Noteworthy News Articles on Mental Health Topics, November 1-9, 2005

Almost from the moment he walked into my office, something bothered me about my 18-year-old patient, Mark, sent to see me by his parents after they found marijuana and steroids in his bedroom. He was tall and muscular, with tousled, dirty-blonde hair, outfitted in a faded T-shirt emblazoned with the words "Sunset Strip," distressed jeans made to look threadbare at midthigh and along the edges of the pockets and a 70's retro leather choker with a few clay beads on it. A shiny silver bolt pierced his left brow. He shook my hand and introduced himself with a smile, then sat down in the suede armchair opposite me, his legs outstretched, his ankles crossed.
"So tell me what's going on," I said.
"I'm in a serious jam, man," he said. "I think I need rehab to get my life back. You know?"
He didn't sound upset about it.
"What have you lost?" I asked him.
"Got two weeks?" He chuckled.
"I'm listening."
"I don't know if I ought to head to rehab or really go deep into analysis with you or what," he said. "Or maybe we just go the Prozac route."
"You think you're depressed?" I asked.
"Hard to say."
He shrugged. "I'm kind of like the quiet guy who goes to the gym, you know, keeps to himself, maybe hooks up with a girl here and there, but doesn't make a big deal of it. He's, like, sort of on the outside looking in, never letting anything get him too down." Mark's lapse into the third person -- "He's ... on the outside, looking in" -- helped me realize what had disturbed me about him from the start. He seemed fake, as if playing a role. He showed no anxiety or sadness or anger. He spoke in clichés. I'm in a ... jam. I need ... to get my life back. Got two weeks? His hair looked intentionally messy. Everything about him, down to his carefully chosen, probably pricey, "worn out" clothing felt scripted.
      I have treated several other teenagers this year who display a similar kind of profound detachment from self. It is a kind of identity disorder I believe has its roots in a society that has drifted free from reality and is creating adolescents (and, I would venture, people of many ages) who are at most participant-observers in their own lives, with little genuine emotion- - like actors playing themselves. The signs and symptoms of this identity disorder are everywhere. Teenagers are embracing lies on a wholesale (and retail) scale. They not only buy clothing made to look old when it is new, but they buy T-shirts emblazoned with logos from bars and bait shops and resorts they have never visited, and that sometimes don't exist at all. More and more, they use illicit substances and alcohol to keep their genuine feelings at bay. They use steroids (and plastic surgery) to alter their appearances and athletic abilities. Their self-esteem floats ever higher, untethered even when their academic performance and family relationships and prospects for the future sink to new lows. They pierce themselves and tattoo themselves and have sex more and earlier, in what I see as desperate efforts to anchor themselves to some sort of reality -- the reality of the flesh.
     If a teenager can feel a steel bolt through her tongue move whenever she speaks, at least she knows she inhabits her own body, even if she doubts her own soul. If she can use low-cut jeans or a glimpse of thong underwear to attract glances from boys around her, at least she knows she occupies space and time at the center of their attention.
     The soil for this detachment from self has been sown for decades, partly by psychiatry itself. By not opposing vigorously enough the dangerous myth that psychoactive medications are a complete answer to depression and anxiety, we have allowed the idea to take root that we need not heed our emotions as evidence of life crises with real and crucial meaning, that we should turn off our inner voices and "listen to Prozac," instead.
     The growth of technology has cleaved us from the reality of self, as well. We say that we are "going" places on the Internet without ever leaving the room. In elaborate Internet-based games, people pay thousands of dollars to own "real estate" that isn't real at all. We watch newscasters (who increasingly could double as models or comedians) report on terrible tragedies, then shift gears and joke about the weather or a baseball game. And we learn to mirror them, to respond to our own losses like channels we can change. We can wage wars that kill tens of thousands of people with "smart" bombs. But we see little, if any, blood. And we can count the dead between episodes of our favorite sitcoms. We sit still for a cloudy sense of whether our president was elected to his first term. Then the president in the television drama "West Wing" delivers a political statement about the war in Iraq, and people actually pay attention. A senator appears as himself in the film "Traffic," in which Michael Douglas is the nation's drug czar. Unless Mr. Douglas really is ...
     The trouble with all this is that the truth always wins. Reality will not be frustrated forever. You have to pay back emotional debt, like the national debt, with interest. A crushing major depression lies in wait for Mark, if I fail to help him face whatever demons from the past drove him away from reality, to drugs. Ever-increasing rates of substance abuse and attention-deficit disorder and depression lie in wait for adolescents emerging into adulthood. And, in not many decades, our nation's sense of itself will, inescapably, depend on theirs.

Being treated unfairly at work may, quite literally, cause heartache. In a Finnish study, published Oct. 24 in Archives of Internal Medicine, men who perceived a low level of justice at work were more likely to suffer angina, heart attack or death from coronary artery disease than those who perceived a high level of justice.
      For the study, over 6,400 men ages 35 to 55 responded to a questionnaire about job strain and effort-reward imbalance. The interviews took place from 1985 to 1990. The men were then followed to track heart problems through 1999. Men who perceived higher levels of justice were more likely to be older and married, and have better jobs and education. They were less likely to be fat. But even after adjusting for these factors and others, the correlation remained between a sense of injustice and symptoms of increased coronary disease. The incidence of heart problems was 30 percent lower among those who perceived a high level of justice at work than in those who did not. This, said Mika Kivimaki, the lead author on the study and a professor of psychology at the University of Helsinki, suggests that justice at work can be protective.
     Dr. Kivimaki acknowledged that the results were based on observational data rather than a controlled experiment, but he did have some suggestions for employers. "Increasing fair decision-making procedures that include input from affected parties and are consistently applied, unbiased, open, correctable and ethical may be beneficial for heart health among employees," Dr. Kivimaki said. "I believe that efforts to follow such principles in workplaces do not contradict sound business practices."

