Growing Up Resilient
Until recently, resilience was thought to be an entirely inborn trait, giving rise to the notion of the "invulnerable child," now recognized to be a mistaken idea. Resilient children are not invulnerable to trauma or immune to suffering. But they bounce back. They find ways to cope, set goals and achieve them despite myriad obstacles like drug-addicted parents, dire poverty or physical disabilities thrown in their path.
     As Dr. Robert Brooks of Harvard and Dr. Sam Goldstein of the University of Utah put it, being resilient does not mean a life without risks or adverse conditions but rather learning how to deal effectively with the inevitable stresses of life. Herein lies an important concept: learning. To be sure, some of what makes up resilience is inborn. But resilience can also be learned, say experts like Dr. Brooks and Dr. Goldstein, psychologists and authors whose newest book, "The Power of Resilience" (Contemporary Books), provides lessons in "achieving balance, confidence and personal strength." They are lessons of considerable importance, as there is no such thing as a life free of losses and setbacks. People who lack resilience are less able to rise above adversity or learn from their mistakes and move on. Instead of focusing on what they can control and accepting responsibility for their lives, they waste time and energy on matters beyond their influence. As a result, the circumstances of their lives leave them feeling helpless and hopeless and prone to depression. When things go wrong or don't work out as expected, they tend to think "I can't do this" or, even worse, "It can't be done."
     Children learn to be resilient when parents and guardians enable and encourage them to figure out things for themselves and take responsibility for their actions. When Ray Charles lost his sight at age 7, his mother insisted that he use his good brain and learn how to make his way in the world. In the movie "Ray," she watched silently after the newly blind boy tripped over furniture, cried for her help and then struggled to his feet unaided.

It's Never Too Late
Children need to learn that they are capable of finding their way on their own. Parents who are too quick to take over a task when children cry "I can't do this" or don't insist that children learn from their mistakes are less likely to end up with children who can stand on their own two feet, take responsibility for their lives and cope effectively with unavoidable stresses. The same applies to parents who provide children with everything they want instead of teaching them limits and having them earn their rewards and to those who make excuses for their children and repeatedly defend them against legitimate complaints.
      But even if these lessons are not learned in childhood, experts like Dr. Brooks and Dr. Goldstein, who also wrote "Raising Resilient Children" and "Nurturing Resilience in Our Children," say it is possible to learn to be more resilient at any age. The trick lies in replacing what they call "negative scripts" that may have been written in childhood, but are not cast in stone, with more positive scripts. People who harbor negative scripts expect that no matter what they do, things will not work out well; they assume that others must change for circumstances to improve.

'Authors of Our Lives'
So lesson No. 1, Dr. Brooks and Dr. Goldstein write, is "to recognize that we are the authors of our lives." "We must not seek our happiness by asking someone else to change," they continue. Rather, we should ask, "What is it that I can do differently to change the situation?" Identify your negative scripts and assume responsibility for changing them.
      Nurture your self-esteem. Be true to yourself rather than trying to be what someone else expects of you. Focus on what you can do, tasks you can achieve, situations you can influence. Take an active role in your community or in an organization or activity that helps others.
     Develop a new skill: learn a language or a new sport or how to fix a car; take up knitting, cooking or woodworking; join a book club; try out for an amateur production; become a docent at a museum; help organizations that feed the elderly and infirm; volunteer your services at community groups like the local Y, school, library or park. There are myriad opportunities; just look or ask around and you will find them.
     Take a chance on change if jobs, habits or activities you've long pursued are no longer satisfying or efficient. Change is frightening to people who lack resilience, but those who try it usually find that they land on their feet, and that fosters resilience. And if a new path does not seem to be working out well, change again.
     Take a long, hard look at the people in your life and consider abandoning friends who drag you down or reinforce your negative scripts. For those -- like family members -- from whom you can't escape, practice ignoring their put-downs and not taking them so seriously. Seek out activities that elevate your spiritual life and nurture your inner strength: for example, art, music, literature, religion, meditation, the great outdoors.

