The nightmare is so common, it's almost a cliche -- as much a part of the college experience as used textbooks and ramen noodles. It's exam day in the class that you haven't shown up for since the beginning of the semester and you're not even sure where the exam is, let alone what's on it. Suffering from depression that started his second year at the University of Michigan, Rodolfo Palma-Lulion lived the nightmare. Palma says at one point he enrolled in a physics class that he really liked, took the first test and got one of the best grades in the class. Then he stopped doing the homework. It was part of a cycle he would repeat with one class after another as his then-undiagnosed depression progressively sapped his ability to function. "I started doing badly, and then I stopped showing up to class altogether so that by the day of the exam I didn't know where the exam was," he says. "I spent the entire two hours of the exam running around trying to find out where it was. It was pretty awful."
      Palma, now recovered and living in Saline with his wife and son, is one of five men who've shared their stories as part of the National Institute of Mental Health's Real Men, Real Depression campaign. The campaign came to the U-M campus at the end of February in the form of posters on the buses, tabletop advertising in the dining halls, TV spots on the flat-screen televisions throughout the residence halls. Associate Dean of Students Stephanie Pinder-Amaker will help incorporate it into the third annual Depression on College Campuses conference, which runs Tuesday and Wednesday at U-M. "It's part of a really big commitment we have to eliminate the stigma of mental illness, period," Pinder-Amaker says. "The goal of the campaign is to educate, to reduce stigma and to encourage people to seek help when they need it."
     Palma says he suspects one of the reasons he was chosen for the Real Men, Real Depression campaign was that as a college-age Hispanic man he fit several groups that are typically reluctant to acknowledge depression. Born in Chile, Palma came to the United States when he was seven. He says in Hispanic societies depression simply isn't talked about. "I talk to men and they don't want to use that word," says Dr. Kevin Kerber, a U-M psychiatrist. "Where women will say, 'I'm depressed,' what, above all, men don't want to look is weak."
     The rate of depression in women is about twice that of depression in men, but, Kerber says, when you add problems like substance abuse and alcoholism, the ratio becomes much more balanced. "There's certainly a suspicion that many of the other problematic male behaviors we hear about are depression. Men probably just underfunction and drink and do a lot of other bad things rather than get their depression treated," he says, noting that it's not an area of psychiatry that's gotten much scrutiny yet.
     Palma isn't a drinker, but he says if he were it would have been easy as a college student to self-medicate with beer and camouflage his depression. To most people it would have looked like typical male behavior. "I didn't want it to be (depression)," he says. "I wanted it to be something else, something cooler, something which I understood." Extroverted and charismatic, he could keep up the charade in public -- at least at first -- but he became less and less able to function in his private life. He still struggles to describe the emotion that led him to detach from classes the way he did. Anxiety was part of it -- a fear that he might fall short of perfection. He avoided his homework because going near it made him feel bad. He'd do poorly in class, then not go back, afraid of doing poorly again. One thing snowballed into the next.
     Easily overwhelmed, he learned to live with depression by avoiding responsibilities that might become too much for him. Some people, he says, never hit rock bottom and just live this way their whole lives. Palma wasn't one of them. At its worst, depression left him basically unable to function. On a bad day he might sleep 15 to 20 hours, not bothering to eat or get dressed. "There is no sharp line (that marks the difference between a low mood and major depression) but when certain kinds of more physical changes occur -- sleep or appetite get thrown out of whack, people start to be unable to enjoy things they used to enjoy -- then you're getting into a different territory," Kerber says. "It wasn't crying; it wasn't sadness," Palma says. "I mean there were times I felt sad, but I think it was just more like general gloomy or grumpiness. I wasn't sad in the way I feel sad when I watch a movie or when something bad happens to someone."
     His housemates and the woman he was dating at the time encouraged him to get help, but it took a while to identify his illness. Doctors told him he had anxiety, that he was experiencing normal adolescent growing pains. One therapist suggested he surround himself with little signs that reminded him to "keep working" or "be more efficient." "I pasted them all over my room," he says with a laugh. "They mocked me. I couldn't do it. I felt more miserable."