A widely tested approach to diagnosing and treating depression, one of the nation's most prevalent and costliest afflictions, is moving into the mainstream of insurance coverage. Prompted in part by employers who cite depression as a frequent cause of absenteeism and low productivity, the big insurer Aetna plans to announce today that it will begin paying for a depression management program in dozens of medical offices around the country.
      Under the plan, Aetna will pay primary care doctors additional fees to screen patients for depression and to provide follow-up consultations for patients who are either put on antidepressants or, in more severe cases, referred to psychiatrists or psychologists. Aetna plans eventually to offer the program nationwide.
     The additional costs of identifying and treating depression, Aetna said, can in many cases be more than offset in avoiding the larger financial costs associated with the disease -- and the higher medical expenses that often arise when other chronic conditions, like diabetes and heart disease, are compounded by depression. Depressed patients with such diseases often stop taking their medications or fail to carry out recommended exercise and diets.
     Researchers said that 33 million Americans require treatment for depression each year, and at least one in six people have the disease, with varying degrees of severity, at some point in their lives. The total economic cost of depression has been estimated at more than $83 billion a year in this country, with more than half of that incurred by employers in lowered productivity, absenteeism and disability, according to a 2003 study in The Journal of Clinical Psychiatry.
     From an employer's standpoint, "depression has the greatest negative impact on productivity for nonmanufacturing companies," said Daniel J. Conti, vice president for the employee assistance program at J. P. Morgan Chase, for which Aetna is an insurer. "It is like the perfect storm for the jobs in today's workplace, the same way a bad back limited a worker on the job for my father in a factory."
     In a parallel approach to depression, Kaiser Permanente, the big nonprofit managed care company, has assigned a mental health aide to each of its salaried primary care physicians in Northern California. A few companies, like Caremark Rx, which specializes in managing care for patients with chronic conditions like diabetes and heart disease, routinely screen these patients for depression, which frequently accompanies those diseases.
     The announcement by Aetna comes after a report on mental health and substance abuse issued yesterday by the Institute of Medicine of the National Academies, a nonprofit public policy advisory group. That report calls for greater collaboration between mental health specialists and family care doctors, who are typically the first physicians that depressed patients turn to, reinforcing a recommendation in 2003 by a presidential commission on mental health.
     Studies have found that in many cases depressed patients receive only cursory attention in the offices of overworked family physicians and other primary care doctors, who nevertheless write an estimated 65 percent to 75 percent of the nation's prescriptions for Prozac and other antidepressant drugs. "People with depression are sitting around, not getting identified, impacting the business community," said Laurel Pickering, president of the New York Business Group on Health, an employers group. "What Aetna is doing is going to be a help."
     The approach has been tested in some research-financed programs already in place by other organizations, which involve family physicians and other primary care doctors who are trained to identify depression and counsel patients. Specially trained nurses call to encourage patients and remind them to take their medicines. Mental health specialists advise primary doctors on difficult cases, and patients with symptoms of severe depression are referred to psychiatrists or psychologists. "The clinical part of it is a no-brainer; it clearly helps patients," said John W. Williams, an associate professor of medicine and psychiatry at Duke University, who is one of the principal investigators for a program on depression and family care doctors for the MacArthur Foundation. "It also helps employers," he said.
     Part of the Aetna screening will involve a written test that has already been in use elsewhere, the Patient Health Questionnaire, or PHQ-9, which was developed at Columbia University and tested by researchers in the MacArthur Foundation program at Dartmouth College and Duke University. Peter Amann, a family practice doctor in Scarborough, Me., has been using the questionnaire in a program organized by MaineHealth, a hospital group, with research grants from MacArthur and the Robert Wood Johnson Foundations. One of his patients, a 60-year-old retired nurse who spoke only on condition of anonymity, said she had felt weighed down by problems. Her husband has had two strokes; her mother-in-law, who is 98, is also ill; and her rebellious teenage son left home and is now in Iraq with the Army Striker Force. After Dr. Amann identified her depression last winter by her answers to the questionnaire, he gave her a prescription for a generic version of Prozac, and she got a follow-up call from a nurse who asked how she was doing. "It was so uplifting, it really feels good that somebody was caring," she said. With encouragement from the doctor, she began to "get out and bike again, walk again," and she resumed volunteering at Saint Maximilian Kolbe Church. "I'm optimistic, Dr. Amann is optimistic," she said. "I made some strides in the right direction."
     Aetna is starting its program by increasing payments by 30 percent to 40 percent for selected primary care doctors that it has been training in a depression care program in six states: New Jersey, Pennsylvania, Maryland, Virginia, Texas and Oklahoma, as well as the District of Columbia. Aetna said it would add $15, on average, to a doctor's $40 fee for a routine visit, when physicians use the screening questionnaire. "The reimbursement is a good step" because the program involves costs for the doctor, said Dr. Michael Klinkman, a family physician at the University of Michigan Depression Center in Ann Arbor. Helen Darling, president of the National Business Group on Health, an organization of large employers, said patients' preference for consulting their primary care doctors on such matters was understandable. "They don't want to say they are going to see a psychiatrist," she said.

Of all the jittery runners who will be shuffling near the Verrazano-Narrows Bridge on Sunday morning, anxious to hear the starting cannon for the New York City Marathon, Curtis Jenkins may be the most improbable. Nine months ago, Jenkins, 29, was addicted to crack, a habit formed when he was 18. In February, he was charged with criminal mischief, his second felony arrest. His first, in 2000, for car theft, landed him in jail for a year and a half. "Gone in 60 seconds? That was me," said Jenkins, a Brooklyn native. "I used my skills in a negative way to make money for crack."
      This time, the judge gave Jenkins a choice: jail or a drug-treatment program. He chose the program. "I know I could have beaten the charge," he said. "But I also know I needed help." Jenkins ended up at Odyssey House, a substance-abuse treatment center that has 830 patients at six residential centers in the city. And there, as part of his recovery, he started running. He runs five or six miles at least three days a week. He has slowly built up to a long run of 18 miles on weekends. Now he is one of five residents who will be in the field of more than 35,000 runners taking a 26.2-mile tour of the five boroughs Sunday.
     Jenkins will be joined by William Walsh, a 26-year-old former plumber's assistant and cocaine user from Brooklyn, who said his last thought before he drifted off each night was of the marathon. Last Sunday, at a 5-mile tuneup race in Central Park, Walsh finished in 35 minutes 8 seconds. There is also Eddie Bryant, 41, a former Marine and father of eight who said he turned to drugs to cope with the death of his parents; Elijah Campbell, a baby-faced 21-year-old who arrived at Odyssey House through the court system and, since June, has cut 10 minutes off his 5-mile race time; and Renee Shepherd, 41, a North Carolina native who said she checked herself into Odyssey House after years of drinking. "In the past, I'd have watched the marathon from a bar," she said. "I never thought that would be me running."
     They are guided by Andre Matthews, Odyssey House's 45-year-old recreation coordinator, who first completed the marathon when he was a resident in 2001. He has run New York every year since and hopes to qualify for the Boston Marathon someday. For now, he is too busy coaching the rookie marathoners. They can seem an unlikely bunch, discussing race strategy, mile splits and hitting the wall. But the leaders of Odyssey House said it made perfect sense. "As they're training for the marathon, they're training for the world beyond Odyssey House," said Vito Tomanelli, the program director. The lessons of long-distance running, from proper pacing to goal setting to delayed gratification, he said, are the same lessons the residents are learning in recovery.
     For Odyssey House residents, the day begins at 6 a.m., and every minute is accounted for, with group therapy sessions, drug counseling, vocational training and work. But Tuesday evenings, residents can work out in Central Park with the Achilles Track Club, an international organization based in Manhattan that helps athletes with disabilities compete in marathons. As they progress from walkers to runners, shed pounds and grow more committed to the sport, the Odyssey House residents earn the privilege to run more often and enter local races on weekends.
     This year, a new weekly hourlong meeting drives home the connection between running a marathon and managing a life. The marathoners and other residents who are starting to run gather Tuesday afternoons in a windowless, subterranean room in Odyssey House's facility on East 121st Street. Seated in a circle and dressed in shorts and sneakers, they talk with Nell Hanks, a mental-health counselor and a volunteer with the Achilles Track Club. Afterward, they head out for their workout. "We talk about how job interview days are like race days, and that's the day you really need to show up," Hanks said. "It's so tangible, without a whole lot of psychobabble. People relate to roadblocks. It becomes a very physical connection."
     Odyssey House staff members said they had noticed the positive effects of racing, no matter the distance. "A client goes out, they get a number, they run a race, they complete something," said John Tavolacci, chief operating officer and head of clinical services. "For some, it's the first time in their life that they've completed anything. They're around other people, and everyone's a winner. They get an official time. On top of that, the times improve. It's concrete. It's very powerful for a person who has a history of losing and not accomplishing things to have this." Jenkins said that through running, "I've learned I'm not going to underestimate myself anymore; I'm going to ask more of myself."
     Fifty Odyssey House residents and staff members will hand out water at the 19-mile mark at 116th Street and First Avenue, a few blocks from their facility. When they see other residents run by, they may realize that the 2006 marathon is not out of the question. Then again, next year's team members may not have arrived at Odyssey House yet. "One of the beautiful things about this program is that there may be someone in jail right now, or homeless on the street, who next year will be running the New York City Marathon," Tavolacci said.