It was early February 2000, and Judge Paula J. Hepner said she could hardly believe what a doctor in the city's juvenile justice system had done to the girl standing before her in Brooklyn Family Court. The girl, Tiffany S., was 14, with a history of suicide threats and a set of serious psychological problems well documented by doctors at a psychiatric hospital for children. They had treated her bipolar disorder with powerful medicines and, knowing that she was facing detention, had recommended that she keep receiving them when the Department of Juvenile Justice took her into custody.
      But soon after Tiffany entered the system, Dr. Ralph L. Williams -- an employee of Prison Health Services and the only full-time doctor for 19 juvenile centers across the city -- stopped her medications. Instead, he placed her on Ritalin, a drug meant to treat attention deficit hyperactivity disorder. It took only days for Tiffany to deteriorate. Soon, she said in an interview, she was hallucinating, fighting with other girls and spending hours staring at a wall. As an additional measure, she said, a Prison Health employee asked her to sign a pledge not to kill herself.
     Judge Hepner ordered Tiffany back to the hospital, records show, and moved to hold Dr. Williams in criminal contempt. In doing so, Judge Hepner joined at least five other judges who would order more vigorous treatment by Prison Health, a company that cares for hundreds of thousands of inmates in New York State and across the country. That May, for instance, Judge Philip C. Segal of Brooklyn Family Court held the juvenile justice commissioner -- whose agency represented Prison Health in court -- in contempt after the company staff neglected to give a 13-year-old boy his H.I.V. medication. Later that month, Harold J. Lynch, a judge in the Bronx, ordered a 13-year-old girl in the agency's custody returned to the Bronx Children's Psychiatric Center. The girl, court records show, had tried to kill herself after a Prison Health doctor discarded her psychiatric medications and gave her Ritalin instead. "This is not just a single case," Judge Lynch told city lawyers. "It's many cases."
     But those cases are only one distressing facet of what would be a four-year effort by Prison Health to provide care to young people in the city's network of juvenile detention centers and group homes -- a job that made the company about $15 million in revenue before it was replaced in 2003. Independent investigations have criticized the quality of that care. Questions have also been raised by some city officials about whether the company was forthright with various other city agencies about its work at Juvenile Justice. Of the roughly 500 youngsters, ages 7 through 16, who were in custody on any given day, some had committed serious crimes. Others had been turned over by parents who could not or would not care for them. Still others were there simply because there was nowhere else to go. One thing is clear about most of them: they were sick and in need of help.
     Prison Health, a profit-making corporation with a troubling record in many states, appears to have poorly served many of those youngsters, according to a review of its work, based on court records and audits, as well as interviews with children, judges, Legal Aid Society lawyers and current and former Juvenile Justice employees. The results, those documents and interviews make clear, were often confusion and mistreatment throughout the company's time in the juvenile justice system, from January 1999 to April 2003.
     For the 5,000 youngsters who passed through each year, the one full-time doctor Prison Health employed oversaw a staff composed mostly of part-time physician assistants, social workers and nurses. Sometimes, current and former counselors who worked at Juvenile Justice said, the medical staff mistakenly gave children medication that had not been prescribed to them. One counselor said that to avoid further errors, Polaroid photos were stapled to medical files to help nurses match names with faces.
     The only independent audit of the company's medical care, commissioned by the Juvenile Justice Department in 2003, six months after Prison Health had already left, found that patient records had been in disarray, and that no doctor had appeared to consult them anyway. Many children with serious illnesses received no follow-up care, the audit said, and most teenagers were not tested for sexually transmitted diseases. The audit was never made public. "The work was poor and put young people at risk," the city comptroller, William C. Thompson Jr., said in an interview. "I'd almost say deplorable."
     Juvenile Justice officials have said they were "generally satisfied" with the company. The agency declined interview requests for this article for five months, until aides to Mayor Michael R. Bloomberg ordered the department's spokesman to answer questions about Prison Health's tenure. Even then, in two interviews, department officials would not discuss the company's record. Richard D. Wright, the president and chief executive of Prison Health, defended its work and the services it offered youngsters in custody. "There were a lot of professional people dedicated to that contract," he said in an interview. "We thought that they were sufficient to deal with the workload."
     Prison Health's performance at Juvenile Justice is the least known aspect of its long and lucrative work in New York. The care the company provided in upstate county jails in recent years has been assailed by state investigators. And its work at the jail complex on Rikers Island has been consistently, if not always diligently monitored by New York City, which awarded the company a new $300 million contract in January. But the care Prison Health provided children in the juvenile system, the city comptroller now says, should have been examined by the city when the company was seeking the Rikers contract in 2000.