     Finally, several factors converged that helped Palma overcome his depression. A former competitive swimmer, he started making exercise a priority again, swimming and playing soccer. He still swims once or twice a week and insists it's a cornerstone of his mental health regimen. A friend recommended therapist Barbara Hutton, who supported his choice to use homeopathic remedies rather than antidepressant drugs. And he met his future wife, Melissa, who refused to let him give up. She pushed him to get help and to demand more for himself. "I knew no matter how much I loved him and wanted him to be healthy, I couldn't do it for him," she says. "There were hard times when I'd say, 'I'm not going to be here if you're not going to get help."' There were days when she would get frustrated and just tell him, "You have to call Barbara."
     Palma says he saw a huge improvement within about two months. He worked with Hutton for about a year, and she helped him put some rituals and patterns into place that are still part of his life. "It's like being lost at sea," he says. "At first, you have to figure out you're on a boat. Then afterwards, you have to seek the guidance of people who know how to read the stars. You need help."  Although he considers his depression beaten, he still has to be mindful of things that could trigger a recurrence. His risk is 50 percent higher than it is for someone who's never experienced a major depressive disorder.
     The Palmas were living in South America when the Real Men, Real Depression campaign started in the spring of 2003. The couple moved back to the Ann Arbor area to be near family when their son was born 15 months ago. And since the campaign came to U-M, Palma sometimes finds himself surrounded by his own face and acutely aware that complete strangers know something very intimate about him. It's uncomfortable at times, but he likes knowing that what he's done is helping people. "Now that I'm I guess what you could call a survivor of depression, it helps me get more out of myself," he says. "Having gone through something like this, you know more about yourself; you know more about who you are. It's not exactly the best thing to go through to find yourself, but I guess it was my mountain I had to cross."

Sometimes when talking to people, I'll tell them that I've just had a lot of coffee, even though it's not true, because I know I fire off in all directions, and I can talk to you about anything - literature, string theory, rock guitar -- I once worked for Leo Fender -- and one thing I say to people is that, of course, I live near the edge; the view is better." Laurence McKinney, 60, who lives near the edge of Boston, is a business consultant, a Harvard graduate and self-described polymath who has had a career that is every bit as frenzied as his conversational style. Among other ventures, he said, he has started pharmaceutical companies, played in rock bands and helped design electric guitars, and written a book about the neuroscience of spirituality. This month, for the first time, he helped start a Web site for people like himself. They are known as hypomanics.
      At some point, almost everyone encounters them -- restless, eager people, consumed with confident curiosity. Researchers suspect that their mental fever shares some genetic basis with that of bipolar disorder, known colloquially as manic depression, a psychiatric disorder characterized by effusive emotional highs and bouts of paralyzing despair. In recent decades, scientists have found that bipolar disorder is widely variable, and that its milder forms are marked by hypomanias, currents of mental energy and concentration that are less reckless than full-blown manic frenzies, and unspoiled, in many cases, by subsequent gloom.
     New research helps explain how people with manic or hypomanic tendencies navigate the small triumphs and humiliations of daily life, and provides clues to how some of them quickly shake off the emotional troughs that their ambitious natures should make inevitable. "It kind of goes against the common assumption, but many people who are inclined to hypomanic or manic symptoms have an underlying resilience," said Dr. Kay Redfield Jamison, a professor of psychiatry at Johns Hopkins University. "They may get trashed by their peers, laid low, but they respond very strongly."
     In a new book, "Exuberance," Dr. Jamison argues that flights of joyous energy similar to hypomanic states frequently accompany scientific and literary inspiration.Psychiatrists have known for more than a century that bipolar disorder, unlike any other mental illness, is often associated with some financial and professional accomplishment. Mania can inspire destructive shopping or gambling sprees, but it can also generate bursts of creative and focused work.
     Psychiatrists and psychologists have found ample evidence for bipolar tendencies in the life histories of many famous writers and painters. The composer Robert Schumann, for example, experienced extreme mood swings; so, some now argue, did the poet Emily Dickinson. Some studies suggest that first-degree relatives of people with bipolar illness, who are likely to inherit some genetic basis for bipolar disorder, are particularly likely to enjoy high socioeconomic status.
