Noteworthy News Articles on Mental Health Topics, December 1- , 2005
Sarah Kershaw, New York Times- 12/1/2005 REDMOND, Wash.--The waiting room for Hilarie Cash's practice has the look and feel of many a therapist's office, with soothing classical music, paintings of gentle swans and colorful flowers and on the bookshelves stacks of brochures on how to get help. But along with her patients, Dr. Cash, who runs Internet/Computer Addiction Services here in the city that is home to Microsoft, is a pioneer in a growing niche in mental health care and addiction recovery. The patients, including Mike, 34, are what Dr. Cash and other mental health professionals call onlineaholics. They even have a diagnosis: Internet addiction disorder. These specialists estimate that 6 percent to 10 percent of the approximately 189 million Internet users in this country have a dependency that can be as destructive as alcoholism and drug addiction, and they are rushing to treat it. Yet some in the field remain skeptical that heavy use of the Internet qualifies as a legitimate addiction, and one academic expert called it a fad illness. Skeptics argue that even obsessive Internet use does not exact the same toll on health or family life as conventionally recognized addictions. But, mental health professionals who support the diagnosis of Internet addiction say, a majority of obsessive users are online to further addictions to gambling or pornography or have become much more dependent on those vices because of their prevalence on the Internet. But other users have a broader dependency and spend hours online each day, surfing the Web, trading stocks, instant messaging or blogging, and a fast-rising number are becoming addicted to Internet video games. Dr. Cash and other professionals say that people who abuse the Internet are typically struggling with other problems, like depression and anxiety. But, they say, the Internet's omnipresent offer of escape from reality, affordability, accessibility and opportunity for anonymity can also lure otherwise healthy people into an addiction. Dr. Cash's patient Mike, who was granted anonymity to protect his privacy, was at high risk for an Internet addiction, having battled alcohol and drug abuse and depression. On a list of 15 symptoms of Internet addiction used for diagnosis by Internet/Computer Addiction Services, Mike, who is unemployed and living with his mother, checked off 13, including intense cravings for the computer, lying about how much time he spends online, withdrawing from hobbies and social interactions, back pain and weight gain. A growing number of therapists and inpatient rehabilitation centers are often treating Web addicts with the same approaches, including 12-step programs, used to treat chemical addictions. Because the condition is not recognized in psychiatry as a disorder, insurance companies do not reimburse for treatment. So patients either pay out of pocket, or therapists and treatment centers bill for other afflictions, including the nonspecific impulse control disorder. There is at least one inpatient program, at Proctor Hospital in Peoria, Ill., which admits patients to recover from obsessive computer use. Experts there said they see similar signs of withdrawal in those patients as in alcoholics or drug addicts, including profuse sweating, severe anxiety and paranoid symptoms. And the prevalence of other technologies -- like BlackBerry wireless e-mail devices, sometimes called CrackBerries because they are considered so addictive; the Treo cellphone-organizer ; and text messaging - has created a more generalized technology addiction, said Rick Zehr, the vice president of addiction and behavioral services at Proctor Hospital. The hospital's treatment program places all its clients together for group therapy and other recovery work, whether the addiction is to cocaine or the computer, Mr. Zehr said. "I can't imagine it's going to go away," he said of technology and Internet addiction. "I can only imagine it's going to continue to become more and more prevalent." There are family therapy programs for Internet addicts, and interventionists who specialize in confronting computer addicts. Among the programs offered by the Center for Online Addiction in Bradford, Pa., founded in 1994 by Dr. Kimberly S. Young, a leading researcher in Internet addiction, are cyberwidow support groups for the spouses of those having online affairs, treatment for addiction to eBay and intense behavioral counseling -- in person, by telephone and online -- to help clients get Web sober. Another leading expert in the field is Dr. Maressa Hecht Orzack, the director of the Computer Addiction Study Center at McLean Hospital in Belmont, Mass., and an assistant professor at Harvard Medical School. She opened a clinic for Internet addicts at the hospital in 1996, when, she said, "everybody thought I was crazy." Dr. Orzack said she got the idea after she discovered she had become addicted to computer solitaire, procrastinating and losing sleep and time with her family. When she started the clinic, she saw two patients a week at most. Now she sees dozens and receives five or six calls daily from those seeking treatment elsewhere in the country. More and more of those calls, she said, are coming from people concerned about family members addicted to Internet video games like EverQuest, Doom 3 and World of Warcraft. Still, there is little hard science available on Internet addiction. "I think using the Internet in certain ways can be quite absorbing, but I don't know that it's any different from an addiction to playing the violin and bowling," said Sara Kiesler, professor of computer science and human-computer interaction at Carnegie Mellon University. "There is absolutely no evidence that spending time online, exchanging e-mail with family and friends, is the least bit harmful. We know that people who are depressed or anxious are likely to go online for escape and that doing so helps them." It was Professor Kiesler who called Internet addiction a fad illness. In her view, she said, television addiction is worse. She added that she was completing a study of heavy Internet users, which showed the majority had sharply reduced their time on the computer over the course of a year, indicating that even problematic use was self-corrective. She said calling it an addiction "demeans really serious illnesses, which are things like addiction to gambling, where you steal your family's money to pay for your gambling debts, drug addictions, cigarette addictions." She added, "These are physiological addictions." But Dr. Cash, who began treating Internet addicts 10 years ago, said that Internet addiction was a potentially serious illness. She said she had treated suicidal patients who had lost jobs and whose marriages had been destroyed because of their addictions. She said she was seeing more patients like Mike, who acknowledges struggling with an addiction to online pornography but who also said he was obsessed with logging on to the Internet for other reasons. He said that he became obsessed with using the Internet during the 2000 presidential election and that now he feels anxious if he does not check several Web sites, mostly news and sports sites, daily. "I'm still wrestling with the idea that it's a problem because I like it so much," Mike said. Three hours straight on the Internet, he said, is a minor dose. The Internet seemed to satisfy "whatever urge crosses my head." Several counselors and other experts said time spent on the computer was not important in diagnosing an addiction to the Internet. The question, they say, is whether Internet use is causing serious problems, including the loss of a job, marital difficulties, depression, isolation and anxiety, and still the user cannot stop. "The line is drawn with Internet addiction," said Mr. Zehr of Proctor Hospital, "when I'm no longer controlling my Internet use. It's controlling me." Dr. Cash and other therapists say they are seeing a growing number of teenagers and young adults as patients, who grew up spending hours on the computer, playing games and sending instant messages. These patients appear to have significant developmental problems, including attention deficit disorder and a lack of social skills. A report released during the summer by the Pew Internet and American Life Project found that teenagers did spend an increasing amount of time online: 51 percent of teenage Internet users are online daily, up from 42 percent in 2000. But the report did not find a withering of social skills. Most teenagers "maintain robust networks of friends," it noted. Some therapists and Internet addiction treatment centers offer online counseling, including at least one 12-step program for video game addicts, which is controversial. Critics say that although it may be a way to catch the attention of someone who needs face-to-face treatment, it is akin to treating an alcoholic in a brewery, mostly because Internet addicts need to break the cycle of living in cyberspace. A crucial difference between treating alcoholics and drug addicts, however, is that total abstinence is usually recommended for recovery from substance abuse, whereas moderate and manageable use is the goal for behavioral addictions. Sierra Tucson in Arizona, a psychiatric hospital and behavioral health center, which treats substance and behavioral addictions, has begun admitting a rising number of Internet addicts, said Gina Ewing, its intake manager. Ms. Ewing said that when such a client left treatment, the center's counselors helped plan ways to reduce time on the computer or asked those who did not need to use the Web for work to step away from the computer entirely. Ms. Ewing said the Tucson center encouraged its Internet-addicted clients when they left treatment to attend open meetings of Alcoholics Anonymous or Narcotics Anonymous, which are not restricted to alcoholics and drug addicts, and simply to listen. Or perhaps, if they find others struggling with the same problem, and if those at the meeting are amenable, they might be able to participate. "It's breaking new ground," Ms. Ewing said. "But an addiction is an addiction."
