Noteworthy News Articles on Mental Health Topics, June 12-20, 2005




Domestic Violence Drops by More Than Half
Associated Press- 6/12/2005

WASHINGTON -- Child abuse and other forms of violence involving families fell by more than half between 1993 and 2002, in line with the decline in crime overall, the government said Sunday. The rate of family violence fell from about 5.4 victims to 2.1 victims per 1,000 residents age 12 and older, according to a report by the Bureau of Justice Statistics. Simple assault was the most frequent type of violent offense. Murder accounted for less than one-half of 1 percent of all family violence between 1998 and 2002 -- the most recent years analyzed for the report. The report looked back to 1993 -- the year the survey was redesigned -- for a long-term trend in family violence, but analyzed the most recent years to glean detailed information on patterns of crime. Almost half of the 3.5 million victims of family violence between 1998 and 2002 were spouses. Fewer than one in 100 died as a result.
      The study by the Justice Department agency found that:
--73 percent of victims were female.
--75 percent of offenders were male.
--most of all family violence happened in or near the victim's home.
--74 percent of victims were white.
--most victims were between 25 and 54.
--79 percent of offenders were white; most were at least 30.
     Esta Soler, president of the Family Violence Prevention Fund, said the report ''offers a ray of hope that our nation is finally on the right track in addressing the violence that devastates so many families in this country. ''But our work is not nearly done. Domestic, dating and family violence are still taking a terrible toil,'' she said. Added Beverly Balos, a law professor at the University of Minnesota who is an expert in domestic violence issues: ''We should be celebrating the overall decline in domestic violence in terms of thinking about services that have been possible over the last 10 years in individual states. It's made a difference in keeping women and children safe.''
     Violent crimes are rape, robbery, aggravated assault and homicides including murder and manslaughter. Family violence includes all types of violent crime committed by someone related to the victim.
     Balos noted the drop in family violence is part of an overall decrease in violent crime in past years. According to the most recent Justice Department report on violent crimes, the violent crime rate remained at the lowest level recorded since 1973. The rate was 22.6 per 1,000 people. In 2002, it was 23.1 per 1,000.
     Family violence is measured through the National Crime Victimization Survey, based on survey interviews with samples of the U.S. population. It is also measured through the FBI's National Incident Based Reporting System, based on statistics compiled by local police departments.
     Figures from the survey show that family violence accounted for 11 percent of all violent crime between 1998 and 2002, both reported to police and unreported. Police statistics show that family violence makes up nearly 33 percent of all police-recorded violence. The report said the discrepancy could result from the willingness of victims and others to report crime to police. Also, the police statistics are not directly comparable to the survey's in terms of geographical coverage. Police figures are based on data from agencies reporting in 18 states and the District of Columbia; the survey's cover the entire country.
     On the Net: Justice Department's Office of Justice Programs: http://www.ojp.usdoj.gov/

