillers, there was really only one option. Every morning, he visited a local clinic for a small cup of methadone, the standard treatment for addiction to heroin and other opiates since the 1960's. But his life soon revolved around the clinic's hours, he said, and the daily routine was humiliating.
"I had to stand in line with a bunch of people who were talking about getting high," and take a urine test for illicit drugs each week, said Aaron, who spoke on the condition that his last name be withheld.
      Then, a year and a half ago, a quiet scientific advance gave Aaron -- and 60,000 other Americans -- a chance to break their dependence on drugs without shame. Buprenorphine, made by Reckitt Benckiser and sold under the brand name Suboxone, became the first prescription medication for people addicted to heroin or painkillers. The small orange tablet is available by prescription at any neighborhood pharmacy. It relieves symptoms of opiate withdrawal like agitation, nausea and insomnia.
      But unlike methadone, buprenorphine (pronounced byoo-pre-NOR-feen) is only weakly addictive, and is thus less tightly regulated. Above a certain dosage, more will not produce a high, so it has a far lower risk of overdose than methadone. And once a patient has taken a pill, the effects last for about three days, greatly decreasing the chance of a relapse.
      Serious drug addiction is a problem that afflicts more than 10 million Americans. The grip of hard-core drugs like heroin and cocaine is notoriously stubborn, and relapse rates are staggering. Rehabilitation programs have only limited success. Dropout rates are high, and even many addicts who do stay in rehab slide back into using drugs periodically. But buprenorphine is the first of a new generation of prescription drugs that is changing the landscape of addiction treatment, providing new hope and moving addiction from clinics and rehab centers, long seen as magnets for junkies, pushers and gloom, into the comfort of the doctor's office.
      In laboratories around the country, researchers are creating prescription medications to alleviate craving or blunt euphoria, and working on vaccines that can prevent people from getting high by mopping up a drug in the bloodstream. In some cases, the research is already bearing fruit: Campral, a new prescription drug to block cravings for alcohol, was approved by the Food and Drug Administration last week. Other medications are likely to enter the market within a few years.
      At some point, experts say, the new treatments will allow addiction to be viewed -- and treated -- like any other chronic, relapsing disease. "There has been a revolution in the way we view addiction," said Dr. Charles A. Dackis, chief of psychiatry at the University of Pennsylvania Medical Center-Presbyterian. "It's being seen now as a disease of the reward centers of the brain, much like pneumonia is seen as a disease of the lungs."
      The new treatments arrive as scientists are beginning to unravel the underlying neurobiology of drug dependence. Researchers have known for some time that all substances of abuse, including nicotine, alcohol, cocaine, marijuana and heroin, activate the same pleasure pathway in the brain. But they are now finding that many drugs cause subtle changes in brain activity that remain for weeks, months or years. Such alterations, studies have found, help unleash the cravings that can plunge recovered users back into the throes of addiction long after their last puff or snort. "We now know the changes these drugs cause in the brain at the molecular level that lead to addiction," said Dr. Eric J. Nestler, chairman of the department of psychiatry at the University of Texas Southwestern medical center. "Because of imaging studies we know where to focus, and that's a brand new advance."
      Although experts acknowledge that drug abuse begins as a voluntary behavior, many argue that at some point a perilous line is crossed. Brain cells that are repeatedly assaulted by addictive drugs change shape. The brain's reward pathway -- the same, primitive system that by evolutionary design makes basic drives like sex and eating pleasurable -- is hijacked. The urge to get high is insatiable. In experiments, lab animals will press a lever for cocaine until it kills them.
      Each drug manipulates the reward circuitry in a different way, but in brain scans every drug lights up a link in the neural pathway called the nucleus accumbens, the universal site of addiction. After repeated bombardment by drugs, the system loses sensitivity to more natural rewards. "These drugs stimulate the reward circuitry so acutely that over time they disrupt it," said Dr. Dackis, adding that addiction is so lethal because it tricks the brain into acting as if the drugs were necessary for survival.
     Over the years, chemical substitutes that mimic addictive drugs, activating the reward circuitry and reducing cravings, have had the most success in treating addiction. Methadone, a reddish liquid first used as a maintenance treatment for heroin addicts in 1964, has long been considered the gold standard. Chemically, it is not so different from heroin. It binds to the same receptors, gradually stimulating them. Patients say they experience a warm glow, though not the euphoric daze of heroin, the feeling of being wrapped in God's warmest blanket.
      In its time, methadone was considered a breakthrough: It got people off heroin, reduced fatal overdoses and slowed the spread of infectious diseases through dirty needles. But it became clear that methadone had its own problems. Like heroin, it was strongly addictive. It was classified by the Drug Enforcement Administration as a Schedule 2 drug, in the same category as cocaine and PCP. And by law, it had to be distributed by special clinics that were so bathed in stigma that several states banned them. Former Mayor Rudolph W. Giuliani of New York declared five years ago, when he was in office, that methadone programs encouraged people to trade one addiction for another, and should be shut down.
      Between 180,000 and 200,000 Americans are on methadone, said Dr. David M. McDowell, director of a program at Columbia University that helps people make the transition from methadone to buprenorphine, then refers them to other doctors for private care. In New York, 36,000 people are on methadone. "The most stigmatized thing in this world is methadone," said Dr. Edwin A. Salsitz, director of Beth Israel Medical Center's methadone program in New York. "There is nothing people try to hide more than being on methadone. They don't want to be seen going into a clinic. They won't tell anyone they're taking it."
