Noteworthy News Articles on Mental Health Topics, May 14- , 2005

For the first time, Massachusetts General Hospital's renowned psychiatry department has accepted money from the pharmaceutical industry to educate doctors around the country. After decades of offering continuing medical education classes in Boston, Harvard Medical School teaching hospital last year raised $6.5 million from Cephalon Inc., Janssen Medical Affairs, GlaxoSmithKline, and Wyeth for its 2005 program. The pool of money will allow the psychiatry department to dramatically expand its continuing medical education program with live lectures in 24 cities, teleconferences, and around-the-clock webcasts.
      Mass. General psychiatrists said without outside funding they would have to charge doctors prohibitively high tuition. They said they have developed ways to minimize the risk that drug company money could bias classroom instruction. ''The companies don't have any input into the curriculum, and there is no ongoing dialogue throughout the year," said Dr. Robert Birnbaum, medical director of the Division of Postgraduate Education for the psychiatry department. ''We're hoping this becomes a national model."
     In recent years, the pharmaceutical industry has become increasingly interested in funding continuing medical education. While companies say their motive is to help educate doctors, the practice is raising concerns in the medical profession. Recently enacted rules have explicitly forbidden companies from nudging course content toward positive discussion of their drugs. But even those measures have not satisfied some critics. ''I am skeptical that a company would give a lot of money just to be able to say 'We were nice to the Mass. General Hospital,' " said Dr. Arnold Relman, a Harvard Medical School professor, former editor of the New England Journal of Medicine, and long-time critic of drug company involvement in education. ''It's much more likely that despite the rules and regulations they hope they will influence the programs and improve their sales."
     Most states require physicians to take 30 to 50 hours of instruction a year to keep current on treatments and to stay licensed. Hospitals, medical schools, and media and education companies nationwide offer thousands of different courses, from hour-long lectures to weekend seminars in exotic locations. Increasingly, the courses are paid for by drug firms, allowing doctors to attend for free or to pay minimal fees. In 2003, drug companies for the first time accounted for more than half of the total funding of courses offered by organizations accredited by the Accreditation Council for Continuing Medical Education, which oversees continuing medical education for doctors. That year, the pharmaceutical industry gave those organizations $944 million for education. Total funding from all sources was $1.77 billion.
     The potential influence of drug companies on doctors' education was highlighted by a federal investigation of Parke-Davis, now owned by Pfizer Inc. According to internal company documents released as part of the probe, the company developed a strategy for marketing its epilepsy drug, Neurontin, for unapproved uses. In a report titled ''1998 Neurontin Tactics," a New York advertising firm suggested that the company sponsor classes on bipolar illness to increase awareness of Neurontin's effectiveness in treating the disorder. Last year, the company pled guilty to criminal conduct and agreed to pay a $430 million fine. 
     Federal regulators and medical community leaders have called for stricter standards, and last year the accreditation council adopted explicit rules to protect against drug company bias in continuing education. For example, it prohibits companies from selecting faculty for courses or from advertising their products during educational activities. But critics say that even with the new rules, drug companies still set the overall agenda by funding only courses that emphasize treatment with expensive brand-name drugs, rather than courses that don't focus on profitable products, such as behavioral therapy for depression. Mass. General's psychiatry department, one of the nation's largest academic psychiatry departments, said it discourages that practice by asking firms to fund the entire curriculum for a year, rather than individual courses. Many of the psychiatrists who teach the courses are consultants for, or receive research funding from, pharmaceutical companies, which they disclose to their audiences as required by the accreditation council.
     Dr. Jerrold Rosenbaum, chief of psychiatry at Mass. General, said the department will not earn a profit from the expanded program. Ninety percent of the drug company money will be used to pay Primedia Healthcare, a Texas-based education and training company that produces brochures, arranges hotels and food during sessions and maintains the website. But psychiatrists who teach the classes will earn extra. In the past, the department gave course instructors credits they could put toward professional dues or books. Now, they will get paid $2,000 to $4,000 per course.
     Birnbaum said that when he raises money for the program, he tells drug companies only about the general therapeutic focus of the courses, the instructors, and the types and number of activities planned. He said some companies do not request more specific information because they are eager to demonstrate that funding decisions are not based on the potential for drug sales.
     Cephalon, a small pharmaceutical company based in Pennsylvania and the department's biggest funder, said it is developing products for anxiety and attention deficit hyperactivity disorder, so funding psychiatry courses fits into its overall strategy. ''We fully expect to be marketing drugs in the psychiatric market, so it helps having our name out there, and aligning ourselves with Mass. General is a positive," said Sheryl Williams, a Cephalon spokeswoman.

Problems Abound at Home for the Mentally Ill
Marc Santora, New York Times- 5/15/2005

For more than a decade, state investigators have been aware of a troubling and dangerous state of affairs at the Brooklyn Manor Adult Home, a place meant to offer refuge to mentally ill people not wanted by anyone else. In a series of reports, most recently a 200-page catalog of abuses, investigators found violations in every imaginable category -- from financial malfeasance to grossly inaccurate medical evaluations of the people, often very sick, who are living there. From Jan. 8 to June 22, 2004, inspectors from the New York State Department of Health, which is charged with overseeing the several dozen such homes in the city, visited Brooklyn Manor 39 times to respond to complaints and concerns. Still, Brooklyn Manor remains open. For the residents of the home, which has 216 beds, life there is as it ever was -- isolated, grim, and unimproved by action by the state.