     Prison Health took over care at Juvenile Justice in 1999 when it bought EMSA Correctional Care, a smaller competitor that had been doing the job for three years. When it was vying for the Rikers contract, though, Prison Health listed EMSA in disclosure statements as an affiliate and indicated that EMSA was still working at Juvenile Justice. The city comptroller now says that Prison Health was in charge of providing juvenile care from the time it bought EMSA, and that EMSA existed only on paper. The comptroller says that the company misled the city, and that as a result, the city missed an opportunity to get a hard look at Prison Health's work in its own backyard before it hired the company for its adult jails. Prison Health says that its filings properly listed EMSA as a separate concern in 2000. The city agencies in charge of awarding the Rikers contract, the Health and Hospitals Corporation and the Mayor's Office of Contract Services, say they found no problem with Prison Health's disclosures.
     Over the years, as Prison Health has expanded nationally, followed by accusations of flawed care by regulators, many of its critics have wondered how it kept winning new contracts, sometimes in a county or state next to one it had left under a cloud. In New York City, anger among judges and lawyers in the juvenile justice system did not prevent the company from landing a huge jail contract across town.
     Of course, caring for youngsters inside the city's three jail-like detention centers and 16 less restrictive group homes can be as dangerous and frustrating as caring for adult inmates. Few young people entering the system have received consistent health care and, as a result, lack any medical record to guide doctors. Often, there are not even family members to question. For many of them, as a result, detention offers the only opportunity to get a physical or dental examination, or even talk to an adult willing to listen. Proper medical and mental health care, say experts and the department's own employees, is vital in helping them become productive adults.
     That care has improved under the two companies hired to replace Prison Health, say city officials and lawyers working in the Family Court system. It could hardly have gotten worse, said Jennifer Baum, a Legal Aid lawyer who represented many youngsters during Prison Health's tenure. "I saw troubled and needy children being mistreated by shabby medical care," she said.
     By the time Prison Health Services acquired it, EMSA had been treating the city's incarcerated children since 1996. EMSA had more experience with children than Prison Health, but it had problems, too. In Westchester County, EMSA had paid $750,000 to settle a lawsuit by the parents of a 17-year-old girl who hanged herself at the jail there in 1996, after a psychiatrist stopped her antidepressant medication. The doctor, Harvey N. Lothringer, had pleaded guilty to second-degree manslaughter three decades before, admitting that he dismembered the body of a young woman who had died during an illegal abortion he performed, and then flushed her remains down a toilet. He spent four years in prison, but in 1973, the State Board of Regents declared the doctor "rehabilitated" and restored his medical license. He began working for EMSA in 1996.
      At Juvenile Justice, counselors and Legal Aid lawyers said they had found EMSA's medical staff too small to properly treat all the children who needed help. But a little less than a year after Prison Health arrived, taking responsibility for the care, that private grumbling turned public. Prompted by complaints from Ms. Baum, a half-dozen Family Court judges filed at least 12 court orders or contempt motions in 2000 to force Juvenile Justice to fix mistakes in care. In one instance, Dr. Joseph K. Youngerman of the Bronx Children's Psychiatric Center pleaded with Judge Lynch to help the suicidal 13-year-old girl who had been taken off her medication; if he could not, the doctor wrote, the center would take her back -- "to spare her (and us all) any repeat" of her breakdown.
     For nearly two years, though, those concerns remained buried in court files. Then, in 2002, the city comptroller, during a routine review, uncovered several problems. He urged Prison Health to re-examine its staffing, which provided only one full-time psychiatrist and one part-time physician for all medical services. The company, the comptroller's office found, did not provide the group counseling required in its contract. There was no system, the comptroller said, to ensure that children taking psychiatric drugs received them on days they were sent to court; unmedicated, they sometimes broke down in front of a judge. Indeed, several employees said that they sometimes were told that drugs for some of the children were unavailable or simply unnecessary, leaving them to handle the untreated patients. "If they get disruptive," said one longtime counselor at a group home, "the staff has to put them in a restraining position, and then you end up with a child-abuse charge."
     For reasons that its spokesman declined to disclose, the Department of Juvenile Justice commissioned its own review in 2003. It was a rare move, and it came only after Prison Health had left. This would be the only outside medical audit. Done by IPRO, a well-known nonprofit health-care auditing firm, it found serious deficiencies, showing that things had been even worse than the comptroller's office had thought. Medical charts had been badly disorganized, the audit said, and "there was little evidence of an oversight physician" reviewing them. Young people who developed medical problems were "almost never" seen by a doctor, but typically examined instead by a nurse, the audit said. About one in six youngsters with chronic health problems like epilepsy, sickle cell anemia and kidney disease never received follow-up treatment while in custody. Tests critical to running an institution full of troubled young people were so haphazardly administered that fewer than one-third of the eligible girls received a Pap test, and only about 1 in 5 eligible youngsters were tested for gonorrhea, chlamydia and syphilis.
     But Prison Health was by now largely beyond accountability. It had left the previous April, when the Department of Juvenile Justice replaced it with two other companies: Health Star Plus, which now provides medical care, and Forensic Health Services, which handles mental health services. Department officials, who had given Prison Health mostly satisfactory evaluations during its four years, would not discuss the problems raised by the audit. "At this point, we have new providers," said Scott Trent, a department spokesman. "It's a new contract. It's entirely irrelevant."