      Methadone's limitations prompted experts to look for medications that were less likely to place recovering addicts in a stranglehold. What they found was buprenorphine. Like methadone, it is a chemical substitute for heroin. But it activates receptors so weakly that it has a better safety profile and many users can be slowly weaned from it, leaving them drug-free. "Buprenorphine is the most important advance certainly in heroin and opiate treatment if not all addiction treatments in the last 30 years," said Dr. Alan I. Leshner, a former director of the National Institutes of Drug Abuse.
      n the brain, buprenorphine pries heroin from opiate receptors, binds tightly for two or three days, then produces just enough stimulation to relieve withdrawal symptoms. It is not perfect by any means. One drawback is that for some longtime heroin users, its effects are too weak, and methadone ends up as their only alternative. But for those who can take it, buprenorphine's effects last longer than methadone's, experts say, which drives the likelihood of relapse down sharply. "If you get stressed out and decide you want to get high, you can go see your dealer but you're wasting your money because there's that three-day safety cushion where buprenorphine is blocking the receptors," Dr. McDowell said.
      Last year, only 5 out of 43 patients at Dr. McDowell's center had relapsed after their first six months on buprenorphine, an 88 percent success rate; on methadone, treatment programs for most forms of drug addiction have less than a 50 percent success rate after six months, he said. In France, where buprenorphine has been on the market less than 10 years, fatal overdoses from heroin and other opiates have fallen almost 80 percent. "In the field of addiction treatment, those figures are just unbelievable," he said.
      Doctors in the United States wrote 80,000 prescriptions for buprenorphine in 2003, a number that is expected to soar in the coming years. Lured by the prospect of privacy, many heroin and opiate abusers are seeking help for the first time. Others are switching from methadone. Dr. Chadd A. Herrmann, a psychiatrist in Manhattan, said he has received about 20 telephone calls in the last three weeks from people looking for buprenorphine. He had to turn them away, he said, because he was still awaiting authorization to prescribe it. In New York, doctors who want to prescribe buprenorphine are required to take an eight-hour training course and then receive approval from the state. Dr. Herrmann, whose practice is on Fifth Avenue, said many of the people who called did so "because of my address." He added, "They make it really clear that they don't want to be in a program or clinic in some other part of the city."
      Perhaps buprenorphine's biggest draw, said Roberta P. Sales, a nurse coordinator at the Columbia program, is that it frees addicts from the methadone clinic. With a prescription, they can get a month's supply of the medication at the pharmacy. The cost is about $5 to $10 a day. "How can you possibly work or go to school when the primary focus of your day is going to a methadone program?" she said. "With buprenorphine, I've had patients literally break down and cry because they can travel to another state and see their family for the first time in years."
      For all its promise, buprenorphine, whose use is confined to opiates, will help only a fraction of the Americans who abuse drugs. Researchers say their focus now is on finding new treatments for a wide variety of drugs. They hope to find medications that are not simply chemical substitutes but eliminate dependence altogether. In some laboratories, researchers are working on developing medications that do away with the cravings that make abstinence from any drug a struggle. "It's never as simple as just washing the drug out of your body," said Dr. Anna Rose Childress, a research associate professor of psychology at the University of Pennsylvania medical school.
      The shift toward treating cravings came largely from imaging studies. Researchers found that when a recovering addict was shown slight cues or reminders of an old drug habit -- an antidrug advertisement, for example, a cigarette or a syringe -- it set off intense activity in the brain's reward circuitry, and produced an urge to relapse. "Often, this is what pulls people back in," Dr. Dackis said.
      Campral, the anticraving medication, made by Merck and approved for alcoholism by the F.D.A. last week, appears to dampen that response by elevating levels of GABA, the brain's major inhibitory neurotransmitter. Dr. Childress believes that GABA helps rein in the reward circuitry that drives people to seek drugs and other pleasurable experiences. Campral has been used in Europe for several years.
      At least two other drugs that increase GABA, topiramate and baclofen, seem to curb cravings for cocaine, heroin, cigarettes and alcohol. Dr. Childress, who is involved in clinical trials of baclofen for cocaine, said the medications may even help conquer compulsive behaviors like pathological gambling and sexual compulsion. Scientists have also found that the prescription medication modafinil, used for sleep disorders, can blunt the euphoria of cocaine.
      Still other scientists are trying to solve two problems common among substance abusers: They often forget to take their medications, and even those who stay in recovery end up "slipping" periodically. Vaccines, some researchers believe, may provide answers to these problems. At Yale and Columbia, for example, researchers are testing a vaccine that uses molecules of cocaine bound to harmless pathogens. When the vaccine is injected into the body, the immune system responds by producing antibodies to the cocaine and to the pathogen it is paired with. After a handful of immunizations over the course of three months, the user has enough antibodies to prevent at least three times the typical dose of cocaine from reaching the brain. "The people that make significant amounts of antibodies say that cocaine isn't what it used to be, and the people who make the highest levels of antibodies stop using it altogether," said Dr. Thomas Kosten, a professor of psychiatry and medicine at the Yale medical school. In Australia, scientists are experimenting with a similar vaccine that blocks nicotine.
      It may be years, experts concede, before the promise of vaccines, anticraving drugs and other new treatments can be fully realized. And if the prospect of a world without drug addiction seems too good to be true, it just might be. None of the drugs is a magic bullet. Psychotherapy will still be needed to help addicts repair frayed relationships and overcome psychological dependence. Moreover, an addict who is determined to get high, experts say, can counteract even the most effective medication -- by not taking it. "In the drug abuse field you have to be humble," said Dr. Margaret Haney, a researcher at the New York State Psychiatric Institute who is involved in clinical trials of the cocaine vaccine. "There is nothing that is going to work for everyone, but we're just hoping to increase the odds that someone will be able to stay clean and have just enough time to get their lives back in order."