Associated Press, 12/1/2005 WASHINGTON -- A patch developed to treat attention deficit hyperactivity disorder in children received a negative review from a Food and Drug Administration scientist, who concluded the drug cannot be safely marketed. The patch uses methylphenidate, the same drug that is in Ritalin. But FDA reviewer Dr. Robert Levin found the patch produces troubling side effects too often to be considered safe. His findings were in briefing documents released by the agency on Thursday in advance of a public meeting on the drug. The reviewer's findings are not the final word. An independent panel of experts convened by the FDA is expected to consider on Friday whether the patch is effective and safe. The FDA has the final call on whether the patch can be made available, but the agency often follows the advice of its panels. The patch, developed by Noven Pharmaceuticals of Miami and Shire Pharmaceuticals Group in the United Kingdom, goes on a child's hip for nine hours, according to submissions by the company. It releases into the body methylphenidate, a stimulant that calms children with ADHD. It is for children between the ages of 6 and 12. Noven pitched the patch as a way to treat ADHD in children for whom taking pills is difficult or unpleasant. It can also be removed if it causes any side effects. But some children who received the patch during trials reported decreased appetites, headaches, insomnia, nausea and developing tics, the FDA said. Some also had skin irritation where the patch was applied. These occurred more often than in children taking Concerta, a pill that uses methylphenidate, and those taking a placebo, the FDA said. In documents submitted to the FDA, the developers of the patch said it was safe and that problematic side effects were similar to those occurring in children who take methylphenidate orally. It is the second time Noven has submitted the patch to the FDA. In 2003, The agency rejected a previous proposal for a 12-hour patch, and recommended Noven test the patch with a nine-hour application. But in the FDA documents, Levin wrote the nine-hour patch ''does not appear to be significantly more acceptable'' than the 12-hour version. ''Generally, it appears that the identical safety concerns remain,'' he wrote. The patch would be sold under the name Daytrana. In a statement on its web site, Noven acknowledged the FDA documents but did not comment on the agency's findings. Why Caffeine Works Ronald Kotulak, Chicago Tribune- 12/1/2005 Caffeine is the most widely used stimulant in the world, consumed in coffee, tea and soft drinks by hundreds of millions of people to get started in the morning and as a pick-me-up during the day. That people like the jolt they get from caffeine is no secret, but what caffeine does in the brain has been unknown. Now a team of Austrian researchers using advanced brain imaging technology has discovered that caffeine makes people more alert by perking up part of the brain involved in short-term memory, the kind that helps focus attention on the tasks at hand. And Americans seem most in need of concentrating their thoughts, since their average daily consumption of 236 milligrams of caffeine, equivalent to more than 4.5 cups of coffee, is three times the world average. "Almost all of us drink coffee or something with caffeine in it and we know why, because we want to be more awake or feel better," said Dr. Florian Koppelstaetter of the Medical University Innsbruck in Austria. "We wanted to know what effect one to two cups of coffee would have on short-term memory." Reporting Wednesday at the Radiological Society of North America meeting in McCormick Place, Koppelstaetter said functional magnetic resonance imaging, or fMRI, was used to measure brain function in 15 healthy volunteers before and after drinking coffee. The findings revealed increased activity in the frontal lobe, where working memory is centered, and the anterior cingulum, which controls attention, in volunteers after they consumed 100 milligrams of caffeine, the equivalent of about two cups of coffee. These areas showed no increased activity when the subjects drank the same fluid without caffeine. "The increased activity means you are more able to focus," Koppelstaetter said. "You have more attention and your task management is better." Short-term memory lasts about 30 to 45 seconds and stores a small amount of information for a limited amount of time. It's the kind of memory used to look up a telephone number and remember it long enough to dial it. Long-term memory, on the other hand, stores an unlimited amount of information for an unlimited amount of time. "What is exciting is that by means of MRI we are able to see that caffeine exerts increases in neuronal activity in distinct parts of the brain going along with changes in behavior," Koppelstaetter said. Study Links Pot, Schizophrenia Ronald Kotulak, Chicago Tribune- 12/1/2005 Researchers from New York's Albert Einstein Medical School found that marijuana smoking may increase the risk of schizophrenia in people who have a genetic susceptibility to the disease. Using a special version of MRI technology called diffusion tensor imaging, or DTI, Drs. Manzar Ashtari and Sanjiv Kumra found that marijuana smokers had brain abnormalities similar to those of schizophrenics. The abnormalities occurred in a bundle of fibers called the arcuate fasciculus, which connects Broca's area in the left frontal lobe with Wernicke's area in the left temporal lobe, a fiber pathway linked to higher aspects of language and auditory functions. The fibers in the arcuate fasciculus bundle are among the last parts of the brain to be formed during adolescence. DTI images, which can peer deep into the brain to reveal connections between neurons, found that connections in the arcuate fasciculus bundle were forming abnormally in marijuana smokers. These are the same fibers that the researchers showed were abnormal in schizophrenics. The researchers studied normal youngsters in late adolescence who didn't smoke marijuana, adolescents who smoked marijuana, adolescents who had schizophrenia and adolescent schizophrenics who smoked marijuana. The formation of the arcuate fasciculus bundle appeared normal in the adolescents who didn't smoke and showed some signs of abnormalities in those who did. The abnormalities were more pronounced in schizophrenics who didn't smoke marijuana and were the most pronounced in those who did. Ashtari said the Albert Einstein team undertook the study because of population studies showing an association between marijuana smoking and schizophrenia. The latest of these studies, reported in the May issue of the Journal of Addiction, involved 1,000 people followed for 25 years. It showed that the heaviest marijuana use was associated with a higher risk of schizophrenia and that schizophrenics who smoked marijuana had more relapses than schizophrenics who didn't smoke. "We're not saying that anybody who smokes marijuana is going to get schizophrenia," Ashtari said. "However, we are saying that if you are genetically predisposed, because your uncle or aunt or father or somebody has schizophrenia in your family, then marijuana increases your risk of contracting the disease."
Associated Press, 12/2/2005 WASHINGTON -- A federal advisory panel determined Friday that the first skin patch to treat attention deficit hyperactivity disorder in children is both effective and safe, bringing the patch a step closer to regulatory approval. However, the panel of independent experts voted to recommend to the Food and Drug Administration that the patch's label encourage its use as an alternative treatment for children with ADHD -- in effect, saying doctors should prescribe it only if taking pills is too difficult for a child. The unanimous vote by the FDA's Psychopharmacologic Drugs Advisory Committee, saying the patch was acceptably safe, came after a formerly critical FDA reviewer reversed his opinion about the drug. The agency will now decide whether to approve the patch. It usually follows the advice of its advisory committees but is not required to. A decision is expected by Dec. 28, said a spokesman for U.K.-based Shire Pharmaceuticals, which developed the patch along with Noven Pharmaceuticals of Miami. Shire spokesman Matt Cabrey said he was surprised that the FDA's reviewer changed his mind and pleased with the outcome..