One Girl's Tale
Tiffany grew up in Brownsville, Brooklyn, and her early life was a painful one. She was put in her grandmother's care by city child-welfare workers when she was 3 to escape the abuse of two drug-addicted parents. But that did not last long. After her brother sexually abused her sister, Tiffany was moved yet again. When she was 13, she ran away. On the streets, she was beaten, and she began to hear voices. She found herself telling people, "I'm not crazy!"
      Tiffany ended up in the custody of the juvenile justice system after she was accused of a minor nonviolent crime in 1999; she agreed to be interviewed on the condition that the charge not be disclosed. But before she got there, she spent a month in the adolescent psychiatry unit at Kings County Hospital Center in Brooklyn. The conclusion of doctors there was precise: Tiffany suffered from bipolar disorder and behavioral problems and required psychiatric medication and individual psychotherapy. Without them, her doctors wrote, "Tiffany is at risk for harming herself."
     Once in custody, Tiffany was placed in a holding center in Manhattan on Jan. 5, 2000. She was taking Depakote to control her mood swings, and Risperidone, an antipsychotic. The next day, records show, she was examined by Dr. Williams. Prison Health had hired the doctor several weeks earlier. But Dr. Williams had already made a mostly negative impression on some lawyers working with the youngsters in custody. In interviews, the lawyers said he replaced psychiatric medication with cheaper, less appropriate drugs. Mr. Wright, the president of Prison Health, said Dr. Williams felt that black children were too frequently put on psychiatric medications they did not need. But Mr. Wright said that the doctor's decisions to withdraw those medications were inappropriate, and that Prison Health forced the doctor to resign in August 2001. Dr. Williams did not return messages left with his lawyer seeking comment for this article.
     Records show that Dr. Williams, after one 80-minute exam, concluded that Tiffany suffered from attention deficit hyperactivity disorder, and despite three court orders discontinued her psychiatric medications in late January. Soon the hallucinations started again, she said in an interview, and her antisocial behavior came roaring back. "I'd see stuff, shadows, people's faces," Tiffany recalled. "I'll be scared. I'll be crying. I always think people are out to get me." She eventually threatened to kill herself, she said, setting in motion her return to Judge Hepner's courtroom, and ultimately the psychiatric hospital, where doctors put her back on her previous medication. "When you have medicine that is working, it seems really irresponsible to alter it," Judge Hepner, in an interview, recalled saying in court. She ordered Dr. Williams to pay a $1,000 fine. The kind of treatment Tiffany received, records and interviews show, began before Prison Health took over EMSA, but judges and lawyers said the pattern grew increasingly familiar afterward.
     In July 2000, a suicidal 15-year-old girl was taken off Depakote -- prescribed by doctors at Craig House, an upstate psychiatric clinic -- and placed on Ritalin, according to court filings and lawyers and judges involved in her case. It would take five weeks to have her medication restored. In March of that year, a 15-year-old boy at Bridges Juvenile Center, a secure center in the Bronx, went days without his psychiatric medications because Dr. Williams visited the center only twice a week. Prison Health's policy, according to court transcripts and interviews, was to discontinue youngsters' medications until a company doctor could complete his own evaluation. But rather than wait for Dr. Williams to show up days later at Bridges, a Manhattan Family Court judge, alerted by the boy's lawyer, ordered the boy sent to Bellevue Hospital Center. "They can't say there's no psychiatrist on staff at the hospital," the judge, Sheldon M. Rand, said in a hearing.
     The company's strategy for treatment, when it went beyond drugs, included the unusual approach of asking a youngster to write up and sign a pledge not to commit suicide. Such pledges, experts in mental health treatment say, accomplish little. "It's an awful tool," said a former Prison Health mental health supervisor in the juvenile system. "It's designed to make the clinician go home and sleep better at night." Tiffany said the whole exercise was stupid. "I just wrote it so they would stop following me," she said.