Queens Home for Mentally Ill Settles Lawsuit for $7 Million
Clifford Levy, New York Times- 8/5/2004

Six years ago, 24 mentally ill residents of a Queens adult home were coerced into having prostate surgery in a medical scheme that generated tens of thousands of dollars in government fees and proved emblematic of New York's troubled system of adult homes. No one was ever held criminally responsible, but yesterday, lawyers announced that most of the men would receive a total of nearly $7.4 million in a settlement with the adult home, as well as a hospital and two doctors, of a lawsuit over the surgery.
     The settlement is a milestone in the system's decades-old history, representing one of the few times that mentally ill residents of the adult homes have been compensated for being mistreated. Seventeen men took part in the case -- the others declined to do so -- and each is to receive $432,653.
      The lawsuit, which was filed in 2001, drew an unusual degree of attention to the adult home system, which shelters 15,000 mentally ill people in New York yet had until then received little scrutiny by government or the news media. The case eventually helped spur Albany to make its first serious efforts at overhauling and more closely supervising the system. The settlement resolves a federal lawsuit brought against the 361-bed Leben Home for Adults, a notorious facility in Elmhurst that like many adult homes, has long been something of a dumping ground for people discharged from psychiatric wards. Also agreeing to the settlement were Leben's former operator, Jacob Rubin; two urologists involved in the surgery; and Parkway Hospital in Forest Hills, where the surgery took place. As is customary in such settlements, the defendants did not acknowledge wrongdoing.
      "This lawsuit, which became a catalyst for adult home reform, is important because it illustrates how individuals without a voice and little power can assert their rights and obtain positive changes in their lives in the face of daunting obstacles," said Jeanette Zelhof, managing lawyer for MFY Legal Services, a nonprofit legal group. Ms. Zelhof brought the lawsuit along with Timothy Clune of Disability Advocates, another nonprofit group, and Lisa E. Cleary of the law firm of Patterson, Belknap, Webb & Tyler, which handled the case pro bono. The lawyers have set up trust accounts for the men to ensure that the money is properly spent. Three of the 17 have died since the suit was filed, and their estates are to receive the money.
      The 24 Leben residents, who were generally so ill with schizophrenia that they had little understanding of what was happening to them, were herded into ambulettes outside Leben in early 1998 and driven to Parkway Hospital. Unsupervised and confused, some wandered the hospital and had to be calmed by guards and nurses before the surgery, according to a state inquiry.
      The State Health Department eventually revoked the license of one urologist who had arranged for the surgery, suspended the license of another who conducted it, and fined Parkway. The state inquiry determined that the Leben residents had endured "assembly-line techniques to mass-produce surgery," and that the procedures generated tens of thousands of dollars in Medicaid and Medicare fees.
      At first, the department did not remove Leben's operator, Mr. Rubin, prompting advocates for residents to criticize what they said was lax regulation typical of the state's oversight of the homes. Mr. Rubin had long had a poor inspection record. At one point, officials ordered the evacuation of Leben's first floor after finding badly damaged walls and ceilings, vermin infestation and soiled linen. Many of the residents were filthy. Only after the lawsuit was filed on behalf of the residents who had the prostate surgery did the Health Department move to revoke Mr. Rubin's license. The home is now called Queens Adult Care, and is run by an operator who is well regarded. Marcy Sheinwold, a lawyer who represented Mr. Rubin and Leben in the lawsuit, did not respond to two messages seeking comment yesterday.
      The case is not over. A group of defendants connected to Americare, a home-health agency that had workers at Leben, has declined to settle. The award for the Leben residents comes as the case against another adult home that has long had a checkered record, the 125-bed Ocean House in Far Rockaway, Queens, has also concluded. Last month, Ocean House's operator, Sherman Taub, and his son, Judah Taub, pleaded guilty in State Supreme Court to engaging in a mortgage fraud scheme to steal more than $2 million from the home. Sherman Taub faces a prison term of one to three years, while Judah Taub is to receive three years of probation, officials said. Sherman Taub was accused of taking control of Ocean House, which is nominally nonprofit, and making it heavily indebted to a mortgage company that he owned.

Survey: NH, Vermont Have Highest Drug Rates
Associated Press, 8/6/2004

New Hampshire and Vermont have among the highest rates of drug use in the nation -- according to responses the states' residents gave on a federal survey. They led much larger states in the 2002 survey by the Substance Abuse and Mental Health Administration, which surveyed 68,000 people nationally.
      Health officials in both states said they weren't surprised. ``What we are seeing is an enabling environment particularly for young people. There is a presumption that marijuana is not harmful,'' said Vermont Health Commissioner Paul Jarris. He said the most common reason people between 12 and 18 age seek drug treatment is for marijuana abuse. ``We are seeing kids lives ruined.'' Alice Bruning, chief of Prevention Services for New Hampshire's Department of Health and Human Services, said the drug's easy availability, combined with a low perception of its risks, have established an environment of tolerance in New England when it comes to marijuana. ``You have a lot of local supply. It's easy to grow in the kind of rural forested communities that we have,'' Bruning said. ``We don't have that general attitude that we don't want people to smoke marijuana ... (but) if we asked someone in the street, 'do you think it's OK for kids to shoot heroin?' They'd say, 'Are you crazy?'''
      The survey, released earlier this week puts both states in rare company. New Hampshire and Vermont rank in the top 20 percent of states with the highest frequency of drug use by people age 12 and over. And only five other states -- Colorado, Delaware, Massachusetts, Montana and South Dakota -- join New Hampshire and Vermont as having the highest rates for marijuana use and use of other drugs among residents aged 12 to 17. The survey estimated drug use rates for nine substances: marijuana, cocaine, heroin, hallucinogens, inhalants, non-medical use of prescription pain relievers, tranquilizers, stimulants and sedatives.
