Noteworthy News Articles on Mental Health Topics, December 18-27, 2005
William Hathaway, Hartford Courant- 12/18/2005 Dr. Kent A. Kiehl has interviewed dozens of psychopaths over the past decade, but as he listens to the easy, casual ingratiating way they talk about their heinous acts he remains as astonished as he is repulsed. "I think, `I can't believe this guy is telling me he bashed in his mother's head with a propane tank,'" Kiehl says. Kiehl and a team of researchers at Hartford Hospital's Institute of Living are using brain scans in an attempt to explain the inexplicable: What makes some people absolutely devoid of empathy and remorse? Society needs answers because of the sheer havoc psychopaths create, the researchers say. Superficially charming, psychopaths lie, steal, rape, rob, embezzle, assault and abuse with no compunction, no conscience. But all psychopaths are notoriously impervious to rehabilitation. Psychopaths account for a quarter of all prisoners in the United States - and for as much as 50 percent of all violent crime, the researchers estimate. There are also hundreds of thousands of psychopaths in the United States who manage to stay out of prison, but nonetheless dole out immeasurable amounts of pain in homes, schools, even corporate boardrooms. Within the pattern of bright blue and yellow blotches on the brain scans he has taken, Kiehl believes he has found the dark contours of the psychopathic mind. When psychopaths see or hear emotional words or pictures of misery, areas of their brains that should light up like a Christmas tree are dark and devoid of activity. Instead, their brains process information such as a picture of a bereaved mother holding her dead child in the same way they would react to a picture of a chair or shovel. Psychopaths seem to know the words, but they can't hear the music, researchers often say. In probing the abyss of the psychopathic mind, Kiehl and others are raising questions about our criminal justice system and our assumptions about human morality. Beyond Bundy Kiehl's own quest began with stories his father, a newspaper editor, told about serial killer Ted Bundy, who grew up in the same Tacoma, Wash., neighborhood as the Kiehls. Bundy was the archetypal psychopath - handsome, disarmingly charming and utterly ruthless. His outwardly clean-cut appearance and his cunning - he volunteered for a suicide hot line and the Republican Party - made Bundy a virtuoso killer. He was known to use crutches as props and feign car trouble to induce young victims to give him a ride. He eventually confessed to more than two dozen murders, but he is thought to have killed dozens more during a spree in the mid- to late 1970s. "The question has always been, `What makes people do something like that?'" Kiehl said. Years later, while doing postgraduate studies in neurobiology at the University of California at Davis, Kiehl decided he would try to answer the question. He launched a campaign to get hired in the lab of the guru of psychopathy: Robert D. Hare, now professor emeritus of psychology at the University of British Columbia. Hare told him he "didn't hire Americans." But after a concerted sales pitch, which included a gift of baseball tickets to a Toronto Blue Jays game, Kiehl says Hare relented and hired the young researcher in 1994. It was an auspicious time in psychopathy research. Hare's research had given the nascent field some terminology to use. And new imaging technology was just beginning to open a window onto the dark world of the psychopathic brain. The personality type had been known for centuries. In the 18th century, Frenchman Philippe Pinel coined the term "insanity without delirium" to describe aberrant behavior accompanied by a complete lack of remorse. The study of psychopathy in the United States dates from 1941, when Hervey Cleckley published a book called "The Mask of Sanity" that described psychopaths as unusually intelligent people, characterized by a "poverty of emotions." But it wasn't until Hare devised his psychopathy checklist in 1980 - which he revised in 1991 - that an easily identified set of personality characteristics defined the condition and opened up a field of research. "There was a gut feeling that there was something different" about psychopaths, Hare said. There was. Grading Psychopaths Psychopaths aren't crazy, at least in a traditional medical sense, but they are unfettered by any sense of shame or guilt. Symptoms can show up early in life. Psychopathic children have total disregard for rules and engage in unusually vicious assaults or torture animals. Kiehl has received a federal grant to see whether children diagnosed with "callous conduct disorder" might actually be budding psychopaths. Researchers have come to the conclusion that while a hostile environment can contribute to the development of psychopathy, many psychopaths are born, not made. Studies of twins suggest that psychopathic tendencies can develop even in loving homes. Some studies suggest that male psychopaths outnumber females by about 3 to 1. The general lack of social causes for the disorder is one reason why most experts no longer use the term "sociopath" to describe a psychopath. Researchers say as many as 1 out of every 100 people in the United States may meet the classification of a psychopath; serial killers make up a tiny minority of them. The revised psychopathy checklist, known as the PCL-R, lists 20 traits and behaviors common to the disorder. Experts who are trained in administering the test score subjects with a 0, 1 or 2 on each item on the checklist. Hare said most people might score a 4 on his PCL-R checklist. A person is not designated a psychopath unless he or she scores 30 or more on the scale of 40. The higher the score, the more devastation a psychopath is likely to cause. Somebody who scores a 27 probably wouldn't be a great dinner guest. Psychopaths are pathological liars who crave stimulation, are sexually promiscuous and unable to control their behavior. They typically lack realistic long-term goals. They may be master manipulators, but psychopaths have a hard time concealing their nature from people trained to use the checklist, Kiehl said. Inevitably, they lie, boast or reveal their callousness. "They can't help themselves," he said. People who deal with psychopaths have observed another shared quality, one not on the checklist or easily measured. There is something different about their eyes. The gaze of the psychopath is disquieting, even frightening, and has been described as cold or penetrating, empty, reptilian, not quite human. They lack any depth to their emotions and the ability to connect emotion to cognition "They don't quite get it," Hare said. "There is something missing." `I Never Hurt People' In the mid-1990s, in Canadian prisons, Kiehl began to perfect the art of using the checklist to score prisoners, who were told their interviews would not be shared with law enforcement authorities. In training tapes he recorded, Kiehl, a burly former football player, maintains a steady voice as he peppers subjects with short questions. In one tape, a 30-something man with long sideburns and thinning hair, dressed in a green windbreaker, answers Kiehl's questions with an easy smile, a collegial, confiding, "just between us boys" air. "Sideburns" confesses to bootlegging cigarettes, petty thefts. "Do you have a temper?" asks Kiehl, who is off camera. "Oh yes, explosive," Sideburns answers. "Do you assault people?" "Oh, I never physically hurt people." "What happens when you lose your temper?" "Oh, I can just lose it. Like the time I killed my girlfriend." The blurted truth comes quick as a cobra strike. There is nothing in the man's face or voice to suggest he even recognizes he had told a lie about hurting people. When he relates how he held his girlfriend's head under water in a bathtub, there is no hesitation or pause in his voice, no change in tenor or inflection that hints he is aware the interview has shifted to a different moral ground. "Police said she was already unconscious," he says, as if the statement absolves him of wrongdoing. He changes the subject to all the stolen electronic equipment he gave the woman. For the first time, Sideburns seems a bit worked up. When you steal electronics, he asks, "Do you know how hard it is to find remote controls?" Spotting The Predators Warning the public about the dangers of such