Mental-Health Parity Bill Passes
Seattle Post-Intelligencer, 3/4/2005

Health insurers will have to treat mental illness the same as physical illness, under a bill the state Senate passed yesterday. The Senate passed the mental-health parity bill with a surprisingly strong vote of 40-9. It already had cleared the House, so now goes to Gov. Christine Gregoire, who has said she will sign it into law. The bill requires insurers to offer the same level of coverage for mental health as they do for physical. For example, if the co-payment for a cholesterol drug is $10, the co-payment for anti-depressants would be $10. Supporters estimate the bill will affect about 900,000 statewide whose insurance plans don't cover mental illness or do so at a lower level than physical illness.

Cancer treatment is more effective when the disease is caught early. Ditto for heart disease that's treated before a stroke or heart attack. But, in mental health, most patients suffer for months or years before doctors intervene. A growing number of psychologists and psychiatrists -- frustrated with what they see as an ''epidemic" of mental illness -- say that attitude needs to change. Doctors need to know how to find mental illness in at-risk children and young adults before the symptoms become full-blown. ''In the whole history of medicine, it's never been possible to overcome an epidemic simply by treatment. You need to have prevention," said Gregory Clarke, a psychologist at Kaiser Permanente's Center for Health Research in Oregon.
      The problem Clarke and others face is how to address an illness that has not yet manifested itself -- and may never. A number of mental illnesses, including depression, bipolar disorder and schizophrenia, are thought to have genetic components that put children at risk if the diseases run in their families. But these children may never develop the illness, so should they sit through hours of talk therapy each month just because their mother is depressed? Should they be prescribed powerful medications with unknown side effects just because they are unusually anxious? Should doctors and schools label children as at-risk for bipolar disorder or schizophrenia when such a label is fraught with stigma?
     Such questions have been at the heart of a national debate prompted by a 2003 report from the President's New Freedom Commission on Mental Health, which suggested a focus on early detection and treatment. Critics, including a Texas congressman who has filed a bill to prohibit use of federal funds for widespread mental health screening, say mental illnesses cannot be identified with a simple brain scan or blood test, and they fear early screening would lead to overmedication of young patients.
     Others support early detection efforts. ''Depression is just such a terrible illness to experience. As one mother said to me, it attacks the soul . . . but you can protect children going through that experience, if you get youngsters early in the course of the illness, you have a much better chance at effective long-term positive outcome," said Dr. William Beardslee, chief of psychiatry at Children's Hospital Boston. Beardslee is involved with two early intervention projects for depression that are among a handful scattered across the country. They use talk therapy and group counseling to educate adolescents with depressed parents about how to keep minor problems from becoming major ones.
     Depressed people are prone to a phenomenon called ''catastrophizing," several experts said. A simple negative experience such as a bad test grade or bad breakup might act as a trigger, sending a person spiraling downward.
     The Chidlren's Hospital approach was shown to have lasting effects by a pioneering study that Clarke published in 2001, which compared at-risk teenagers who received 15 sessions of talk therapy with those who didn't. After a year, the group that got no intervention had three times the rates of depression as the group that did receive therapy. The treatment is now being duplicated at some schools and at four test sites around the country, including Boston. Even if ''it's just delaying the onset of depression, that's a benefit," Clarke said. Because the risk for developing clinical depression is greatest when people are 15 to 25 years old, a prevention program might be able to keep them healthy until they are out of the window of risk, he said. Research at this point focuses mainly on those at known risk of depression because of age or family history, or special cases like women who have just given birth.
     Ricardo Muñoz, a psychologist at San Francisco General Hospital, works with postpartum mothers to prevent depression and help them interact with their child. Studies have shown, he said, that depressed mothers may pass on their problems to their babies by some combination of genes and interaction. ''There's something that happens to babies of depressed mothers fairly fast so that if . . . the mother is depressed for a good chunk of time, this could have an impact on how the baby learns how to respond to stress, even learns how to feel."
     As more and more mental illnesses are thought to show signs early in childhood, researchers are also beginning to work to get to children as soon as feasible. Dr. Joan Luby, a psychiatrist at Washington University in St. Louis, works to uncover mental illnesses in preschool-age children by having youngsters watch two puppets interact and asking them to identify with one of the characters. Schizophrenia researchers have identified a number of ''prepsychotic" symptoms in teenagers thought to be the early signs of the disease. The Child and Adolescent Bipolar Foundation last month issued guidelines for mental health professionals attempting to diagnose bipolar disorder in children, which may have different symptoms than the adult form.
     Some prevention programs for these less common mental illnesses can be more controversial. Some programs use therapy in combination with medication, under the theory that it could be possible to stave off the illness altogether, or lessen its intensity. But the medications sometimes used -- antipsychotics, antidepressants, and other psychiatric drugs -- have been linked to harmful side effects, including suicide and diabetes.
     On the other hand, the risk might be worth it. ''Why wait five or six years for these symptoms to wreak havoc, to have a neurobiological effect? You wouldn't think of leaving seizure disorder for years, because they generalize, they move from one side of the brain to the other," said Dr. Timothy Wilens, a pediatric psychopharmacologist at Massachusetts General Hospital who does drug-based interventions with at-risk children, some preschool-age. He noted that the greatest problems parents face is a lack of resources: Few doctors are trained to detect precursors of mental illnesses early in life, or know what to do if a serious risk does exist.
     Betty Ruth, a social worker at Boston University, campaigned vigorously for prevention services in Massachusetts in 2001 -- not as part of her job, but because as a mother of a depressed daughter she feared that her son might also be at risk. Desperate but unable to access a prevention program, she wrote to researchers, requested their checklists and guidelines, and then sat down and gave them to her son, assigning homework such as reading books like ''Learned Optimism" over the next three months. Her son isn't depressed now, but Ruth said the helplessness and panic she felt was something no parent should experience. ''Parents should be able to turn to the system and say, 'I've got one kid who's depressed,' " and expect to get help.