Of all the advances in the last decades in arresting and prosecuting rapists, none have been more revolutionary than testing of DNA, the genetic strands unique to each individual that can link a suspect to a sex crime with cool scientific certainty- - a tool more trustworthy than a witness's recollection, or a host of other forensic measures. DNA can remove much of the guesswork for the police and prosecutors, and it can reach back to grab those who committed crimes decades ago or were charged but dodged conviction. At the same time, DNA can relieve rape victims of the burden of identifying a predator who attacked from behind or in darkness, whose face they never saw, and it can bring a resolution to victims who gave up on justice years ago and learned to live with the injury. But there is something DNA cannot do: replace the testimony of victims. They must still take the stand, and with that can come a measure of pain.
      Kathleen Ham was raped in Manhattan 32 years ago. She wants her name to be public along with her account of the crime to show that she is not ashamed, and today she will testify in State Supreme Court in Manhattan, confronting for a second time the man accused of attacking her on a summer night in 1973. She will recall how a man came through the window. How he pulled a sheet over her head, and held a knife at her throat. How she screamed and fought him, but was not as strong. How she never saw his face.
     The first trial, in 1974, ended with a hung jury. Ms. Ham, 58, learned in April that the defendant, who is now known as Fletcher Anderson Worrell, had been conclusively matched to the assault by DNA. Since then, she has been forced to revisit the attack, and retrace the arc of a damaged life, the years of insomnia and self-rebuke that sometimes felt to her like a walking death. "He's been out there for 32 years," Ms. Ham, a lawyer who lives in California, says in her warm voice turned gravelly by years of chain-smoking. "And I've been in my own private jail."
     DNA helped to track Mr. Worrell, 59, back through the years, tying him as a suspect to at least 24 other rapes in New Jersey and Maryland, all of them committed after the rape of Ms. Ham. Ms. Ham's three-decade story is framed by remarkable changes in the criminal justice system -- especially rape prosecutions. Prosecutors have become skilled in sex crime cases, and in respectful handling of victims. Revised laws place fewer burdens on those who were attacked, and juries are more sympathetic. Yesterday, she was torn with worry, but resolved. "I think underlying this," Ms. Ham said, "is a certain part of me that says that even if it hurts, things are supposed to be done right."
     DNA has transformed thousands of other sex and violent crime cases across the country. The F.B.I., which maintains the national databank of DNA criminal case profiles, says that DNA has so far helped in the prosecution of 27,806 cases nationwide. DNA testing is unlocking old rape cases as fast as local law enforcement laboratories can analyze evidence and dispatch results to the databank. In the last few years, DNA helped to clarify seven unsolved rapes in New Iberia, La., three decade-old cases in Baltimore, dozens of cases in Ohio. DNA testing has provided new leads in more than 200 old rape cases in New York.
     Mr. Worrell has sat calmly through a series of pretrial hearings, a stocky man of 5-foot-9 with broad arms and sloping shoulders. Described in court papers as a long-practicing Muslim, he came to court wearing a bushy beard and a macramé kufi cap. Mr. Worrell's lawyer, Michael F. Rubin, has asked the court to dismiss the case, arguing that New York authorities had information on his whereabouts years ago and should have arrested him then. The court denied the motion.
     On the night of June 26, 1973, Ms. Ham had just moved to Manhattan, and was staying at a friend's studio apartment on West 21st Street in Chelsea. She had been a student at Berkeley in the 1960's, and was still a free spirit. In 1968 she had hitchhiked, on a whim, across Europe to Prague, to see the uprising there before the Russian tanks rolled in. "I said, this is history, I have to see it," Ms. Ham said, drawing on a cigarette and describing her fearless younger self like a character from a novel she read and put away long ago. She is not tall, but has straight bearing, a sophisticate's language and a Park Avenue voice. A photograph from 1975 shows a smiling, slim woman with hair flowing to her shoulders, classic cheekbones and bold red lipstick. Today she is heavier, and her curls are closer-cropped. She had come to a city very different from today's New York: shadowed with fiscal crisis, and crime so rampant that 13 police officers had been killed in the line of duty just two years before.
     Awakened by a noise that night, she saw the man's sneaker on the fire escape, then his hand on the window. Then the sheet was over her head. She heard her own screams, but they seemed to come from a distance, as though she were standing to one side. His knife left its serrated imprint on her throat. The police report would show that a neighbor had heard the screams and called 911. "When I saw I was still alive, I was disappointed," Ms. Ham said. She sensed that her life had been altered, but did not know how. Police officers quickly apprehended Mr. Worrell on the street. They let Ms. Ham take a look at him in the back of the patrol car, and again at the station house, standing by himself behind one-way glass. But she had not seen the attacker's face: "I don't know, I don't know," she told the police. Only later did she think that she could have identified his voice. Astonishingly, the 911 tape -- with the neighbor reporting her screams and pleading for help -- was erased. During her examination at St. Vincent's Hospital, Ms. Ham recalled, she put up a front of cool control. The doctor's official report cast doubt on whether she had been raped. She appeared too calm, he wrote. The night after the attack, when Ms. Ham sought refuge in the home of old friends, a street noise made her scream. "That was when I realized that my life was taken away from me," she said.
     Then came the trial. Under the law at the time, the prosecutors had to prove that force was used on Ms. Ham, and that the rape was consummated. They had to have a witness. Mr. Worrell's defense lawyer, George C. Sena, kept Ms. Ham under cross-examination for a day and a half. His third question was whether she was a virgin. He repeatedly suggested that Ms. Ham had engaged in rough love with a pimp. "Well, why didn't you get out then?" Mr. Sena asked. "Were both your legs broken?" The jury split, with 3 jurors unable to convict. Her retelling of the trial spills out in thousands o fwords, but when she reaches the end, she falls silent, exhausted. "My sense of fairness and justice just went out the window," Ms. Ham said. "The rape was a simple accident, it wasn't my fault. The trial was no accident -- I had insisted on justice. I stepped right in front of that truck."
     But the case wasn't closed. Someone set aside an intimate piece of evidence, a reminder of how she had been violated, though it had not been much use in the trial: her underpants. They went into a folder, and the folder was stored deep in the files of the Manhattan district attorney's office. While awaiting trial in Ms. Ham's case, Mr. Worrell, who used the name Clarence Williams at the time, sexually assaulted and shot a woman in Queens, according to court documents. On Oct. 31, 1975, 11 months after Ms. Ham's trial, Mr. Worrell was convicted in the Queens attack, and was later sentenced to up to 10 years in prison. After the conviction in Queens, Mr. Worrell also pleaded guilty to Ms. Ham's rape. But in October 1976, based on a legal fine point, his Queens conviction was overturned on appeal. He then withdrew his guilty plea in Ms. Ham's case and left New York, jumping bail in both cases.
     Not a year later, in September 1977, Mr. Worrell was arrested in Washington for burglary under a different name, papers filed by his defense lawyer show. But he persuaded the authorities that he was unfit for trial, and they sent him to a psychiatric facility for criminals. Three years later he was deemed healthy enough for release. In 1980, he enrolled at Southeastern University in Washington, and settled with a local family, according to his lawyer, Mr. Rubin. Seven years later, a man who became known as the Silver Spring rapist started a four-year spree of sexual assault in the Montgomery County suburbs. His method was distinctive: he scouted a house with an open window and a woman who was alone inside. He covered the victim's face. At least 22 rapes fit the pattern. There were at least two rapes with similar details in Morris County, N.J., in 1993. That year, Mr. Rubin said, Mr. Worrell left the United States for Egypt, where he stayed for a decade. He came back to settle in Stone Mountain, Ga., working as an Arabic translator.
    In May 2004, Mr. Worrell went to Brock's Gun Shop near Atlanta and filled out an application under his own name for a 12-gauge pump action shotgun. He wrote that he had never been indicted for a felony or committed to a mental institution. The background check brought up warrants for the two sexual assault cases in New York. And with that, three decades of changes in criminal justice came rushing into the present.
     Two assistant district attorneys in Manhattan, Martha Bashford and Melissa Mourges, were assigned the case. Both are veterans of cold case investigations and skilled in dealing with the sensibilities of sex crime victims. In 1973 the prosecutor, the defense lawyer, the judge and most of the jurors were men. Among their first steps was checking the folder from Ms. Ham's case. And there, preserved in the dark, they found the underwear. A spot of semen yielded a DNA sample. Manhattan crime lab specialists compared it to a sample from Mr. Worrell. It was a statistically perfect match, the district attorney's office said. The Manhattan prosecutors sent Mr. Worrell's DNA profile to the F.B.I.'s nationwide databank of criminal DNA profiles. Mr. Worrell matched DNA evidence recovered in at least nine Silver Spring rapes, and the two assaults in Morris County.
    Instead of calling Ms. Ham directly, Ms. Bashford contacted a friend of hers to break the news that the suspect had been found. "I became hysterical, I was sobbing," Ms. Ham recalled. "I was frightened of the whole thing coming up again." Ms. Ham, who had moved back to California, became a successful civil court lawyer. But friends knew she had quirks. She could never stay anyplace without at least one exit door unlocked. She sleeps only a few hours a night still. She never married, and attributes that directly to the rape. "I just didn't want to be kissed," Ms. Ham said. "I didn't like to be touched by strangers." And in the early 1990's, when her law practice was thriving, Ms. Ham abruptly developed a phobia that made it impossible for her to enter a courtroom. She had to give up trial litigation.
     Yesterday, as she prepared to testify, her mood careened. She was hyperventilating, chain-smoking, taking hot baths, trying to focus on the crossword puzzle, her abiding solace. "All these years, I felt badly," she said. "I knew he would do it again." She is set to take the stand this morning.