psychopaths is a passion for Hare, author of the book "Without Conscience." Hare said zebras and other animals congregating around an African waterhole know to scatter when they see a lion. "There you can identify a predator, but psychopaths don't wear bells around their necks," Hare said. Psychopaths tend to thrive "where the rules are obscure, where there is chaotic upheaval," Hare said. "Countries such as Yugoslavia and the Soviet Union after their breakups were a warm niche for psychopaths, who simply moved in to take advantage of the chaos." A corporation that is disorganized and growing quickly offers the same type of fertile environment, Hare said. In a book tentatively titled "Snakes in Suits" to be published next spring, Hare blames scandals such as the destruction of Enron at least partly on a category of psychopaths who typically know how to stay out of jail. Hare's checklist today has provided a generally accepted definition of the psychopath, the "who" and the "what" that allows researchers from different disciplines to study the phenomenon. Hare says his checklist has been both abused and underused. He railed against a judge in Texas, for instance, who has sentenced defendants to death because he has deemed them psychopaths, even though they were never examined by people trained to use his checklist. But Hare also says many parole boards underutilize psychopathic evaluations when considering whether to release a prisoner. How a prisoner scores on the 20 characteristics of Hare's checklist "is the best predictor of recidivism that we have," said Diana Fishbein, a researcher at RTI International of Research Triangle Park in North Carolina. About half of prisoners released from jail wind up back there within three years, Kiehl said. The number skyrockets to at least 4 in 5 when the prisoner is a psychopath. And psychopaths seem to be immune to any sort of therapy that might better those odds. One study explored whether group therapy might lower the recidivism rate of psychopaths. Sixty percent of untreated psychopaths in the study were back in jail after a year. But 80 percent of psychopaths who participated in group therapy were convicted of another offense in the same period. "They used the sessions to learn how to exploit the emotions of others," Kiehl said. Some people debate the value of using the checklist to determine sentences for individual killers. The recidivism rate is not 100 percent for psychopaths, noted Dr. Michael Norko, director of the Whiting Forensic Division of Connecticut Valley Hospital. And using the checklist is akin to doing a DNA analysis for an incurable disease. What are you going to do if you find it? "It would be different if we had a pill for psychopathy," Norko said. Devoid Of Emotion Kiehl says he believes that brain imaging studies can pinpoint the biological cause of psychopathic behavior and possibly lead to a remedy, perhaps even a psychopathy pill. "If we could develop a treatment for psychopaths, it would alleviate an enormous burden on society," said Kiehl, who is director of the clinical cognitive neuroscience laboratory at the institute's Olin Neuropsychiatry Research Center. He has a theory of where in the brain to look. His previous work showed a peculiar pattern of brain activity in psychopaths when they were presented with different words or images. Using both an electroencephalograph (EEG), which measures electrical activity in the brain, and functional magnetic resonance imaging scans, which measure oxygen use, Kiehl found striking differences between psychopaths and non-psychopaths in the activity of several regions of the brain. He is particularly intrigued by abnormalities in psychopaths' brains, in what he calls the paralimbic system, a loose organization of brain structures involved in processing emotion. In most people, that picture of a distraught woman holding a dead child will trigger heightened activity in these brain areas, including a region called the amygdale. In contrast, the brains of criminal psychopaths respond much as they would to any inanimate object. Kiehl and other scientists have also found heightened brain activity in the frontal cortex of psychopaths when they are presented with emotionally charged words or images. The frontal cortex helps govern reason and planning. Some scientists have interpreted that as evidence that the root of psychopathic behavior lies in the frontal cortex. But Kiehl and others see it differently. People with injuries to the frontal cortex do not exhibit the goal-directed aggression or callousness often associated with psychopaths, Kiehl says. Kiehl believes psychopaths enlist areas of the frontal cortex to process information that the brain usually processes in its emotional centers. On his desk at the Institute of Living, Kiehl keeps a replica of a railroad spike, a memento of an 1848 accident that befell a Vermont construction foreman named Phineas Gage. An explosion drove a 3-foot-7-inch tamping iron through Gage's brain. The sheer improbability of his survival - the tamping iron entered under his cheekbone, exited the top of his skull and landed 25 feet away - assured Gage a place in the history of medical oddities. But the changes in his behavior made him famous. Gage, who had been a reliable worker and a sober, churchgoing, devoted family man, became an irresponsible cad, ignoring his wife, children and job. In short, he acted like a psychopath. Kiehl notes that the tamping iron damaged the paralimbic system in Gage's brain, the same areas that seem abnormal in the brain's of psychopaths. Kiehl's theory explains, for instance, why psychopaths seldom seem to experience anxiety or fear in the same way normal people do and why they do not fully comprehend the meaning of emotions such as love or compassion. "For a psychopath, it is all cognition," Kiehl said. His lab has received federal grants totaling $6 million for the study of psychopathy. In one study, he is investigating whether one reason that drug abuse treatment programs have a high failure rate in prisoners is because so many psychopaths are enrolled. Psychopaths do not respond to traditional treatment and Kiehl suspects that, while psychopaths are heavy drug and alcohol abusers, they do not develop the same sort of dependency on drugs as non-psychopaths. To test his hypothesis, he hopes to persuade Connecticut correctional officials to allow his team to study teen and adult inmates. If Kiehl's ideas are borne out by research, they may suggest ways to change psychopathic behavior. For now, Hare believes that any therapeutic approach must appeal to the psychopath's own self-interest because treatments based on an appreciation of somebody else's feelings are bound to fail. Understanding the underlying physiology of the disorder could lead to a drug that might actually restore emotional responses and cure psychopaths, said Dr. James Blair, an expert in psychopathy and a researcher at the National Institute of Mental Health, part of the National Institutes of Health. Blair points out that the symptoms of psychopathy are almost exactly the opposite of symptoms of people who suffer from post-traumatic stress and anxiety disorders - conditions for which treatments now exist. Roots Of Morality Kiehl hopes that by explaining how psychopaths' minds work, he can help arm society with the tools to deal with them. One of his research associates, Jana Schaich-Borg, also wants to answer a more fundamental question: Why are most humans moral in the first place? If Kiehl is correct that a failure of the emotional processing centers of the brain is at the root of psychopathy, then it follows that moral behavior might arise in those same areas. If a pill could create emotional responses in a psychopath, could such a drug also give him a moral core? Schaich-Borg plans to investigate whether psychopaths feel disgust - or the deeply ingrained reaction that people in most cultures have about, say, handling feces or having sex with a sibling. She speculates that the areas of the brain that govern disgust in a normal person may also play a role in the formation of more sophisticated moral beliefs, which are absent in psychopaths. For years, the link between instincts and moral decision-making has been inferred from fictional ethical scenarios. Schaich-Borg offers one example: Five people are tied up on a railroad track and a locomotive barrels toward them. You