Psychiatric inpatients are always closely watched, but not this closely. In a groundbreaking experiment at Massachusetts General Hospital, a handful of patients battling depression have agreed in recent weeks to be wired up for 24-hour-a-day, mobile monitoring of their palm sweat, heart rate, voice dynamics, movements, and location.
      The study aims to show that such measures can reliably reflect a patient's state of mind as treatment progresses, researchers say. But more broadly, it seeks to prove that technology has reached the point where it can monitor a person's basic emotional tenor through ordinary days.
     To that end, researchers are developing an easy-to-wear system that continuously gathers masses of information, then quickly crunches and transmits it, providing objective data to help with diagnoses and provide early warning when crisis nears. ''The Holy Grail of what we're trying to do is to develop an automated system that can just look at the physiology and be able to predict if patients are depressed and if they're going to become more depressed," said Michael Sung, a media lab researcher at Massachusetts Institute of Technology who is working on the study.
     Researchers on aging have long been developing ways to monitor elders' physical well-being from afar, but work on using physiological sensors to track emotions in people of all ages -- 24 hours a day -- is still in its infancy. Only in the past two or three years, researchers estimate, has the technology gotten small and powerful enough to make such monitoring possible, inspiring Sung and his colleagues to grand visions of possible future uses.
     Imagine, they say: You are having a breakdown and reaching for a drink when your cellphone rings: ''Hold on!" says your Alcoholics Anonymous sponsor from across town, alerted by a device that monitors the subtle sweating of your palms. Or: You are feeling just fine, but suddenly your palmtop computer flashes: ''Warning! You seem to be entering the manic phase of your bipolar disorder." Or: You tell your therapist you're feeling vaguely bad. ''Let's wire you up and see whether it's more anxiety or depression," is the response.
     Monitoring physical signs of emotion could add highly objective elements to the often-subjective business of psychiatric diagnoses, said Dr. Carl Marci, the Mass. General psychiatrist leading the study. The study is expected to last about a year and observe 20 patients. The patients are considered competent enough to decide whether to enroll.
     Ultimately, physiological monitoring could become a key component of a typical psychiatrist's toolkit, said Alex Derchak, principal scientist at VivoMetrics, a California-based firm that makes the ''LifeShirt", a monitoring system that combines a variety of sensors in a shirt that patients wear all day and night. LifeShirt was federally cleared for marketing as a medical device in 2002 and is used mainly for medical studies. But Derchak said it is also at work in about 25 studies ''that are specifically focused on different aspects of mental health: issues such as anxiety, panic, autism, bipolar disorder -- they're all different flavors of the mental health story." Rhode Island researchers are using LifeShirt on autistic children to determine when they are in a state conducive for learning, Derchak said. At the University of California at San Diego, researchers are using the shirt to record the chaotic movements that patients with bipolar disorder make during a manic phase. VivoMetrics officials say the shirt is also meant to be used during clinical trials of psychiatric drugs, to help track their effects.
     In the experiment in Mass. General's inpatient psychiatric unit, researchers are using a system called LiveNet that employs cheaper, off-the-shelf technology contained mainly in a fanny pack rather than a shirt. They can follow the patients' voice dynamics, motions, and heart rates, along with tracking their movements: Do they stay in bed? Are they wandering the ward? They also monitor the patients' skin conductance -- subtle changes in palm sweat that reflect nervous system activity and levels of arousal. And four times a day, patients record how they feel in a palmtop computer.
     The patients suffer from such persistent depression that they are hospitalized to undergo a series of electroshock treatments, a last-ditch measure that is often effective. A typical course lasts about two weeks. The researchers check what the monitoring data tell them against the traditional measures of discerning improvement: standard interviews with psychiatrists. In a highly preliminary analysis of the data from the five patients who have been followed so far, it appears that the system can pick up the post-shock improvement in mood that patients tend to experience, Sung said.
     The ultimate goal, Marci said, is to find ''signatures of depression that can aid in diagnosis, relapse-prevention, and choice of treatment." In particular, ''Can we predict who's going to respond to electroshock therapy? And can we find objective measures that are early indications of relapse?"
     One patient in the study, a 34-year-old woman who asked to remain anonymous, said she recalls little inconvenience from the monitors during her two-week stay for electroshocks. She said she was pleased to contribute to work that could someday help fight depression: ''If I could save one person from going through how I feel, I would jump over the moon." In her case, she said, she had long assumed she disliked leaving her house because of depression, but her psychiatrist told her she had an anxiety disorder. It would be helpful ''if there were a way for them to figure that out faster without guesswork," she said. Also, she said, ''It's kind of hard when somebody asks you what's going on in your mind -- it's kind of hard to explain it."
     For all their computerized sophistication, systems such as LiveNet and LifeShirt are not mind readers. They cannot, for example, say definitively that a patient is feeling anger or happiness, said Lisa Feldman Barrett, a Boston College professor who researches emotion. Rather, they measure things such as levels of arousal and whether a person is experiencing broadly positive or negative emotion at a given point, she said. But even that crude level of detection can prove useful in research and in therapy, she noted.
     Marci recently wrote a paper about an experiment in which a patient in therapy, an unemotional-seeming woman, was wired up for skin-conductance monitoring during her session. The monitoring turned up a high level of arousal that indicated undisclosed anxiety. When told of this, the patient said that it was the first anyone ''had seen her true very high level of anxiety," and that at last someone could understand her constant suffering. Considerable progress in therapy followed. ''The technology facilitated this incredibly accurate empathic interpretation that then led to this 'Aha!' moment," Marci said.
     Marci demonstrated the LiveNet system last month at the exhibit ''Getting Emotional" at the Institute of Contemporary Art. As he wandered from painting to sculpture to video, he recorded his feelings on a palmtop computer while the system monitored his heart rate, skin conductance, motion, and voice dynamics. A few days later, the initial results were in. His emotional state had varied considerably as he viewed the works. When he watched ''Black Mouth," a cryptic, upsetting video clip featuring contorted sound and a mud-spattered, gaping-mouthed girl, his skin conductance and heart rate indicated he was semi-anxious, while his low voice features suggested helplessness. But later, in a section of the exhibit featuring portraits of intimacy, he said his skin conductance and heart rate indicated he was balanced and relaxed.