Her testimony began with silence, and for a long moment she appeared overwhelmed with pain. In a Manhattan courtroom yesterday, Kathleen Ham, a 58-year-old lawyer living in California, got a second chance to testify against a man accused of raping her 32 years ago, a moment she had both anticipated and dreaded. When a prosecutor, Assistant District Attorney Martha Bashford, asked Ms. Ham to go back in time, the witness paused, wiping her hand across her forehead as though she was struggling to clear her thoughts.
      Then she recalled how on June 26, 1973, she had been staying for a few days at a friend's apartment at 317 West 21st Street. She was awakened in the last hours of the night by an unseasonable chill and a light on the fire escape. She saw a man in tan shoes in the frame of the window. She immediately screamed, she testified. "There was a huge fight," Ms. Ham said, as the man pushed her down onto the narrow daybed where she had been sleeping and covered her face with the sheet. "He had a knife and he used it on me," she said.
     She admitted that she did not remember all the details of the rape because, she said, she blanked them out at the time. "You just have to remove your mind from everything that's happening to you," she said. "You just can't be there."
     Manhattan prosecutors who are trying Fletcher A. Worrell, 59, in State Supreme Court are armed with powerful evidence they did not have at his first trial in 1974: a DNA analysis of semen found in Ms. Ham's underwear that they say is a scientifically perfect match with Mr. Worrell's. After the first trial ended in a hung jury, Mr. Worrell left New York, jumping bail before his retrial, and a warrant was issued for his arrest. Mr. Worrell was tried then as Clarence Williams, the name he gave police officers who arrested him. DNA has also pointed to Mr. Worrell as a suspect in at least 24 other rapes in Maryland and New Jersey. The authorities located Mr. Worrell in May 2004 after he applied for a permit to buy a shotgun in Georgia, and the background check turned up the New York arrest warrant. Ms. Bashford and another prosecutor, Melissa Mourges, found Ms. Ham's aqua-colored underpants in the cold-case file. She identified them in court yesterday.
     Although the names of rape victims are not customarily published, Ms. Ham has insisted that her name be included in accounts of the trial, saying she is not ashamed to be a victim of rape. In comments before the trial, Ms. Ham said it was agonizing for her to testify again. After the rape, the man told her he was a drug addict, Ms. Ham testified yesterday, and went through her purse, taking $4, all the cash she had. "Did you ever see his face?" Ms. Bashford asked her. Ms. Ham looked at the ceiling, trying to control her emotion, then answered, "No."
     But she said she did see his green shirt with a dot pattern, soaked with sweat, the same shirt that a now-retired police officer later testified Mr. Worrell was wearing when he was arrested shortly after the attack. Mr. Worrell appeared in court in warm clothing, a heavy brown sweater with white dots over a grey turtleneck shirt. He has a full salt-and-pepper beard, and wore black-rimmed glasses and a brown macramé kufi cap. His lawyer, Michael F. Rubin, told the jury that Mr. Worrell had "adopted the Muslim faith." Mr. Worrell sat very quietly in court, looking straight ahead, without moving.
     The opening day of the trial was very different from reports of the first trial. Back then, the defense lawyer, George C. Sena, cross-examined Ms. Ham for a day and a half. Through his line of questioning, the transcript shows, Mr. Sena suggested that Ms. Ham was a racist and succeeded in casting doubt on whether she had been raped. Yesterday, Mr. Rubin told the jury in his brief opening statement that he had no intention of assailing Ms. Ham. "I'm not here to convince you that she was not assaulted," Mr. Rubin said. "It's terrible what happened to her." Rather, Mr. Rubin said he would base his defense on questioning whether Mr. Worrell was the rapist. He limited his cross-examination of Ms. Ham to 12 minutes. But Mr. Rubin insisted that Ms. Ham look directly at Mr. Worrell, to say whether she recognized him. "I don't even want to look at him," she said, but she did, and acknowledged, as she had in 1974, that she could not affirm that he was her assailant. Mr. Rubin asked her if she had tried to hit her attacker in the face. "I was fighting instinctually," she said, bristling. "I was trying to get away, trying to get out." Prosecutors presented two photographs in profile of Ms. Ham, taken shortly after the crime, showing knife marks down her neck.
      The jury, of eight women and four men, also heard testimony from Roosevelt Snipes, a retired New York police officer who was one of two officers who answered a 911 call placed by a neighbor of Ms. Ham's at 5:14 a.m. The tape recording of the call has been erased, but prosecutors recovered a computer record of it, which notes that a person was heard screaming. Officer Snipes testified that he saw Mr. Worrell run out of Ms. Ham's front door, and chased him down the stairs into the street, over a chain- link fence and across a playground. Mr. Worrell, he testified, got away from him for about 10 minutes, but he and his partner found him a block away and arrested him. He had $4 in his pocket, Officer Snipes said. Officer Snipes said he could still recognize Mr. Worrell, three decades later.
      In her opening argument, Ms. Bashford contended that Mr. Worrell was the only person on earth who could have the DNA profile that was developed from the sample in Ms. Ham's underwear. "If you looked at the DNA of more than one trillion people," Ms. Bashford said, it would not be possible to find another match. At the end of her testimony, Ms. Ham described the impact of the crime on her life. "I haven't had a good night's sleep in 32 years," she said. "I had to leave New York, which I loved, because I was frightened. I had my life stolen from me."