can save them, but only by pulling a lever and switching the locomotive to a different track, where two other people are tied. Do you pull the lever? People answer instinctively, and study after study shows that they are split right down the middle and argue their positions passionately. "Some people say they won't play God under any circumstance," said Schaich-Borg, who said she personally would pull the lever. But what if you could save the people on both sides of the railway spur by shoving a single man in front of the train? "Nearly everybody says no," she said. But, she said, a psychopath wouldn't care a whit whether the lever was pulled or not. She wants to compare what happens in people's brains when the question is asked. In the pattern of neural activity, she believes she may see the outline of human morality. And those imaging scans may illustrate why predators such as Ted Bundy are a rarity, rather than a rule in society. Kiehl says most people probably make moral choices using both rational and emotional parts of their brain. But he and Hare both say much more research needs to be done to shed light into the abyss of the psychopathic mind. "Unless we understand what makes these people tick," Hare says, "we are all going to suffer." Smoking Down, Prescription Drug Abuse Up in Teens WASHINGTON — Cigarette smoking is at its lowest level in a survey of teenagers and use of illicit drugs has been declining, but continuing high rates of abuse for prescription painkillers remain a worry, the government reported today.
Sandy Banks, Los Angeles Times- 12/19/2005 Until the night he smashed her car windows, broke into her home and threatened to kill her, Priscilla thought her boyfriend was a reasonable guy. "We'd been best friends since I was 12, and he was always like my protector," she said. But when she became pregnant by him at 17, his attention turned menacing. "He got really jealous, like he didn't even want me spending time with the baby," said Priscilla, now 20 and worried enough about her safety that she asked that her last name not be revealed. "I knew that he could be violent, but I didn't think he would do that to me." His late-night attack last May sent Priscilla and her mother searching the Internet for help. They found Break the Cycle,(www.break-the-cycle.org) a national group based in Los Angeles aimed at helping teenagers prevent and stop partner abuse. The group helped Priscilla get a restraining order, taught her to navigate the legal system and counseled her on ways to maintain a safe and healthy relationship with her son's dad. Now Priscilla is working with Break the Cycle to spread the word to other young women. With a $15,000 grant from the Los Angeles Times Family Fund of the McCormick Tribune Foundation, Break the Cycle is expanding its "Ending Violence" program, which sends lawyers and counselors into schools, colleges and community centers to teach teens about healthy relationships and the legal means to stop abuse. Last year, thanks to the generosity of Times readers, the Family Fund spent $1.4 million supporting Southern California charities' work with disadvantaged families. Its donation helped Break the Cycle reach almost 20,000 teens. "Typically, a lot of the young people we see have already experienced dating abuse or domestic violence in their families," said Break the Cycle attorney Jimena Vazquez. Still, the group's biggest hurdle often is teaching teens to recognize danger. "A lot of teens don't understand there's a lot of abuse besides physical," she said. "We talk about verbal abuse, sexual abuse…. A lot of time is spent talking about relationships, what they should and shouldn't be like." Like Priscilla, many teenage girls are flattered by a partner's obsessive attention and surprised when it turns violent. "So many of them don't think of jealousy and possessiveness as being part of an abusive relationship," Vazquez said. "They think it's normal for their boyfriend not to let them talk to other boys…. They think, 'Great. He wants to spend all his time with me.' They don't recognize that could be a warning sign." The group works primarily with girls 12 to 22, an age group at high risk for dating violence. Abuse by a partner is three times as common among teenage girls as among older women, studies show. Teenage girls often feel locked in unhealthy relationships, either because they are dating someone older and presumably more powerful or because their boyfriends are part of their social circle and breaking up would mean losing friends or status. Until she enlisted help from Break the Cycle, Priscilla's boyfriend used his tough-guy demeanor to frighten and intimidate her. "He would try to overpower me if I didn't have Jimena Vazquez, but now he feels overpowered. He backs down," she said. Now Priscilla helps counsel other young women — particularly Latinas like herself — to recognize and deal with abusive partners. "Now I notice the things that girls do to keep the drama going, the way they complain, but they keep going back, no matter if the guy is rude or mean or rough," she said. "In the Mexican culture, there's a lot of pressure to stay with your baby's father. Your parents tell you to get married, to stick with the man…. The ones who've been beaten up, those are the ones that hide the most; they feel ashamed. The guys promise them the world and they go back. "We try to show those girls, there is life after this. You don't have to put up with it. He is not the only person you can be with." Supplement May Stifle the Craving for Cocaine Eric Nagourney, New York Times- 12/20/2005 A nutritional supplement widely sold as an antioxidant may help cocaine addicts give up the drug, researchers have found. The supplement, N-acetylcysteine, appears to reduce addicts' desire for cocaine. The findings were presented last week at a meeting of the American College of Neuropsychopharmacology. When hospitalized addicts were given the supplement, known as NAC, and then exposed to pictures related to cocaine, they reported less desire for the drug than addicts given a placebo, said a researcher, Dr. Peter Kalivas of the University of South Carolina. When M.R.I. scans were taken of some of the patients' brains, the researchers also saw differences associated with the supplement. "What we found is that it inhibited the cravings, and it blunted the cortical activation that you normally see when an addict is looking at cues that induce craving," Dr. Kalivas said. NAC already has some other medicinal uses, but the researchers cautioned against cocaine users' taking it until more research is conducted. Feedback: Relief From Chronic Pain Eric Nagourney, New York Times- 12/20/2005 People who have chronic pain may be able to reduce their suffering by using brain-scanning equipment that lets them see their brain activity and try to modify it, researchers say. The process, which the researchers say may eventually prove useful as a treatment, is described online in The Proceedings of the National Academy of Sciences (www.pnas.org). For the study, the researchers asked a group of chronic pain sufferers to view their brain activity on a functional M.R.I. scanner. A group of healthy volunteers were given painful heat stimuli to the hand and were also scanned. The equipment was modified to allow the volunteers to see brain activity as it occurred. The scanner was focused on a part of the brain involved in the perception of pain, the rostral anterior cingulate cortex. The researchers asked the volunteers to try to change the patterns they saw on the screen, giving them suggestions for strategies. One chronic back pain sufferer, for example, thought of little people digging out the pain. After practice, the study found, the volunteers were able to make detectable changes in the way their brains processed pain signals, and they reported feeling less pain. The improvement was not found in members of control groups who were given no M.R.I. information or who were shown images from another part of the brain. In the past, the study noted, people have learned to control other autonomic functions like heart rate. But the study's senior author, Dr. Sean C. Mackey of the Stanford University School of Medicine, urged caution in interpreting the results. Dr. Mackey said, "We still have a lot of work to do to prove that this has long-term clinical efficacy." The study, supported by a grant from the National