LEBANON, N.H. --To help substance abusers overcome their addictions, Dr. Matthew Hopkins keeps an unusually frenetic schedule: four jobs at three workplaces in New Hampshire The 38-year-old psychiatrist loves working with patients other doctors can't stand: alcoholics and drug addicts prone to manipulation and lying. "I just look at it as a symptom of their disease and try to fix it," he said. "I see the person behind the addiction." He also sees himself. When patients tell him, "Doctor, you have no idea how bad this is," Hopkins answers: "Actually, yes I do." Drinking and Driving Are Vexing New Mexico Anew Ralph Blumenthal, New York Times- 12/4/2005 SANTA FE, N.M. - After pleading guilty to drunken driving, Joseph Tapia followed the judge's orders and showed up one night in November at a forum at Santa Fe Community College to hear from accident victims. The trouble was, Mr. Tapia appeared to be drunk. "He was making sounds, staggering and swaying as he stood in line, telling people to hurry up," Sgt. Joseph O'Brien, a Santa Fe County sheriff's deputy, told the sentencing judge, Magistrate Pat Casados, after tracking her down at home while Mr. Tapia, a 51-year-old suspended lawyer and repeat offender, stood in handcuffs. The episode highlights the intractability of the problem of drunken driving in New Mexico, which until the early 1990's regularly led the nation in the rate of alcohol-related road deaths. But the carnage stirred an outcry, leading to legislative measures that cut the toll and made New Mexico something of a model. Now experts worry that despite their best efforts, the gains are eroding. New Mexico is still seeking solutions. It is the only state with a D.W.I. czar. A groundbreaking federal grant has put 10 full-time officers on patrol for drunken drivers in five problem counties. And this year New Mexico became the first state to require first offenders to install a device on their vehicles that prevents their starting if the driver's breath betrays appreciable alcohol. But with fatalities again on the rise, some embarrassing incidents involving public officials and a string of deaths involving serial offenders, some of whom were still on the roads after as many as two dozen arrests for driving while intoxicated, experts worry that New Mexico is losing ground. Recently, an Indian tribal police chief was charged with drunken driving after a wreck; the chief business officer for the Albuquerque school system was accused of driving drunk and pleaded no contest; a judge was forced to resign after intervening to release a friend arrested for drunken driving; a chief state district judge resigned after pleading guilty to aggravated D.W.I. and possession of cocaine; another judge quit after being accused of altering court records to make her appear to have been tougher on offenders, and two Albuquerque police officers in the D.W.I. unit were found to have drunken-driving convictions. New Mexico is hardly alone in suffering from what has been called the most common crime in the United States. Nationwide, about 1.5 million drunken-driving cases are filed annually - 300,000 more than all theft and larceny cases combined, according to F.B.I. figures. The impact has been disproportional in New Mexico, a largely poor and rural state of about 1.9 million people, where overburdened courts, haphazard record-keeping, ethnic and cultural factors, and a society that long winked at alcohol abuse are all cited as factors. The problem is more complex than mere alcohol consumption. New Hampshire leads the nation in drinking, with 4 gallons a year per person, far more than New Mexico's 2.4 gallons. But New Hampshire's alcohol-related road fatality rate is less than half of New Mexico's. "Why, after all this legislation, this funding, this research, the grass-roots programs, why are we not making better progress now?" asked Nancy Owen Lewis, an anthropologist specializing in addiction studies and the director of academic programs for the School of American Research in Santa Fe. Dr. Lewis spoke in October at a conference on the problem held at the school, where Judith Scasserra-Cinciripini had worked until she was killed on her bicycle on July 27 by a drunken driver with three convictions and a blood-alcohol level three times the legal limit of 0.08 grams per deciliter. The driver pleaded guilty to vehicular homicide and was sentenced Nov. 23 to 12 years in prison. In September, a multiple offender in Albuquerque killed a court employee who happened to have processed some of the driver's previous drunken-driving arrests. The driver, Ruby Sanchez, is being held on $250,000 bond and is awaiting trial. "There is a long history of D.W.I. in New Mexico," said Rachel O'Connor, an injury specialist named last year by Gov. Bill Richardson to coordinate research and enforcement programs as the first D.W.I. czar. As far back as 1913, the first New Mexico Legislature voted to jail and fine drunken drivers. By 1982, when 375 people died in alcohol-related vehicle accidents, New Mexico had the worst record in the nation, more than three deaths for every 100 million vehicle miles - almost twice the national average, according to Federal Highway Administration figures. The state sought various remedies, passing a measure holding liquor sellers accountable for intoxicated customers involved in serious accidents. It revoked licenses of drivers with a blood alcohol level of 0.10, won court approval for sobriety checkpoints and banned open alcohol containers in vehicles. But nothing galvanized public action like a crash in 1992 when a drunken driver going the wrong way on Interstate 40 killed an Albuquerque woman and her three daughters on Christmas Eve. In the ensuing furor, with the driver, Gordon House, sentenced to 22 years in prison, the drunken-driving threshold was lowered to 0.08, from 0.10, jail terms were specified for repeat offenders, liquor drive-up windows were shuttered and licensing restrictions were expanded. By 2000 fatalities had dropped by about 48 percent, to 194, with Montana and six other states and Puerto Rico overtaking New Mexico in the rate of alcohol-related road deaths. Since then, the number of New Mexico deaths has crept back up, to 219 last year, prompting an investigation by The Albuquerque Journal. Arrests, which had hit a high of 23,597 in 1993, declined to a low of 18,719 in 1999 but began climbing the following year to 19,400 last year. At the same time, convictions dropped from a high of 17,392 in 1993 to a 20-year-low of 11,735 last year. Conviction rates dropped from nearly 75 percent in 1985 to 60 percent last year. And drunken drivers still kill people on New Mexican roads at twice the national average, state figures show. "What everybody gets flabbergasted about are the repeat offenders," said Linda Atkinson, executive director of the D.W.I. Resource Center, a nonprofit victims-advocacy group in Albuquerque. But, Ms. Atkinson said, first offenders account for 70 percent of the drunken-driving fatalities. The challenge, experts said, is prevention. "People are trying to enact laws based on emotion rather than what works," said State Senator Phil A. Griego, a three-term Democrat who credited his two arrests for drunken driving and the "learning experience" of three days in jail in 2002 for helping lead him to sobriety and prominence as an anti-D.W.I. crusader. What worked, Mr. Griego said, were tough law-enforcement and the forced installation of ignition-interlock devices, under the law he co-sponsored. He credited the device, which is set off by a blood-alcohol level of 0.025, with helping him stay sober. "I was probably a drunk for 28 years," said Mr. Griego, who is 57. "There was no way I was going to stop until I killed somebody, killed myself or got thrown in jail." Ms. Atkinson, of the D.W.I. Resource Center, said that while the research and the laws and the money were in place, "we haven't been able to put the pieces together." Terry Huertaz, executive director of Mothers Against Drunk Driving in New Mexico, said many factors worsened the state's problem, including the proximity to Mexico, where young people flock for inexpensive drinks and entertainment. Ms. Huertaz said a 2001 federal study also showed that Indians and Hispanics, two major population groups in New Mexico, had a disproportionately larger chance of getting into an accident after drinking than other groups, and that offenders often slipped through a chaotic and overburdened court system. Many cases are heard in municipal courts, where no transcripts are made of the proceedings and judges often lack law degrees and receive minimal legal training. But judges reject the blame. George Anaya Jr., a Santa Fe magistrate who was in the audience at the conference after the death of Ms. Scasserra-Cinciripini, grew upset, standing to say that probation officers were overwhelmed with monitoring offenders. Judge Anaya said high turnover in the district attorney's office meant cases were transferred from lawyer to lawyer, and cited an "outrageous" scarcity of space for keeping records. "There's a revolving door with the D.A.'s," he said. New Mexico this year increased penalties for drunken driving. First offenders lose their licenses for a year and must use the ignition device for a year. Limited licenses for driving to work were abolished. Drivers with multiple offenses lose their licenses for up to five years. Criminal penalties can be up to 90 days in jail for first offenders and three years for a seventh conviction. But maximum penalties are rarely imposed. If anything illustrated the seriousness of the problem, it was the appearance of Mr. Tapia at his court-ordered victim impact panel at the community college on Nov. 9. Lining up to pay his $20 and register with the other 65 offenders alongside posters of gruesome accident scenes, Mr. Tapia created a disturbance, drawing the attention of Sergeant O'Brien, who was there to deliver one of the lectures. "If you can't come in sober, you're not going to be let in," the officer said. Mr. Tapia, whose law license was suspended for "probation violations," was no stranger to Mike Eiskant, a Santa Fe police officer who arrived with a Breathalyzer. "When I saw him, I said, 'I know this guy,' " said Officer Eiskant, who recalled chasing him in a car and on foot several years ago in another drunken-driving case. "You've arrested me a couple of times" Mr. Tapia acknowledged. After refusing several times to take a breath test - "What part of 'no' don't