      It was, then, business as usual last Sunday when a 51-year-old man burned to death in his bed after setting the mattress on fire with a cigarette, with some residents left walking the nearby streets dazed and complaining of how haphazard the resulting evacuation had been. The fire may have been accidental, but the death of the man, Charles Dunbar, gave rise to yet one more appreciation of how little has changed at the home, according to residents, lawyers who work with them and the state's own investigative reports.
     Despite attempts by the state to revoke its license, despite a temporary ban on referring new residents to the home, and despite the current battle by state officials to have the administrator fired, the home is still full of the ill and the defenseless. "It is hard for me to understand what has happened," said Tanya Kessler, a community organizer with the Coalition of Institutionalized Aged and Disabled. "Certainly the state last year responded to a lot of complaints from residents and was out at the home a lot," she said. "The question now is why has it failed to take the next step?"
     That failure, interviews and records show, is a result of a mixture of legal wrangling, bureaucratic infighting and historical indifference. The state, which is charged with monitoring adult homes like Brooklyn Manor, has been conflicted in its own response. On the one hand, investigators have been aggressive in finding out about problems and diligent in reporting them. On the other, lawyers and others who work with the residents say state officials have not always been aggressive in acting on the findings. William C. Van Slyke, a spokesman for the State Health Department, said that any inaction was the result of things beyond its control, including court decisions and the limited authority granted to the department by the State Legislature. "Our posture here is as aggressive as it can be given the loopholes that exist in the statutory authority," he said. He said the Health Department has much more power in its oversight of nursing homes and hospitals, for instance, than it does when it comes to adult homes. "We continue to have serious concerns about this facility," he said.
     The list of abuses compiled by state investigators is long. When patients were sick or injured, staff members failed to get them urgent medical care. When a doctor was made available, exams lasted only two or three minutes. Sometimes residents were taken into the home when they should have been sent elsewhere because of the severity of their illnesses, while at other times residents were discharged without due notice or explanation, including some who were barely capable of caring for themselves.
     As early as 1991, state investigators found problems at Brooklyn Manor, uncovering evidence that the operator of the home, Benito Fernandez, then the husband of State Senator Nellie Santiago, took more than $45,000 in retirement benefits from a resident who had entrusted the money to the home. Over the ensuing years, more reports by state investigators found that not only was money being misappropriated, but that the level of supervision and coordination of care was abysmal. As far back as 1996, there was a push to have the home's license revoked. However, senior officials in the State Department of Social Services, which oversaw the homes until 1998, reversed the effort without explanation. Throughout, the administrators of the home and their lawyers have defended their record, and characterized the investigations as flawed.
     Brooklyn Manor, anyway, has been able to fend off the state's efforts, which were energized after a series of articles in The New York Times in 2002 that documented the overall condition of the largest adult homes. At the time, the State Health Department made a full push to have the home's license revoked. But the effort was derailed in court. On Dec. 6, 2004, a judge ruled that the inspection reports compiled over more than a decade were invalid because they only documented problems and did not offer remedies. The ruling also provided the basis for a successful fight by Brooklyn Manor to be removed from the state's "Do Not Refer" list -- intended to warn nursing homes, hospitals and other care facilities against sending people to Brooklyn Manor. The state was frustrated by the ruling, which has made it harder to enforce actions against the most dangerous homes.
     The state should not have been surprised. A year earlier, a court had made a similar ruling after an effort to revoke the license of an adult home. Presumably, the state had had months to make its reports meet the court's standards. Mr. Van Slyke said the department had tried to adjust its inspection reports to account for the decision and said the judge's ruling was akin to a court invalidating a traffic ticket because the driver was not told that he could have stopped speeding by taking his foot off the accelerator. Mr. Van Slyke said the state opted not to try to take control of the home itself, and is still seeking to have the administrator who runs the home on a daily basis removed. But the most drastic action, closing the home, is not really an option: there is virtually nowhere else for the residents to go.
     After the state began closing its psychiatric wards in the 1960's, adult homes were used for some of those who were deemed too ill to live on their own but not sick enough for hospitalization. Although Gov. George E. Pataki's administration created a panel to study alternative housing options, adult homes remain the easiest solution for vast numbers of the vulnerable population they serve. There are some 15,000 mentally ill people living in more than 100 homes in the state. The panel studied the feasibility of creating smaller, more specialized homes for some residents of adult homes in 2003. State health officials said they had surveyed some 2,500 residents and helped many receive better care, but, to date, too few facilities have been built.

NEW YORK - Like dormitories and dining halls, Adderall was something Cory Clair figured he'd leave behind in college. But when he went off the medication and started a new job in January, his mind began wandering at work — just as it did in class before he was diagnosed with attention-deficit disorder and was prescribed the drug, a common treatment for a related problem, attention-deficit (hyperactivity) disorder. "I thought I'd have it for school, and then I'd be out and wouldn't need it anymore," said Clair, who works in public relations in New York. "I was wrong."