Institutes of Health, was led by R. Christopher DeCharms of Omneuron, a life-sciences technology company. Dr. DeCharms is trying to develop the equipment for commercial use. The Chaos of Homelessness Elissa Ely, M.D., New York Times- 12/20/2005 I knew from a note left by her case manager that the homeless woman I was waiting to see had a history of trauma, terrible mood swings, past suicide attempts. I had booked an hour for an intake evaluation. She arrived 35 minutes late, sat down and shook out long braids. She was plump, and wore what looked like someone else's ill-fitting button-down shirt. She opened her pocketbook, eyeliner, loose cigarettes, Kleenex tumbling out. "I've got to see a doctor right away," she said, and she began to weep. In the next 15 seconds, I learned that she had been beaten by her father, that she had found her fiancé in bed with her daughter, that she had not slept in two nights. On top of that, she said, she had been late catching the bus from the shelter to the subway to get to the clinic and late getting the subway to the bus to get to the shelter the night before. That meant that she had missed dinner and breakfast. She didn't know if she could go on one minute more. I opened up my lunch bag and handed her the first thing I came across. It was a large banana. I had been looking forward to eating it. She finished it in three bites and dropped the peel into her pocketbook. We talked a few more minutes but the intake forms remained blank. She was essentially incoherent; not psychotic, but washed away in a flood of disorganization and emotion, unable to grab any branch long enough to pull herself onto land. Finally, I gave her a card with an appointment for the next week and a week's prescription for a benign sleeping medication. Five nights later, I was in a different shelter when the staff phone rang. It was the drug and alcohol abuse counselor whose office was two doors away. The walls are plasterboard, and I could hear him talking into the phone from his cubicle. There was weeping in the background. "I have someone who needs to see a psychiatrist right away," he told me. "Sign her up," I said. "Just a minute," he said, and, putting his hand over the receiver, told the weeper: "I'm going to sign you up. You can see her next week." The weeping became loud wailing. "What's her name?" I asked. It was familiar. So, now, was the weeping. A mental image surfaced of braids and objects tumbling from a purse. "Tell her we met last Friday," I said. "I'm the doctor she saw in the clinic." The wailing continued. "Tell her I gave her the banana," I said. The weeping stopped. "Oh," I heard her say through the wall. "That doctor." "Ask her if she's sleeping any better," I said. He asked her, then told me that she had not filled the prescription yet. "Tell her I'm going to see her the day after tomorrow," I said. "We made an appointment. Nine o'clock. She has a card." "O.K.," he said. "I'll tell her." Without the banana, she would not have recognized me. I was simply another branch floating by. In the chaos of her life, it was natural to see a psychiatrist in one shelter during the day on Friday and a second one in a different shelter on Wednesday night. But by the happy coincidence of being the same person in two places, I had headed off redundancy. Luck and a piece of fruit had provided the beginning of consistent care. Now we could get down to work. Friday morning came. 9:00. 9:30. 10:30. She never showed. At the night shelter two days later, the drug counselor said he had not seen her. She had moved into the land of the missing. Life should be easier to organize. One patient, one doctor. But the muddle is a metaphor for homelessness, part of the diffusion that comes when you have no base. Calendars and appointment cards mean nothing. The solution is unclear, at least to me. A banana makes an impression, but not for long enough. A Sudden Shift in Moods Stacey Colino, Washington Post- 12/21/2005 Like most teenagers, Andrew Solomon was often at the mercy of his moods -- but in his case this situation persisted into his thirties. "During my up periods, I'm lucid and articulate," said Solomon, author of the partly autobiographical "The Noonday Demon: An Atlas of Depression," which won the National Book Award for nonfiction in 2001. "I have clarity and can see patterns in my work, and I can write loads of publishable material in one night. I'm also very affectionate with people I care about." But when his moods would turn, as they invariably did, he could withdraw or have angry outbursts. While cyclothymia's mood changes can be abrupt and unpredictable, they are not as severe as in the more serious forms of the disease, which are known as Bipolar I and Bipolar II. The main difference between cyclothymia and Bipolar I is in the severity of mania, and the difference between cyclothymia and bipolar II in the severity of depressive symptoms. But the milder condition can still be disabling and disorienting. "People who have more or less continuous mood fluctuations, as people with cyclothymia do, can end up with more limitations in life than people with major disorders," Goodwin said. "Because they don't know how they're going to feel from day to day, they don't have a firm footing in relationships or in their work. And they lack the ability to have confidence in what a mood means, whether it's a signal about a relationship or a work situation or a spontaneous change." The German psychiatrist Ewald Hecker introduced the concept of cyclothymia in 1877, but its definition has evolved from a mild problem with mood to its current status, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), as a mood disorder alongside bipolar disorder and major depression. Cyclothymic disorder also appears in the International Classification of Diseases (ICD-10), published by the World Health Organization. Yet the condition has traditionally been overlooked by those who have it and the doctors who've treated them. This may be because there's a fine line between pathological and normal mood fluctuations. "The threshold is when a person is really having trouble in their relationships or at work or in school," said Kleinman. "Often, he added, "it's a friend or family member who says, 'I think there's a problem here.' " Complicating matters, people usually seek professional help when they're feeling down, not up. " . . . They come in because they're depressed or hurting," Goodwin said. "They don't come in saying, 'Doctor, I'm hypersexual or too creative.' We'd all love to have that." People who come in during a down period of cyclothymia may be misdiagnosed with -- and mistreated for -- unipolar depression. In therapy, there's also a mood-driven memory bias: When people are depressed, they tend to remember their past depressions, not their periods of euphoria or super-productivity, according to Goodwin. So what they report can give a mental health professional a skewed picture of what's really been going on with them. Cycles of Vulnerability The cause of cyclothymic disorder, which usually begins in the teens or twenties, is unknown, but there appears to be a genetic component. People who have a family history of bipolar disorder are particularly susceptible. In a recent study involving healthy, symptom-free volunteers, researchers in France found that a cyclothymic temperament clusters in families with affective disorders, particularly in those with a legacy of bipolar disorders or depressive disorders. There's also likely an environmental influence, since stress, personal loss, drug or alcohol use, or even insufficient sleep can trigger episodes or mood fluctuations. In people with cyclothymia, "the brain has less capacity to buffer itself against what's happening in the environment," Goodwin explains. Linda Sexton was diagnosed with cyclothymia in 1983, when her children were toddlers. A daughter of the poet Anne Sexton, who suffered from severe depression and committed suicide when Linda was 21, Linda began to have mood swings when she struggled with disciplining her children. "When I found myself replicating the spanking I had experienced as a child and promised I wouldn't do, I went into therapy," said Sexton, who lives in the San Francisco Bay area. "I was having periods of depression during which I was unable to complete tasks and didn't feel like I had anything to offer my children, which was killing me