you understand?" he asked -- Mr. Tapia was arrested for disorderly conduct. "I come to class and this is how they treat me," he said. Officer Eiskant said that little surprised him anymore. "I've seen people come drunk to their D.W.I. trial," he said. Group Probes Mentally Ill in Connecticut Nursing Homes Associated Press, 12/4/2005 NEW LONDON, Conn. --An advocacy group is investigating the placement of the mentally ill in nursing homes to determine if Connecticut is violating state and federal laws. The Judge David L. Bazelon Center for Mental Health Law, working with state groups, is focusing on nursing home residents with psychiatric disabilities who have not exercised their right to court hearings or are in locked wards without proper psychiatric care. The organization, based in Washington, D.C., also is looking into whether Connecticut has a plan to place the mentally ill in community settings. "We are looking into the situation in Connecticut because there is such a large number of individuals in nursing homes and also because of the existence and use of these locked units," said Karen Bower, a Bazelon center lawyer who is leading the investigation. More than 2,700 people with psychiatric disabilities live in nursing homes in Connecticut, and "in all likelihood that's a low estimate," said Wayne Dailey, spokesman for the state Department of Mental Health and Addiction Services. A survey by the state's Office of Protection and Advocacy for Persons with Disabilities two years ago found 1,268 psychiatric patients living on locked wards. Some are referred by the mental health department, but most are discharged from psychiatric hospitals, emergency rooms or from private homes, often with the approval of a guardian or conservator. Once residents, who are as young as 18, are placed in nursing homes, their care is monitored by the state Department of Public Health, which focuses on their physical, not psychiatric, treatment. "Connecticut has not begun to even seriously consider that it needs standards and regulations for these units," said Jan VanTassel, executive director of the Connecticut Legal Rights Project, which is working with the Bazelon center. Representatives of Bazelon have been working with the office of protection and advocacy and the legal rights project for the past several months, interviewing people with mental illness living in nursing homes. "We are talking to people and learning about how they wound up in the nursing home and whether or not there is any interest in leaving the home and being in a more community-based setting," Bower said. According to state law, no one can be committed to a "hospital for psychiatric disabilities" without a hearing before a judge, the right to legal counsel and the right to cross-examine witnesses. The law also says patients who are committed have the right to an annual court review of their status. Such a review is not available to the mentally disabled in nursing homes. The Bazelon center is considering a lawsuit against Connecticut over the issue of the mentally ill in nursing homes, but Dailey said legal action is not necessary. State officials are studying the possibility of using Medicaid money to move residents out of nursing homes. A report is due to the General Assembly in January. "Right now I think there's reason for optimism to think the issue might be addressed without legal action," Dailey said. On the Net: http://www.bazelon.org Danger Signs in Teenage Suicide Paul Raeburn, New York Times Magazine- 12/4/2005 In the mid-1980's, David Shaffer, a psychiatrist, became disturbed by an increase in teenage suicides. After declining for decades, the rate started climbing in the late 1950's, especially for boys. By the 1980's, it had tripled -- to 11.3 per 100,000 teenagers 15 to 19, according to the Centers for Disease Control and Prevention. In more recent surveys of teenagers, the C.D.C. has found that about 8 percent of high-school students answer yes when asked if they had attempted suicide during the past year. About 1,500 succeed annually, making suicide the third-leading cause of death in teenagers after accidents and homicides. Shaffer wanted to know what was happening -- and whether anything could be done about it. There were plenty of theories. Defenders of family values blamed working mothers and divorce. Some churches blamed the game Dungeons & Dragons, for its supposed demonic content. One therapist argued that most suicides were committed by gay teenage victims of discrimination. And then there was the music that kids were listening to. "A whole lot of people were criticizing rock stars," Shaffer says. When Shaffer began his research, most people thought suicide was a random act -- that little could be done to predict or prevent it. But Shaffer, now chief of the Division of Child and Adolescent Psychiatry at Columbia University, didn't believe that. He studied records of 140 teenagers who committed suicide during the 1980's in and around New York City. Most exhibited at least one of three characteristics. The first was depression. The second was alcohol abuse -- found in two-thirds of the 18-year-olds. And the third was aggression -- beating somebody up or punching walls. Shaffer devised a 10-minute questionnaire, for 9th and 10th graders, to inquire about depression, substance abuse and any previous suicide attempts. (Aggression is usually evident without screening, he notes.) The questions are simple: Have you been depressed? Have you ever tried to kill yourself? Do you have a problem with alcohol or drugs? If kids responded with a strong yes to any of these, they were asked more questions. The quiz, he found, elicited more revealing answers than face-to-face interviews. As Shaffer was developing the questionnaire, he realized that it could also serve as a quick mental-health checkup. The National Institute of Mental Health says that about 50 percent of mental illness begins by adolescence, and often gets worse later. Shaffer's questionnaire could find these kids before they began that downward spiral. Shaffer went public with TeenScreen four years ago, offering it to schools at no charge. It is given to students with their parents' consent. With only word-of-mouth marketing, the questionnaire has spread to 461 sites in 43 states. This year, it was given to 122,000 kids, up from 14,000 only two years ago. About 30 percent of the kids who take the test screen positive. (That's not a diagnosis; it's simply an indication that they need further assessment.) After winnowing by a health professional, a little more than half of these kids are then referred for a complete evaluation, according to Laurie Flynn, TeenScreen's executive director. TeenScreen won special praise two years ago in the final report of President Bush's New Freedom Commission on Mental Health. The report said that TeenScreen was "a model for early intervention" and called for the expansion of such programs in schools. "Early detection and intervention are a good idea," says the commission's chairman, Michael F. Hogan, director of the Ohio Department of Mental Health. Despite its success, the program has raised questions. Do we want our kids to have their mental-health evaluated by their schools? And when high-risk kids are identified, who's going to take care of them? Some of the criticism comes from political conservatives, like Phyllis Schlafly, who has written that TeenScreen challenges "the fundamental right of parents to decide what medical treatment is appropriate for their own children." Other critics worry that TeenScreen will funnel too many kids into treatment and lead to overuse of medication, with possibly dangerous results. TeenScreen's backers emphasize that their aim is merely to identify kids at risk, not to encourage use of antidepressants. "We have nothing to do with providing recommendations for treatment," Flynn says. "What parents choose to do is entirely up to them." Though the criticism hasn't slowed TeenScreen's growth, it still disturbs Shaffer and Flynn. "We search the Web daily to find it," Shaffer says. As TeenScreen extends its reach, it inevitably sends more and more kids into a mental-health system that is notoriously unable to meet the needs of those already seeking help. If 30 percent of kids taking the TeenScreen questionnaire test positive, a high school with 1,000 students could find itself with 300 kids who need further screening. More than half of those would need a complete evaluation. "It may at times be putting the cart before the horse to spend a lot of money to create large-scale screening programs when there aren't sufficient facilities to deal with kids," says Dr. Eric D. Caine, a psychiatrist at the University of Rochester Medical Center and a director of its Center for the Study and Prevention of Suicide. Flynn responds that TeenScreen requires participating schools to "show us they have the credentialed people in place" to arrange for treatment. Schools typically draw on community health professionals to provide care, often on a sliding fee scale for families that can't afford it. "We've never had a site close because they didn't have services," she says. If communities struggle to find services, she says she thinks that that's not the worst thing. "As long as the problem is hidden, we're never going to get more help." Others worry that TeenScreen is draining scarce resources away from special groups of kids who need help. "There are some settings where we know from research that a high proportion of young people have mental illness," Hogan says. Those include the juvenile justice system, where as many as 60 to 70 percent of kids have a mental illness, and the foster care