Noteworthy News Articles on Mental Health Topics, August 12- , 2005


In Gambling's Grip
Marianne Szegedy-Maszak, Los Angeles Times- 8/12/2005

The day that Marilyn Lancelot won the biggest jackpot of her life, she left the casino in Yuma, Ariz., with every penny of the $4,000 that had poured out of the slot machines. This time she knew that she would never gamble again. She was right, although not for the reasons she thought. The next day, seven police cars appeared in her Phoenix driveway and she was taken out of her house in handcuffs. The 61-year-old grandmother had embezzled more than $300,000 from her employer to support her gambling addiction. "I had something wrong with me," says Lancelot, now 75 and living in a retirement community in Phoenix. "Some people can't think that gambling is an illness but maybe it is. I know that I couldn't stop. My head wouldn't let me."
     Lancelot's turn of phrase contains clinical truth. Researchers are learning that the heads — or to be more accurate, the brains — of pathological gamblers are biologically different from those of most of the estimated 73 million Americans who are able to play bingo, pull the arm of a slot machine or flip some aces and then simply stop. Not only does the research shed light on how this addiction is both similar and distinct from other addictive disorders, it also could contribute to new treatments.
     The need is undeniable. With legalized gambling in 48 states, 40 states with lotteries and online gambling available in any home with Internet access and a credit card, the triumph of the occasional big win has been accompanied by a rich yield of individual lives in shambles. About 1.6% of Americans have a full-blown gambling addiction and an additional 2% have a serious problem with gambling, says Jon Grant, assistant professor of psychiatry at Brown Medical School and author of "Stop Me Because I Can't Stop Myself," (McGraw Hill, 2003). By these estimates, nearly 4% of the population experiences a mild to severe gambling problem — and as the number of gamblers goes up, so does the number of those with a gambling problem. In California, "We think that virtually everyone knows someone who has a problem," says Bruce Roberts, executive director of the California Council on Problem Gambling, who has experienced the frightening trajectory of gambling addiction. Officially, about 1 million Californians are considered problem gamblers.
     Now, with the aid of neuroimaging techniques and a greater understanding of neurotransmitters, researchers are discovering that the brain's hard-wired reward system and frontal lobes have certain unique characteristics in these gamblers. Even some of their personalities and genes may be different from those without gambling problems. "We are finding that pathological gambling is very definitely a brain disease," says Timothy Fong, a psychiatrist and codirector of the UCLA Gambling Studies Program. "The central question is: Were pathological gamblers born that way or are the changes in their brains the results of excessive gambling? We are far from answering that question in a meaningful way."
     Pathological, or compulsive, gamblers simply cannot stop gambling, even when their losses cripple their lives. The narratives, though as unique as each life, have a similar trajectory: a fascination, then obsession with gambling, punctuated by a few wins and colossal losses often involving houses, jobs, personal relations and savings, finally resulting in a shattered life. Nearly 20% of pathological gamblers have filed for bankruptcy protection, compared with 4.2% of non-gamblers. But perhaps a more telling, and certainly more tragic consequence, is that compulsive gamblers are nearly four times as likely to have attempted suicide than non-compulsive gamblers.
     The disorder was officially categorized by the American Psychiatric Assn. as a diagnosable disorder in 1980, but was categorized as an "impulse control" disorder rather than an addiction like alcoholism. As research during the last 25 years has revealed, however, it is both. The brain can become addicted to behaviors as well as substances, Grant says. "It can be addicted to anything that we find rewarding," he says. "If we find it too rewarding, we will want to do it again and again. Even when they lose all their money and credit cards, they describe intense cravings much like people do for drugs."
     The explanation for why gambling is the drug of choice for one person, and for another it's heroin is still unknown. But the key to most addictions can be found in the brain's reward system, particularly a region called the ventral striatum. Neuroimaging studies of compulsive gamblers point to a different functioning in this neural system.