because I considered them the most precious thing in my life." Then she'd have surges of hypomanic behavior -- for instance, going out and buying 10 pairs of shoes at a time. Gradually, her cyclothymia got worse, especially when she was treated with antidepressants. She had free-floating anxiety and surges of self-hatred. Her marriage fell apart. In 1996, Sexton was diagnosed with a full-blown bipolar disorder. At this point, diagnosing cyclothymia isn't an exact science. "It's kind of a cookbook diagnosis that's based on a standard number of criteria the patient meets," explains Dave M. Davis, a clinical psychiatrist and medical director of the Piedmont Psychiatric Clinic in Atlanta. Currently, mental health professionals rely on a clinical evaluation, DSM-IV checklists and an accurate history of the person's moods and behavior. A relative of the patient can often help with compiling such a history, Goodwin said, because he can make connections between a person's behavior and negative consequences or recall a pattern of behavior. "I had a lawyer once who had come in because he was feeling depressed," Goodwin recalls. "He didn't see himself as hypomanic, but he was so irritable that his kids didn't want to come home and eat with him. His wife reminded him it was the same summer that he bought three cars and called all of his bosses [expletive]s and got fired. Then he turned to his wife and said, 'Is this what the doctor meant by hypomania?' He just hadn't put two and two together." Back on an Even Keel "There isn't much point in treating cyclothymia without mood stabilizers," Goodwin said. "This is not something over which [people] can exert total voluntary control." While drugs like lithium and depakote have been the treatment of choice for both bipolar and cyclothymic disorders in the past, they often carry unpleasant side effects such as weight gain and sluggishness. In 2003, a breakthrough came with the FDA's approval of Lamictal for the long-term treatment of bipolar disorders. "It's very effective on the depressive side and mildly effective on the high side," Goodwin said. "With it, these people can begin to trust their emotions again." What doesn't help are antidepressants taken by themselves, as Jennifer Richards discovered after being misdiagnosed with depression more than 10 years ago. "The antidepressants I was given made my moods worse," recalled Richards, a receptionist in Boston. "I'd feel invincible and drive 100 miles an hour or max out my credit cards. Or I'd become very angry, loud and obnoxious; I hadn't experienced outbursts like that before. Friends stopped talking to me, and I was fired from two jobs." It wasn't until she began treatment with a new psychotherapist that she was diagnosed with cyclothymia and put on a mood stabilizer. After that, she said, "I wasn't afraid of myself anymore." Not only can antidepressants throw someone with cyclothymia into mania, they can boost the risk of having the disorder evolve into full-blown bipolar, Goodwin said. "It happens up to one-third of the time. Antidepressants should only be used with a mood stabilizer, and they should not be used indefinitely." The trouble is, people are often reluctant to take a mood stabilizer when they're on a high swing. "When you're hypomanic and you feel euphoric and on top of the world, who wants to take a medication that will take that away?" said Prentiss Price, a psychologist at the Counseling and Career Development Center of the Georgia Southern University in Statesboro and author of "The Cyclothymia Workbook." "But the higher the mood gets, the more at risk you are for problems with judgment or risky behavior." Of course, therapy is also important. "They need to relearn who they are and get off their addiction to their highs," Goodwin said. "It's like cocaine addicts: They feel like they need that high to be interesting, appealing, sexually attractive or fun people." Thanks to medication and psychotherapy, Andrew Solomon's moods are now under control: He still has up days and down days, but he spends more time on an even keel. "Now I usually have reactive swings," he said. "When something happens, I might have an exaggerated response to it. But my moods have become more logical and rational and less extreme. They're easier for me and for other people to live with." Resources Families for Depression Awareness ( http://www.familyaware.org/ ), offers help in recognizing and dealing with depressive and mood disorders. Depression and Bipolar Support Alliance ( http://www.dbsalliance.org/ ), offers confidential screening for bipolar disorder, depression and anxiety, plus information and referrals to support groups. Conviction Is Overturned for Schizophrenic Killer Anemona Hartocollis, New York Times- 12/21/2005 New York's highest court yesterday overturned the conviction of Andrew Goldstein, a schizophrenic who pushed a young woman to her death in front of a subway train in 1999, finding that Mr. Goldstein's rights had been violated when a psychiatric expert testified about statements made by people who were not cross-examined. In a 6-to-1 decision, the Court of Appeals ordered a new trial for Mr. Goldstein. While expressing regret for the pain another trial might cause the family of the victim, Kendra Webdale, the judges said the constitutional issues raised by Mr. Goldstein's conviction could not be ignored. This would be the third trial for Mr. Goldstein, 36, who was convicted of second-degree murder in his second trial, in March 2000, after the first one ended in a hung jury. He is serving 25 years to life in prison, the maximum sentence. Mr. Goldstein's schizophrenia was diagnosed 10 years before the murder of Ms. Webdale, 32. He had stopped taking his antipsychotic medication before killing her. A public outcry led to a state law permitting courts to force mentally ill people to comply with treatment. It is known as Kendra's Law. During the trial, Mr. Goldstein's lawyer used an insanity defense, arguing that his client was suffering from a transient psychotic episode, perhaps exacerbated by his failure to take his medication, on Jan. 3, 1999, when he walked up behind Ms. Webdale and pushed her off the N line platform at 23rd Street. The prosecution acknowledged that Mr. Goldstein was mentally ill but said he had a history of using his mental illness as an excuse for bad behavior. In its conviction, the jury rejected the insanity defense. The appeals court ruled that Dr. Angela Hegarty, the psychiatrist who testified for the prosecution, should not have been allowed to testify about interviews with people who had known Mr. Goldstein - including a supermarket security guard, a girlfriend of Mr. Goldstein's former roommate, and Mr. Goldstein's former landlady - unless those people were available to be cross-examined by the defense. The defense objected to Dr. Hegarty's testimony about the interviews but the judge permitted it. The court cited a 2004 United States Supreme Court decision, Crawford v. Washington, in saying that Mr. Goldstein had a constitutional right to confront the witnesses against him. "The people's case that defendant was sane when he killed Kendra Webdale was a strong one, but we cannot say it was so strong that no rational jury could have rejected it," Judge Robert S. Smith, writing for the majority, said. Mr. Goldstein's lawyer, Natalie Rea, who works for the appeals bureau of the Legal Aid Society, said yesterday that the decision would have a broader impact on "how psychiatric experts can testify" in New York. "The concept is very simple," she said. "An opinion is only as good as the statements it is based upon." The office of Robert M. Morgenthau, the Manhattan district attorney, is reviewing the decision and may appeal it to the United States Supreme Court, said Barbara Thompson, a spokeswoman. She noted that Mr. Goldstein was convicted in 2000, while the Supreme Court decision cited by the Court of Appeals was handed down last year. Jay Dankner, a lawyer for the Webdale family, said the family was prepared to retry the case. "It's a very strong family," he said. Ms. Webdale's mother, Patricia, has traveled the country lecturing about what she perceives as the failure of the mental health system to protect her daughter, Mr. Dankner said. Before Mr. Goldstein killed Ms. Webdale, he had repeatedly been hospitalized and usually discharged within three weeks, the cutoff for state