system, where about one-third are afflicted, he says. In recent years, for the first time since the Second World War, suicide in teenagers has fallen. The growing use of antidepressants might be one explanation, Shaffer notes. He says that raising the drinking age to 21 nationally could be another. Nevertheless, there are still many kids out there, lost in a private world of pain and emotional anguish. "These are kids who are solitary, who haven't spoken to anyone," he says. And if schools don't try to find them, it's not clear who will. Fighting Anorexia: No One to Blame Peg Tyre, Newsweek- 12/5/2005 Emily Krudys can pinpoint the moment her life fell apart. It was a fall afternoon in the Virginia suburbs, and she was watching her daughter Katherine perform in the school play. Katherine had always been a happy girl, a slim beauty with a megawatt smile, but recently, her mother noticed, she'd been losing weight. "She's battling a virus," Emily kept on telling herself, but there, in the darkened auditorium, she could no longer deny the truth. Under the floodlights, Katherine looked frail, hollow-eyed and gaunt. At that moment, Emily had to admit to herself that her daughter had a serious eating disorder. Katherine was 10 years old. Who could help their daughter get better? It was a question Emily and her husband, Mark, would ask themselves repeatedly over the next five weeks, growing increasingly frantic as Katherine's weight slid from 48 to 45 pounds. In the weeks after the school play, Katherine put herself on a brutal starvation diet, and no one--not the school psychologist, the private therapist, the family pediatrician or the high-powered internist could stop her. Emily and Mark tried everything. They were firm. Then they begged their daughter to eat. Then they bribed her. We'll buy you a pony, they told her. But nothing worked. At dinnertime, Katherine ate portions that could be measured in tablespoons. "When I demanded that she eat some food--any food--she'd just shut down," Emily recalls. By Christmas, the girl was so weak she could barely leave the couch. A few days after New Year's, Emily bundled her eldest child into the car and rushed her to the emergency room, where she was immediately put on IV. Home again the following week, Katherine resumed her death march. It took one more hospitalization for the Krudyses to finally make the decision they now believe saved their daughter's life. Last February, they enrolled her in a residential clinic halfway across the country in Omaha, Neb.--one of the few facilities nationwide that specialize in young children with eating disorders. Emily still blames herself for not acting sooner. "It was right in front of me," she says, "but I just didn't realize that children could get an eating disorder this young." Most parents would forgive Emily Krudys for not believing her own eyes. Anorexia nervosa, a mental illness defined by an obsession with food and acute anxiety over gaining weight, has long been thought to strike teens and young women on the verge of growing up--not kids performing in the fourth-grade production of "The Pig's Picnic:' But recently researchers, clinicians and mental health specialists say they're seeing the age of their youngest anorexia patients decline to 9 from 13. Administrators at Arizona's Remuda Ranch, a residential treatment program for anorexics, received so many calls from parents of young children that last year, they launched a program for kids 13 years old and under; so far, they've treated 69 of them. Six months ago the eating-disorder program at Penn State began to treat the youngest ones, too-20 of them so far, some as young as 8. Elementary schools in Boston, Manhattan and Los Angeles are holding seminars for parents to help them identify eating disorders in their kids, and the parents, who have watched Mary-Kate Olsen morph from a child star into a rail-thin young woman, are all too ready to listen. At a National Institute of Mental Health conference last spring, anorexia's youngest victims were a small part of the official agenda--but they were the only thing anyone talked about in the hallways, says David S. Rosen, a clinical faculty member at the University of Michigan and an eating-disorder specialist. Seven years ago "the idea of seeing a 9- or 10year-old anorexic would have been shocking and prompted frantic calls to my colleagues. Now we're seeing kids this age all the time;" Rosen says. There's no single explanation for the declining age of onset, although greater awareness on the part of parents certainly plays a role. Whatever the reason, these littlest patients, combined with new scientific research on the causes of anorexia, are pushing the clinical community--and families, and victims--to come up with new ways of thinking about and treating this devastating disease. Not. many years ago, the conventional wisdom held that adolescent girls "got" anorexia from the culture they lived in. Intense young women, mostly from white, wealthy families, were overwhelmed by pressure to be perfect from their suffocating parents, their demanding schools, their exacting coaches. And so they chose extreme dieting as a way to control their lives, to act out their frustration at never being perfect enough. In the past decade, though, psychiatrists have begun to see surprising diversity among their anorexic patients. Not only are anorexia's victims younger, they're also more likely to be black, Hispanic or Asian, more likely to be boys, more likely to be middle-aged. All of which caused doctors to question their core assumption: if anorexia isn't a disease of type-A girls from privileged backgrounds, then what is it? Although no one can yet say for certain, new science is offering tantalizing clues. Doctors now compare anorexia to alcoholism and depression, potentially fatal diseases that may be set off by environmental factors such as stress or trauma, but have their roots in a complex combination of genes and brain chemistry. In other words, many kids are affected by pressure-cooker school environments and a culture of thinness promoted by magazines and music videos, but most of them don't secretly scrape their dinner into the garbage. The environment "pulls the trigger," says Cynthia Bulik, director of the eating-disorder program at the University of North Carolina at Chapel Hill. But it's a child's latent vulnerabilities that "load the gun." Parents do play a role, but most often it's a genetic one. In the last 10 years, studies of anorexics have shown that the disease often runs in families. In a 2000 study published in The American Journal of Psychiatry, researchers at Virginia Commonwealth University studied 2,163 female twins and found that 77 of them suffered from symptoms of anorexia. By comparing the number of identical twins who had anorexia with the significantly smaller number of fraternal twins who had it, scientists concluded that more than 50 percent of the risk for developing the disorder could be attributed to an individual's genetic makeup. A few small studies have even isolated a specific area on the human genome where some of the mutations that may influence anorexia exist, and now a five-year, $10 million NIMH study is underway to further pinpoint the locations of those genes. Amy Nelson, 14, a ninth-grader from a Chicago suburb, thinks that genes played a role in her disease. Last year Amy's weight dropped from 105 to a skeletal 77 pounds, and her parents enrolled her in the day program at the Alexian Brothers Behavioral Health Hospital outside Chicago. Over the summer, as Amy was getting better, her father found the diary of his younger sister, who died at 18 of "unknown causes." In it, the teenager had calculated that she could lose 13 pounds in less than a month by restricting herself to less than 600 calories a day. No salt, no butter, no sugar, "not too many bananas", she wrote in 1980. "Depression can run in families," says Amy, "and an eating disorder is like depression. It's something wrong with your brain:' These days, Amy is healthier and, though she doesn't weigh herself, thinks she's around 100. She has a part in the school play and is more casual about what she eats, even to the point of enjoying ice cream with friends. Scientists are tracking important differences in the brain chemistry of anorexics. Using brain scans, researchers at the University of Pittsburgh, led by professor of psychiatry, Dr. Walter Kaye, discovered that the level of serotonin activity in the brains of anorexics is abnormally high. Although normal levels of serotonin are believed to be associated with feelings of well-being, these pumped-up levels of hormones may be linked to feelings of anxiety and obsessional thinking, classic traits of anorexia. Kaye hypothesizes that anorexics use starvation as a mode of self-medication. How? Starvation prevents tryptophane, an essential amino acid that produces serotonin, from getting into the brain. By eating less, anorexics reduce the serotonin activity in their brains, says Kaye, "creating a sense of calm;" even as they are about to die of malnutrition. Almost everyone knows someone who has trouble with food: extremely picky eating, obsessive dieting, body-image problems, even voluntary vomiting are well known. But in the spectrum of eating disorders, anorexia, which affects about 2.5 million Americans, stands apart. For one thing, anorexics are often delusional. They can be weak with hunger while they describe physical sensations of overfullness that make it physically uncomfortable for them to swallow. They hear admonishing voices in their heads when they do manage to choke down a few morsels. They exercise compulsively, and even when