Are these people mentally ill? In a report released last week, researchers estimated that more than half of Americans would develop mental disorders in their lives, raising questions about where mental health ends and illness begins. In fact, psychiatrists have no good answer, and the boundary between mental illness and normal mental struggle has become a battle line dividing the profession into two viscerally opposed camps. On one side are doctors who say that the definition of mental illness should be broad enough to include mild conditions, which can make people miserable and often lead to more severe problems later. On the other are experts who say that the current definitions should be tightened to ensure that limited resources go to those who need them the most and to preserve the profession's credibility with a public that often scoffs at claims that large numbers of Americans have mental disorders.
      The question is not just philosophical: where psychiatrists draw the line may determine not only the willingness of insurers to pay for services, but the future of research on moderate and mild mental disorders. Directly and indirectly, it will also shape the decisions of millions of people who agonize over whether they or their loved ones are in need of help, merely eccentric or dealing with ordinary life struggles.
     "This argument is heating up right now," said Dr. Darrel Regier, director of research at the American Psychiatric Association, "because we're in the process of revising the diagnostic manual," the catalog of mental disorders on which research, treatment and the profession itself are based. The next edition of the manual is expected to appear in 2010 or 2011, "and there's going continued debate in the scientific community about what the cut-points of clinical disease are," Dr. Regier said.
     Psychiatrists have been searching for more than a century for some biological marker for mental disease, to little avail. Although there is promising work in genetics and brain imaging, researchers are not likely to have anything resembling a blood test for a mental illness soon, leaving them with what they have always had: observations of behavior, and patients' answers to questions about how they feel and how severe their condition is. Severity is at the core of the debate. Are slumps in mood bad enough to make someone miss work? Does anxiety over social situations disrupt friendships and play havoc with romantic relationships?
     Insurers have long incorporated severity measures in decisions about what to cover. Dr. Alex Rodriguez, chief medical officer for behavioral health at Magellan Health Services, the country's largest managed mental health insurer, said that Magellan used several standardized tests to rate how much a problem is interfering with someone's life. The company is developing its own scale to track how well people function. "This is a tool that would allow the therapist to monitor a patient's progress from session to session," he said. Although the current edition of the American Psychiatric Association's catalog of mental disorders includes severity as a part of diagnosis, some experts say these measures are not tough or specific enough.
     Dr. Stuart Kirk, a professor of social welfare at the University of California, Los Angeles, who has been critical of the manual, gives examples of what could, under the current diagnostic guidelines, qualify as a substance abuse disorder: a college student who every month or so drinks too much beer on Sunday night and misses his chemistry class at 8 a.m. Monday, lowering his grade; or a middle-aged professional who smokes a joint now and then drives to a restaurant, risking arrest. "Although perhaps representing bad judgment," Dr. Kirk wrote in an e-mail message, these cases "would not be seen by most people as valid examples of mental illness, and they shouldn't be because they represent no underlying, internal, pathological mental state." Separating the heavies from the lightweights -- by asking, say, "Did you ever go to a doctor for your problem, or talk to anyone about it?" -- has a significant effect on who counts as mentally impaired.
     After researchers reported in a large national survey in 1994 that 30 percent of Americans adults had a mental illness in the past year, Dr. Regier and others reanalyzed the data, taking into account whether people had reported their mental troubles to a therapist or friend, had received treatment or had taken other actions. They found that the number of people who qualified for a diagnosis of mental illness in the previous year plunged to 20 percent over all; rates of some disorders dropped by a third to half.
     But limiting the count to those who have taken action does not give an accurate picture of the extent of illness, argue other researchers, who have been sharply critical of efforts to drive down prevalence estimates. Dr. Robert Spitzer, a professor of psychiatry at Columbia University and the principal architect of the third edition of the diagnostic manual, wrote in a letter to The Archives of Psychiatry, "Many physical disorders are often transient and mild and may not require treatment (e.g. acute viral infections or low back syndrome). It would be absurd to recognize such conditions only when treatment was indicated." He added, "Let us not revise diagnostic criteria that help us make clinically valid standard diagnoses in order to make community prevalence data easier to justify to a skeptical public."
     Dr. Ronald Kessler, a professor of health care policy at Harvard and the lead author of the 1994 survey and the nationwide survey released last week, said squeezing diagnoses so that many mild cases drop out could blind the profession to a group of people it should be paying more attention to, not less. "We know that there are prodromes, states that put people at higher risk, like hypertension for heart disease, which doctors treat," he said. "You can call these milder mental conditions what you want, and you may decide to treat them or not, but if you don't identify them they fall off the radar, and you don't know much of anything about them." In the survey released last week, Dr. Kessler and his colleagues found that half of disorders started by age 14, and three-quarters by age 24. "These are people who may show up at age 25 or later as depressed alcoholics, maybe they're in trouble with the law, they've lost relationships, and from my perspective we need to go upstream and find out what's happening before they become so desperate," Dr. Kessler said.
     One condition whose estimated prevalence has bounced around like a Ping-Pong ball in this debate is social phobia, extreme anxiety over social situations. In a 1984 survey, investigators identified social phobia primarily by asking about excessive fear of speaking in public. They found a one-year prevalence rate of 1.7 percent. But psychiatrists soon concluded that other kinds of fears, including a fear of eating in public or using public restrooms, were variations of social phobia. When, in 1994, these and others questions were included, the prevalence rate rose to 7.4 percent. Dr. Regier re-evaluated the data using a different criterion for severity and found a much lower rate: 3.2 percent. Last week, Dr. Kessler reported a rate of 6.8 percent. "You can see why people have a hard time believing these numbers because they change so much depending on how you look at the data," said Dr. David Mechanic, director of the Institute for Health, Health Care Policy and Aging Research at Rutgers University.
     Yet the cutoff points for disease severity have real effects on the lives of people like Paul Pusateri, 48, a Baltimore business analyst. Mr. Pusateri said he was outgoing through college but then had a panic attack in his mid-20's, as he was preparing to give a speech. He managed to build a career and family despite surges of anxiety before speeches and meetings. But finally, more than two decades after the first symptoms, he reached a point where he dreaded even small or one-on-one meetings with familiar co-workers. "It's very bizarre; the only way I can describe the feeling is, Imagine walking down the street at dusk having someone put a gun in your face and threaten to kill you -- having that absolute terror before a routine work meeting," he said.
     Mr. Pusateri said that, perhaps unconsciously, he applied severity criteria to his own growing mental struggles. He may have set the bar too high: only when he began badly mangling presentations at work, and then dreaded going in at all, did he tell his wife that he felt he was in trouble. His wife had watched a therapist talk about social phobia on television, and soon he was getting help. He considers himself lucky to have found a diagnosis at all, not to mention a therapist. "I was desperate by the time I did anything about it, I saw that my livelihood was at stake," he said. Yet by all outside appearances, and by some strict definitions, he might not have qualified as having a disorder until he took some action.
     In the coming years, Dr. Regier's office will be responsible for clarifying the thresholds of disease for the next diagnostic manual, to somehow identify difficult cases like this one, while remaining credible to insurers and to the public at large. After a prolonged controversy last year over the use of antidepressants in children, most experts say the last thing psychiatry needs now is for this process to turn into a public fight over who is sick and who is not. But this fight may be hard to avoid. The two sides are far apart, debates over the diagnostic manual are traditionally contentious and despite increasing openness about mental illness the public tends to be skeptical of any prevalence numbers over a few percent. "That's the problem," said Dr. Regier, "people hear these higher prevalence rates and they immediately start thinking about severe, disabling schizophrenia. But we know these surveys include a lot of mild cases, and we need to ask, How significant are these?"

Contrary to researchers' expectations, dysfunctional family relationships and poor communication styles appear to have little effect on whether young children become depressed, a study has found. While many children under 5 exhibit symptoms of depression, they often have not been exposed to known risk factors, experts find. And many children who are exposed to those risk factors appear to be resilient.
      In the study, Australian researchers looked at many factors, including marital partner change, mothers' health in pregnancy, a child's health in the first six months of life and maternal anxiety in more than 5,000 mothers over a period of five years. But few of them correlated with early childhood depression.
     The authors warned that their results, published in the June issue of Social Psychiatry and Psychiatric Epidemiology, depended on reports by mothers about their children's experiences, and that the mothers' emotional states might have affected those reports. They also conceded that young, single, low-income mothers were often lost to follow-up during the years of the study, and that the children of those mothers might be expected to have higher rates of depression. "If what we have found is correct," said Dr. Jake Najman, the lead author and a professor of sociology at the University of Queensland, "then depression in children has a large constitutional component" that is transmitted either genetically or by exposure to risks before or during pregnancy. Dr. Najman suggested that early intervention might help prevent depression from developing in early life.