      After a few months of struggling to pay attention to co-workers and complete assignments on time, Clair finally made an appointment with a doctor and renewed his Adderall prescription, which his health insurance covers. "The difference is remarkable," Clair said. "When you're on it, you stay focused on what you're doing."
     The kids of the ADHD drug boom are growing up, and some are finding that what they thought would be a school-age ailment may in fact last a lifetime. As they enter the work force — and as older people are increasingly diagnosed — drugs for the disorder are becoming more common in the workplace.

Chicago Mental Hospital's Prognosis in Doubt
Karen Mellen, Chicago Tribune- 5/16/2005

A flurry of lobbying by mental health advocates and a push by legislators won a reprieve last spring for the Tinley Park Mental Health Center, which Gov. Rod Blagojevich wanted to shutter to help close a massive budget hole. This year, budget projections remain dire, state officials still want to close the hospital and some advocates believe the state will eventually sell the only facility for mentally ill patients from the South Side to Kankakee and Grundy Counties.
     As a result, many physicians and advocates are lobbying the Illinois Department of Human Services to ensure that enough money is allocated to programs in communities. Others say they will still fight to keep the center open, on behalf of employees and a group of people among the most vulnerable: those with severe mental illness who cannot pay for treatment. "If they're not stabilized and treated adequately, in a timely manner, in their communities, they often end up in the criminal justice system," said Anders Lindall, director of public affairs for the American Federation of State, County and Municipal Employees, Council 31, which represents state employees. "Those outcomes really cost more than if we were to make an appropriate investment in keeping Tinley open and operating at full capacity," Lindall said. People with the most severe mental diseases, such as bipolar disorder or schizophrenia, sometimes go into a psychotic state that leads to hospitalization.
     Beginning Monday, the state is reducing beds at the mental health center along 183rd Street by 25 percent and cutting 15 percent of staff. That will drop the Tinley Park budget to $20.22 million for the upcoming fiscal year. But the budget at the Madden Mental Health Center in Maywood would increase nearly 30 percent, to add patient beds and centralize some operations, such as intake of patients. The real boon to the state would be selling the 213-acre site in Tinley Park for an estimated $31 million. Some advocates and lawmakers, though, vow to fight to ensure proceeds from the sale would go toward building another hospital or programs to provide mental health care, and not to the general fund.
     Dr. Nada Stotland, incoming vice president of the American Psychiatric Association, said that when the Tinley Park center opened nearly 50 years ago, the country setting was touted as a therapeutic benefit though most patients do not walk the grounds now. The center belongs to the people who are mentally ill, she said, not the governor's office to wipe out red ink in the transportation budget, for instance. "This may be crying in the wind," Stotland said. "I want the proceeds from the sale of the land to be put in trust, so it can't be used for anything else but to be used for the care of people with mental illness."
     Others are concerned there is no plan for what to do with patients if the facility closes. State officials have suggested such scenarios as leasing beds in private hospitals or opening small offices for outpatient treatment and day programs. Dr. Christopher Fichtner, director of the Division of Mental Health in the Department of Human Services, could not provide specifics on what would happen if the Tinley Park center is closed. No date has been suggested for a possible closing and, under state law, a committee of the General Assembly must approve the action.
     But Fichtner said the trend in the medical community is to treat people with mental illness at outpatient centers. In such a scenario, more case managers would keep track of people in hopes of averting hospitalization by monitoring medication and stress levels. And when someone must be hospitalized, Madden would be available, he said.
      Fichtner said a better alternative would be for the state to pay for patients to be treated at private community-based hospitals. Doing so would allow the state to be reimbursed by the federal government, which does not happen when a patient receives treated in a state-run center, he said. "It is also possible to close an institution, put money into the community and maintain those services," Fichtner said.  Brenda Hampton, facility director for Tinley Park, acknowledged anxiety among patients and families, many of them worried about driving many miles to Madden. But she said the state wants to provide access to care within communities and is looking at ways to do so.
     On a recent morning, patients at Tinley Park played cards in a day room or watched TV. Staff described a schedule for patients that includes participation in group therapy daily as well as individual meetings with doctors.
     On Monday, advocates for the mentally ill and providers are scheduled to meet with officials from the Department of Human Services to discuss a task-force report. The task force concluded the state must "maintain a public hospital presence in the region," without defining exactly what that would be. State Sen. Maggie Crotty (D-Oak Forest) said there must be not just a presence but an actual hospital in the south region. She said that even when the budget is in the red, government must still care for the most defenseless. "There are times when a person is in crisis, when they would need to be somewhere with more intense help," Crotty said. "I think we should be there."

CHICAGO -- Women who take Prozac or certain other antidepressants late in pregnancy raise the risk that their babies will suffer jitteriness, irritability and serious respiratory problems during their first couple of weeks, researchers say. Babies born to women taking antidepressants in the last three months of pregnancy were three times more likely to develop drug-related symptoms than those born to women who did not use the drugs or took them only in early pregnancy, according to a University of Pittsburgh study that pooled previous research. The study was published in Wednesday's Journal of the American Medical Association. Most of the symptoms are mild and usually disappear after about two weeks, but some require intensive care hospitalization, the researchers said.