Even in a "good divorce," in which parents amicably minimize their conflicts, children of divorce inhabit a more difficult emotional landscape than those in intact families, according to a new survey of 1,500 people ages 18 t0 35. "All the happy talk about divorce is designed to reassure parents," Elizabeth Marquardt, author of the study, described in her new book, "Between Two Worlds." "But it's not the truth for children. Even a good divorce restructures children's childhoods and leaves them traveling between two distinct worlds. It becomes their job, not their parents', to make sense of those two worlds."
      Ms. Marquardt, 35, is an affiliate scholar with the Institute for American Values, a nonpartisan advocacy group that strongly emphasizes marriage. She is, she says, the first child of divorce to publish a broad study on how divorce affects children. It is no small question. The nation's divorce rate reached record levels in the late 1970's and early 1980's, and Norval D. Glenn, a professor of sociology at the University of Texas, said that about a quarter of all Americans age 18 to 35 were not yet 16 when they experienced their parents' divorce.
     There are no reliable national statistics on divorce, but most experts say that even with divorce rates edging down, about three-quarters of a million American children see their parents divorce each year. The new survey, based on the first nationally representative sample of young adults, highlights the many ways that divorce shapes the emotional tenor of childhood. For example, those who grew up in divorced families were far more likely than those with married parents to say that they felt like a different person with each parent, that they sometimes felt like outsiders in their own home and that they had been alone a lot as a child. Those with married parents, however, were far more likely to say that children were at the center of their family and that they generally felt emotionally safe.
     In the study, all those from divorced families had experienced their parents' divorce before age 14 and had maintained contact with both parents. Most of the time, Ms. Marquardt maintains, children with married parents need not concern themselves with their parents' thoughts and feelings while those with divorced parents must be more vigilant, more attuned to their parents' moods and expectations, more careful to adjust to the habits of the parent they are with -- and more concerned about looking or acting like the other parent.
     The debate over how divorce affects children has long been polarized, with many researchers focusing on statistical data emphasizing that most children with divorced parents do fine in life and many clinicians emphasizing the emotional distress that many of the children feel. And given the political overtones, many scholars who study family diversity have been concerned that focusing on how divorce hurts children could lead to efforts to restrict the availability of divorce. "Life is filled with trade-offs, and I worry that it's so easy to slip from descriptions of problems to one-size-fits-all prescription," said Stephanie Coontz, a historian at Evergreen State College in Washington and the author of "Marriage, a History." "There will always be couples who need divorces."
     Ms. Coontz and others acknowledge the growing consensus that most children with divorced parents grow into successful adults -- but say that the process is difficult for them. "The key is to separate pain from pathology, " said Robert Emery, director of the Center for Children, Families and the Law at the University of Virginia. "While a great many young people from divorced families report painful memories and ongoing troubles regarding family relationships, the majority are psychologically normal." Mr. Emery's own smaller, local studies have had findings similar to Ms. Marquardt's. About half of those from divorced families agreed that they had a "harder childhood that most people," compared with 14 percent from married families.
     "The effects of divorce may not seem so important in a hard-nosed statistical analysis of outcomes, but in a subjective way, they may be very important," said Andrew Cherlin, a family demographer at Johns Hopkins University. "Many adults with very successful lives still carry the residual trauma of their parents' breakup."
     Ms. Marquardt's book paints a detailed picture of the kinds of tensions children live with, using examples both from her own life -- her parents separated when she was 2 -- and from interviews with 70 other young adults. A chapter on secrets begins with her memory of being 10 years old, at the kitchen table with her father and not knowing what to answer when he asked, "Is Paul living with you and your mother?" She recounts her efforts to remember that in her mother's house, it was all right to say "screwed up" while in her father's she would be corrected to "messed up."
     The lonely task of reconciling two worlds is a constant theme. One young woman in the book describes moving between her mother and stepfather's home, where thrift was a high value, and her father and stepmother's, where money flowed freely and abundance was valued. She took her mother's rules so seriously that even at meals with her father, she ate far more than she wanted, getting a stomachache in her effort to make sure there would be no leftovers to throw out. She never told her parents about her inner conflict, for fear that it would be rude. "Children of divorce feel less protected by their parents, and they're much less likely to go to their parents for comfort when they are young, or for emotional support when they are older," Ms. Marquardt said. "They often feel a need to protect their mother emotionally." "I think we need to recognize these things," she said. "In one women's magazine, a mother wrote that she'd told her 7-year old-daughter she didn't need protecting, but that her daughter just does it anyway. Saying those words isn't helpful to the daughter. It just makes her look silly, like it's her problem that she feels she has to protect her mom."

The captain of the tour boat that capsized in Lake George, N.Y., last month, killing 20 people, used alcohol in the days surrounding the accident, federal investigators said yesterday. The finding alarmed the victims' families but could not, experts said, establish whether the captain was under the influence of alcohol at the time of the accident.
      The captain, Richard Paris, tested positive for urine ethanol glucuronide, an organic compound that the body produces when it breaks down alcohol, according to test results released by the National Transportation Safety Board, which is investigating the Oct. 2 accident, one of the deadliest boating disasters in the state's recent history. Mr. Paris told investigators that he had a drink the night before the accident but that he was not impaired in any way in his handling of the tour boat, the Ethan Allen, the next afternoon. The test can confirm the consumption of alcohol up to 80 hours after its elimination from the body, so the positive result neither confirms nor disproves Mr. Paris's account.
     Mr. Paris, 74, a retired state trooper who had given tours on the lake since 1986, was not tested in the first hours after the accident. The Warren County sheriff, Larry J. Cleveland, said he lacked any evidence of drunkenness that he would have needed to compel a sobriety test. Mr. Paris voluntarily submitted to the safety board's tests, conducted about 46 hours after the accident. The lack of an immediate test angered many people, including relatives of the victims, and led Gov. George E. Pataki to propose legislation making such testing mandatory. It is expected to be months before the safety board concludes its findings, but a stability test has already suggested that the vessel was overloaded.
     The new test results upset several survivors of the accident. The 20 victims were all elderly tourists; 19 lived in Michigan and one in Ohio. "I certainly would like to know why this happened, and I still can't believe that they did not do the testing sooner," said Anna May Hawley, 74, of Trenton, Mich., who stayed afloat while her husband, Earl, 76, drowned. "It can't be very accurate after two days." Another survivor, Carol Ann Marsh, 54, of Sterling Heights, Mich., said she could not understand why Mr. Paris did not volunteer to take drug and alcohol tests immediately after the crash. "For his own protection, why didn't he insist on it?" she asked. Mrs. Marsh's mother, Ann G. Beamish, 79, drowned.
     Drew D. Ferguson, a spokesman for Shoreline Cruises, the tour boat operator, said yesterday that the company believed Mr. Paris did nothing wrong. Mr. Paris remains an employee but is not giving tours because the boating season is over, Mr. Ferguson said. Mr. Paris did not return a telephone message left at his home in Lake George yesterday afternoon.
     While the ethanol glucuronide test demonstrates that he had consumed alcohol, it is considered of limited use in determining whether Mr. Paris was impaired at the time of the accident, according to two experts in toxicology who were not involved in the investigation. "It's very difficult to show impairment, or when the person actually drank, based on a urine test," said James E. Klaunig, a professor of toxicology at the Indiana University School of Medicine in Indianapolis. As a general rule, he said, "urine shows use; blood shows impairment." The level of ethanol glucuronide found in Mr. Paris's urine at the time of the test - 5,330 nanograms per milliliter, according to the safety board - cannot be used to determine his blood-alcohol level 46 hours earlier, when the accident occurred.
     The urine test is typically used to determine whether defendants on probation or parole have violated the terms of their release, or whether workers with a history of drug or alcohol abuse have relapsed, according to Dr. Jerrold B. Leikin, director of medical toxicology at Evanston Northwestern Healthcare Omega, an occupational medicine clinic in Glenview, Ill., and a professor of medicine at Northwestern University. He said he was surprised the test had been used in an accident investigation. "The rationale for performing post-accident drug testing is to assist in the determination of acute impairment before the substance is excreted," Dr. Leikin said. "In this case, sadly, there is no way to reconstruct the forensic metabolism to determine whether the captain was under the influence at the time of the accident." The Warren County district attorney, Kathleen B. Hogan, has opened a criminal inquiry. She said yesterday that she would hire independent experts to analyze the safety board's data, including the test results.