     A study published in February in the journal Nature Neuroscience compared 12 pathological gamblers and 12 healthy people. While lying in a functional magnetic resonance imaging machine (fMRI), all were asked to choose a playing card by pressing a button. If the card was red, they won money; otherwise they lost money. The task activated the ventral striatum, also known as the nucleus accumbens, an area of the brain that is primed for pleasure and reward-seeking behavior. But the experience of pleasure was far less pronounced for pathological gamblers. The more serious the gambling problem, the less activation of that region.
     When the area is working normally, it responds appropriately to pleasure stimuli — such as winning money or getting a gift — filling us with a sense of happiness or satisfaction. When it is not working properly, as in cocaine addicts, this area seems almost indifferent. What would make a normal person react does nothing for people addicted to substances or behaviors. Even more stimuli, such as drugs, alcohol or gambling, are needed to feel the pleasure from a particular activity. "You experience something very nice that gives you pleasure," says UCLA's Fong. "But then other parts of the brain seem to shut down and you need to have the reward so much that it takes over the rest of the brain."
     Marilyn Lancelot remembers the feeling of surrendering to the impulse of playing the slot machines. She couldn't have cared less about horse races or bingo, but the slot machines mesmerized her. "Gambling occupied everything in my mind," she recalls. "When I sat at the slot machines, it was like a switch and they shut off everything real. The slots would become me and my dream world."
     Research presented at the American Academy of Neurology meeting in April found that executive function, the brain circuitry that underlies inhibition and self-control, was deeply impaired in pathological gamblers. These impairments made the gamblers unable to truly comprehend the trade-off between short-term reward and long-term negative consequences.
     This loss of self-control in turn affects other important brain functions needed to step on the brakes when emotions spin out of control. Those who suffer from attention-deficit disorder experience difficulty with executive function, and researchers have found, not coincidentally, that a high percentage of pathological gamblers also have ADD.
     Many studies suggest that compulsive gamblers may have reduced frontal lobe activity, which may in turn be triggered by decreased activity in the basal ganglia, a deeper part of the forebrain that generates two important neurotransmitters called dopamine and norepinephrine.
     The feel-good neurotransmitter dopamine, in particular, has intrigued those studying compulsive gamblers. Several studies have looked at a dopamine receptor gene and have found real differences in the structure of that gene between gamblers and non-gamblers. That genetic predisposition has direct consequences on brain chemistry. The dopamine receptor sites in the midbrain that are driven by anticipation, but uncertain of the rewards, are especially sensitive. They require more and more dopamine to create the rush of happiness and satisfaction. When gambling is the trigger for the dopamine rush, a vicious cycle is created.
     A study in the Archives of Neurology last month looked at 11 patients with Parkinson's disease who were taking an artificial dopamine, nine of them took pramipexole and two others took a similar drug called ropinirole. Eventually they all became compulsive gamblers, and seven of them did so within three months
     A 53-year-old registered nurse, who had gambled only once in five years, began going to casinos once a week. A 54-year-old minister who had gambled only an occasional $20 at a local casino began to gamble almost daily and over several months lost more than $2,500. And a 52-year-old married man who had never had a problem lost more than $100,000 gambling. He also developed a voracious appetite for food and sex, gaining 50 pounds and engaging in extramarital affairs.
     Although the research focused on medication side effects for those with Parkinson's disease, the study also shed light on both dopamine and compulsive gambling. "This research makes us more sensitive to the idea that there are deficits in certain brain areas of gamblers," says Leann Dodd, a psychiatrist at the Mayo Clinic and lead researcher in the study. "It adds to the evidence that gamblers might have a decreased capacity to get stimulation from their pleasure system and they need extra stimulus to get there."
     Roberts, of the California Council on Problem Gambling, whose costly "drug of choice" was poker, experienced the physical and behavioral rush of gambling. He made his last bet Dec. 12, 1989, and realized that he had "to get help or die." He had refinanced his home nine times to support his compulsive gambling and had lied about nearly everything to his wife. "Even today I may be flipping through channels and see poker on TV," he says. "It may be someone I played with years ago and I stop to take a look. I can feel my insides changing. It is kind of like a little adrenaline rush, the way you feel when you come close to having an accident on the freeway. You feel your body coming alive to the stimulus."