A study last month in The Lancet, a major British medical journal, uncovered 93 cases of seizures in infants whose mothers had been taking selective serotonin reuptake inhibitor (SSRI) antidepressants, most commonly Paxil (paroxetine). The article suggests that a baby whose mother is using SSRIs may suffer withdrawal symptoms including seizures when the child is born and abruptly stops getting the drug through the mother's bloodstream. But the study -- based on a survey of reports of adverse drug reactions -- contains no definitive evidence of this effect. There has been no clinical trial comparing infants whose moms did and didn't take Paxil during pregnancy. (Paxil is available to pregnant women by prescription, though manufacturer GlaxoSmithKline says on its Web site that some complications, including seizures, have been reported in babies whose mothers had used the drug during pregnancy.)
      However inconclusive, the Lancet report has provoked a new alarm about the effects of these antidepressant medications, whose safety in older children and whose impact on suicide has been widely questioned recently. It also has refocused attention on a crucial issue: Which is worse, the side effects of an imperfect but effective drug, or the serious condition it is intended to treat?
      It is generally agreed that less medical intervention during pregnancy is better, since medications given to the mother may harm the fetus. But though often undiagnosed, depression in pregnancy is quite common, with an estimated 10 to 25 percent of pregnant women in the United States having clinical signs of depression.
      More important, numerous studies have documented the adverse effects of maternal depression on fetal and infant well-being. Untreated depression during pregnancy has been associated in several studies with premature labor and low birth weight. A Danish study published in The Lancet in 2000 reported that maternal emotional distress led ultimately to congenital malformations. A study from Emory University in 2001 revealed that infants whose mothers had been depressed during pregnancy showed a higher than normal stress response at the age of 6 months. Depressed women are also at higher risk for using alcohol, drugs and tobacco, as well as for very poor diet and sleep habits, all of which have been shown to impair fetal development more than antidepressants do.
      Continuing maternal depression is also a danger to the child during the postpartum and early childhood periods. Recent data indicate that maternal depression is a major predictor of poor bonding and negative parenting behaviors, including less interaction, more yelling and spanking. "The poor-sleeping, poor-eating, high-stress condition of untreated depressed mothers-to-be is far more likely to lead to preterm birth or other complications in the newborn than antidepressant medication," said Andrei Rebarber, associate professor of maternal fetal medicine at New York University. Rebarber said obstetricians need to carefully screen patients for common symptoms of depression: abnormal emotional instability, inadequate weight gain and possible substance abuse.