      Bruning said demographics play a big role in Northern New England's high drug use rates, where Maine, New Hampshire and Vermont rank in the top fifth of states with the most first-time marijuana users between the ages of 18 and 25. In the same age group, the survey reported 30 percent of New Hampshire residents, 29 percent of Vermont residents and 23 percent of Maine residents used marijuana in the month before the survey, compared to less than 7 percent nationwide.
      Bruning linked marijuana use to binge drinking, which studies show to be highest at small, private colleges in the Northeast -- campuses full of well-off students with the time and the freedom to do what they want. ``It looks as if it's the same kind of population that's binge drinking,'' she said. ``More and more students are coming to college with either their behaviors already well under way or their expectations for what they're going to have at college well under way.''
      But so-called ``soft drugs'' like marijuana are not the only problem for largely white, middle-class New Hampshire and Vermont. Heroin use is up in both states. Jarris said Colombian drug dealers, operating through gangs in Massachusetts, were specifically targeting Vermont, New Hampshire and Maine. And Vermont is one of 14 states that does not monitor prescription drugs that can be diverted to illegal use. When police crack down on one drug, such as heroin, illegal use of drugs like Oxycontin will increase, Jarris said. He said Vermont officials were working to educate people not to use illegal drugs, to treat people with drug problems and to crack down on the drug trade. ``We've had an environment where we have often chosen to believe this is an out-of-state problem,'' Jarris said. ``We have years of work to do to.''

Tennessee Struggles to Curb Methamphetamine Use
Kimberly Brown, Boston Globe- 8/7/2004

COOKEVILLE, Tenn. -- The last time Norma Barney got high was the same spring day last year when her children were taken from her, whisked out of school by the state and placed in foster care. "In one day, I lost my kids, I lost my home, I lost my husband," said Barney, now 31, whose husband is behind bars for cooking the methamphetamine they had both sold. "A complete stranger had my kids. It about killed me." Barney entered rehab. She found a job, went to Narcotics Anonymous meetings, and for the first time in her life, earns a paycheck and is off public assistance. "I finally did something with myself," she said. Hers is a rare success story, the case of a methamphetamine addict who beat the overwhelming odds of a 95 percent relapse rate. Now, 15 months clean, she represents a glimmer of hope in a struggle that is as much hers as it is Tennessee's.
      For the past few years, this state has been scrambling to figure out how to beat an epidemic of methamphetamine use considered by some measures to be the nation's worst. In the last fiscal year, federal authorities cleaned up 1,147 clandestine labs statewide and are poised to far surpass that total this year, officials say. Methamphetamine abuse is taxing police resources, courts, jails, and hospitals.
      But officials say the drug's impact is most devastating for the state's foster care rolls. In an 18-month period that ended July 2003, the Tennessee Department of Children's Services placed more than 700 children in foster care after they were abused or neglected by parents using methamphetamine. The issue costs the state an estimated $4 million for care of children in its custody, the department says. "These are the innocent victims," said Betsy Dunn, a caseworker who removed Barney's children from their home near Cookeville, midway between Nashville and Knoxville, in a part of the state hit hardest by methamphetamine. "I'm talking to young children that can make meth, children that are the primary caretakers of their younger siblings," Dunn said. "I've never seen anything like it. It's just horrific. I call it the devil drug." Captain Nathan Honeycutt, a 27-year police veteran, said he, too, has never seen anything like it. "Most of us in this profession," he said, "believe it will get worse before it gets better."
      Methamphetamine -- known as speed, crystal, and ice -- became popular during World War II, used by soldiers to stave off fatigue and hunger, and among California biker gangs in the 1950s and '60s. Use of the drug slowly spread to other parts of the country. Some states, particularly in the Northeast, have seen little methamphetamine use. Only one lab was raided in Massachusetts in 2003, according to federal officials.
      In Tennessee, Drug Enforcement Administration officials trace much of the speed epidemic to men with California ties who moved to the state in the mid-1990s and began showing others how to cook the drug on kitchen stoves or practically anywhere. Made from easily available raw materials and the essential ingredient, pseudoephedrine -- often extracted from common cold and allergy drugs like Sudafed -- methamphetamine grew in popularity as the "poor man's cocaine" or modern-day moonshine.
      When methamphetamine soared in popularity in the early '90s, many mistook it for a short-lived fad. Instead, it grabbed hold and has not let go. "It's a neurotransmitter," said Dr. Sullivan Smith, who runs the emergency room in Cookeville, is the county medical examiner and also is trained by the DEA to dismantle methamphetamine labs. "It dumps dopamine into your brain," he said. "You are Superman, you are Wonder Woman, you can do anything. It doesn't matter what happens; it's all wonderful."
      But the drug damages the brain's ability to achieve pleasure normally, and users become desperate to renew those feelings. Often addicts stay awake for days, turning to crime to pay for drugs and neglecting their children. And, Smith said, the paranoia most addicts suffer allows for little normalcy in the children's lives. "It's an abusive environment," he said. For children found playing or crawling on the floors of squalid homes that have highly flammable drug labs, where contaminants seep into walls and settle in carpets, "We just don't know the long-term effects," Smith said.
      In Cookeville, a quiet, low-rise city of almost 27,000 people and the closest thing to an urban center for the 14-county, rural Upper Cumberland region, the drug has touched many people. And many are trying to fight it. The Putnam County sheriff, David Andrews, pledged to attack the problem in 2002, and his officers have closed about 100 labs in the county, which has 70,000 people. A federal grant is paying for a full-time county methamphetamine prevention officer. The district attorney, Bill Gibson, won a federal grant to dedicate a prosecutor to methamphetamine crimes and to mount an aggressive education effort.