they can count their ribs, their image in the mirror tells them to lose more. When 12-year-old Erin Phillips, who lives outside Baltimore, was in her downward spiral, she stopped eating butter, then started eating with chopsticks, then refused solid food altogether, says her mother, Joann. Within two months, Erin's weight had slipped from 70 to 50 pounds. "Every day, I'd watch her melt away," Joann says. Before it struck her daughter, Joann had been dismissive about the disease. "I used to think the person should just eat something and get over it. But when you see up close, you can't believe your eyes. They just can't." (Her confusion is natural: the term anorexia comes from a Greek word meaning "loss of appetite.") Anorexia is a killer--it has the highest mortality rate of any mental illness, including depression. About half of anorexics get better. About 10 percent of them die. The rest remain chronically ill--exhausting, then bankrupting, parents, retreating from jobs and school, alienating friends as they struggle to manage the symptoms of their condition. Hannah Hartney of Tulsa, Okla., was first hospitalized with anorexia when she was 10. After eight weeks, she was returned to her watchful parents. For the last few years, she was able to maintain a normal weight, but now, at 16, she's been battling her old demons again. "She's not out of the woods," says her mother, Kathryn. While adults can drift along in a state of semi-starvation for years, the health risks for children under the age of 13 are dire. In their preteen years, kids should be gaining weight. During that critical period, their bones are thickening and lengthening, their hearts are getting stronger in order to pump blood to their growing bodies and their brains are adding mass, laying down new neurological pathways and pruning others--part of the explosion of mental and emotional development that occurs in those years. When children with eating disorders stop consuming sufficient calories, their bodies begin to conserve energy: heart function slows, blood pressure drops; they have trouble staying warm. Whatever estrogen or testosterone they have in their bodies drops. The stress hormone cortisol becomes elevated, preventing their bones from hardening. Their hair becomes brittle and falls out in patches. Their bodies begin to consume muscle tissue. The brain, which depends at least in part on dietary fat to grow, begins to atrophy. Unlike adult anorexics, children with eating disorders can develop these debilitating symptoms within months. Lori Cornwell says her son's descent was horrifyingly fast. In the summer of 2004, 9-year-old Matthew Cornwell of Quincy, Ill., weighed a healthy 49 pounds. Always a picky eater, he began restricting his food intake until all he would eat was a carrot smeared with a tablespoon of peanut butter. Within three months, he was down to 39 pounds. When the Cornwells and their doctor finally located a clinic that would accept a 10-year-old boy, Lori tucked his limp body under blankets in the back seat of her car and drove all night across the country. Matthew was barely conscious when he arrived at the Children's Hospital in Omaha. "I knew that I had to get there before he slipped away," she says. With stakes this high, how do you treat a malnourished third grader who is so ill she insists five Cheerios make a meal? First, say a growing number of doctors and patients, you have to let parents back into the treatment process. For more than a hundred years, parents have been regarded as an anorexic's biggest problem, and in 1978, in her book "Golden Cage," psychoanalyst Hilde Bruch suggested that narcissistic, cold and unloving parents (or, alternatively, hypercritical, overambitious and overinvolved ones) actually caused the disease by discouraging their children's natural maturation to adulthood. Thirty years ago standard treatment involved helping the starving and often delusional adolescents or young women to separate psychologically--and sometimes physically--from their toxic parents. "We used to talk about performing a parental-ectomy," says Dr. Ellen Rome, head of adolescent medicine at the Cleveland Clinic. Too often these days, parents aren't so much banished from the treatment process as sidelined, watching powerlessly as doctors take what can be extreme measures to make their children well. In hospitals, severely malnourished anorexics are treated with IV drips and nasogastric tubes. In long-term residential treatment centers, an anorexic's food intake is weighed and measured, bite by bite. In individual therapy, an anorexic tries to uncover the roots of her obsession and her resistance to treatment. Most doctors use a combination of these approaches to help their patients get better. Although parents are no longer overtly blamed for their child's condition, says Marlene Schwartz, codirector of the Yale eating-disorder clinic, doctors and therapists "give parents the impression that eating disorders are something the parents did that the doctors are now going to fix:" Worse, the state-of-the-art protocols don't work for many young children. A prolonged stay in a hospital or treatment center can be traumatic. Talk therapy can help some kids, but many others are too young for it to be effective. Back at home, family mealtimes become a nightmare. Parents, advised not to badger their child about food, say nothing--and then they watch helpless and heartbroken as their child pushes the food away. In the last three years, some prominent hospitals and clinics around the country have begun adopting a new treatment model in which families help anorexics get better. The most popular of the home-based models, the Maudsley approach, was developed in the 1980s at the Maudsley Hospital in London. Two doctors there noticed that when severely malnourished, treatment-resistant anorexics were put in the hospital and fed by nurses, they gradually gained weight and began to participate in their own recovery. They decided that given the right support, family members could get anorexics to eat in the same way the nurses did. These days, family-centered therapy works like this: A team of doctors, therapists and nutritionists meets with parents and the child. The team explains that while the causes of anorexia are unclear, it is a severe, life-threatening disease like cancer or diabetes. Food, the family is told, is the medicine that will help the child get better. Like oncologists prescribing chemotherapy, the team provides parents with a schedule of calories, lipids, carbohydrates and fiber that the patient must eat every day and instructs them on how to monitor the child's intake. It coaches siblings and other family members on how to become a sympathetic support team. After a few practice meals in the hospital or doctor's office, the whole family is sent home for a meal. "I told my daughter, `You're going to hate this,' says Mitzi Miles, whose daughter Kaleigh began struggling with anorexia at 10. "She said, `I could never hate you, Mom: And I said, `We'll see." The first dinner at the Miles home outside Harrisburg, Pa., was a battle--but Mitzi, convinced by Kaleigh's doctor she was doing the right thing, didn't back down. After 45 minutes of yelling and crying, Kaleigh began to eat. Over the next 20 weeks, Kaleigh attended weekly therapy sessions, and Mitzi got support from the medical team, which instructed her to allow Kaleigh to make more food choices on her own. Eleven months later, Kaleigh is able to maintain a normal weight. Mitzi no longer measures out food portions or keeps a written log of her daily food intake. Critics point out that the Maudsley approach won't work well for adults who won't submit to other people's making their food choices. And they charge that in some children, parental oversight can do more harm than good. Young anorexics and their parents are already locked in a battle for control, says Dr. Alexander Lucas, an eating-disorder specialist and professor emeritus at the Mayo Clinic in Minnesota. The Maudsley approach, he says, "may backfire by making meals into a battleground. "The focus on weight gain;" he says, "has to be between the physician and the child." Even proponents say that family-centered treatment isn't right for everyone: families where there is violence, sexual abuse, alcoholism or drug addiction aren't good candidates. But several studies both in clinics at the Maudsley Hospital and at the University of Chicago show promising results: five years after treatment, more than 70 percent of patients recover using the family-centered method, compared with 50 percent who recover by themselves or using the old approaches. Currently, a large-scale NIH study of the Maudsley approach is underway. Mental-health specialists say the success of the family-centered approach is finally putting the old stigmas to rest "An 8-year-old with anorexia isn't in a flight from maturity;" says Dr. Julie O'Toole, medical director of the Kartini Clinic in Portland, Ore., a family-friendly eating-disorder clinic. "These young patients are fully in childhood." Most young anorexics, O'Toole says, have wonderful, thoughtful, terribly worried parents. These days, when a desperately sick child enters the Kartini Clinic, O'Toole tries to set parents straight. "I tell them it's a brain disorder. Children don't choose to have it and parents don't cause it." Then she gives the parents a little pep talk. She reminds them that mothers were once blamed for causing schizophrenia and autism until that so-called science was debunked. And that the same will soon be true for anorexia. At the conclusion of O'Toole's speech, she says, parents often weep. Ironically, family dinners