How to Treat?
Once the decision has been made to treat depression during pregnancy, consideration should be given to psychotherapy, which is the first choice for mild to moderate symptoms. Interpersonal psychotherapy, where pregnant women work on developing new motherhood skills, has shown encouraging results in preliminary studies. Group psychotherapy, which helps treat social isolation, has also been recently shown to be effective. But severe depression has been found to respond better to medication, with psychotherapy as a helpful adjunct. The decision to prescribe an antidepressant is based on the consideration that the risks of the treatment are outweighed by the risks of the depression. A psychiatrist should be involved, at least initially.
      One psychiatrist with special training in this field is Shari Lusskin, director of reproductive psychiatry at New York University. Lusskin has studied the effects of depression on pregnancy and is convinced that early intervention can be beneficial for mother, child and family. "Exposure to maternal depression has long-term consequences on the fetus," said Lusskin, who recently authored a chapter titled "The Treatment of Psychiatric Disorders in Pregnancy" in Up to Date, an educational computer tool for clinicians. "We are beginning to understand the interplay of these factors at different points in fetal development."
     Lusskin has identified several risk factors for depression during pregnancy, including a history of depression, a family history of mental illness, a lack of social support from spouse and friends, and anxiety about the fetus, especially if the pregnancy is unplanned. Screening for such factors is vital, Lusskin said. "Pregnant women with severe depression can feel guilty about these symptoms and not reveal them," Lusskin said. "And doctors don't screen pregnant woman carefully enough for these symptoms."
     Some studies suggest that SSRI antidepressant use in pregnancy is relatively safe, though the wider body of research shows both risks and benefits. A small seminal study published in the New England Journal of Medicine in 1996 showed that third-trimester exposure to fluoxetine (Prozac) led to more premature deliveries and neonatal complications including poor tone, breathing difficulties and a weak cry. But another study published in the American Journal of Obstetrics and Gynecology in 2003 reviewed records of 138 mothers on SSRI antidepressants during pregnancy and found no complications in the infants. Other studies have demonstrated temporary increases in jitteriness and delayed development in neonates whose mothers were taking SSRIs. But no studies have shown long-term effects at up to seven years.

Postpartum Factors
The Lancet study's suggestion that withdrawal seizures are linked to withdrawal of SSRIs is too speculative to be applied to clinical practice and too preliminary to greatly alter prescribing patterns. Ian Holzman, professor of pediatrics and chief of newborn medicine at Mount Sinai School of Medicine in New York, said he believes SSRIs are relatively safe, but he would like to see more studies over a longer period of time. In the meantime, Holzman would prefer that the drugs not be given at the end of the third trimester in anticipation of a condition such as postpartum depression. "I wouldn't want to expose a baby for a non-problem which may or may not occur," he said.
      Lusskin disagreed, saying that postpartum depression, which occurs in the first five weeks after delivery at a rate three times greater than in a control group of non-pregnant women, often can be predicted by history, poor social support, marital strife and poor bonding with the infant. She said a drug like Paxil can be prescribed prophylactically for high-risk women. Still, anticipatory prescribing before the end of pregnancy would lead some women to receive a drug they might not need -- an approach that might be difficult for an obstetrician to justify.
     The same factors are not involved in the decision on whether to breast-feed an infant when the mother is taking antidepressants. The direct effects on the infant -- of both the mother's depression and the drug to treat it -- are less severe. First, the amount of the drug expressed in breast milk is less than one one-hundredth of what the fetus receives in the womb. Second, the mother may decide to continue the drug but stop breast-feeding, whereas she doesn't have a similar option while she's pregnant. The long-term health benefits of breast-feeding to the infant are well known. Holzman said that breast-feeding while on antidepressants is probably safe, and he doesn't recommend that mothers avoid it because of the medicine.
     While the mother is still pregnant, the risk/benefit equations are more complex because two beings are involved. But by considering the mother first, and making sure she is in the best health possible, the baby tends to do better. This is why many obstetricians support the use of antidepressants during pregnancy. It is not a perfect situation, but for many women the risks of the disease far outweigh the risks of the drug. "The number one person to treat is the mom," said Sreedhar Gaddipati, assistant professor of maternal fetal medicine and director of labor and delivery at New York-Presbyterian Hospital/Columbia University. "You have to ask yourself, 'Is this the same treatment you would give her if she weren't pregnant?' This is your starting point. "Of course, once you've decided that she needs treatment, you have to choose the course of treatment that is the least toxic to the fetus."