Living with an unrelated adult, especially an unrelated man, substantially increases the risk that a child will die violently, researchers reported yesterday. According to the study, children who live with adults who are not biologically related to them are nearly 50 times as likely to die at the adults' hands as children who live with two biological parents, the researchers said.
      The study, published in the November issue of Pediatrics, examined the cases of all children younger than 5 who died in Missouri from 1992 to 1999. For their data, the researchers used the records of the Missouri Child Fatality Review Program.
     Of the children studied, 149 died from injuries inflicted by an adult who helped provide care. The authors compared the children who died violently to a comparison group of 298 children who died of natural causes. Of those who died violently, 37 lived in households with two biological parents and no other adults. The rest lived with one or more unrelated adults who helped with child care.
     Children in single-parent households or with foster or stepparents were at no greater risk of dying at their hands than children who lived with two biological parents. But the presence of male adults unrelated to the victims sharply increased the risk of fatal maltreatment. In homes with unrelated adults, 84 percent of the killers were unrelated to their child victims, and 94 percent of those unrelated adults were men. The researchers said their findings ran to counter to the widespread belief that single-parent households increased the risk of injury. The researchers acknowledged that the study had certain limitations: they lacked information on factors like drug and alcohol abuse, domestic violence and depression, among other deficiencies.
     Some experts say that despite the study's findings children living with stepparents are at a higher risk. "There is abundant evidence, including U.S. evidence, that children are much more likely to be murdered in stepparent homes than in two-genetic-parent homes," said Martin Daly, professor of psychology at McMaster University in Hamilton, Ontario. "This has been shown both for common-law and registered-marriage households considered separately," Dr. Daly said. He pointed out that the study used as a control group other children who died, and not the general population. That factor might have altered the results. Moreover, he said, the study showed "fewer kids living with two biological parents than expected, even in the 'control' death group" of children who died, apparently of natural causes.
     Patricia G. Schnitzer, the lead author on the study and an assistant professor of nursing at the University of Missouri, conceded that the small number of stepparents in the study might have produced misleading results. She emphasized that the study provided no evidence of cause and effect. "What we have done," she said, "is identify households where there are unrelated adults living with children as a risk factor for fatal inflicted injuries." This, Dr. Schnitzer said, "has important implications for child care policy." She said that even though living with an unrelated adult increased the risk, over all "the majority, 55 percent, of the fatal injuries in our study were inflicted by the child's biological parent."

When a person is lying, distinctive changes occur in the digestive tract, researchers have determined. The standard polygraph test, often criticized as inaccurate, may be improved if it is combined with a test for the stomach changes, they say. The findings were presented last week at an American College of Gastroenterology conference.
      One author of the study, Dr. Pankaj J. Pasricha of the University of Texas Medical Branch at Galveston, said the test for changes in the gastrointestinal tract, an electrogastrogram, was painless and simple to perform. It measures activity in the digestive tract. "We expected to see an effect because we know that stress does affect GI function," Dr. Pasricha said. But when 16 volunteers were hooked up to heart and digestive tract monitors, the researchers were surprised to find that lying had a closer correlation with stomach changes than with heart changes. When the subjects lied, their heart rates increased, but it also did so at other times. On the other hand, lying was consistently associated with a decrease in the slow waves of the digestive tract.
     The study began as a high school project for Dr. Pasricha's daughter, Trisha, who is listed as an author. (Dr. Pasricha's wife is a former F.B.I. agent.) The volunteers, of course, were not trained at deception, so even the electrogastrogram could probably be fooled. "It's possible that people who are really, really good liars could overcome or control some of the body's autonomic responses," Dr. Pasricha said.