are one of the best ways to prevent a vulnerable child from becoming anorexic. Too often, dinner is eaten in the back seat of an SUV on the way to soccer practice. Parents who eat regular, balanced meals with their children model good eating practices. Family dinners also help parents spot. any changes in their child's eating habits. Dieting, says Dr. Craig Johnson, director of the eating-disorder program at Laureate Psychiatric Hospital in Tulsa, triggers complex neurobiological reactions. If you have anorexia in the family and your 11-year-old tells you she's about to go on a diet and is thinking about joining the track team, says Johnson, "you want to be very careful about how you approach her request." For some kids, innocent seeming behavior carries enormous risks. Children predisposed to eating disorders are uniquely sensitive to media messages about dieting and health. And their interpretation can be starkly literal. When Ignatius Lau of Portland, Ore., was 11 years old, he decided that 140 pounds was too much for his 5-foot-2 frame. He had heard that oils and carbohydrates were fattening, so he became obsessed with food labels, cutting out all fats and almost all carbs. He lost 32 pounds in six months and ended up in a local hospital. "I told myself I was eating healthier," Ignatius says. He recovered, but for the next three years suffered frequent relapses. "I'd lose weight again and it would trigger some of my old behaviors, like reading food labels,' he says. These days he knows what healthy feels like. Ignatius, now 17, is 5 feet 11, 180 pounds, and plays basketball. Back in Richmond, Va., Emily Krudys says her family has changed. For two months Katherine stayed at the Omaha Children's Hospital, and slowly gained weight. Emily stayed nearby--attending the weekly therapy sessions designed to help integrate her into Katherine's treatment. After Katherine returned home, Emily home-schooled her while she regained her strength. This fall, Katherine entered sixth grade. She's got the pony, and she's become an avid horsewoman, sometimes riding five or six times a week. She's still slight, but she's gaining weight normally by eating three meals and three or four snacks a day. But the anxiety still lingers. When Katherine says she's hungry, Emily has been known to drop everything and whip up a three-course meal. The other day she was startled to see her daughter spreading sour cream on her potato. "I thought, `My God, that's how regular kids eat all the time'," she recalls. Then she realized that her daughter was well on the way to becoming one of those kids. THE SIGNS A person with anorexia may show any or all of these symptoms. Parents should talk about their concerns to kids and consult a doctor or counselor for treatment options. 1. Loses weight dramatically 2. Refuses to eat certain foods 3. Obsesses over body weight, calories, food or dieting 4. Has bizarre eating rituals, such as rearranging food on the plate, excessive chewing or eating food in a certain order 5. Makes excuses to avoid mealtimes and eating 6. Complains frequently about feeling fat 7. Exercises obsessively, even during bad weather or illness; feels the need to burn off any calories taken in 8. Frequently weighs herself 9. Won't eat in front of others 10. Denies being hungry 11. Wears baggy clothes to hide appearance 12. Moody, depressed, withdrawn THE PRICE OF PERFECTION Heart: Starved of energy, it can't pump properly. Patients of all ages feel weak, and have trouble keeping warm. Electrolyte shortages can cause palpitations. Digestion: The GI tract slows, leaving patients feeling constipated and full. This can exacerbate their already strong aversion to eating. Hormones: Extreme weight loss disrupts sex-hormone production. This can delay puberty in both girls and boys. Girls who remain anorexic into adulthood can suffer from infertility. Hair becomes thin, dry and brittle from protein deficiencies. Skin dries out and is easily bruised; may sprout a fine layer of hair as insulation. Bones: Robbed of essential nutrients like calcium, anorexic children lack the basic building blocks for a strong skeletal system. If kids don't lay down enough bone during puberty, they're at increased risk for fractures later in life. Muscles: Atrophy sets in, sapping strength and mass. Kidneys: A severe lack of fluids can lead to organ failure. GETTING HELP Treatment: The first step is restoring healthy body weight. Then: 1. Psychotherapy can address the underlying emotional issues of anorexia, such as obsessiveness compulsiveness, profound mental rigidity and perfectionism 2. Medications help treat the depression and anxiety that often accompany anorexia 3. Family therapy can help young patients confront stresses in the home that may be exacerbating their conditions FOR MORE INFORMATION: 1. National Eating Disorders Association (tips for teachers and parents, specialist referrals): nationaleatingdisorders.org 2. Something Fishy (chat rooms offer online support for families and patients): www.something-fishy.org 3. National Institute of Mental Health (research news, treatment strategies, statistics): www.nimh.nih.gov/publicat/ eatingdisorders.cfm A Father Descirbes His Daughter's Journey James Berrien, Newsweek- 12/5/2005 Thirteen fathrs stood in a circle holding hands. Each one of us had a different story about how we got to this place. Thirteen of us standing together at the Laureate Psychiatric Center in Tulsa, Okla., trying to understand how to help our children, and ourselves. Each of our kids was trying to recover from what I have come to learn is as insidious and life-threatening a disease as exists today. What we had in common was a feeling of powerlessness coupled with the very real sadness that our children were dealing with something so hard to understand, so upside down, that all our natural instincts--of protectiveness, of support and of control--were ineffective. We had learned, or had at least been told during family terapy sessions, that despite the popular notion, we the parents were not responsible for our daughters' illnesses. Individuals are thought to be genetically predisposed to eating disorders, so maybe weere off the hook. On the other hand, these were our babies, and we wanted to make them better. Six months earlier, my wife, Mary Jane, and I learned that our 16-year-old daugher, Lacey, had been quietly and couraeously battling anorexia. We had no idea it was happening. We had family dinners together every night. Sure, she was moody, impatient and private about her life. But what teenager isn't? Then some of 1 acey's friends and coaches called her older sister, Reid, to wam her of the problem, and thanks to Reid's persistence, an emotional confession ensued that brought us all face to face with this unexpected situation. It took an amazing amount of courage for Lacey to be open with herself and with us. But once the secret was out, we had no idea what to do. Our initial impulse was to fix the problem ourselves. A teacher at Lacey's school introduced us to Dr. Diane Mickley, founder of the Wilkins Center for Eating Disorders in Greenwich, Conn., and at her recommendation, Lacey started seeing a nutritionist, a therapist and Diane herself. In many ways this was the hardest part for all of us. We were advised to be trusting and supportive without being too intrusive. Because Lacey's disease was triggred by a feeling of being out of control, we hoped that, with help, she could begin to recover on her own by understanding a that she did, in fact, have some control. This turned out, ultimately, to be an impossible challenge. will always remember the day we sat again in Diane's office as she phoned the Laureate Center. Three days later we were all headed to Tulsa. It was an incredibly emotional time. We shopped for the things Lacey would need and took note of the things she would not be allowed to have (imagine airport security times 100). I bought a silver band for each of us to wear as a symbol of love and support. We spent our last night together at a place we would come to know all too well, the Embassy Suites, and in the morning said our goodbyes. As I write this, I can see in my mind the hug and tears that Mary Jane, Lacey and I shared in what felt like the most desperate moment of our lives. I know that Reid, who was not with us, ached from afar. The thought of leaving Lacey alone, 1,500 miles away in a place where her every action was monitored, was beyond comprehension. And so the process of helping Lacey heal in the hands of devoted professionals began. We called the center every evening and spoke with her only after giving a code number that showed we were "approved" callers. We visited several times, and were constantly thinking about how to help her and how to stay healthy ourselves. We brought Lacey home after two months, with the approval of her doctors, in time to celebrate our 25th wedding anniversary. Surrounded by friends and family, Lacey and her sister stood to make a toast. Lacey joked about how hard it was to tear herself away from Tulsa, and both Mary Jane and I knew that our little girl had returned home, much healthier and better equipped to deal with the challenging nature of the disease. Our process together is not over, and Mary Jane and I still struggle with the notion of staying involved but not getting in the way. It has helped tremendously that we have been open with everyone from the very beginning. For Lacey, I know, this has been hard. But we all realize that there is no shame here, no one to blame. We are a closer and more open family as a result. As a dad, I have learned that I can't make everything better. As a husband, I have learned that I can't