      The drugs involved include Prozac, Paxil and other antidepressants known as selective serotonin reuptake inhibitors or SSRIs, and also serotonin norepinephrine reuptake inhibitors, which include Effexor. At least 80,000 U.S. women yearly take the drugs during pregnancy, the researchers estimated. Serious respiratory problems develop in perhaps one out of 100 infants born to these women, said Dr. Eydie Moses-Kolko, a psychiatrist who led the study.
     The Food and Drug Administration and drug makers recently agreed to labeling changes on these drugs to include information about the symptoms, which some doctors call neonatal behavioral syndrome, or withdrawal syndrome.
     Moses-Kolko said there has been little research on whether the drugs have any lasting effects in children, although one study found that affected newborns were developmentally normal at 8 months. ''I don't think this is cause for alarm,'' but patients and doctors should be aware of the risk, she said. Women should talk to their doctors about reducing use of the drugs late in pregnancy but should also be aware that the risks of major depression might outweigh the short-term problems the drugs might cause in newborns, she said.
     On the Net:
JAMA: http://www.jama-archives.org
FDA: http://www.fda.gov/medwatch/SAFETY/2004/may--PI/Effexor--PI.pdf

BOSTON -- A group of 20-something drinkers seemed to lose the urge to binge-drink when they took pills made from kudzu, that ubiquitous vine that blankets the South, researchers reported. The finding, described as groundbreaking by one expert, might one day lead to a way to attack the binge-drinking problem.
      Researcher Scott Lukas, with Harvard-affiliated McLean Hospital, had no trouble finding volunteers for the study, which required them to hang out in an ''apartment,'' complete with television, recliner and fridge stocked with beer. This apartment-style laboratory was set up in the hospital, and the volunteers were told to spend a 90-minute session drinking beer and watching TV. Those who took kudzu pills drank an average of 1.8 beers per session, compared with the 3.5 beers consumed by those who took a placebo.
     Lukas was not certain why, but speculated that kudzu increases blood-alcohol levels and speeds up its effects. In other words, the drinkers needed fewer beers to feel drunk. ''That rapid infusion of alcohol is satisfying them and taking away their desire for more drinks,'' Lukas said. ''That's only a theory. It's the best we've got so far.''
     In 2003, David Overstreet and other researchers at the University of North Carolina-Chapel Hill studied the plant found it had a similar effect on rats. ''There's a lot of anecdotal evidence from China that kudzu could be useful, but this is the first documented evidence that it could reduce drinking in humans,'' said Overstreet, who reviewed the study and called Lukas' work ''groundbreaking.''
     The 14 men and women chosen for the study were people who said they regularly had three to four drinks a day. After all of them spent a 90-minute session drinking and watching TV, they were divided in two groups for follow-up sessions. A chemist extracted several forms of plant estrogen from the roots, stems and leaves of kudzu and used it to make tablets. One group was given two tablets three times a day for a week, and the other group was given placebos. After another round of 90-minute beer-drinking, the placebo group was given the kudzu tablets and vice versa. ''Unbeknownst to them, I was weighing that mug of beer every time they took a sip,'' said Lukas, who hid a digital scale inside an end table where the subjects were told to rest their beers. ''We actually got a sip-by-sip analysis of their drinking behavior.''
     None of the test subjects had any side effects. ''It's perfectly safe, from what we can tell,'' Lukas said. ''Individuals reported feeling a little more tipsy or lightheaded, but not enough to make them walk into walls or stumble and fall.''
     Though kudzu won't turn drinkers into teetotalers, Lukas said, he hopes it can help heavy drinkers to cut back. ''That way, they're a lot closer to being able to cut down completely.'' Lukas' study, published in this month's issue of Alcoholism: Clinical and Experimental Research, was inspired by Dr. Wing Ming Keung, a pathology professor at Harvard Medical School who has studied the potential medical applications of kudzu. Keung said he has extracted a compound from kudzu root that he hopes to turn into a drug for reducing alcoholics' cravings. ''The most urgent need is helping people who cannot help themselves, who need a drug to help them stop drinking,'' Keung said.
     On the Net:
McLean Hospital: http://www.mclean.harvard.edu
Alcoholism: Clinical and Experimental Research: http://www.alcoholism-cer.com

Advocates Fear Loss of Mental Center Funds
Karen Mellen, Chicago Trubune- 5/17/2005

Keith Kemp wants to be optimistic. As legislative chairman of the National Alliance for the Mentally Ill of the South Suburbs, he believes in a proposal to eventually close the Tinley Park Mental Health Center and move more money into outpatient programs. But the draft budget for the next fiscal year calls for a decrease of $3.57 million to the Tinley Park center--and no corresponding increase in other programs for the mentally ill in the south suburbs. The budget for Madden Mental Health Center in Maywood would be increased for more beds and centralize intake. "We never get on the list for this governor, or any other governor," said Kemp, of Chicago Heights, at a meeting Monday with the head of the Illinois Department of Human Services. Later, Kemp said he would lobby legislators for more funds, even though Springfield is dealing with a budget shortfall. "We want that money back," he said.