     Most recently, researchers have turned their attention to the mild end of the bipolar spectrum, and sliced it into many permutations. Bipolar II, III and IV, for example, each include depressive episodes and varieties of hypomania, or exuberant moods. Cyclothymic disorder involves rapid cycling from moderate depressive to manic symptoms, and hyperthymia is a state of elevated mood. "When you look across the entire bipolar spectrum, you find that maybe 10 percent to 15 percent of these people never get depressed: they're just up," said Dr. Ronald C. Kessler, a professor of health care policy at Harvard Medical School. As one psychiatrist put it, Dr. Kessler said, "The goal in life is constant hypomania: you never sleep too much; you're on; you keep going."
     With the exception of Bipolar II and cyclothymic disorder, which are accepted as standard psychiatric diagnoses, these permutations of low-level bipolar disorder overlap with each other and with normal ranges of mental function so much that some scientists question how distinct they are. "For some of us, there is a lot of wariness about this tendency to see bipolar disorder everywhere," said Dr. William Coryell, a professor of psychiatry at the University of Iowa School of Medicine, adding that "it's very difficult to determine reliable boundaries between one diagnosis and another" and document the true prevalence of the conditions.
     Yet even if bipolar disorders can be reliably diagnosed in only 2 percent of the population, some now believe that hypomania or similar charged states are more prevalent than previously imagined. About 6 percent of college students score high on personality tests that measure hypomanic tendencies, some studies find, and about 10 percent of children rate as temperamentally "exuberant," a related quality.
     Outsized delight in small successes may be central to what kindles hypomanic natures and sustains them. In an effort to learn how the joys and sorrows of daily life affect mania and depression, Dr. Sheri Johnson, a professor of psychology at the University of Miami, began surveying men and women in whom bipolar disorder had been diagnosed. Originally, Dr. Johnson was interested in the effect of negative events, like struggles at work or arguments at home. "But the people in the study told us we were getting it wrong, that it was when good things happened that they felt they had their manias," Dr. Johnson said.
     In two studies involving 149 people, one completed in 2000 and the other a continuing project, Dr. Johnson has found that personal victories like a promotion or an award very often precede or coincide with manic symptoms, though the person may be feeling neither manic nor depressed when life takes a good turn.
     Even when small successes do not arouse manic symptoms, they appear to prompt exaggerated surges of confidence. In one study, scheduled for publication later this year, Dr. Johnson led a team of psychologists who rated a group of 153 college students on a hypomanic scale, which included items like: "There have often been times when I had such an excess of energy that I felt little need to sleep at night," "I often feel excited and happy for no apparent reason," and "I often feel I could outperform almost anyone at anything." The scale was intended to identify people at risk for developing bipolar disorders.
     The researchers gave the students a hand-eye coordination test, then told them that they had scored very well, regardless of their true scores. Offered a choice of which test to take next, the hypomanic group selected a significantly more challenging exam than their peers did. These students not only expected to do very well, Dr. Johnson reports, they were more willing than peers to pursue difficult goals after an initial success. Researchers do not know whether this surging confidence and hunger for challenge persists, or for how long, but it is a familiar pattern to some psychiatrists who treat mild forms of bipolar disorder.
     Dr. John Gartner, a psychiatrist in Baltimore who specializes in treating hypomania, recently published "The Hypomanic Edge," a book that identifies hypomanic symptoms in the lives of American historical figures from Christopher Columbus to the biotech entrepreneur J. Craig Venter. "These are people who are always moving the goal posts," Dr. Gartner said in an interview. "If they do well at one thing, they shoot for the moon." In a footnote in his book, Dr. Gartner recounts the story of how Henry Ford sailed off on a luxury steamer on a whim in 1915 to personally end World War I and bring world peace. "I'll bet this ship against a penny," Ford boasted to the reporters, "that we'll have the boys out of the trenches by Christmas."
     This grandiosity practically begs for a tragic fall. Difficult goals are by definition less likely to be achieved, even by those with mental power packs, and there is little question that people with hypomanic tendencies feel disappointment deeply. For some, their fevered, scavenging curiosity may overwhelm any excess rumination: new projects beckon before the old ones can be mourned. "I'm not so much smarter than other people as faster," said Mr. McKinney, the polymath near Boston, who contacted Dr. Gartner after hearing of his book. "I swing more often, I make errors, but I make them faster. That's how I sometimes describe it. If you can focus this energy, you can do great things with it. If not, well, I think it can be difficult."