They raised children and grandchildren. They outlived their husbands, surviving the hardships of both youth and old age. But when they needed protection from the relatives they had cared for and loved, they found themselves in a social service system intended for younger women or children. The women, who spoke on the condition that their full names not be used out of concern for their privacy and to avoid further conflict, are now safe in one of the nation's first shelter programs for abused elders, started this year at the Hebrew Home for the Aged in Riverdale, the Bronx. One gave only her first name, Frances; the other agreed to be identified by her last initial, as Mrs. B.
      Frances, 86, said she went to the police after her son-in-law hit her and pushed her around. She landed in a shelter for battered women equipped for much younger women, where for a month she sat in a chair during the day and slept in a church with the other shelter residents at night. Mrs. B., 79, spent two months in homeless shelters with her 19-year-old grandson, who she said became violent toward her when he was on drugs. "He'd throw anything in his hand, but I endured it because he was my grandson," she said. When she finally went to the police after being locked out of a shelter for families because of his erratic behavior, she was directed to a domestic violence officer whom she could not reach.
     By these different routes, Frances and Mrs. B. became two of the first residents of the Hebrew Home's new program for abused elders, one of about eight such programs in the country, according to the National Clearinghouse on Abuse in Later Life, an advocacy group. "It's 100 percent better here" than in the battered women's shelter, Frances said. She gestured to a social worker who had worked with her since she came to the program in January. "God bless the child that sent me here," she said. "I lost one daughter and gained one."
     In 1981, when Congress first addressed elder abuse as a pervasive national problem, a House committee on aging called for the creation of emergency shelters for older victims, providing the services and medical care needed by older men and women. Since then, reports of elder abuse have multiplied, reaching 472,813 in 2000, the latest number available, according to the National Center on Elder Abuse, a research group financed by the United States Administration on Aging. This number is probably low because not all abuse is reported.
     But for the most part, those shelters have not materialized. "It's a huge need, and it's not being met," said Joanne Otto, executive director of the National Adult Protective Services Association, a nonprofit group that provides training and advocacy around elder abuse. Domestic violence shelters, she said, are often ill suited to the "continuum of needs" of elder victims, including geriatric care, physical therapy and peer counseling. Ms. Otto cited a lack of federal funds and legislation, including the Elder Justice Act, which has been introduced several times but not passed. "There's a reluctance to acknowledge the enormity of the problem of elder abuse," she said. In terms of police protection and services, and even accurate figures on the prevalence of elder abuse, she said, "it's like where domestic violence was 20 years ago."
     On a September afternoon, Frances sat with a social worker named Emily Brooks at the Hebrew Home's Harry and Jeanette Weinberg Center for Elder Abuse Prevention, a free program started in January to provide temporary emergency shelter for up to 31 abused elders. The home raised $1.1 million for the program, which houses victims among the general population. Frances's neighbors do not know her circumstances. If they ask whether her daughter will visit, she said: "I tell them, 'no, we're distant.' I don't have to go into detail."
     For Frances, the trouble began last year, when she had a heart attack and a triple-bypass operation. She lived in Oregon then, and her daughter, who lived in New York, persuaded Frances to move back with her. Though mother and daughter had gotten along in the past, they were soon in conflict, said Ms. Brooks, the social worker. Frances liked to be independent -- to cook for herself, to walk around the neighborhood. Her daughter felt she was becoming forgetful and unsafe. But mainly they fell out over money. According to Frances, her daughter began demanding $300 a month for rent, which they had never discussed before. Frances refused. Finally, just after Christmas last year, her daughter "sent her husband to hit me because she wanted my money," Frances said. "She told him, 'hit her hard.' " Frances left the apartment in search of a police officer. "Since that day, I have no use for my daughter," she said. "Even on the day I pass on, I don't want her to know."
     Before opening a shelter program for abused elders, the nursing home studied battered women's shelters. But the cultures of nursing homes and shelters are different, said Daniel A. Reingold, president of the home. "As a nursing home, everything we do is geared toward involving the family in care," he said. "Now we open a shelter, and for those residents we prevent family contact. Our care for some residents is diametrically opposed to everything we stress with our staff." Legally, this policy puts the home in uncharted territory, he said, because some of the relatives banned from the home may not be abusers. This can be especially complicated with patients suffering from dementia, who may not recognize abuse or be able to ask for help, said Sara Aravanis, director of the National Center on Elder Abuse.
     Frances, who said her mind was clear, said her daughter told people she had Alzheimer's disease so that if she complained, no one would believe her. As a result, Frances said: "I had nobody to talk to. I didn't want to involve my grandson, because that's his mother and father I'm talking about. And he's going to believe them, not me, because I'm much older, and his father and mother tell him that I make up stories."
     For Mrs. B., who had been in the Hebrew Home for a week when she was interviewed, the days there hung heavy with guilt and worry for her grandson, whom she had raised and -- to her mind -- failed. In his drug rages, he had cursed her and thrown things at her, making her fear for her life. But it was worse not knowing where he was, she said. "Even with all he's done, I'm sick over it," she said. "I don't know if he's in jail, if he's O.K. There must be something else I could have done, but I don't know what."
     Like most abuse victims, Mrs. B. wants to return to the community, even if it means putting herself at risk. The program is meant to provide temporary shelter, Mr. Reingold said, though some residents, including Frances, may stay. Joy Solomon, the center's legal director, who previously worked as a prosecutor on cases involving child abuse and domestic violence, said it was common for abused elders, especially women, to want to return to the children who had hurt them. "They feel shame that it's their own child, and feel responsible for the child's behavior," Ms. Solomon said. "They want to be mothers. We have no choice but to accept their decision." For these elders, she said, even more than for younger women who are abused by their partners, there is often no question of starting a new home independent of their abusers. "Home is home," Ms. Solomon said. "It's comfortable, and they know their surroundings. They want to be with the people they love, even if those people are hurting them."
     For Mrs. B., social workers at the home were trying to find a subsidized apartment. "It's very nice here -- they do everything for you, but I've always had my own apartment, that's what I want," Mrs. B. said. "My time is running out. I can't drift forever. This is my fifth year with breast cancer. This was supposed to be it." Her worst injury, she said, was the knowledge "that I have helped my family, and when it came time for them to help me, they weren't there for me; I'm my only family." Before coming to the shelter, she went to her church to leave a message for her grandson, trying to make contact with him. The minister's wife had told her, " 'You've done all you can for him; do something for yourself,' " she said. But still, she worried. Even if he finds her and hits her again, she said, she will not report him to the police. He is, after all, her own flesh and blood. And it was not her grandson that was bad, it was the drugs, she said, adding, "I've taken so much from him, one more thing can't hurt."

Jump forward to an early Monday morning this past July. Upham, now 27, had been up all night after another weekend of drugs and sexual hookups with strangers he met online.

But instead of pushing his limits for indulgence again, he made a different choice. Around 3 a.m., Upham sent an e-mail to his friends and family with some unexpected news.

"Over the past four months," he wrote, "I have become a regular user of crystal methamphetamine." He added, "I acknowledge, without shame, a concern for my mental, physical and emotional health."

While meth abuse is well-established in the U.S. heartland and increasing in New York and Los Angeles, it has had a low profile in the Washington area, where crack cocaine and marijuana are still the targets of most anti-drug programs run by law enforcement and public health agencies.

But meth use is increasing in portions of the gay community, according to local health officials, area addiction and mental health practitioners, and specialists in gay health issues. The District's Whitman-Walker Clinic, which provides HIV/AIDS and other health services to a largely gay clientele, reports that 75 percent of its new drug treatment clients list crystal meth as their primary drug of abuse. Five Crystal Meth Anonymous groups meet near Dupont Circle, a neighborhood with many gay residents. Two and a half years ago there were none. Suburban treatment centers report an increase in meth-related referrals, including some in teenagers. The D.C. government has just awarded its first grant for an anti-meth public education campaign, which will target the gay community.

The Post reported in July that police in Southern Maryland had found a small methamphetamine lab in the bathroom of a La Plata townhouse -- along with a cache of weapons, including grenades and seven rifles, some with bayonets. But that close-in lab is an exception. Federal drug authorities said in a 2002 report that the few meth labs in this region are located in the rural Shenandoah Valley.

Methamphetamine is a homemade, highly impure version of amphetamine, a stimulant that was widely abused in the 1950s through the 1970s. Its main ingredient is distilled from the pseudoepinephrine found in many over-the-counter cold and allergy medications.

Commonly known as crystal, crystal meth and Tina, meth is a potent, highly addictive drug that some experts say can cause long-term neurological and cardiovascular damage. The drug supercharges the central nervous system, causing the brain to churn out dopamine. This neurotransmitter affects brain processes that control movement, emotional response and the ability to feel pleasure and pain.

"Someone said [meth] is like smoking a cigarette, having an orgasm and eating chocolate all at the same time," said Amy Bullock-Smith, clinical program manager for the Whitman-Walker Clinic's addiction services, "and all that lasting about 12 hours."

Meth induces euphoria almost immediately after the odorless, bitter-tasting powder is smoked, the most common way meth is used. It takes a few minutes to feel the same rush from snorting, swallowing, injecting or, less commonly, dissolving it in water and taking it as an enema. This is followed by six to eight hours, and sometimes as much as 24 hours, of increased energy, suppressed appetite and other stimulating effects.

Meth labs can be set up in homes, motels, apartments, trailers, houseboats, cars -- anywhere that heat and basic lab tools can be used to cook down cold and allergy medications to extract their active ingredients. Other chemicals used to make meth -- according to news reports and numerous Web sites that offer "recipes" -- include iodine crystals, red phosphorous from the strike pad on matchbooks, muriatic acid, acetone, methanol and drain cleaner.