     On Monday, Secretary Carol Adams of the Department of Human Services met at Tinley Park with members of a task force assembled to make recommendations on realigning mental health services. "We're looking for a plan with roots and legs," Adams said. She acknowledged that the decrease in spending for the Tinley hospital was not reinvested into community programs because of the budget shortfall. Eventually, Adams said, the state wants to close down the Tinley Park center. Estimates are the state could earn about $31 million by selling the 213-acre site at Harlem Avenue and 183rd Street. Adams left open the option of building another public hospital in the south region but said later that any such decisions would be guided by available funds.
     State officials are considering how to deliver services for poor people with mental disorders, with the trend toward keeping people out of hospitals by providing them with more outpatient care. As part of the planning process, the state is considering paying for treatment at private community hospitals, either by paying for beds as needed or by contracting for a wing to be set aside for state patients. Under those scenarios, the state would be eligible in most cases for reimbursement by the federal government. Under current rules, the federal government does not pay for care for adults at facilities where more than half of the beds are for psychiatric patients, which is the case at the freestanding state psychiatric hospitals.
      The National Alliance for the Mentally Ill of the South Suburbs agrees with the philosophy of treating people in their communities, said president John Rowley, but is concerned about how much money would be funneled toward the mentally ill if the Tinley Park center is closed. Indeed, one task-force recommendation is to ensure that a plan to move patients out of the public hospital is fully funded before the change occurs.
     John Cameron, director of community relations for American Federation of State, County and Municipal Employees, Council 31, which represents employees at Tinley Park, said he does not believe state officials will provide adequate funding for the mentally ill after the hospital is closed.
"Unfortunately, I believe it remains a cover story for the decision that has already been made," he said, referring to the discussions about how to change the system of care.

The Choice of Life
Gail Griffith, Washington Post- 5/18/2005

On Saturday evening, March 10, 2001, my 17-year-old son, Will, returned from an evening of bowling with friends. He sat at the kitchen table and told me he'd had a great night: He bowled over 100 twice in a row, he said, and then he, his girlfriend and cousin went to a pizza joint afterward. He appeared cheerful and light. "You seem to be feeling a lot better, Will," I told him. It wasn't a casual remark; Will had been diagnosed with major depression in the fall of 2000, and after an agonizing and worrisome few months, he appeared to be shaking it off. I thought the latest medications were finally beginning to take effect. Or maybe it was just the passage of time, but by all markers, he looked as though he was genuinely on the mend. "Yeah, Mom, I think I am better. No, really, I think I'm okay." I kissed him on the forehead and went to bed buoyed by our exchange. For the first time in months I felt confident that we, that he, had turned the corner.
      Will watched the basketball playoffs with his stepsister and her friends for an hour or so. He then went to his bedroom, wrote out four suicide notes and at 3 a.m. ingested 100 times the normal dose of the sedative antidepressant Remeron, washed down with a bottle of Snapple Iced Tea. I discovered Will late the next morning in his bed, semi-conscious, gagging and incoherent, his heart racing and skin covered in sweat. We rushed him to the emergency room at George Washington University Hospital. After a day-long battle by a medical team to stabilize his vital signs, we came face to face with the devastating realization that our son had attempted to take his own life. It was the worst moment of my life. Thankfully, Will survived.
     How do you explain the suicidal impulses of a child? We give our children life; we think we know everything about them. And why shouldn't we? We tell them what to think and do from the moment they are born. So it comes as a terrible shock to learn that your child is harboring such a deadly secret. Suicide is not a rational act; it is, rather, the worst possible outcome of a treatable illness, depression. A child in the throes of depression is suffering mental anguish not unlike the bodily pain of a wrenching physical illness. And the process of healing is no different: The sooner you obtain relief, the better the prognosis.
     In the immediate aftermath of Will's suicide attempt, our family and a set of clinicians came together to analyze what went wrong. We began an urgent and heart-rending process to determine the next course of action -- a treatment plan for Will that at a minimum might safeguard against another suicide attempt and at best might conquer his depression.
     As we grappled with the situation, we learned a lot about our son, and about the limited treatment options for teen depression. We immersed ourselves in the controversy over the use of antidepressants to treat teenage patients and weighed the advantages and drawbacks of outpatient vs. residential treatment. We were stymied by the staggering inadequacies of our managed-care system, and we discovered that our best hope for helping Will was to become at least as well informed as the therapists treating him. For any family in the thick of a crisis, it is a lot to handle.
     Teen suicide is now a public health crisis. In the years since Will's suicide attempt, I have watched it rip through families and lamented the paucity of ready solutions. Roughly 2,000 American teens between the ages of 13 and 18 attempt suicide every day. That's a stunning statistic for a society that, on the surface, has so much to offer children. In 1999 the U. S. Surgeon General issued a report stating that 3.5 million teenagers suffered from depression. Yet 80 to 90 percent of depressed adolescents go undiagnosed and untreated. And if left untreated, depression can lead to suicide.