     And that is one catch. Dr. Peter Whybrow, director of the University of California's Neuropsychiatric Institute in Los Angeles, said that he considered true hypomanic types to be rare and that some of them crashed at midlife, or later. "Usually what happens in the clinical domain," Dr. Whybrow said, "is that these people come in when they've had a business reversal and they're very depressed. They look back on their lives and realize that they were hyperactive, hypomanic, that they started a lot of projects but finished very few of them." The view may be better, but it is easy to lose your balance.

For many psychiatric disorders, drug therapy has become the norm. But phobias -- irrational fears that can paralyze and disrupt people's lives -- have been largely resistant to chemical intervention, and behavioral therapies have remained the treatment of choice. Recently, however, a tuberculosis drug with surprising effects on the brain has given psychiatrists hope that a new approach to phobias and other severe anxiety disorders may be in the offing. The drug, D-cycloserine, an antibiotic, does nothing to soothe panic or calm nerves. Instead, it increases learning and memory, and may help people overcome their fears faster in psychotherapy, which can be costly and take years.
      In November, researchers at Emory found that people who combined the drug with behavioral treatment to conquer their fear of heights improved drastically after only two sessions, instead of the usual eight. Elsewhere, researchers are studying its effects on social phobia, panic disorder and obsessive-compulsive disorder. And a group at Columbia is exploring whether the drug may help people grappling with anorexia nervosa. "Treating anxiety with Valium or antidepressants works on the symptoms, but doesn't really get rid of the fear except to cover it up in the moment," said Dr. Michael Davis, a psychiatrist at Emory who was involved in the study on heights, published in The Archives of General Psychiatry. "Psychotherapy is really the best way to treat these disorders, and this makes it better and faster."  For panic disorder, phobias and other severe anxiety disorders, psychiatrists often rely on a specific type of treatment called exposure therapy, in which patients gradually learn to feel comfortable in situations they dread.
     Studies have shown that a glutamate receptor in the amygdala, a part of the brain that governs emotion, plays a role in learning to adjust to threatening stimuli. Since D-cycloserine is known to act on these receptors, Dr. Davis, who has applied for a patent on the concept of using the drug to enhance learning during psychotherapy, decided to test whether it might accelerate the breaking of people's fearful associations, a process called extinction.
     For the study, his team assembled a group of 28 people so terrified of heights that they refused to park in multilevel garages or would go out of their way to book rooms on the lower floors of hotels. They all took part in sessions involving a virtual reality program that simulates rides in a glass elevator. Some received a dose of D-cycloserine beforehand, others were given a placebo. After two sessions, people who were given the medication had almost fully recovered and showed fewer symptoms of anxiety than those in the placebo group. "The people who had the drug were also more likely to report crossing bridges and going to the tops of buildings in their daily lives," said Dr. Kerry Ressler, an assistant professor of psychiatry and behavioral sciences at Emory and an author of the study.
     Early results were released in 2003. Since then, 10 other teams around the world have been testing the drug on a vast lineup of disorders treated with psychotherapy. Anorexia nervosa, a disorder with high relapse rates and few medications, is one of them. Because D-cycloserine specifically affects learning, not anxiety per se, psychiatrists suspect it may help anorexic patients unlearn their negative perceptions of food. "We're approaching some of the disturbed eating behavior as though it were phobic," said Dr. Timothy Walsh, a professor of psychiatry at Columbia and the director of eating disorders research at the New York State Psychiatric Institute. Dr. Walsh is leading a study in which anorexic patients, aided by a therapist, are given D-cycloserine and trained to overcome their anxiety about food. He said the first results would be known in the summer.

WASHINGTON -- You're never too old to quit smoking, government officials said Tuesday, announcing that Medicare will immediately start covering the cost of counseling for certain beneficiaries who want to quit tobacco. Medicare's new smoking cessation program ``has great potential to save and improve lives for millions of seniors,'' said Mark McClellan, administrator for the Centers for Medicare and Medicaid Services. Not every Medicare beneficiary qualifies for the new benefit -- only those who have an illness caused by tobacco use or complicated by tobacco use.