Resources
• Postpartum Support International offers information on postpartum depression and maternal care: www.postpartum.net/
• CERHR (Center for the Evaluation of Risks to Human Reproduction) has scientific reports on drugs' and other chemicals' effects on fetal development: cerhr.niehs.nih.gov/
• WebMD (enter "depression and pregnancy" in the search field of this consumer Web site for several good articles and reports): www.webmd.com

Another Reason to Quit Smoking
Julie Davidow, Seattle Post-Intelligencer- 3/5/2005

SEATTLE - Parents already know secondhand smoke is bad for their kids. Asthma, bronchitis, ear infections and pneumonia have all been linked to lighting up around children. But researchers at the Fred Hutchinson Cancer Research Center in Seattle have found a new incentive for parents to ditch the habit. If parents quit smoking by the time their child is in third grade, they increase that child's odds of also quitting smoking for at least one month within two years of graduating from high school, according to a study published in the March issue of the journal Addiction. "The message is if you quit now, you will one day help your child quit smoking," said Jonathan Bricker, a clinical psychologist and staff scientist at Fred Hutchinson.
      The findings also offer a potential tool that could help address rising smoking rates among 18 to 24-year-olds, Bricker said. Young adults now have the highest smoking rates of any age group, according to the Centers for Disease Control and Prevention. Teenage smoking rates, by contrast, have fallen every year since 1996, according to a University of Michigan survey sponsored by the National Institute on Drug Abuse and released late last year. "Twenty years from now, that rate (among young adults) could be much lower if adults today quit smoking," Bricker said.
     Children of smokers already face tough odds. Thirty-six percent of children from families where both parents smoke are daily smokers by 12th grade compared with 14 percent of children whose parents don't smoke. In a 2003 study, Bricker also found that children were less likely to become smokers if their parents quit by the time they were 8 or 9 years old. Knowing their parents successfully quit smoking may provide a model for children who later decide they want to quit, said Bricker. Parents and children also may share a genetic proclivity toward quitting. "I think we're really just at the beginning of understanding the potentially powerful impact of parents quitting smoking," Bricker said. "Our hope is that this study would provide new motivation for (parents) to quit."
     Researchers used information collected from 1,553 families in Washington as part of the Hutchinson Smoking Prevention Project, a study funded by the National Cancer Institute. All of the families had at least one parent and a child who smoked regularly. It's unclear from the latest study whether parents who quit later also significantly impact their child's chances of quitting. "There weren't enough parents (who quit late) for us to determine that," Bricker said. "We think others should look at that."

More Teens Are Abusing Prescription Drugs
Daniel Costello, Los Angeles Times- 3/5/2005

Ryan Smith remembers the night, during his junior year of high school, when a friend gave him his first Vicodin. "It felt so incredible. I remember thinking, `I am going to do this for the rest of my life,'" he says. Over the next year, Smith, now 22, and his friends moved on to other pills -- Xanax, Valium, OxyContin and the attention deficit disorder medication, Adderall, called "kiddie cocaine" for its ability to be crushed and snorted. "At the time, it felt like I knew more kids who were doing pills than who weren't," he says of his Utah high school days.
     Daniel Smith, his younger brother, began using prescription drugs the same way when a friend offered him Vicodin while watching a school football game during his sophomore year. By that summer, he began taking "weak painkillers" such as Lortab and Percocet. Finally, he turned to highly addictive OxyContin, using it several times a week
     Although the brothers eventually went through an addiction program, they never considered themselves "druggies." They were using pills safe enough to be used by millions of Americans, drugs both legal and easy to get. Each generation typically finds a new illicit drug to make its own: LSD in the '70s, cocaine in the '80s and Ecstasy and heroin in the '90s. Today's middle and high school students are experimenting with prescription drugs.
     Their drugs of choice are those often preferred by adults. After amphetamines such as Ritalin, they're turning to painkillers such as Vicodin and Percocet, then sedatives and tranquilizers. Nationwide, prescription pills have become a societal force. Adults and children rely on them for a growing list of afflictions, including anxiety, depression, even shyness, for which few alternatives were available a generation ago. Nearly half of all Americans take at least one prescription drug.
Meanwhile, direct-to-consumer drug marketing that touts new and expanded uses has become widespread. Adults and children alike are exposed to print, television and radio ads promising happier, more fulfilled lives. For young people, experts say, all these factors appear to have blurred the line between the benefits and dangers of the medications.
     As prescription drug sales have soared -- up nearly 400 percent since 1990 -- prescription medication has become the fastest-growing category of drugs being abused, with the biggest growth of abuse among people ages 12 to 24, according to the federal Substance Abuse and Mental Health Services Administration. After marijuana, prescription drugs are the drugs most commonly abused by teenagers, the federal agency says. Nationally, an estimated 14 percent of high school seniors have used prescription drugs for non-medical reasons at least once in their lifetime, according to a 2004 University of Michigan survey that tracks drug trends among middle and high school students.