reimbursement, Mr. Dankner said, despite a history of assaults. The family is pursuing a civil negligence case against several hospitals that treated Mr. Goldstein. "He should never have been let out on the street," Mr. Dankner said. Kendra's Law, signed by Gov. George E. Pataki in 1999, permits the authorities to supervise mental patients and ensure that they do not pose a danger to themselves or to others and that they take prescribed medications. Under the law, a court order can be used to force a mentally ill patient to comply with treatment. During Mr. Goldstein's second trial, the psychiatrist for the defense, Spencer Eth, testified that Mr. Goldstein's psychosis meant that he "couldn't plan, he couldn't intend, he couldn't know as we understand what 'know' means what he was doing or that it was wrong," the appeals court papers said. The prosecution's psychiatrist, Dr. Hegarty, found that Mr. Goldstein had a "relatively mild" disorder and that his psychotic symptoms were "substantially in remission" at the time of the killing, the court noted. Dr. Hegarty testified that Mr. Goldstein had antisocial tendencies and was driven to violence against women by feelings of rejection and sexual frustration. She cited interviews she had conducted with people who had encountered Mr. Goldstein. In one interview, a security guard at a grocery store said that two years earlier Mr. Goldstein said, "I'm sick, I'm sick," after assaulting a woman shopping there. In a dissenting opinion yesterday, Judge Susan Phillips Read said that while it was "reasonable" for the majority to apply the Crawford case, she did not believe that the jury had based its conviction on the interviews. "Psychotic symptoms do not rapidly appear and disappear as defendant's supposedly did while he stood on the subway platform," she said. "Far more likely, the jurors readily rejected what they must have viewed as a rather outlandish defense theory, unsupported as it was in fact or professional literature." Food Addictions Rise in Diet-Conscious Era Candice Choi, Associated Press- 12/25/2005 ALBANY, N.Y. -- Grabbing a handful of cookies off the plate, stealing a roommate's food, overeating while home alone. These could be signs of compulsive overeating. In the United States, the nation's fixation on weight is only making the disorder more prevalent, specialists say. The number of support groups for people whose lives are controlled by food has risen sharply in recent years. Doug Gross, Associated Press- 12/25/2005 ATLANTA -- Anita Alston sleeps on an air mattress because she can't afford a bed yet. Just up the road, Katrina Lawson is using bed sheets for curtains until she can buy the real thing. Both women in their 20s have learned plenty about working hard and saving money since moving into their first homes last month. As former foster children -- two of the roughly 20,000 each year who ''age out" of the system without ever having a permanent home -- they didn't need another lesson in doing without. ''The only thing I was ever concerned about was food and a roof over my head for me and my daughter," said Lawson, a native of Peoria, Ill., who moved to Atlanta in 2000 after living with four foster families since she was 7. Psychotherapy on the Road to ... Where? Benedict Carey, New York Times- 12/27/2005 ANAHEIM, Calif. - The small car careered toward a pile of barrels labeled "Danger TNT," then turned sharply, ramming through a mock brick wall and into a dark tunnel. A light appeared ahead, coming fast and head-on. A locomotive whistled. "Uh-oh," said one of the passengers, Dr. Martin Seligman, a psychologist and a pioneer in the study of positive emotions. But in a moment, the car scudded safely under the light, out through the swinging doors of Mr. Toad's Wild Ride and into the warm, clear light that seemed to radiate from the Southern California pavement. "Well," Dr. Seligman said. "I don't know that I expected to be doing that." One of several prominent therapists who agreed to visit Disneyland at the invitation of this reporter, Dr. Seligman was here in mid-December for a conference on the state of psychotherapy, its current challenges and its future. And a wild ride it was. Because it was clear at this landmark meeting that, although the participants agreed it was a time for bold action, psychotherapists were deeply divided over whether that action should be guided by the cool logic of science or a spirit of humanistic activism. The answer will determine not only what psychotherapy means, many experts said, but its place in the 21st century. "In the 1960's and 1970's, we had these characters like Carl Rogers, Minuchin, Frankl; psychotherapy felt like a social movement, and you just wanted to be a part of it," said Dr. Jeffrey Zeig, a psychologist who heads the Milton H. Erickson Foundation, which every five years since 1980 has sponsored the conference in honor of Dr. Erickson, a pioneer in the use of hypnosis and brief therapy techniques. "Now," Dr. Zeig continued, "well, therapists are becoming more like technicians, and we're trying to find the common denominator from the different schools and methods to see what works best, and where to go from here." The meeting brought together some 9,000 psychologists, social workers and students, along with many of the world's most celebrated living therapists, among them the psychoanalyst Dr. Otto Kernberg, the Hungarian-born psychiatrist and skeptic Dr. Thomas Szasz, and Dr. Albert Bandura, the pioneer in self-directed behavior change. "This is like a rock concert for most of us," said Peggy Fitzgerald, 56, a social worker and teacher from Sacramento, holding up a program covered in autographs. Ms. Fitzgerald said she attended war protests during the 1960's, and "this has some of that same feeling." Calls to arms rang through several conference halls. In the opening convocation, Dr. Hunter "Patch" Adams - the charismatic therapist played on screen by Robin Williams - displayed on a giant projection screen photos from around the world of burned children, starving children, diseased children, some lying in their own filth. He called for a "last stand of loving care" to prevail over the misery in the world, its wars and "our fascistic government." Overcome by his own message, Dr. Adams eventually fell to the floor of the stage in tears. Many in the audience of thousands were deeply moved; many others were bewildered. Some left the arena. At the conference, many said they found it heartening that psychotherapy was finding some scientific support. For example, cognitive therapy, in which people learn practical thought-management techniques to dispel self-defeating assumptions and soothe anxieties, has proved itself in many studies. The therapy, some participants said, has even attracted the attention of the Nobel Committee. The two men who developed it, Dr. Albert Ellis, a psychologist in New York, and Dr. Aaron Beck, a psychiatrist at the University of Pennsylvania, brought crowds to their feet. A frequent theme of the meeting was that therapists could not only relieve anxieties and despair but help clients realize a truly fulfilling life - an idea based on emerging research. In his talk, Dr. Seligman spelled out the principles of this vision, called positive psychology. By learning to express gratitude, to savor the day's pleasures and to nurture native strengths, a people can become more absorbed in their daily lives and satisfied with them, his research has suggested. A just-completed study at the University of Pennsylvania found that these techniques relieved the symptoms of depression better than other widely applied therapies, Dr. Seligman told the audience. "The zeit is really geisting on this idea right now," said Dr. Seligman, who has consulted with the military on how to incorporate his methods. Dr. Dan Siegel, a child psychiatrist at the University of California, Los Angeles, was one of several speakers to emphasize how psychotherapy changes the wiring of the brain. For example, he said, brain imaging findings suggest that secure social interactions foster the integration of disparate parts of the brain. "When I'm telling you my feelings, discussing memories, in this close relationship, I'm achieving better neurological integration," Dr. Siegel said. "I'm repairing the connections in the brain." Many therapists at the conference said that if the field did not incorporate more scientifically