      Medicare officials said Tuesday they did not have an estimate of how much the new program would cost or how many people would be eligible for it. It covers only counseling sessions, not the cost of nicotine patches and gum or products pitched to help smokers quit. About 300,000 senior citizens die annually from smoking-related illnesses, according to the Centers for Disease Control and Prevention. Medicare operated a pilot program for smoking cessation in seven states between November 2002 and December 2004. The official who oversaw it, Jim Coan, said the government paid about $32 for each counseling session, which usually lasted from three to 10 minutes. The maximum amount of claims that could be submitted per participant was four per year. Coan did not have cost estimates for the program. He said about 7,500 people participated, far short of the goal that had been set for the program.
     The new nationwide benefit covers only those with smoking-related illnesses or complications. In the pilot program, any Medicare beneficiary living in the seven states -- Alabama, Florida, Missouri, Nebraska, Ohio, Oklahoma and Wyoming -- could participate. Dr. Ronald Sturm, a senior economist with the RAND Institute, a nonprofit research group, said Medicare's decision to limit the annual benefit to two cessation attempts per year -- each including a maximum of four counseling sessions -- would limit the program's costs. Still, elderly people who have smoked throughout much of their life aren't typically the best candidates to quit smoking -- unless they are facing a life-threatening scenario. ``Will they quit smoking in their last few years? Not likely,'' Sturm said. ``It's not going to change much. It's not going to cost much.''
     Officials at the American Medical Association applauded the government's move. They said seniors actually have a better chance of successfully quitting smoking than do people in other age categories. ``Studies have shown that seniors who try to quit smoking are 50 percent more likely to succeed than all other age groups, and seniors who quit can reduce their risk of death from heart disease to that of nonsmokers within two to three years after quitting,'' said Dr. Ronald Davis, an AMA trustee.
     On the Net: Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov



Marriages That Last a Lifetime
Kristi L. Gustafson, Albany Times Union- 3/22/2005

She was drawn to his quick wit. He couldn't resist her sweet nature and fiery red hair. Their first date: the unveiling of a band shell in a park near their hometown in Newburton, Conn. He came to her house, picked her up. It was warm and breezy that day. Afterward they went for ice cream.
That was more than 65 years ago.
     Now Alberta and Winton Catlin, who are residents of a retirement community in Queensbury, N.Y., are renewing their vows along with six other couples. Six grooms escort their brides past the guests. Walking down the aisle, each woman clutches a carnation bouquet; boutonnieres are fastened to the men's lapels. With wide smiles, the Catlins' eyes focus on the makeshift altar, while white and gold helium-filled balloons dance overhead.
     The ceremony comes just shy of their 65th wedding anniversary this April. Another reason to celebrate: They and the other five couples are among the 3 percent of couples in the United States whose marriages last more than 50 years, says Finnegan Alford-Cooper, an associate professor in the department of sociology and anthropology at Stetson University in Florida.
     Since the mid-1990s, Alford-Cooper has conducted research on couples married 50 years or more. Her research spawned "For Keeps: Marriages That Last a Lifetime." Alford-Cooper says: "There is no simple recipe for a long-term marriage. A complex interplay of social and personal factors plays a role. "Happier couples report high levels of love, trust, respect and compatibility They enjoy each other's company. They are each other's best friend:"
     Winton, 95, and his bride, 86-year-old Alberta, hold hands as they sit in front of their friends, repeating their vows after the Rev Father Michael Abraham, the retirement community's minister.
"He is my best friend," Alberta says. "The one who makes me happier than anyone else could." .
The enthusiasm is so great, the couples shout out their "I haves," announcing they've honored, cherished and loved one another over the years.  As the couples exit the room to their reception -- complete with a multitiered wedding cake, jumbo shrimp, chocolate-covered strawberries and freeflowing champagne -- there are handshakes and congratulations all around. Each couple is met with hugs and kisses from their friends and fellow residents.