     When depression strikes a teenager, it often shows up in a confusing set of symptoms that are difficult to distinguish from normal adolescent behavior -- moodiness, irritability, irregular sleep patterns, drug or alcohol use, difficulties at school. But there is another, less common but more troubling pattern of teen suicides, which occurs more often, but not exclusively, in adolescent boys. I call these the "stealth" candidates for suicide -- the kids who appear to be doing just fine, even very well. It's the type of kid my son Will appeared to be. How often have we seen media reports of the "star athlete" or "president of the student council" or the kid voted "most likely to succeed" -- the teenager with everything going for him -- who comes home on a Saturday night, loads a gun and shoots himself? If there is a suicide note, it is vague in the extreme: "Sorry for the inconvenience." Or "I just couldn't handle stuff anymore." This type of kid typically closets emotions while aiming at goals and self-imposed standards that are impossibly high or prompted by perceived expectations of their parents. They are loath to disappoint family and friends. In our pressure-cooker society, how do we convince our children that nothing is as important as their health and well-being?
     The first stop on the road to diagnosis is often the family pediatrician or managed care gatekeeper. Few are expert in diagnosing and treating adolescent depression. If you are lucky enough to locate a competent therapist or psychiatrist to treat a teen (no mean feat), you need to become educated about the therapeutic options for your child and weigh the risks vs. the benefits of antidepressant medication.
     As I talk with friends and families of depressed teenagers, I have concluded that parents are ill-equipped to steer their children through the rugged terrain of mental illness. Worse, we have so little confidence in our judgment that our anxiety over doing the "right thing" often results in doing nothing at all. Sometimes families of troubled teens refuse to accept the overwhelming evidence pointing to a teenager with depression when it is right in front of them. Abusing drugs and/or alcohol, risky sexual behavior, truancy, petty larceny, self-mutilation (including "cutting" and eating disorders) -- each one of these behaviors is in its own way a cry for help. Two or more together should make alarm bells go off.
     Parents confronted with the challenge of handling a troubled adolescent often see the problem as a reflection of our own parenting skills, or lack thereof. We worry that we will be judged harshly by the community if we own up to a "failing" kid. Some adults worry that a "mental illness" label will follow their children through school and prevent them from attaining their goals. If your child were battling cancer, you would not sit by and wait for the disease to run its course. And if your teen is depressed, he or she is up against a life-threatening illness and you need to seek help. Immediately.
     My experience with Will leads me to this: If you suspect your teen is depressed, doing nothing is a luxury you cannot afford. No one on the planet knows your child better than you do. Trust in that knowledge, trust your instincts and then fight like hell to get help for your child. If there is a hurt more wrenching than watching your child suffer, I do not know it.
     The six weeks following Will's suicide attempt were fraught with frustration bordering on panic. We were aware that, statistically, an adolescent who has made a failed attempt is 10 times more likely to try again if the depression is not treated successfully. I couldn't sleep through the night without getting up several times to make sure he was still breathing. We never let him out of our sight.
     Eventually, with the help of an educational consultant, we found a therapeutic boarding school in Montana with a stellar reputation. Despite Will's reluctance, we enrolled him. There he was monitored 24/7 and received the therapeutic treatment he needed and at the same time graduated from high school (with honors).
     After returning home from Montana, he began to contemplate his future. On a job application for a volunteer government program, Will was asked to write about a challenge he had faced in his life and how he managed to overcome it. He wrote: "A year and a half ago, I suffered from severe clinical depression. I tried several medications, spent time in a psychiatric hospital, but still continued to sink lower and lower. Finally, I came to a point where I was torn between my sense of obligation to my family and friends and my complete disinterest in continuing to live my life. My depression got the better of me and I tried to commit suicide in March of 2001. "Since then, I have made an almost full recovery -- I have found medications that work for me and I am feeling positive about where my life is going. It is a drastic change from how I felt before and it has taught me that absolutely no problem or negative situation is without a solution."
     We -- and Will -- were lucky. Our son survived a suicide attempt and a crippling bout of depression. And although the specter of Will's illness is never wholly erased, for now we are back on level ground. Moreover, I learned that depression does not need to kill its young victims. Families, communities and the medical establishment need to step up to the challenge and intervene swiftly to make available accurate diagnoses and effective treatment, so that our children, whose lives too often hang in the balance between risk and reason, are not left alone to choose death over life.

CHICAGO - As the definition of adulthood has shifted in this country and young people are living with their parents even into their 20's, one group has been mostly left behind in this phenomenon: thousands of people who grow up in foster care. Nationally each year, some 20,000 youths who were once removed from their homes because of abuse or neglect leave their second home -- the child welfare system -- because they get too old for it. In some states, they are allowed to stay on until they turn 21, but in many more places, they "age out" when they turn 18. And that, the authors of a new study to be released on Thursday by the Chapin Hall Center for Children at the University of Chicago say, can have devastating consequences. The study, which is believed to be the broadest of its kind in 20 years, looked at a rarely examined group -- more than 600 young people, mostly 19 years old and in Illinois, Iowa and Wisconsin, who recently left foster care or will soon do so.
      As a group, the youths from foster care wrestled with tougher problems than a wide national sample of 19-year-old Americans, the study said. More than a third of those coming from foster care had no high school diploma or general equivalency diploma, compared with about 10 percent of people their age. Those from foster care were also far more likely to be pregnant, unemployed, unable to pay the rent, or getting counseling.