      Last year Cookeville also became the state's first municipality to regulate the sale of over-the-counter medicines containing pseudoephedrine and ephedrine, requiring shoppers to show identification and sign for purchases. "If you don't have any pseudoephedrine, you can't make methamphetamine," Mayor Charles Womack said, although the pills are available without regulation in neighboring communities. Retailers had successfully fought against a bill in Nashville to require similar regulation statewide, officials said.
      In fact, about 30 bills related to the methamphetamine problem were introduced this year. But state legislators, overwhelmed by the magnitude of the problem and doubting a piecemeal approach, enacted two laws and asked Governor Phil Bredesen to appoint a task force. One of the new laws increased the penalties for possession and distribution of methamphetamine to equal those for cocaine-related offenses. The other gave police the power to quarantine homes, offices, or hotel rooms used as methamphetamine labs. The governor's task force is expected to issue recommendations in September. But Smith, a member of the task force, warned there will be no silver bullet. "You have to have meaningful sentences for meaningful crimes," he said. "And I think addicts need help; they need treatment. And we need awareness."
      Now that Barney has her children back, they are living together in a home with a big backyard, a hamster named Minnie, two birds, a cat, and a fish tank. "My kids never really had pets because I was too messed up," Barney said. "They didn't get to play for years of their life. . . . They didn't get to be kids." "You can see it in their eyes, how hurt they were," she said. "It's always in the back of their minds now: 'What if Mama gets high today?' "

1 in 7 Have Personality Disorder
Kathleen Doheny, Detroit News- 8/7/2004

NEW YORK -- Personality disorders are much more common in the United States than researchers had thought, affecting nearly one in seven adult Americans, a new survey finds. Researchers say that 31 million people, or 15 percent of the adult population, suffer from at least one type of personality disorder.
      About 43,000 adults were interviewed for the survey, said lead author Bridget Grant. The study appears in the July issue of the Journal of Clinical Psychiatry. Grant is chief of the Laboratory of Epidemiology and Biometry at the National Institute on Alcohol Abuse and Alcoholism.
      Most common was obsessive-compulsive disorder, suffered by 16.4 million -- nearly 8 percent -- of adults. "The person is totally preoccupied with rules, schedules, the need to have perfectionism," Grant said. More than 9 million, or 4.4 percent, have a paranoid personality disorder -- a distrust and suspicion of others, she said. Nearly 8 million -- 3.6 percent -- have antisocial personality disorder. These people "constantly break the law, hurt other people," Grant said. And 6.5 million -- 3.1 percent -- have schizoid personality disorder, in which a person detaches from social relationships and has a restricted range of emotional expression. Nearly 5 million -- 2.4 percent -- have avoidant personality disorder. "This person is very socially inhibited," Grant said. "They feel inadequate as people." About 4 million -- 1.8 percent -- have histrionic personality disorder, marked by excessive expression of emotions and the seeking of excessive attention. Another 1 million -- 0.5 percent -- have dependent personality disorder, marked by clingy behavior and the need to be taken care of excessively. Because some people have more than one personality disorder, the numbers total more than the 30 million, the number affected by at least one such disorder.
      The survey is part of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, which helps physicians diagnose conditions. "We interviewed face-to-face over 43,000 adult Americans" who were "a representative sample of the U.S.," Grant said. Grant's team asked a series of questions, then analyzed the answers to see whether the information pointed to a personality disorder.

Divorced Parents Move, and Custody Gets Trickier
Leslie Eaton, New York Times- 8/8/2004

Not too long ago, Jacqueline Scott Sheid was a pretty typical Upper East Side mother. Divorced and with a young daughter, she had quickly remarried, borne a son, and interrupted her career to stay home with the children while her husband, Xavier Sheid, worked on Wall Street. Early last year, Mr. Sheid lost his job and saw his only career opportunity in California. But Ms. Sheid's ex-husband, who shares joint legal custody of their daughter, refused to allow the girl to move away. So Ms. Sheid has spent much of the last year using JetBlue to shuttle between her son and husband on the West Coast and her daughter (and ex) on the East. The New York court system, which she hoped would help her family to resolve the problem, has cost her tens of thousands of dollars in fees for court-appointed experts, she said, and has helped to prolong the process by objecting to her choice of lawyers. Worst, she added, "they are making me choose between my children."
      Ms. Sheid is caught up in what legal experts and social scientists say may be the most contentious and fastest-growing kind of custody litigation in the country today: relocation cases. Also known as move-aways, these involve a parent who wants to move with a child over the other parent's objections. More fathers, who play a larger role in their children's daily lives than in earlier decades, are refusing to allow their children to move out of town, forcing mothers - who about 80 percent of the time have physical custody of children -- to remain in the same city. And more mothers are fighting back.
      Spurred by such changes in society, in the law and in the economy, relocation cases are roiling families, and courtrooms, from California to Colorado to Connecticut. Relocation "is the hottest issue in the divorce courts at the moment," said Judith S. Wallerstein, a leading expert on divorce from Marin County, Calif., who favors the rights of mothers to move. Though there are no reliable statistics on these cases, the highest courts in at least seven states have tackled relocations in the last three years, and lawyers say they represent just the tip of the litigation iceberg.
      "We tell people, the best parent is both parents, and it's hard to be a long-distance parent," said David L. Levy, president of the Children's Rights Council, a longtime advocate for fathers' rights and joint custody. "There are 15 million noncustodial fathers in this country, and 3 million noncustodial mothers. They shouldn't be marginalized."