     And yet, some people can feel the same excitement and gamble within their means, enjoying the game, while others are completely out of control. Perhaps it is also a question of personality. In a paper last month in the Archives of General Psychiatry, researchers looked at the personality and temperament of 939 men and women, all born in 1972 or 1973, to see if they could discern some personality traits that compulsive gamblers all shared. They also wanted to find out if these traits related to those in substance abusers. All the participants were given a personality test when they were 18, and then at 21 they were screened to see if problem behaviors such as compulsive gambling, drug and alcohol abuse or nicotine dependence, had emerged. The researchers found that the problem gamblers shared many personality traits with others with addictive disorders: risk taking and impulsivity.
     Until now, treatment has consisted primarily of cognitive behavioral therapy, which can help gamblers control impulses. But increasing understanding of the neurobiology of the disorder may result in new and more effective treatments. One promising treatment is the drug naltrexone, an opioid receptor antagonist. In several preliminary studies, the drug reduced the urge to gamble and when gambling did occur, there was much less enjoyment or enthusiasm for it. Side effects can be unpleasant, and the drug can be toxic to the liver. Antidepressants and mood stabilizers have also been used to treat gamblers, but they have had only mixed success. But, writes Richard Rosenthal, the director of the UCLA Gambling Studies Program, "Medication should be thought of as an adjunct to the treatment of pathological gambling. Most gamblers can be treated successfully without it."
     Both Marilyn Lancelot and Bruce Roberts credit their recoveries with a treatment program, not with drugs. They changed their behavior and simply stopped gambling. For other people, more intensive supportive therapy is necessary, or even placement in a residential treatment facility where each hour of the day is scheduled. Roberts' life is financially stable and he now organizes educational programs on the human costs of gambling addiction. Lancelot now boasts a triple-A credit rating, works part time and is saving money. In January she will celebrate 15 years of being free from gambling. "I'll bet that the next 15 will be even better," she says. "But I don't bet."

Signs of trouble
Pathological gambling is classified not under addictions in the Diagnostic and Statistical Manual of Mental Disorders, or DSM IV — the diagnostic bible of the American Psychiatric Assn. — but rather with kleptomania and pyromania as an "impulse control" disorder. A person must demonstrate five or more of the following 10 characteristics to be considered pathological, although some experts say that possessing several of these characteristics can point to signs of trouble. Signs of being a pathological gambler include:
•  Preoccupation with gambling, reliving past gambling experiences or thinking of ways to get money with which to gamble.
•  A need to gamble with increasing amounts of money to achieve the desired excitement.
•  Repeated and unsuccessful attempts to control, cut back or stop gambling.
•  Restlessness or irritability when attempting to cut down or stop gambling;
•  Gambling as a way to escape from problems or relieve a depressed or unhappy mood.
•  After losing money, returning another day to get even or "chase" one's losses.
•  Lying to family members, therapists or others to conceal the extent of involvement in gambling.
•  Committing illegal acts such as forgery, fraud, theft or embezzlement to finance gambling.
•  Jeopardizing or losing a significant relationship, job or educational or career opportunity because of gambling.
•  Reliance on others to provide money to relieve a desperate financial situation caused by gambling .

 

Non-Soldiers Suffer Post-Traumatic Stress
Associated Press, 8/13/2005

GLENVILLE, N.Y. -- For hundreds of thousands of Americans, mental illness is just a drive down the road. Ask Beth Puglisi. The 45-year-old mother was out to fill her gas tank on a bitter-cold January day last year. She turned the wheel of her pickup, felt a wrenching jolt, and watched the roadway fly into a spin. ''No!'' she heard herself screech. The rubbery aroma of spilled antifreeze filled her nostrils.  In the days after her crash with a car, she took to the couch, weeping -- but not over her fractured vertebra and dislocated shoulder. Her mind was staggering. ''It felt like a death,'' she says. Her body was quickly tended, but it took months before doctors even put a name to her other injury: post-traumatic stress disorder.