Chronic Insomnia Baffles Sleep Experts
Associated Press, 6/15/2005

WASHINGTON -- Millions of Americans lie awake at night counting sheep -- or have a stiff drink or pop an allergy pill, hoping it will make them drowsy. But experts agree all that self-medicating is a bad idea, and the causes of chronic insomnia remain mysterious. Almost a third of adults have trouble sleeping, and about 10 percent have symptoms of daytime impairment that signal true insomnia. Sufferers readily cite the resulting problems: walking around in a fog, as memory and other cognitive functions slow. Dozing off at the wheel or at work. Depression. Lack of energy.
      But for all the complaints, scientists know surprisingly little about what causes chronic insomnia, its health consequences and how best to treat it, a panel of specialists brought together by the National Institutes of Health concluded Wednesday. Two things are clear, the panel found: Chronic insomnia is a major public health problem. And too many people are using unproven therapies, even while there are a few treatments that do work. The hope is that the report will dispel some of what panelist Dr. Sean Caples of the Mayo Clinic decried as ''misinformation and myths.''
     Among the panel's findings:
--Cognitive/behavioral therapy -- a psychology-based treatment that trains people to reduce anxiety and take other sleep-promoting steps -- is very effective, and doesn't cause side effects. But it can be hard to find health providers trained in the techniques. Insomniacs should check with board-certified sleep specialists and psychologists.
--Newer prescription sleep pills called Sonata, Ambien and Lunesta work without many of the side-effect concerns of older agents known as benzodiazepines. One study of Lunesta showed effectiveness with six months of use, but more research on long-term use of all three is needed, as chronic insomnia can linger for years.
--The most commonly used treatments are alcohol and over-the-counter sedating antihistamines like Benadryl. Alcohol use actually disrupts quality sleep, and antihistamines can cause lingering daytime sedation and other cognitive problems.
--The most common prescription insomnia medicine is an older, sedating antidepressant called trazodone, even though there's no good evidence that it offers more than a two-week benefit, and it comes with side effects.
--There is no evidence backing the effectiveness of the popular dietary supplements melatonin and valerian to fight insomnia.
     Self-medicating aside, why do even doctors reach for trazodone and other unproven treatments? The panelists suspect that some are reluctant to prescribe controlled substances, a category that includes prescription sleep aids. That shouldn't be a concern with the newer pills, known as non-benzodiazepines, which come without the abuse potential of older sleep aids because they're eliminated from the body much faster, explained panelist Dr. Charles Zorumski, psychiatry chief at Washington University School of Medicine.
     The panel called for a broad range of research into insomnia, noting that if scientists understood its underlying causes, they could develop better treatments. Most, but not all, insomnia is thought to accompany other health problems, from arthritis and depression to cardiovascular disease. The question often is whether the insomnia came first or was a result of the other diseases -- and how trouble sleeping in turn complicates those other problems. ''We know way too little about all those variables,'' said panel chairman Alan Leshner, chief of the American Association for the Advancement of Science. Treating depression or restless legs syndrome, for example, could cure some people's insomnia without them ever using a sleeping pill, said Richard Gelula of the National Sleep Foundation, which praised the new report. Other diseases aside, the risk of insomnia seems to increase with age and to be more common among women, especially after menopause. Smoking, caffeine and numerous prescription drugs also affect sleep.
     The NIH is spending about $200 million this year on sleep-related research, some targeted to specific disorders and others examining the underlying neurobiology of sleep, said Dr. Carl Hunt, chief of the agency's National Center on Sleep Disorders Research. The agency was awaiting the panel's review before deciding what additional work should be directed at insomnia, he said. ''We need to take a fresh look at this,'' Hunt said Wednesday.
     On the Net: National Institutes of Health insomnia report: http://consensus.nih.gov

The mental health care crisis faced by black Houston-area residents "seems to be even more acute" than in four other large cities, a leader of the National Urban League said Tuesday. At the same time, Houston obviously has a "greater level of expertise and a very scholarly expertise" among black mental health professionals, said Sandra Goodridge, director of health and quality of life for the National Urban League. About 60 of those leaders — health care providers, clergy, educators and community leaders — attended a conference hosted by the Houston Area Urban League to draw attention to the needs for better health care funding and an education campaign to battle the stigma that many blacks still associate with mental illness.
      Hundreds of thousands of people in Harris County receive no treatment for mental health problems, said Dr. Lois Moore, administrator of the University of Texas Harris County Psychiatric Center. Citing the 2004 report published by the Mental Health Needs Council Inc. of Harris County, Moore said about 507,000 adults in the county have mental health problems, including 135,000 who have "severe" mental illness. Among children and adolescents in the County, about 186,000 have mental health problems, including 108,000 with a "serious" emotional disturbance. "One of every 32 uninsured Americans lives in Harris County," Moore said, and she added that 26 percent of Harris County residents have no health insurance. Moore also said Texas ranks 49th among the 50 states in state funding for health care programs.
     Even if Harris County had a well-funded and well-organized system for providing mental health care services, community leaders and health professionals contend many blacks delay help because of a long-held "stigma" that dates to slavery. Because of that stigma, many wait until they are "in crisis" and delay seeking help until they are in need of acute care for psychiatric problems, the health care professionals said.
     Goodridge said the National Urban League, which had similar conferences in Seattle, Philadelphia, Indianapolis and Memphis, Tenn., discovered similar problems in those cities. "A lot of the problems blacks are facing around the country are similar, in terms of the need for knowledge, the need for understanding mental illness, the need for culturally appropriate ways to destigmatize treatment for mental illness," Goodridge said.