expect Mary Jane to feel everything I feel. We are lucky to have been able to find and afford the best care. We are lucky to have hugely supportive friends and family. Most of all, we are blessed to have two healthy daughters who love each other and who love us. My guess is we will continue to wear our silver rings long past Lacey's recovery as a reminder of how lucky we all are to have each other. Instant Millions Can't Halt Winners' Grim Slide James Dao, New York Times- 12/5/2005 CORBIN, Ky., Nov. 30 - For Mack W. Metcalf and his estranged second wife, Virginia G. Merida, sharing a $34 million lottery jackpot in 2000 meant escaping poverty at breakneck speed. Years of blue-collar struggle and ramshackle apartment life gave way almost overnight to limitless leisure, big houses and lavish toys. Mr. Metcalf bought a Mount Vernon-like estate in southern Kentucky, stocking it with horses and vintage cars. Ms. Merida bought a Mercedes-Benz and a modernistic mansion overlooking the Ohio River, surrounding herself with stray cats. But trouble came almost as fast. And though there have been many stories of lottery winners turning to drugs or alcohol, and of lottery fortunes turning to dust, the tale of Mr. Metcalf and Ms. Merida stands out as a striking example of good luck -- the kind most people only dream about -- rapidly turning fatally bad. Mr. Metcalf's first wife sued him for $31,000 in unpaid child support, a former girlfriend wheedled $500,000 out of him while he was drunk, and alcoholism increasingly paralyzed him. Ms. Merida's boyfriend died of a drug overdose in her hilltop house, a brother began harassing her, she said, and neighbors came to believe her once welcoming home had turned into a drug den. Though they were divorced by 2001, it was as if their lives as rich people had taken on an eerie symmetry. So did their deaths. In 2003, just three years after cashing in his winning ticket, Mr. Metcalf died of complications relating to alcoholism at the age of 45. Then on the day before Thanksgiving, Ms. Merida's partly decomposed body was found in her bed. Authorities said they have found no evidence of foul play and are looking into the possibility of a drug overdose. She was 51. Ms. Merida's death remains under investigation, and large parts of both her and Mr. Metcalf's lives remain wrapped in mystery. But some of their friends and relatives said they thought the moral of their stories was clear. "Any problems people have, money magnifies it so much, it's unbelievable," said Robert Merida, one of Ms. Merida's three brothers. Mr. Metcalf's first wife, Marilyn Collins, said: "If he hadn't won, he would have worked like regular people and maybe had 20 years left. But when you put that kind of money in the hands of somebody with problems, it just helps them kill themselves." As a young woman, Ms. Merida lived with her family in Houston where her father, Dempsey Merida, ran a major drug-trafficking organization, law enforcement officials say. He and two of his sons, David and John, were indicted in 1983 and served prison sentences on drug-related convictions. John Murphy, the first assistant United States attorney for the western district of Texas, who helped prosecute the case, said the organization smuggled heroin and cocaine into Texas using Mr. Merida's chain of auto transmission shops as fronts. Mr. Murphy described Mr. Merida as a gruff, imposing man who tried to intimidate witnesses by muttering loudly in court. Mr. Merida received a 30-year sentence but was released in 2004 because of a serious illness, Mr. Murphy said. He died just months later in Kentucky at age 76. When Dempsey Merida and his two sons went to prison, his wife moved the family to northern Kentucky. Virginia Merida married, had a son, was divorced and married again, to Mack Metcalf, a co-worker at a plastics factory. But he drank too much and disappeared for long stretches of time, friends of Ms. Merida said, leaving her alone to care for her son and mother. She worked a succession of low-paying jobs, lived in cramped apartments, drove decrepit cars and struggled to pay rent. For his part, Mr. Metcalf drifted from job to job, living at one point in an abandoned bus. Then one July day in 2000, a friend called Ms. Merida and gave her some startling news: Mr. Metcalf had the winning $3 ticket for a $65 million Powerball jackpot. Ms. Merida had refused to answer his calls, thinking he was drunk. "Mack kept calling here, asking me to go tell Ginny that he had won the lottery," said Carolyn Keckeley, a friend of Ms. Merida. "She wouldn't believe him." At the time, both were barely scraping by, he by driving a forklift and she by making corrugated boxes. But in one shot, they walked away with a cash payout of $34 million, which they split 60-40: he received about $14 million after taxes, while she got more than $9 million. In a statement released by the lottery corporation, Mr. Metcalf said he planned to move to Australia. "I'm going to totally get away," he said. But problems arrived almost immediately. A caseworker in Northern Kentucky saw Mr. Metcalf's photograph and recognized him as having been delinquent in child support payments to a daughter from his first marriage. The county contacted Mr. Metcalf's first wife and they took legal action that resulted in court orders that he pay $31,000 in child support and create a $500,000 trust fund for the girl, Amanda, his only child. Ms. Collins, his first wife, said Mr. Metcalf abandoned the family when Amanda, now 21, was an infant, forcing them into near destitution. "I cooked dinner and set the table for six months for him, but he never came back," said Ms. Collins, 38. They were divorced in 1986. Even as he was battling Ms. Collins in court, Mr. Metcalf was filing his own lawsuit to protect his winnings. In court papers, he asserted that a former girlfriend, Deborah Hodge, had threatened and badgered him until he agreed, while drunk, to give her $500,000. Ms. Hodge vowed to call witnesses to testify that Mr. Metcalf had given money to other women as well. Mr. Metcalf's suit was dismissed after he walked out of a deposition, according to court papers. Still, there were moments of happiness. Shortly after winning the lottery, he took Amanda shopping in Cincinnati, giving her $500 to buy clothing and have her nails done. "I had never held that kind of money before," Ms. Metcalf said. "That was the best day ever." Pledging to become a good father, he moved to Corbin to be near Amanda, buying a 43-acre estate with a house modeled after Mount Vernon for $1.1 million. He collected all-terrain vehicles, vintage American cars and an eccentric array of pets: horses, Rottweilers, tarantulas and a 15-foot boa constrictor. He also continued to give away cash. Neighbors recall him buying goods at a convenience store with $100 bills, then giving the change to the next person in line. Ms. Metcalf said she discovered boxes filled with scraps of paper in his home recording money he had given away, debts he would never collect. His drinking got worse, and he became increasingly afraid that people were plotting to kill him, installing surveillance cameras and listening devices around his house, Ms. Metcalf said. Then in early 2003, he spent a month in the hospital for treatment of cirrhosis and hepatitis. After being released from the hospital, he married for the third time, but died just months later, in December. Virginia Merida seemed to handle her money better. She repaid old debts, including $1,000 to a landlord who had evicted her years earlier. She told a friend she had set aside $1 million for retirement. But she splurged enough to buy a Mercedes and a geodesic-dome house designed by a local architect in Cold Spring for $559,000. She kept the furnishings simple, neighbors said, but bought several arcade-quality video games for her son, Jason. For a time, Ms. Merida's mother lived with her as well. "I was at her house a year after she moved in, and she said she hadn't even unpacked," said Mary Jo Watkins, a neighbor. "It was as if she didn't know how to move up." Then in January, a live-in boyfriend, Fred Hill, died of an overdose of an opiate-related drug, according to a police report. No charges were filed, and officials said it was not clear if the opiate was heroin or a prescription drug. But neighbors began to believe that the house had become a haven for drug use or trafficking. "I think we all suspected that some drug problems were going on there because so many people were coming and going," Ms. Watkins said. In May, Ms. Merida filed a complaint in Campbell County Circuit Court against one of her brothers, David, saying that he had been harassing her. In June 16, a circuit court judge ordered both brother and sister to keep away from each other. It was unclear why she filed the complaint, and David Merida would not comment. When Ms. Merida's son found her body on Nov. 23, she had been dead for several days, the county coroner's office said. There was no evidence of a break-in, or that she had been attacked, officials said. Toxicological studies on her remains will not be completed for several weeks. It is unclear how much of Ms. Merida's estate remains, but it appears she saved some of it. That may not have been the case with Mr. Metcalf, his daughter said. Six months after his death, his house in Corbin was sold for $657,000, about half of what Mr. Metcalf had paid for it. In a brief obituary in The Kentucky Enquirer, Ms. Merida's family described her simply as "a homemaker." On a black tombstone, Ms. Metcalf had this inscribed for her father, "Loving father and brother, finally at rest."
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