     Like any couple, the Catlins had their ups and downs over the years. They lost a son in 1961. They cried together and then talked it through. They know they've argued, but neither can recall over what. And they never went to bed angry. Dinner is their special time. From when they were first married, through the years as their children grew up and even today, they would sit down, have a "proper supper." And, for the duration of their marriage, they always made time for one another, especially at dinner. Conversation ranged, over the years, from work to the kids and school to daily happenings, to what may be bothering them, to politics, movies and much, much more, says Winton.
     Jack Greenhill, 93, and his wife, Jean, 91, dated two years before getting married. Since their Aug. 20,1933, marriage they've never spent more than a couple of days apart -- and even that was rare. They know their roles, says Jack with a laugh. That's a plus. "She's the boss," he says. "Oh, I know," Jean retorts Today they've got five children, 16 grandchildren, 32 great-grandchildren -- two more on the way -- and three great-great-grandchildren. They kiss a lot, and that sure can't hurt, says Nancy Casey, one of their daughters. She is 65 and lives nearby. "They may snap at each other," Casey says, "But they get over it right away."
     The secrets to happiness, longevity and many years of wedded bliss lie in shared morals, values and faith, says Nancy Pina, relationship expert and author of "The Right Relationship Can Happen: How to Create Relationship Success." The Greenhills, both Methodist, always stressed family first--putting that before work, friends or anything else -- and made honesty the highest priority. "We talk about everything," says Jean, who, to this day, plays classical music for her husband on the piano. It relaxes and entertains them both. "We have no secrets." And not a day goes by that they don't say "I love you."
     As for the Catlins, two of the things that brought them together --.humor and hair color -- make for an ongoing joke today. She teases him that he's bald. He, as always, has a comeback "When I was in line for hair all they had was red," he jokes, looking at Alberta and glancing at their wedding picture. In it, her deep red hair is swept back "I wouldn't take it." They both laugh. She takes his hand. "It never stops," Alberta says. "And I wouldn't want it to."

The death of a child not only alters a family forever but also sharply increases the risk that parents will later be hospitalized for a mental illness, researchers are reporting in the largest study to date of parent bereavement and mental health. The risk is greatest during the first year after the child's death but remains elevated even five years afterward, the researchers found, and includes higher rates of schizophrenia, depression and abuse of drugs and alcohol. The overall rate of psychiatric hospitalization among bereaved parents in the study was less than 3 percent over five years, but, experts noted, doctors do not usually admit patients for mental illness unless their condition is urgent. The paper appears in the current issue of The New England Journal of Medicine. "This is a very important study, because bereavement traditionally has been way underrecognized and undertreated in medicine and psychiatry," said Dr. M. Katherine Shear, director of the Bereavement and Grief Program at the University of Pittsburgh School of Medicine, who was not involved in the research.
      Because a vast majority of people who grieve the death of a child do so without lasting mental health problems, psychiatrists have not had a good sense of how much, or even whether, the deaths can increase the likelihood of psychological illness, she said, adding, "This study is large and rigorous enough" to put those questions to rest.
     In the study, Dr. Jiong Li of the Danish Epidemiology Science Center led a team of doctors who analyzed the medical records of more than a million people who had at least one child born before 1999. The records are part of Danish databases that include detailed information on people who have sought treatment for mental health problems. A total of 17,033 parents in the database had lost a child under 18, and 495 of them were hospitalized for psychiatric problems for the first time in the five years afterward.
     In the year after the death, bereaved mothers were almost seven times as likely as their nongrieving peers to be hospitalized for a mood disorder, like depression; about four times as likely to be admitted for schizophrenia; and nearly three times as likely to be admitted for abusing drugs and alcohol. Bereaved fathers were at lower risk than bereaved mothers during this first year, but were still nearly six times as likely as nongrieving fathers to be admitted for a mood disorder like depression, and more than twice as likely for schizophrenia. With time, the difference in risk between the bereaved parents and their peers narrowed significantly, but after five years the bereaved group still had a higher rate of hospitalization for psychiatric problems - about 40 percent higher in fathers, nearly 80 percent in mothers. Neither the child's age nor the parents' age at the time of death significantly affected the risk of hospitalization, but parents who had lost an only child were at higher risk than those who had larger families.