It was classic: She was anxious to get married. He didn't want to be pressured for the ring. Liz Naiman and Rich Boardman met two years ago while teaching at a high school in Amherst, N.H. They planned to move in together at the start of the school year. But two weeks before the move Mr. Boardman, 28, dropped a bomb. He didn't want to go ahead with it. In fact he didn't know if he wanted to be with Ms. Naiman at all. "He couldn't give me any answers as to why he had changed his mind," Ms. Naiman, 27, recalled. "He was completely shut down." Months of relationship limbo followed. Finally Mr. Boardman decided he wanted to stay together and to marry. Ms. Naiman put forth conditions: He had to write a letter of apology to her parents; he had to cut down on his "frat-boy activities"; and he had to agree to go to couples therapy. He agreed.
      Once seen as the province of married people with accrued stock in resentment and stale sex lives, couples therapy for the unmarried has evolved as an acceptable, even desirable, way of navigating modern love for those in their 20's and 30's. Aware of the high price of divorce, comfortable with the idea of therapy in general and free from cultural pressures to rush down the aisle, modern couples are turning to professionals earlier in the game to help them work through their relationship problems. No exact figures exist on the growth of premarital couples therapy, researchers say, but therapists and other marriage and family therapy professionals say that young unwed couples are pursuing therapy more avidly than older generations did.
     Dr. Diane H. Ranes, a clinical psychologist at the Carolina Partners Counseling Center in Durham, N.C., said in her practice of 35 clients a week, 10 to 15 are in their late 20's to mid-30's, living together or seriously dating and often considering their first marriage. A decade ago few such couples came through her office, she said. In Los Angeles, Dr. Marion F. Solomon, a marriage therapist who is also a member of the extension faculty at the University of California, Los Angeles, has counseled about 25 unmarried couples in the last few years. "If I had one young couple 15 years ago, it was a lot," she said.
     For unwed couples encountering problems and who have decided, at least for the moment, not to break up, therapy serves as a sort of vetting system for the relationship, a role once taken by parents or religion. Today couples seek a therapist not just to manage a crisis -- for volatile arguments, when infidelity has occurred, when one person wants a commitment but the other is reluctant -- but often, experts say, as validation: a second opinion on whether the relationship has legs.
     The length of therapy depends on the couple, the therapist and the nature of the conflict. Some clients, like Ms. Naiman and Mr. Boardman, have gone for just a few sessions. Others go for months and occasionally years. Psychotherapy techniques for young, unmarried couples are no different from those for marital therapy. For the most part therapists, who charge $75 to $250 a session, think of their work as short term. It is common, however, for couples to return for regular tuneups.
     Besides being fluent in therapy talk, people who grew up in the age of divorce, the 1970's and 80's, are all too familiar with broken homes. It is part of contemporary wisdom that relationships are unstable. (Recent studies indicate a marginal decline in divorce rates but show that over 40 percent of marriages fail.) Dr. Solomon said: "A lot of young unmarried couples come in saying: 'I'm not going to have happen to me what happened to my older sister or my parents. We want to see if we can resolve these issues now before we start hating each other.' " Dr. Ranes said her clients were haunted less by hostile divorces than by seeing parents in stagnant or empty marriages. "When these are contrasted to the idealizations of marriage and love in our culture, the result is very high standards," she said.
     Erica, 30, a screenwriter in Manhattan, who, like others interviewed for this article, asked not to have her full name published out of concern for her privacy, has been in therapy with her fiancé since last fall, only a year after they met at a fund-raiser for Senator John Kerry and six months after they became engaged. She credits therapy with breaking what had become a fighting cycle. "I got tired of saying things that I wanted to take back later," she said. "When you're fighting, you go down the rabbit hole." The presence of a third party, she said, calms things down. "You play better in front of other people. Then you can take that home. It's like, hey, let's do that the next time we're in the kitchen yelling at each other."
     Dorian Solot, the executive director of the Alternatives to Marriage Project in Albany and an author of "Unmarried to Each Other: The Essential Guide to Living Together as an Unmarried Couple" (Avalon Publishing Group, 2002), said that most young unmarried couples don't view their relationships as casual but rather as a form of marriage. She cited the 2000 United States Census, which showed a 72 percent increase in the number of unmarried couples living together from 1990 to 2000, and a tenfold increase from 1960 to 2000.
     Cohabitants, or couples who spend at least four nights a week together, are likely to face many of the same difficulties as their married counterparts, experts say. "If there's a conflict they can't resolve on their own, it's a no-brainer to many of these couples that they'd seek therapy," Ms. Solot said. "If they think their partner has a lot of potential, but there are kinks to work out first, they'll often seek counseling before they make any lifetime promises."
     Couples therapy is a logical solution for a fraying romance, however unromantic that may sound. Rather than enter into a marriage fraught with problems, young couples want to work through the angst before the stakes get too high, experts say. It is a form of preventive medicine. "The preventive idea is in the air," said Dr. Peter Fraenkel, an associate professor of couples and family therapy in the clinical psychology doctoral program at the City University of New York and a faculty member at the Ackerman Institute for the Family. He was also the director of the prevention and relationship enhancement program at the New York University child studies center, one of the marriage education programs around the country that offer workshops. These programs, which focus on building relationship skills, rather than on psychotherapy, began primarily for newlyweds and engaged couples, but are attracting more young couples who are still figuring out whether to go forward. "I've seen a growing number of couples like that in my private practice and in this course at N.Y.U., from about one in 12 in the early 90's to one in six by the start of this decade," Dr. Fraenkel said.
     Not surprisingly, there are few hard and fast numbers supporting this trend. Bill Northey, the research specialist at the American Association for Marriage and Family Therapy, said, "You're asking people to report on a new transitional period: premarital cohabitation and prolonged engagements." He noted that the age of first marriage is becoming later. (The median age in 2003 was 27.1 for men and 25.3 for women, according to the Census Bureau.) "It's created a vacuum of what you're supposed to do, so you see a lot more issues coming up in this time period for people in their 20's and 30's," Mr. Northey said. And, he added, this group is more relationship savvy than the previous generation. "So when they see red flags early on, they are more likely to try to do something about it."
     Erica, the screenwriter, likens couples therapy to picking out paint colors for the living room. "In our generation, we don't have to be experts at everything anymore," she said. "You don't have to be the decorator. You can get a fabulous decorator and still have a lovely home that's yours. And you can have someone help you with the communication problems in your relationship, and it's still your relationship."
     Jesse James, 34, who runs a design showroom in Brooklyn with Constantinos Anagnopoulos, said it took the two of them a long time to work out the problems in their relationship. They only recently quit therapy after five years. "It was excruciating at times to realize that we couldn't communicate like adults," Mr. James said. "But we always had more to say in the sessions. And that confirmed how much we really wanted to be together." Mr. Anagnopoulos, 30, said: "Over time the recurring issues started to feel smaller in scope. We realized that the bickering was just part of our relationship."
     But it is evident that couples therapy does not always lead to happiness. Sometimes it leads to a breakup. Alex, 33, a public interest lawyer in San Francisco, said he and his former girlfriend knew they were going to therapy to figure out not just what was going wrong but whether they even wanted to stay together. "What's surprising is that the cliché adult problems -- money, sex, religion -- are actually true. We didn't have a sex problem, but religion and money were definitely issues," he said. He was optimistic because his parents had saved their marriage through couples counseling. But after a few sessions his girlfriend backed out. "I got angry in a session, and I think she felt kind of ambushed," he said. Two months later the relationship was over. Alex has no regrets. "I don't think marrying this person would have been the right thing for me," he said.
     Sarah, 35, a Los Angeles film producer, said she wished she had such a realization before she married. Six months into her relationship with the man she was to marry, she suggested they seek counseling to work through what she called his porn addiction. She said he put it off, saying he wanted to do it after the wedding. They recently did a few sessions with a therapist, but Sarah is fairly certain a separation is imminent. She called therapy "a big step in the process of coming to terms with where we're at," adding, "It really helped me gain a lot of clarity." Still, she said, "I'd highly recommend doing it before getting married."