     Perhaps more striking about the group from foster care, though, those allowed to stay in the child welfare system -- living in foster homes or youth facilities beyond their 18th birthdays -- seemed to fare better than those who headed out at 18. Those who left at 18 were half as likely to be enrolled in school or a training program than those still in care, the study found. Those who had left care were 50 percent more likely to be unemployed and out of school than those who stayed in. About 14 percent of those who left, in fact, reported finding themselves homeless at some point. Of those who left care, 11.5 percent reported sometimes or often not having enough to eat, compared with less than 4 percent of those who stayed in care.
     "Most states do not allow them to stay in much beyond 18, and that's the legacy of what we thought, historically, was the point of becoming an adult," said Mark E. Courtney, the study's lead author and the director of Chapin Hall Center here. "But it doesn't make sense anymore. What parent kicks their child out at 18? Why are we treating these kids radically differently than parents are treating every other kid?" Dr. Courtney said he was unsure precisely how many states allow youths to stay in care until they are 21, but said that Illinois is one in that small group, while youths in Iowa and Wisconsin -- and most other states -- generally leave the foster care system when they turn 18 or 19.
     It is uncertain, though, how much it might cost states to extend such benefits to 21, and in tight budget times, money may be one reason states have been reluctant. "The reluctance could be a fiscal issue or it could be the whole issue, too, of older wards -- you're not cute and cuddly anymore," said Robert F. Harris, the public guardian who represents wards in Cook County, Ill. "But by and large, young people need the benefit of societal support past 18 -- and even past 21."
     Shalonda Williamson, one of those surveyed in Dr. Courtney's study, said in an interview that she has been in the system since she was 9. Now 20, she is studying computers at college in Chicago, but remains in the formal care of the child welfare system here. To her, that is a relief. She has somewhere to live. "If I had gotten out at 18, I think I'd be totally different than I am now," she said. "When you're 18, you're not really an adult anyway. I think it's around 20 when you start getting your life together." Even now, Ms. Williamson acknowledged, she does not have every adult question answered: She has no bank account or summer job.
     But Richard Wexler, executive director of the National Coalition for Child Protection Reform, based in Alexandria, Va., said the "dismal" findings described in Dr. Courtney's study and others emerging from the foster system across the country should not necessarily leave child welfare experts clamoring to hold youths in the system longer. "When we talk about people aging out, we get away from the central point," he said. "What these results should tell us is that we've got to stop throwing so many children into foster care in the first place. What you can see is, regardless of what the problems were going in, foster care surely didn't fix them."
     The Chapin Hall study cost $1.6 million and was financed by the three states and the William T. Grant Foundation.

The pacemaker-like device, called a vagus nerve stimulator, is surgically implanted in the upper chest, and its wires are threaded into the neck, where it stimulates a nerve leading to the brain. It has been approved since 1997 for the treatment of some epilepsy patients, and the drug agency has told the manufacturer that it is now "approvable" for severe depression that is resistant to other treatment. But in the only rigorously controlled trial so far in depressed patients, the stimulator was no more effective than surgery in which it was implanted but not turned on.
      While some patients show significantly improved moods after having the $15,000 device implanted, most do not, the study found. And once the device is implanted, it is hard to remove entirely; surgeons say the wire leads are usually left inside the neck.
     Proponents say that many severely depressed patients do not respond to antidepressants or electroshock therapy and that those patients are desperate for any treatment to relieve their suffering. "These people have no other options, so we need to consider anything that shows potential to help," said Dr. Harold A. Sackeim, chief of biological psychiatry at the New York State Psychiatric Institute, who consults for Cyberonics Inc., the Houston company that makes the stimulator.
     But Dr. Michael Thase, a psychiatrist at the University of Pittsburgh who consults for the company, said there was "simply not a good enough basis in evidence" for approval. While the device is promising, Dr. Thase said, "the shaky state of the evidence means we have to be very cautious with this and prepare for the possibility that the hoped-for benefit isn't there."
     The drug agency has given mixed signals about the stimulator. In August 2004, it told Cyberonics in a letter that the treatment was not approvable, saying more information was needed. But in February, after the company provided more data, the agency changed that position, informing the company that the stimulator could now be approved. The company's stock price has fluctuated as investors try to anticipate the agency's decision, which the company is hopeful will come by the end of the month. The Senate Finance Committee recently began looking into the F.D.A.'s potential reversal, but Cyberonics officials say they have been assured by the agency that this will have no bearing on its final decision.
     In a conference call with reporters and analysts on Thursday, Robert Cummins, the company's chief executive, said no other treatment had been deemed approvable by the drug agency for stubbornly depressed patients. Clearly, he said, "the status quo for millions of Americans, their families, psychiatrists and payers is neither safe nor effective."
     Still, some patient advocates and other experts are now questioning how the device has come so close to approval with such limited evidence for its effectiveness. "I've never seen anything quite like this," said Dr. Peter Lurie, deputy director of health research at Public Citizen, a nonprofit group that is a frequent critic of the F.D.A. and the drug and medical-device industries. "What we could be setting ourselves up for is an epidemic of implantation of a device with no proven effectiveness." Experts who were involved in the approval process say they were moved by the desperate prognosis for severe depression and by powerful testimonials.