      As fathers' rights groups have organized around the country, judges and legislators have become more sensitive to the heartbreak of parents separated from their children. But now mothers with physical custody say they feel trapped in untenable situations, especially since alimony has become uncommon and the economy remains rocky in many regions. Judges say that they find all custody cases difficult, but for many, relocations can be the toughest and most time-consuming. When warring parents live far apart, it is hard to come up with a plan that allows them to share the child. "It's much more difficult to come up with a Solomon-like decision," said Sharon S. Townsend, a longtime family court judge who is now the state administrative judge in western New York. And the task has only become more difficult since 9/11, she said, as parents have become more reluctant to let children travel alone.
      The United States remains a highly mobile society; a 2000 Census Bureau survey found that in a 12-month period, 43.4 million people changed residences. Americans have become more likely to move longer distances, the survey found, and divorced people are far more likely to move than those who are married.
      Ultimately, relocation cases usually come down to "the best interests of the child," but there is little agreement about what that means. In many states, including New York, judges have a laundry list of factors to consider, but no clear way to weigh their importance. Although the laws differ in each state, judges hearing such cases usually begin in a traditional way, weighing whether one parent is more fit than the other. But then they have to assess the motives for the proposed moves and for the objections. Does the parent who wants to move have a compelling reason, or is she just trying to keep the child away from the father? Does the parent who opposes the move really want to be involved with the child, or is he just trying to control his ex-wife?
      Complicating matters, lawyers say, judges technically do not have jurisdiction over the parents' right to move, only over the relocation of the children. Practically, though, judges know they can often stop a move by threatening to give the other parent custody. (Noncustodial parents can move without dealing with the court at all.)
      The legal and moral difficulty of such cases was made clear in April in a case decided by the California Supreme Court involving the two sons of Gary LaMusga (pronounced LA-moo-shay) and Susan Poston Navarro, who divorced in 1996. Ms. Navarro, who had primary physical custody of the boys, remarried and had another child. In 2001, she asked the court for permission to move to Cleveland, where her husband had gotten a better job. Mr. LaMusga objected, saying that she was trying to alienate the boys from him, and asked for primary custody if she moved. After the State Supreme Court agreed to hear the case, the amicus briefs poured in from representatives of women's groups, Legal Aid lawyers, law school deans, and mental health professionals.
      But the crux of the debate over the best interests of children was summed up in two papers filed by researchers. One, favoring the right to move, was written by Dr. Wallerstein, the founder of the Center for the Family in Transition, who is known for her studies on the long-term effects of divorce. She argued that the most important things for children after divorce were that their relationship with their custodial parent was protected and that their wishes were heard.
      An opposing brief was written by Richard A. Warshak, a Dallas psychologist whose most recent book is "Divorce Poison: Protecting the Parent-Child Bond From a Vindictive Ex" (Regan Books, 2003). Dr. Warshak wrote that Dr. Wallerstein had ignored research showing that children do better when both parents are involved in their day-to-day lives, something that cannot be accomplished through summer or holiday visits. As Dr. Warshak said in a telephone interview, "If it weren't a problem to live apart from your children, then it wouldn't be a problem for a mother to leave a child behind."
      But Dr. Wallerstein said in an interview that she agrees that in the best of circumstances, children do best with both parents. "That sounds like a very good argument for marriage," she said dryly. "The issue is, the people who come to court are not cooperative parents."
      In a ruling that is expected to influence courts around the country, the California Supreme Court ruled against Ms. Navarro. It decided that the parent with physical custody has the right to choose the child's residence, unless the other parent can show some detriment to the child. At that point, a judge has to undertake a "best interests" custody inquiry.
      The ramifications of the decision are a matter of debate, even among those closely involved. "We won't know until the next five years," said Philip M. Stahl, who was the court-appointed psychological evaluator. While he hopes courts will follow a best-interest standard in which no factor is automatically most important, he said, "The difficulty will be if people view this change as, 'We have to keep parents in the same community.' " Kim M. Robinson, Ms. Navarro's lawyer, said her client was considering asking the United States Supreme Court to review whether the decision violates her constitutional right to travel. And the California Senate is planning to hold a hearing later this month on legislation that would permit moves under most circumstances.
      The next relocation battleground may be Colorado, where in 2001 the legislature abolished a legal presumption that custodial parents have the right to move. Now the State Court of Appeals has ruled that the parent who wants to move must show a direct benefit to the child, not just an indirect one like a job opportunity for a parent. Some legal commentators have contended that this places an insurmountable barrier to moves.
      The case involves Michelle A. Ciesluk and Christopher J. Ciesluk, who were divorced in 2002. Their son, Connor, now 7, lives primarily with his mother in Parker, Colo. In early 2003, Ms. Ciesluk lost her job when Sprint reduced its work force; the company offered to rehire her, she said, but only if she moved to Arizona. In Denver, she has not been able to find a job with benefits, she said in a telephone interview, and is working for $10 an hour as an administrative assistant. "How hard is it? Oh, honey," Ms. Ciesluk said. "Very, very hard. The money thing, worrying about where my next meal will come from, worrying about Connor. My whole life is on hold."
      Mr. Ciesluk declined to be interviewed, his lawyer said, and referred a reporter to his legal briefs. That filing said Mr. Ciesluk opposes the move because "he does not want to lose the relationship he presently has" with his son, and would not be able to attend the boy's athletic and school activities. He added that Mr. Ciesluk is "aware of the difficulties in maintaining a close relationship from a distance." Ms. Ciesluk is planning to appeal the decision barring her move with Connor, said her lawyer, Anne Whalen Gill.