WASHINGTON -- Both college towns, Boston and Boulder, Colo., share another distinction: They lead the nation in marijuana use. Northwestern Iowa and southern Texas have the lowest use. For the first time, the government looked at the use of drugs, cigarettes, alcohol and various other substances, legal as well as illegal, by region rather than by state for a report Thursday. Regions could be as specific as Riverside, Calif., or as broad as all of the state of New York (minus New York City). Federal officials say the information will help states decide where they should spend money for treatment and prevention programs.
      For marijuana, 5.1 percent of people around the country reported using marijuana in the previous 30 days. In Boston, the home of Boston University, Boston College, Northeastern and several other colleges, 12.2 percent reported using marijuana in the previous 30 days.
      John Auerbach, executive director of the public health commission for the city of Boston, said the survey might not reflect current marijuana use in Boston because the data came from 1999-2001 national surveys. ''All that said, we're not surprised that substance abuse is a serious issue in the Boston area,'' Auerbach said. ''The mayor and the health department have made the issue of substance abuse a top public health priority.''
     Auerbach also acknowledged that the data may reflect the city's significant 20-something population. ''College students in general have a more relaxed attitude about marijuana than other age groups,'' he said. ''But in general, I don't think Boston has a markedly differently perspective on marijuana than other parts of the country.''
     The federal report doesn't explain why certain regions fare worse than others when it comes to smoking pot or cigarettes, or for heavy alcohol use, only that they do. In Boulder County, the home of the University of Colorado, 10.3 percent reported using marijuana during the same time period. But a public health official who has studied marijuana usage there said he too had doubts about the report.
     Dr. Chuck Stout, the county's public health director, said he has studied marijuana usage among teens. The percentage of high school students in Boulder County who acknowledged smoking marijuana differed little from state and national averages. He said he doubted that students at the university were heavier marijuana users than students at dozens of other universities around the country. ''Where you have concentrations of younger, active people, you'll have more experimentation with a variety of risk behaviors, but that's true for so many other parts of the country as well,'' Stout said. ''I think this (report) is a huge stretch.''
     Federal officials said they highlighted the marijuana report because it's the most commonly used illicit drug. But the survey also measures 11 other categories. For example, the survey measures binge drinking -- defined as five or more drinks in one setting. Nationally, 20 percent of people age 12 and older reported one or more episodes of binge drinking during the previous month.
     Boston scored high in that category, too, with nearly 30 percent of respondents acknowledging binge drinking. But the Northeast and Southeast regions of North Dakota reported binge drinking among 32 percent of residents of that age group. Overall, North Dakota had the highest rate of binge drinking when compared with other states -- 29.2 percent. ''The further north you are, typically, the more alcohol is consumed,'' said Douglas Wright, a mathematical statistician with the federal government who helped put the report together.
     On the Net: Government estimates on substance abuse: http://oas.samhsa.gov