     At a critical meeting of an F.D.A. panel last June, six patients with chronic severe depression said they felt much better that the stimulator had been implanted, as part of an investigational study. At that meeting, the panel voted 5 to 2 to recommend that the device be approved. One patient, Charles Donovan III of St. Louis, said the stimulator had saved his life. "I went from being a complete mental-health vegetable to someone who had the energy and confidence to do this book," Mr. Donovan said in an interview. But the panel did not hear from patients who did not benefit from the stimulator, according to the transcripts. One of them, Katherine Coram, 57, of Silver Spring, Md., signed up for the trial after seeing a newspaper advertisement about it. "Believe me, when you're depressed for long enough, you get to a stage where you're willing to try almost anything," Ms. Coram said in an interview.
     In the study, doctors implanted the device in 235 severely depressed people. The stimulator sends timed pulses of electricity to the vagus nerve, which has wide connections throughout the brain. Half of the patients then had their stimulators turned on. The investigators did not know which of their patients had their stimulators on. After three months, researchers "unblinded" the study and compared levels of depression in the two groups based on standard measures of disease severity, the F.D.A. documents show. They found that 17 of the 111 patients who had implants turned on and completed the trial showed significant improvement. But 11 of 110 who had no stimulation and completed the trial also felt significantly better. The difference between the two groups was small enough to be attributable to chance. Alan Totah, vice president of regulatory affairs for Cyberonics, said at the meeting, "The primary endpoint did not reach statistical significance." But Mr. Totah said "the results did show a positive trend in favor" of the stimulator.
     Hoarseness was a common complaint. Many patients who have had a stimulator on also said that it put a quiver, rumble or other odd inflection in their voices. "I certainly knew mine was on," Ms. Coram said. "I could feel it. You get this constricting pain in the back of the throat. I couldn't talk sometimes." Ms. Coram said that she was slightly more functional at work after the surgery but that it did not last. Later, she said, after she took a doctor's advice and had the stimulator's pulse turned up higher, "my life fell apart." "I was very anxious and agitated, much more so than before," she went on. "I felt suicidal for a while, worse than I had been in 8 to 10 years."
     But several members of the panel that voted for approval said that given the alternatives for people like Mr. Donovan and others who did well, the insignificant difference between the two groups was cast in a different light. "The feeling was that anything that gives these people hope is potentially worthwhile," the chairwoman, Dr. Kyra Becker, a neurologist at the University of Washington, said in an interview. "But the whole meeting was uncomfortable, and everyone wanted to see another trial done, no question about it."
     Dr. Becker said that if she had voted her conscience, solely on the basis of the evidence, she would have voted not to approve. A member who voted against approval, Dr. Richard Malone, a psychiatrist at Drexel University College of Medicine in Philadelphia, said he was bewildered by the recommendation. "I walked out of there thinking I was nuts," Dr. Malone said in an interview. "It was stunning, but then I find much of life is stunning." The F.D.A. usually follows the recommendations of advisory panels.
     Another reason some psychiatrists are intrigued by the device for depression is a finding in the evidence that some people with the implant might do better over time. In follow-up data, Cyberonics reported to the drug agency that about 30 percent of those in the study showed significant improvement on one measure of depression after six months or more. "The effect appears to be sustained, which is very significant in these patients, who almost always relapse," Dr. Sackeim said.
     But other experts say it is extremely difficult to interpret this long-term evidence. Many patients in the study were taking psychiatric medications, or had electroconvulsive therapy, both of which can improve mood. These and other factors are difficult to control for, despite the company's efforts to do so, they said.
     Cyberonics says that the long-term evidence it has provided to the federal agency satisfies requirements for approval, and that senior agency officials have told the company as much. The agency has a higher standard of proof for approving new drugs than it does for devices. Devices require a "reasonable assurance" that they are safe and effective and that potential benefit outweighs the risk.
     F.D.A. officials said they could not comment on any product that was pending approval. But Dr. Donna-Bea Tillman, director of the agency's office of device evaluation, said "it is not the kiss of death" if a product's effectiveness is not supported by a well-controlled clinical trial. "We consider safety and effectiveness in relation to the alternatives that patient population has, including whether they have any alternatives at all," Dr. Tillman said.
     If a device is approved, the agency specifies precisely which patients should have access to it, she said. Whether to recommend it is then left to doctors' judgment. And that is a prime concern among critics of the approval process, like Public Citizen and other groups concerned about patient protection. Once a product has been approved, the manufacturer can promote it aggressively, and some doctors may recommend it to any patient, whether severely or moderately depressed.
     Some people may not wait for approval. Sue Wanemaker, 51, who lives near Denver, said she had a vagus stimulator implanted last April for her depression. Ms. Wanemaker, who also has epilepsy, said she had noticed little benefit, and added that when turned up high the stimulation made her feel suicidal. She has since had the device turned down. "I'm going to hang in there," she said in a phone interview, "because why not, I've got it in now, and -- there it goes!" With that, her voice trilled for a few moments.