      As states like Colorado increasingly turn to "best interest" analyses, they may find that there are some drawbacks to what is essentially a subjective approach, including the likelihood of more litigation, uncertainty for families and increased costs and delays. In New York, which has been a "best interests" state since a 1996 decision called Tropea v. Tropea, judicial decisions about relocations are all over the map. This year alone, judges have decided at least two dozen cases involving relocation. While most moves have been refused, a small number were approved. "It doesn't give lawyers a lot of ability to predict what will happen," said Barbara Ellen Handschu, the incoming president of the American Academy of Matrimonial Lawyers and an expert in New York on relocations.
      Ms. Sheid, the Upper East Side mother, who spoke to a reporter on the condition that her children's names not appear in print, has little good to say about her experience in court. She was belittled by the judge, she said, and stereotyped by the court-appointed experts, who portrayed her husband as a greedy, selfish Wall Street tycoon and her as a wimpy little woman. She said they ignored her husband's financial obligations, which include the support of his teenage daughter and elderly parents. The court-appointed lawyer and psychologist both declined to comment, as did Ms. Sheid's former spouse. Like most parents in relocation cases, Ms. Sheid finally decided to try to settle with her former husband, who lives in the Connecticut suburbs. At this point, her main goal is to make sure her daughter, now 8, can continue to attend her New York City school. Moving her to California seems out of the question. "I'm hoping maybe the only thing a parent in my position can hope for," Ms. Sheid said, her voice trailing off, "that maybe when she's older "

For Psychotherapy's Claims, Skeptics Demand Proof
Benedict Carey, New York Times- 8/10/2004

Good therapists usually work to resolve conflicts, not inflame them. But there is a civil war going on in psychology, and not everyone is in the mood for healing. On one side are experts who argue that what therapists do in their consulting rooms should be backed by scientific studies proving its worth. On the other are those who say that the push for this evidence threatens the very things that make psychotherapy work in the first place.
      Which side prevails may shape not only how young therapists are trained and what techniques practitioners use in the future, but also how tightly health insurers restrict the therapies they are willing to pay for, and thus how much the estimated 20 million Americans who enter psychotherapy each year have to pay out of their own pockets. Ultimately, some experts say, the survival of one-on-one counseling, or talk therapy, as an accepted mode of treatment for mental disorders may hang in the balance.
      The issue of which therapies are based on science and which are not has recently become so divisive that the incoming president of the American Psychological Association, Dr. Ronald Levant of Nova Southeastern University in Fort Lauderdale, Fla., said in a telephone interview that he had already assembled a task force to address the controversy, and to find some common ground on which to anchor future practice.
      The topic was debated before a raucous, packed hall at the annual meetings of the American Psychological Association in Honolulu, held July 28 to Aug. 1. The association, with more than 150,000 members, is the largest professional association of psychologists. "The split in the field is bigger than it ever has ever been," said Dr. Drew Westen, a professor of psychology, psychiatry and behavioral sciences at Emory University. "The intensity of the acrimony, the distaste, has never been so high."
      At bottom, the dispute is over the nature of psychotherapy: Is it an intuitive process, more art than science? Or is it more a matter of a therapist following specific procedures that reliably help people get better? Over the last decade, a group of academic researchers has argued for the instruction-manual approach, compiling a list of short-term therapies that studies show work for a variety of mental disorders. The techniques are standardized, easily described in manuals for therapists, and can quickly help people with phobias, panic attacks and other problems. They include cognitive therapy, in which people learn to refute pessimistic or degrading thoughts, and exposure therapy, in which they overcome anxieties by gradually learning to face the situations they fear.
      This evidence-based approach already has had a significant impact in the marketplace. Some managed care companies, including Magellan Health Services, the country's largest managed mental health insurer, base their coverage for psychotherapy on what the research says and expect their therapists to practice techniques that are backed by studies. Some companies also limit the number of sessions they will authorize for a given diagnosis based on the findings of research. And many insurers now require therapists, patients or both to document therapeutic progress, providing evidence that what is taking place in the consulting room is working.
      Dr. Jerome V. Vaccaro, a psychiatrist and the president of PacifiCare Behavioral Health, a large mental health insurer based in California, said his firm closely monitored how well each patient being seen by therapists in PacifiCare's system is doing. Patients fill out questionnaires at their first therapy session, and then after their fourth or fifth, he said. "If things are going well, there's improvement, fine, that's what we want to see," Dr. Vaccaro said. "If things aren't going well, or the person's getting worse after a few sessions, then we'll be calling the therapist to ask what they're doing." The idea, he said, "is to make you, the therapist, accountable for outcomes."
      Some of the country's top clinical psychology programs, like those at Indiana University and the University of Maryland, have a strong emphasis on evidence-based therapies. But in a field where practitioners are used to following their own instincts, this "show me" approach has stirred outrage. Some therapists say that the healing they offer in their offices every day is too complex to be captured in standard studies, and that having to justify it to a third party is a breach of patient privacy. They argue that to insist on proof that a therapy works denies many people adequate treatment, or the forms of treatment that they most need.
      One middle-aged woman, who entered therapy after her father died, was distraught when her insurer recently stopped coverage after 10 sessions, citing lack of evidence for more, said Dr. Patricia Dowds, the woman's therapist. No one tracks how many people have been dropped from therapy based on such arguments. But "every colleague I know has stories," Dr. Dowds said.
      Some therapists even worry they might be sued for not practicing techniques on the hard-evidence list, though experts say they know of no such cases so far. An article in the March 2002 newsletter of the California State Board of Psychology warned that therapists working with families "who use any procedures not validated by empirical research would do well to fear examination by an attorney knowledgeable of the research."