WASHINGTON -- A subtle change in a memory-making brain region seems to predict who will get Alzheimer's disease nine years before symptoms appear, scientists reported Sunday. The finding is part of a wave of research aimed at early detection of the deadly dementia -- and one day perhaps even preventing it.
      Researchers scanned the brains of middle-aged and older people while they were still healthy. They discovered that lower energy usage in a part of the brain called the hippocampus correctly signaled who would get Alzheimer's or a related memory impairment 85 percent of the time. ''We found the earliest predictor,'' said the lead researcher, Lisa Mosconi of New York University School of Medicine. ''The hippocampus seems to be the very first region to be affected.''
     But it is too soon to offer Alzheimer's-predicting PET scans. The discovery must be confirmed. Also, there are serious ethical questions about how soon people should know that Alzheimer's is approaching when nothing yet can be done to forestall the disease. Still, the discovery may provide leads to scientists searching for therapies to at least delay the onset of the degenerative brain disease. It already affects 4.5 million people in the U.S. and is predicted to strike 14 million by 2050 as the population ages. Moreover, researchers are honing in on lifestyle choices that may help protect the brain in the first place. ''It's exciting that we can even talk about prevention,'' said William Thies, scientific director of the Alzheimer's Association. He noted that just 10 years ago there was hardly any research into that possibility.
     Among the findings presented Sunday at the association's first Alzheimer's prevention conference:
--People who drink fruit or vegetable juice at least three times a week seem four times less likely to develop Alzheimer's than nonjuice drinkers, according to a study of 1,800 elderly Japanese-Americans. The theory is that juice contains high levels of polyphenols, compounds that may play a brain-protective role.
--Less education, gum disease early in life, or a stroke were more important than genes in determining who got dementia, concluded a study of 100 dementia patients with healthy identical twins. Education stimulates neuronal growth; gum disease is a marker of brain-harming inflammation.
--Decreasing social activity in old age is a risk factor, a National Institute on Aging study suggests. It is not clear if the men in the study became less social because Alzheimer's already was at work, but social activity is mentally stimulating.
     A brain-healthy lifestyle aside, a big quest is to develop ways to identify Alzheimer's disease before symptoms emerge -- finding biomarkers that could be targets for preventive therapies. Think of it as hunting the equivalent of the cholesterol test for Alzheimer's, Dr. Neill Graff-Radford of the Mayo Clinic said. He measured blood levels of different types of beta amyloid, the sticky protein that makes up Alzheimer's hallmark brain plaques, in 565 people. Those with lowest ratios of a particular amyloid type were three times more likely to develop dementia within five years. The reason: Probably less amyloid was floating in the blood because it was sticking in the brain instead.
      PET scans already can show Alzheimer's plaques in advanced disease. Mosconi's study is the first to so rigorously examine people's brains before symptoms appear. PET, or positron emission tomography, scans show images of how brains use glucose, or sugar, which is the brain's main fuel. Mosconi scanned 53 healthy people. She tracked them for up to 24 years. Six so far have developed Alzheimer's and 19 developed an Alzheimer's precursor called ''mild cognitive impairment,'' or MCI. Those people showed less glucose metabolism in the hippocampus than the still healthy.
     Other research supports the hippocampus' early role. University of Wisconsin researchers gave a different brain scan, called a functional MRI, to healthy adult children of Alzheimer's patients. The researchers found that the hippocampus was not as active as in people without that familial risk. To prove if these early indicators are real, the National Institute on Aging, with financial help from the pharmaceutical industry and Alzheimer's Association, is beginning a $60 million study to scan the brains of 800 older Americans and try to pin down Alzheimer's earliest biological changes. That Alzheimer's begins developing so early means even young people should adopt a brain-healthy lifestyle, said Dr. Mark Sager of the Wisconsin Registry for Alzheimer's Prevention. ''what we're hoping is that 55 is not too late,'' he said.
     On the Net:
Alzheimer's Association: http://www.alz.org/
National Institute on Aging: http://www.nia.nih.gov/



Genetic Makeup Contributes to Smoking Addiction
Tracy Davis, Ann Arbor News- 6/19/2005

Dr. Ovide Pomerleau, a professor of psychology and director of the Nicotine Research Program at the University of Michigan, discusses his research over the last 30 years focused on the genetic and heritable aspects of smoking.
Q. Is the tendency to smoke inherited?
A. All the evidence we have at this point indicates that smoking runs in families and that it is more than 50 percent heritable. That means basically, not that the environment in which people find themselves doesn't contribute, but it means at least half the contribution to the effect, smoking or not smoking is from the genes.
Q. Is environment still a factor?
A. Environment is very important. Obviously people wouldn't smoke tobacco if tobacco weren't available. Nicotine is the principal addictive substance in tobacco. It can be obtained in other ways, but basically, inhalation through tobacco smoke is perhaps the closest (thing) to a perfect drug delivery system because it allows the smoker to control the dosage puff by puff It's called a nice fancy term, fingertip titration.
Q. Do some people have addictive personalities?
A. I would have said no 30 years ago when I began working with smokers. My basic position, based on the data, was that smokers are just like anyone else, except they smoke. But I cannot say that anymore because. . . due to very effective anti-tobacco campaigns, easy quitters, have quit. The more resistant people who have a harder time quitting continue to smoke. Those people typically have other kinds of addictions. Particularly I could note other drug use, marijuana, cocaine and a very strong relationship between people who have alcohol abuse problems and smoking. If one wishes to use the term addictive personality, this would describe that category of current smokers.
Q. Are people who are heavy drinkers more likely to be smokers, or vice versa?
A. I would say yes. Certainly, if you start with people who are drawn to alcohol, they are more likely to be smokers. If you think of the traditional bar, you think of people smoking as well as drinking. So that association is out there in the environment. In the lab we have looked at this in a number of ways. We have asked people who have never smoked but who have a history of smoking in their family to come in and be exposed to small doses of nicotine. And we find the more smokers in their family the greater the reactivity We also find that if these people have either a family history of alcohol abuse or a personal history of alcohol abuse, their reactivity is also increased. So there's that kind of evidence. There are other studies that show the cross-talk between smoking and nicotine. Smoking can also counteract the effects of drinking to some extent ... and it can also be used by people as a way to function a little better when they've had quite a bit to drink.
Q. Is that why there are some "social smokers" such as people who only smoke when they drink?
A. That's a harder one to answer because it may well be that if they're with other smokers they are conforming or being seen as fitting in. And so the alcohol encourages a certain amount of socialization, that's its effect at lower doses.
Q. Do you think the idea that smoking has such a heritable aspect makes it harder for smokers to quit, especially if they know there's a genetic component?
A. I'm often asked the question, "Does knowing there's a genetic component give sort of an excuse, `Oh well I can't help it, it's in my genes.'" You know, in a sense everything that we do is in our genes. It wouldn't occur if we didn't have the biological structure to support it. It doesn't mean, however, that we don't have control over what we do; because there are many options and many choices people can make. I guess the best way I can put this to you is that if you know that you are going to be highly tempted by something, it may be to your advantage to take special precautions to control your tendency
     In other words, you accept the fact that you are drawn, say, to nicotine and you would take special precautions. If for example you are a young person who doesn't smoke and you know that all of your family smokes, it's very likely that it will be very easy for you to pick it up and like it. Well, if your friends offer ... all the more reason to practice say ing, "No, I don't want to do this. This is going to be a very difficult habit for me to break. I'm going to be realistic about that and I am not going to start it." That's one way. Another way for regular smokers who have tried to stop smoking many times and have not succeeded; at that point, it may not simply be a matter of making a resolution. ... It may take something more serious.
     There are now a number of pharmaceutical products available that really begin to do a pretty good job of providing relief from craving, withdrawal and that make it a little bit easier to function while learning to behave like a nonsmoker. The two obvious categories include the nicotine replacement products, such as the patch and spray.... Another compound that's available is Bupropion, also known as Wellbutrin and for smoking purposes it's called Zyban. It has a proven record of being helpful with cigarette smoking.
     What's interesting is this compound, though it's officially an antidepressant, it acts on nicotine receptors. It gets into those parts of the brain that are relevant to nicotine's action. It looks as if it has the equivalent function of a nicotine antagonist. So it sort of holds those receptors at bay and keeps them less active and allows the person not to have to rely on getting the nicotine anymore, because they don't get as much of an effect from it