A Local View
Aside from its growing use in gay clubs, meth has made little impact in local jurisdictions, officials say.

In its most recent drug threat assessment report, published in 2002, the Department of Justice's National Drug Intelligence Center described meth abuse as "limited" in Maryland, "a low but increasing threat to Virginia," particularly southwestern Virginia, and "not yet a serious problem in the District."

The department said that most meth available in this area was produced in southwestern states or Mexico. It was distributed to users by teenagers and young adults, mostly at nightclubs and raves, large dance parties usually held in warehouses or open fields.

Over the past five years there has been a surge in the number of gay men in the Washington area seeking treatment for meth abuse. Kevin Shipman, manager for special populations in the District's Addiction Prevention and Recovery Administration, notes that the number of meth referrals to the Whitman-Walker Clinic's outpatient drug programs is five times higher this year than in 2000.

Local substance abuse treatment programs for adolescents report seeing small but growing numbers of youthful meth abusers.

At the Inova Kellar Center, senior case manager Mary Ellen Ruff said this mental health center in Fairfax is seeing a lot of adolescents who have experimented with meth, though she does not have specific figures. She blames the drug's accessibility, pointing out that teens "don't have to go downtown to get it, but can buy it from their neighbors." She said some teens who abuse attention-deficit hyperactivity disorder (ADHD) drugs -- kids without the disorder who get the drugs illegally and use them as stimulants -- move up to crystal meth.

Whitman-Walker's Bullock-Smith said the men turning to her clinic for help with meth addiction are typical of Washington's professional caste -- Type A personalities in fast-paced jobs that require a lot of mental energy. "It's not necessarily the folks who want to party all the time," she said.

She points out that people with untreated ADHD seem especially attracted to meth because, much like legally prescribed stimulants such as Ritalin (methylphenidate), the drug paradoxically calms and focuses them. Researchers have suggested that, like crystal meth, methylphenidate amplifies the brain's release of dopamine, thereby improving attention and focus in individuals who have weak dopamine signals.

Because the drug's effects can include a supercharged libido, extended periods of high energy and sleeplessness and a much-reduced ability to make sound judgments, unprotected and promiscuous sex is a high risk. Recent studies from San Francisco and Chicago confirm that gay meth abusers are at significantly heightened risk for becoming infected with HIV and other sexually transmitted infections.

A 2003 study in the American Journal of Drug and Alcohol Abuse found that meth users are likely to experience increased respiration and blood pressure, irregular heartbeat and insomnia.

A report in Psychological Medicine in 2003 said that long-term users may experience paranoia, hallucinations, tremors, mood disturbances, repetitive motor activities, homicidal or suicidal thoughts and irreversible damage to small blood vessels that increase the risk of stroke. Children of meth users frequently are at risk for neglect and abuse, the authors found.

Researchers reported in the American Journal of Psychiatry in 2001 that prolonged exposure to even low doses of meth can damage up to 50 percent of the brain's dopamine-producing cells.

Those who overdose on meth experience hyperthermia and convulsions that, if not treated, can result in death.

"While some people enjoy the short-term benefits," said Bullock-Smith, "it's the long-term effects, like the psychosis, that bring them to me."

Breaking Tina's Spell
The National Institute on Drug Abuse says the only treatment known to be effective for methamphetamine addiction is cognitive behavioral therapy to modify thinking and behaviors and to increase skills in coping with stressors. The agency says that meth recovery groups, such as Crystal Meth Anonymous, appear to help sustain drug-free recovery, though relapse rates are high.

As for the brain damage meth causes, researchers Gene-Jack Wang and colleagues at the Brookhaven National Laboratory in Upton, N.Y., have offered evidence that some areas of the brain begin to heal after abstaining for as little as two months. Other damage is longer-lasting.

George Kolodner, a board-certified addiction psychiatrist and medical director of the Kolmac Clinic in Silver Spring, said his clinic saw an increase in crystal meth users beginning about two years ago, but the trend has not accelerated since then. He said meth users are the most difficult patients to treat because there is no medication to prevent craving or treat the protracted post-use symptoms, such as dysphoria, or depressed mood.

"With other substances," said Kolodner, "we can help people get off and keep off by decreasing their cravings. With meth and cocaine, we don't have that."

Randy Pumphrey, executive director of the Washington Psychiatric Institute's Lambda Center, which provides substance abuse services to gay people, said that in the past four years meth has increased from being "something we saw every once in a while" to the third most commonly abused substance, after alcohol and crack, among new clients.

If someone is dependent, said Pumphrey, "they are going to need a period apart from their environment -- and also need hospitalization" to deal with the paranoia, severe depression or even homicidal feelings that can accompany the detox process.

After this acute phase, Pumphrey said, patients usually participate in a daytime treatment program for several weeks before joining an extended support program such as Whitman-Walker's six-month evening program for recovering addicts.

Kolodner said the relative newness of meth-specific support groups is a challenge to treatment because few have been in recovery long enough to serve as mentors.

Bullock-Smith explains that Whitman-Walker's three-phase addiction recovery program requires a substantial commitment. To graduate, clients must attend one to three meetings a week at the clinic, participate in an outside 12-step group, have a sponsor, undergo breathalyzer and urinalysis tests to verify that they are not using, see a therapist, have a psychiatric evaluation and complete "lots of homework."

Let's Talk About It
A committee including the police department and other District agencies, substance abuse professionals, youth organizations, nightclub owners and recovering addicts began to meet this summer to plan a response to what they view as a growing meth crisis.

Like community-level anti-meth efforts in other cities, the D.C. Crystal Meth Working Group is planning a campaign aimed at educating the nonusing public, preventing meth abuse among gay men and offering treatment referrals to current users. The District health department has provided a $42,000 grant for the group to work with Whitman-Walker on the campaign.

This is a good start, said group member Bruce Weiss, executive director of the Sexual Minority Youth Assistance League, which serves gay, lesbian, bisexual and transgendered youth. The group will seek $1 million from the D.C. government and try to ensure that fighting meth is included in the five-year plan of the task force advising the mayor on anti-drug priorities.

Community activist Christopher Dyer, who chairs the group's social marketing campaign subcommittee, said the campaign's slogans, "Let's Talk About Crystal Meth" and "Crystal Meth Sucks," will be launched in nightclubs with posters, pins and T-shirts.

Another group member, Ed Bailey, co-owner of Nation, a Southeast Washington dance club, said major club owners across the country support anti-meth campaigns like this one. The drug has cut into their business because people typically do not drink alcohol when they are using meth, he said. Over time they also become increasingly isolated and don't go to clubs.

Since deciding to live meth-free after one too many sleepless, drug-driven weekends, Chad Upham said he depends mainly on Crystal Meth Anonymous groups and constructive activities with family and friends to support his recovery. Although he saw a doctor for a standard checkup, he -- unlike some of his recovering friends -- isn't taking any medications to treat anxiety or depression.

Upham is discovering that Tina continues to tempt.

"I am thinking desirously about the people, places and things that were associated with my using," he said. Running into a person he knew from those "hot days and nights" revives thoughts of "all that fun."

But he pulls himself back to his new reality -- denying the drug, listening to his family, co-workers and new friends in the support groups he attends several nights a week.

They have "embraced me in my weakness," said Upham, "continually saying that I am brave, courageous and strong for taking the steps to get and stay healthy and live independent of drugs for satisfaction."