testable principles, its future was bleak. Using vague, unstandardized methods to assist troubled clients "should be prosecutable" in some cases, said Dr. Marsha Linehan of the University of Washington, who has developed a well-studied method of treating suicidal patients. Yet it was also apparent in several demonstrations of the spellbinding thing itself - artful psychotherapy - that some things will be difficult, if not impossible, to standardize. Dr. Donald Meichenbaum, research director of the Melissa Institute for Violence Prevention and Treatment in Miami, showed a film of the first session he conducted with a woman who was suicidal months after witnessing her boyfriend die in a traffic accident. After gently prompting her to talk about the accident, Dr. Meichenbaum then zeroed in on something he had noticed when the woman entered his office: she was clutching a cassette tape. He asked about the tape and learned that it was a recording of her late boyfriend's voice, expressing love for her. "I play it over and over, and it makes me so depressed," said the woman, in a tiny voice. And here Dr. Meichenbaum stopped the film and addressed the audience. "The tape!" he said. "When during the session do you go for the cassette tape? What do you do with the tape?" For several long moments not a creature stirred, not even a laptop mouse. This community of therapists was now trying to save a soul, a person who was alone and did not want to live. What to do with the tape? "Consider between now and the next time I see you, in two days, consider whether you would be willing to play the tape," Dr. Meichenbaum went on to say he had told the woman. "I would be privileged and honored" to hear it. "Why?" he now asked, turning to the audience. "Because it not only increases the likelihood she'll return but empowers her to come back" and take an active role in therapy. Which is exactly what she did, he said. "Now, is any research study ever going to tell you exactly the right thing to do when your client comes in with a tape of her dead lover's voice?" Dr. Meichenbaum asked. Most of the audience of more than 1,000 people wandered out of the talk wide-eyed. One, Terrina Picarello, 40, a marriage and family therapist from Greensboro, N.C., said, "That is what you come for: inspiration." Ms. Picarello said that the conference was well worth the money she spent, more than $800 in fees and travel, and the week she had taken off to attend, even though she found some of the presentations on marriage counseling disappointing. "Way too much talking by the therapist, I thought," she said, after one of them. "It seemed so old-fashioned, like it was drawn from another era." And there was the rub. As psychotherapy struggles to define itself for an age of podcasts and terror alerts, it will need ideas, thinkers, leaders. Yet the luminaries here, many of whom rose to prominence three decades ago, were making their way off the stage. And it was not clear who, or what, would take their place. Across the street at Disneyland, where just about any metaphor is available for the taking, Dr. Siegel was working out the meaning of the park for himself. A native of Los Angeles, he has many memories of visiting as a child, perhaps nowhere more so than the circular drive in front of Sleeping Beauty's Castle. "The circle of choice," he said, looking around. "This is where you decide, where you think about your mood and which way you want to go - to Frontierland, Tomorrowland." By all appearances in Anaheim, the field of psychotherapy has arrived at the circle of choice. The question is, How to get to Tomorrowland? The Claim: Depression Rates Rise During the Holidays Anahad O'Connor, New York Times- 12/27/2005 THE FACTS: Despite the notion that the holiday season is filled with joy, psychiatrists have long argued that the time can also be fraught with stress, expectations that go unfulfilled, depression and, for some, loneliness. But for all the talk, studies over the years have found little evidence that depression rates actually climb around Christmas, Hanukkah and New Year's Eve. Researchers have looked at patterns of suicide rates and psychiatric emergency room visits. One of the largest studies, published in the Archives of General Psychiatry in the 1980's, found that psychiatric visits tended to dip in the weeks before Christmas and then rise afterward. As for suicides, most studies, including one by the Mayo Clinic that looked at a 35-year period, have found that there is virtually no relationship between the holidays and suicides. If anything, studies have found, suicide rates are at their lowest in December, possibly because those with depression have more family and friends around to help them cope. But there is one exception, said Dr. Gail Saltz, a psychiatrist at NewYork-Presbyterian/Weill Cornell hospital. One form of depression, seasonal affective disorder, is tightly linked with winter. But the treatable condition has more to do with the short, dark winter days than with holiday stress, Dr. Saltz said. THE BOTTOM LINE: Research shows that the holidays do not set off a spike in rates of major depression. When Teenagers Abuse Prescription Drugs, the Fault May Be the Doctor's Howard Markel, M.D., New York Times- 12/27/2005 Every Thursday evening, I counsel a group of teenagers with serious substance abuse problems. None of the youngsters elected to see me. Typically, they were caught using drugs, or worse, by their parents or a police officer and were then referred to my clinic. To be sure, all the usual intoxicants - alcohol, marijuana, amphetamines, LSD and cocaine - are involved. But a new type of addiction has crept into the mix, controlled prescription drugs, including potent opiate painkillers, tranquilizers and stimulants used to treat attention deficit disorders. This is hardly unique to my clinic. Several studies report that since 1992, the number of 12- to 17 -year-olds abusing controlled prescription drugs has tripled. In fact, dabbling with some of the pharmaceutical industry's finest psychoactive compounds constitutes the fastest growing type of drug abuse in the United States, outpacing marijuana abuse by a factor of two. One of my patients, Mary, illustrates this trend all too well. A voracious reader and a talented musician in her high school orchestra, Mary at 16 is also a "garbage head," meaning that she will ingest anything she thinks will give her a high. Last December, she was taken to the hospital for an overdose of hallucinogenic mushrooms, alcohol, and ketamine, a chemical cousin of angel dust that doctors sometimes use to anesthetize patients and that, more commonly, veterinarians use to sedate large animals. Lately, she has been playing with one of the strongest opiates and potentially addictive painkillers ever created, Oxycontin. She downs a few with a single shot of vodka and calls the combination "the sorority girl's diet cocktail," because it simultaneously allows for a stronger kick of inebriation and far fewer calories than mere alcohol alone. The most recent Monitoring the Future report, the continuing study of teenage drug use conducted by the University of Michigan and the National Institutes of Drug Abuse since 1975, found that 5.5 percent of all high school seniors abused Oxycontin, up from 4 percent in 2002. Oxycontin abuse has increased 26 percent since 2002 among 8th, 9th and 12th graders. A listing of Food and Drug Administration-approved uses for Oxycontin shows that it is specifically for patients in moderate to severe round-the-clock pain like that in advanced stages of cancer. So where does this physically robust teenager obtain her pills? Weeks earlier, she had a tonsillectomy, a minor though uncomfortable procedure by any standards. The surgeon wrote a prescription for 80 tablets. Mary spent the next week in a narcotized and medically sanctioned bliss, until her mother confiscated the last 20 tablets. At medical conferences, I hear colleagues fault parents who abuse and obtain these controlled substances but leave them easily accessible in their unlocked medicine chests where teenagers can help themselves. Other experts fault the Internet, where almost anyone can obtain controlled prescription drugs from offshore pharmacies with a few clicks on a home computer. The favorite scapegoat is deceptive: addicted patients who, the argument goes, "doctor shop" and manipulate the physicians into