For Teenagers, a Tweak on 'Just Say No'
Dulcie Leimbach, New York Times- 6/20/2005

Let's face it: teenage boys tend to take more risks than teenage girls do. This is both good and bad. Good if your son's penchant for graffiti translates into designing the school yearbook; bad if you're lying awake at 1 a.m. wondering why he is not home after the midnight gong. When it comes to teenage temptations -- from sports stunts to daredevil driving to experimenting with alcohol, tobacco and marijuana -- parents are right to be more concerned about boys than girls, said Dr. R. Andrew Chambers, an assistant professor of psychiatry at Indiana University School of Medicine. With drugs and alcohol in particular, epidemiological studies broadly suggest that boys are twice as likely as girls to become addicted, Dr. Chambers said.
      So listening anxiously for your son's key in the front door may be reasonable behavior and not obsessive (as your husband may imply). Part of boys' risk-taking behavior is driven by the constant changes chugging away in their brains as they grow. (Everyone's brain matures by about age 25.) Risky behavior also seems more likely with teenagers in groups. And studies have shown that the earlier adolescents dabble in tobacco, alcohol or drugs, the harder it is for them to kick the habit later.
     Which raises the question: can parents abandon the "just say no" slogan of the Reagan era for a new mantra that says "just wait" - until you are old enough to know better? Maybe. Psychiatrists, scientists and others who study teenagers and their ways offered a range of responses, from endorsing "just wait" to shying away from any encouragement to imbibe.
     One factor in this debate is that scientists understand more about how the adolescent brain works. Two years ago, a study led by Dr. Chambers, then an assistant professor of psychiatry at Yale, found that because of continuous neurological developments in adolescence and young adulthood, increased preferences for risky behavior and novelty seeking emerge, predisposing teenagers to experiment with drugs and ending up with addictive behaviors.
     The neural circuits that release chemicals that link new, adultlike experiences with the motivation to repeat them develop more rapidly during the teenage years than do the mechanisms that control these urges and impulses (which depend on exercising reason and judgment at the conscious level, basically knowing right from wrong). As a result, teenagers are not only more likely to feel enticed by drugs than older people are, but the effects on their brain can also be long lasting.
     Teenage smoking, which continues to decline but slower than in the past, offers an illustration. A report published in 2000 said that just a few cigarettes could lead to addiction. The study, which tracked the smoking habits of 700 12- and 13-year-olds in Massachusetts for a year, revealed that addiction could begin within days of inhaling a first cigarette. Children that young "have an extremely hard time quitting compared to 18-year-olds," said Dr. Joseph R. DiFranza, who led the study and is a professor of family medicine at the University of Massachusetts Medical School in Worcester. A "just wait" message with tobacco, therefore, does not sit well with Dr. DiFranza because there is "no safe level of use with tobacco," he said, adding: "Even when tobacco use starts at an older age, the addiction rate is much higher. You're never old enough to smoke."
     Frances Leslie and James Belluzzi, pharmacology professors at the Transdisciplinary Tobacco Use Research Center at the University of California, Irvine, discovered last year that rats tested during the earliest adolescent stage (equivalent to about 12 human years) developed a significant taste for nicotine after one brief exposure. "Exposure to nicotine can modify crucial brain development during the teen years," said Dr. Leslie, particularly in areas like decision-making abilities.
     Parents also worry, of course, about drugs and alcohol. The adolescent brain, Dr. Chambers said, is just as vulnerable to drug and alcohol addiction as it is to tobacco. "If you use a drug after 25," he said, "you are far less likely to get addicted than when you're 15."
     Marijuana poses a deep challenge because it is more potent than it was 30 years ago, and children are trying it as early as 11 years old, said Scott Burns, deputy director of the White House Office of National Drug Control Policy. "There are more kids in treatment for marijuana addiction than for alcohol treatment," he said.
     Dr. Marc N. Potenza, an assistant professor at the Yale University School of Medicine who specializes in addictions and worked on the 2003 Yale study with Dr. Chambers, said more research into the causes of specific addictions was necessary before endorsing a "just wait" approach. "There are critical periods when a lot of changes are occurring in the brain, and adolescence is one such period," Dr. Potenza said. "And the changes are quite dramatic." What motivates one teenager to take risks, he said, depends on the individual. The transition from childhood to adulthood is fraught with biological and social needs to differentiate oneself and experiment. But parents can still hold significant sway over their children's behavior. "It may not feel that way to a parent," Dr. Potenza said, but teenagers are sensitive to parental nudges and advice, including information about their health. So if you are lying awake waiting for your son to come home, try thinking creatively, like ways to keep him and his pals hanging out in the living room on Friday nights rather than at the pizza parlor or worse. Even exercising their brains. Have they ever played Scrabble?