      Dr. Glen O. Gabbard, a psychiatrist and psychoanalyst who teaches therapeutic technique at the Baylor College of Medicine in Houston, said, "The move to worship at the altar of these scientific treatments has been destructive to patients in practice, because the methods tell you very little about how to treat the real and complex people who actually come in for therapy."
      For more than a century, the practice of psychotherapy rode on the shoulders of charismatic figures, from Freud and Jung to Fritz Perls, Carl Rogers and other luminaries of the so-called human potential movement. Primal scream and rebirthing therapies vied with more traditional approaches. The effectiveness of these methods was established not by studies but by the force of the therapist's personality, and testimonials of recovered patients.
      But in the late 1980's, the increasing use of drugs like Prozac and the arrival of managed care forced therapists to start justifying their methods with better evidence. In 1995, a group of leading psychologists published a report identifying what it called empirically validated therapies. They argued that these therapies had good track records and that clinicians should be aware of them and receive training in using them. An empirical grounding, many hoped, would also help re-establish the field's respectability and repair its image among insurers as a money sink. "When I started in practice as an intern, these therapies were just emerging," said Dr. Dianne Chambless, a professor of psychology at the University of Pennsylvania, who led the panel. "I used them on my clients, and they worked; it was a powerful thing to see."
      The champions of an empirical approach say that, despite skeptics' complaints, accountability has brought more credibility, and insurers and policy makers are gradually becoming more convinced that psychotherapy is a rigorous treatment, not indulgent and open-ended. The move to science, the empiricists assert, also has given the field a base from which to evaluate and discredit fringe therapies or those that promise instant healing. "It deeply frosts me, these people who are against measurement and evidence," said Dr. David Burns, a psychiatrist who trains residents at Stanford University School of Medicine. "It's a kind of narcissism in our field to say, 'I'm so great, I know what I'm doing,' and it puts us back 2,000 years to a time of cults, when every snake oil salesman's got something and the parade just goes on."
      Those who oppose the use of treatment manuals and lists of approved therapies respond in kind. "This entire approach to develop manuals and require practicing psychologists to use them is fundamentally insane," Dr. Levant said. So the arguments continue, and passions on either side, experts say, are not likely to cool any time soon. Recently, however, some researchers have been trying to find some accommodation between the two camps by focusing on what it is about any therapy that makes it effective, rather than holding one method above another. Studies suggest, for example, that factors like how motivated patients are, their readiness for change, the gifts of the therapist, and the strength of the bond between patient and therapist all make a difference in whether psychotherapy is successful.
      Ken Heideman, a 45-year-old meteorologist in Boston, said that his own experience in therapy illustrated this. Mr. Heideman has struggled with severe recurrent depression since college, he said, and over the years he has tried a variety of drugs and visited many therapists. But eventually, he found someone who helped free him from his disabling moods for the first time in his adult life. "I've been through a whole lot and I feel I can say that what ultimately is going to move someone toward healing and resolution, the most important factor, is the chemistry between client and therapist," he said. "It can be a psychiatrist, or someone with a degree in social work, and anywhere in between. What counts is whether there's that connection between the two people."
      Dr. Bruce E. Wampold, a professor in the counseling psychology department at the University of Wisconsin, has found that a therapist's competence may be the most critical variable, whatever the brand of therapy. Analyzing data from more than 12,000 people treated with a variety of evidence-based therapies, from cognitive to interpersonal techniques, mostly for depression, he found that the treatments worked equally well, regardless of the specific techniques. More important, Dr. Wampold said, was the individual therapist: some could help their patients improve significantly in eight sessions or so, others could not. "It's not what treatment you give that matters but how competently you give it, " he said.
      But even a gifted therapist can leave a patient cold. Like the tango, psychotherapy takes two, and chemistry is hard to predict or measure. Dr. Burns has tried to do it by conducting systematic surveys of the residents he trains at Stanford and the people these students treat. Most of the time, he said, the residents assume they are well liked. "At first it's very upsetting when they read these evaluations because about 100 percent of the time the clients don't actually like them," Dr. Burns said. "So perceptions of what is a good relationship can be really off base."
      Perhaps the only emerging consensus among experts is that research into psychotherapy should not rely solely on clinical trials, in which one group of people is given a treatment and then compared with other people who receive a placebo. Though well suited to testing drugs, this kind of study, said Dr. Westen of Emory, tends to impose artificial limits on psychotherapy: treatments are by necessity short; techniques are often standardized in manuals; and many participants are excluded because their problems are too complicated for a single diagnosis. The chaos of real life is blocked out.
      Dr. Chambless, Dr. Levant, Dr. Westen and others who have been strongly divided now argue that researchers should also follow patients treated in psychotherapy clinics out in the world, to see how well they do, and why. "The fact is that we're still in a state where we have very little knowledge, and the question is not what theory works, but what works for whom," said Dr. Larry E. Beutler, a professor of psychology at Pacific Graduate School of Psychology in Palo Alto, Calif.
      It would be nice, for example, if researchers could find a way to deconstruct why Mr. Heideman, the meteorologist, feels his therapy has been so successful. After four years in treatment, he is now able to express his anger once in a while, he says, adding that his therapist "has angered me, and challenged me and I just woke up; it was like the Big Bang for me." Mr. Heideman's therapy includes cognitive methods, like challenging his assumption that if he showed anger, some catastrophe would come about. The therapy, in short, is a blend of a good therapist match and evidence-based technique, of intuition and science. Mr. Heideman sees his success so far as the fulfillment of an article of faith that many who have suffered mental illness share: when you're ready to change, the right therapist will turn up.