prescribing the medications, alter the prescriptions themselves or buy them from drug dealers at exorbitant prices. None of these targets come close to the real root of the problem. Many doctors are too quick to write prescriptions for these powerful drugs. The National Center for Addiction and Substance Abuse recently reported that 43.3 percent of all American doctors did not even ask patients about prescription drug abuse when taking histories; 33 percent did not regularly call or obtain records from a patient's previous doctor or from other physicians before writing such prescriptions; 47.1 percent said their patients pressured them into prescribing these drugs; and only 39.1 percent had had any training in recognizing prescription drug abuse and addiction. Yet from 1992 to 2002, prescriptions written for controlled substances increased more than 150 percent, three times the increase in prescriptions for all other drugs. The morning after hearing about Mary's Oxycontin holiday, I called her surgeon and asked him whether he had read her medical chart detailing an extensive history of substance abuse. "Why did you prescribe this narcotic bazooka when a BB gun of a painkiller such as acetaminophen might have done the trick?" I asked. Sheepishly, the surgeon replied, "Well, I guess I wasn't thinking." No one in pain - physical or psychic - should suffer. But the fact remains that we doctors still do the bulk of prescribing of the substances. The search for root causes of the epidemic with controlled substance abuse has to include doctors as active participants. A big part of the solution depends on reserving prescriptions for those who need, rather than desire, them. Serious Depression Raises Risk of Heart Ailments Nicholas Bakalar, New York Times- 12/27/2005 A large Swedish study published last week reports that men and women hospitalized for depression are about one and a half times as likely as others to develop coronary heart disease. The risk is even greater for people hospitalized before age 50. The researchers identified 44,826 men and women hospitalized for depression from 1987 to 2001 in Sweden, and then traced their history of heart disease using the Swedish national discharge registry. The study appears in the December issue of The American Journal of Preventive Medicine. As patients get older, the risk declines, and people ages 70 to 79 at the onset of depression have no increased risk for cardiac illness compared with people in control groups. But those hospitalized for depression from age 25 to 49 were almost three times as likely to suffer heart attacks as those not hospitalized. The association between severe depression and heart disease held even after accounting for socioeconomic status and geography. According to Dr. Kristina Sundquist, the senior author and an associate professor of medicine at the Karolinska Institute in Stockholm, this strong association between severe depression and heart disease suggests that treating depression could be a preventive. "However," she said, "in order to find evidence that successfully treated depression would make the risk for heart disease decrease, other types of studies are needed, such as randomized controlled studies." Dr. Sundquist said she doubted that such a study could be ethically undertaken because it would require a control group of untreated patients. Hurricane Takes a Further Toll: Suicides Up in New Orleans Adam Nossiter, New York Times- 12/27/2005 NEW ORLEANS - Mental health professionals say this city appears to be experiencing a sharp increase in suicides in the wake of Hurricane Katrina, and interviews and statistics suggest that the rate is now double or more the national and local averages. At least seven people have killed themselves in the four months since the storm, officials say, here in a city whose population is now no more than 75,000 to 100,000. That compares with a national rate of 11 suicides per 100,000 for all of 2002, and a rate in New Orleans of about nine per 100,000 for all of 2004. There is broad agreement that the problem is likely to get worse. Stevenson Palfi, 53, a well-known local filmmaker, was apparently the latest to take his own life. Mr. Palfi's house in the Mid-City section had taken eight feet of water, and he was in despair over losing years of files and photographs, a computer - in fact, all the contents of his office. The aftermath of the storm pushed him "right off the cliff emotionally," said a friend, Mary Katherine Aldin. "This just hit him so hard," she said. "It was a cumulative devastation to him emotionally." Mr. Palfi sat down to write a suicide note and a will, then shot himself on the second floor of his Banks Street home in the early hours of Dec. 14, Ms. Aldin said. The signs of despair are pervasive here: a woman, having returned to see her flooded-out house for the first time, runs screaming down Mirabeau Avenue in the Gentilly neighborhood, where the police find her babbling uncontrollably; in a Bourbon Street nightclub, a man draws a gun and shoots himself in the head, even as dancers sway to the music; from half-ruined houses, the police retrieve homeowners, weeping and distraught; psychiatrists report that previously stable patients are now preoccupied with death and suicide. "I would call the scope of this disaster, the scale of mental health problems, unprecedented," said Charles G. Curie, the mental health administrator at the federal Department of Health and Human Services. Officials say that among those who have killed themselves was Dr. James Kent Treadway, a pediatrician who was a fixture in the Uptown neighborhood. Dr. Treadway, 58, committed suicide in his partly destroyed house on Nov. 16. "He's got no practice, the house is flooded, his office was destroyed," said his brother-in-law, Michael Caire. "He just doesn't know how he's going to make it in the future." Officials have also reported suicides among evacuees in cities like Houston, where large numbers of them have settled. And in addition to those who have killed themselves here, about two dozen have tried to do so, a rate that is most likely, officials say, also far higher than normal. Jeff Wellborn, administrator of the Police Department's mobile mental health squad, said members of his unit were being called in frequently when a homeowner, witnessing the extent of losses for the first time, broke down. "They're coming into town, and they get so depressed they can't handle it anymore," Mr. Wellborn said. "Most of the time they are crying." "These are not the same people we dealt with before the storm," he said. "They had no mental health history. We are seeing almost exclusively new patients." Health professionals confronting this tide of despondency view it as one more sign that New Orleans, with its miles of ruined neighborhoods, moribund downtown and enclaves of semi-normality, is far from recovered. Nobody here can escape the persistent evidence of the city's devastation. First exchanges are often about how much damage your house has suffered, or whether your house still exists. "There are a lot of people walking around with an endemic low-grade depression," said Dale F. Firestone, a local psychotherapist. For an undetermined number, it is worse, experts said. "I've had some very depressed people from Katrina," said Dr. Douglas W. Greve, a psychiatrist with a practice in the French Quarter. "These are profound depressions. In the past I would have hospitalized these patients." "I'm beginning to get experiences with acute anxiety," Dr. Greve said. "Anxiety and depression, abuse of alcohol, that's gone way up." A handful of his patients have been suicidal, he said, adding, "I think it's going to get worse." Children, too, are suffering, said Dr. Douglas S. Pool, a psychiatrist who treats the young. "You actually get kids as young as 5 talk about not wanting to live, wanting to die," Dr. Pool said. Dr. Denise L. Dorsey, president-elect of the New Orleans Psychoanalytic Center, said that for many, the devastation was beyond an ability to cope. "Looking down a street where it's house after house, and the garbage and the innards of the houses, there's something about it that people in general can't grasp," Dr. Dorsey said. "It's not within the realm of any experience anyone's ever had. Your ordinary American doesn't have that in their repertoire of experience."
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