     Once associated mainly with the horror of combat, PTSD has stretched to take in more frequent swerves along life's road -- car crashes, house fires, a sudden death or severe family illness, witnessing a disaster, or even learning of one. PTSD has broadened the model of mental illness to cover disturbances set off solely by external events, outside of the mind. Almost anyone can be vulnerable. Research suggests the disorder is now present in 5 percent of Americans, or more than 13 million, according to the PTSD Alliance, which unites professionals and advocates. It is expected to touch 8 percent of adults during their lives. By contrast, just over 3 percent of Americans have cancer.
     Puglisi had been in accidents before, but she never felt this way. She couldn't stop picking over this crash in her mind. It wasn't her fault; it just wasn't. So why did it have to happen? Why? Her family encouraged her to talk: ''Each time I would tell someone about it, I could feel it and smell it -- the whole thing.'' In a kind of flashback typical of PTSD, she could still smell the antifreeze.
     As PTSD's debilitating anxiety took hold, Puglisi started to feel nervous, flushed, even lightheaded when she was driven to a doctor or physical therapist. She would tremble, and her chest would tighten: ''Just thinking about it was making me crazy.'' When she tried driving again, she'd have to circle around to avoid making the same kind of turn as in the crash. She'd bypass where it happened. Ashamed, she asked her husband to drive the children to their activities. While television droned war news from Iraq, she felt trapped in her own combat zone: ''When you're in the war, you have no idea if you're going to be alive or dead in 10 minutes. That's exactly the way I felt.''
     Warring soldiers have carried home psychological scars for centuries. The ancient Greeks noticed it. In American wars, it has been called shell shock, combat fatigue and post-Vietnam syndrome. Though skeptics discounted some cases as shams meant to win compensation, other extreme cases were taken for schizophrenia. Medical authorities first accepted PTSD as a distinct psychiatric condition in 1980 at the urging of Vietnam veterans and their medical caretakers.
     In PTSD, stress hormones like adrenaline scorch a painful event deep into long-term memory, scientists believe. Lab studies show such hormones normally improve memory in animals. They seem to overshoot the mark in PTSD. People get very edgy and fearful, prone to nightmares or flashbacks. They desperately want to avoid reminders of their shock, even to the point of feeling numb. PTSD happens more often in women, in cases of multiple traumas (Puglisi had another road accident just a couple weeks earlier), and in people with depression. Once defined, the disease was soon embraced, and insurance coverage expanded. Here was a psychiatric condition touched off by concrete events, not something hidden in the mind's dim recesses. It could theoretically happen to anyone, even the hardiest and soundest of mind. It wasn't your fault.
     The federal government established the National Center for Post-Traumatic Stress Disorder. It began researching PTSD and treating hundreds of thousands of veterans. Survivors from rape and car crashes began to seek therapy in greater numbers too. In 1994, the sudden death of a relative, or even learning that one was hurt, joined the expanding list of PTSD traumas in the chief diagnostic manual for psychiatry.
     By the late 1990s, when Dr. Greenbrier Almond was working as a psychiatrist at a West Virginia veterans hospital, PTSD was already its leading diagnosis, above heart disease and diabetes, he says. Over the past five years, the number of cases among veterans -- mostly from combat -- has exploded nationally by almost 80 percent to 215,871 last year, according to the Department of Veterans Affairs. It is the agency's fastest-growing disability.
     No similar statistics are collected for civilians, but the numbers are clearly substantial. Dr. Almond, who has left the veterans hospital, now treats PTSD in abused children at a community health clinic. Research at Henry Ford Health System, Harvard and Georgia State has identified the two leading causes of PTSD as unexpected deaths of relatives and car crashes. Combat ranks far down on the list.
     Some bad diagnosticians and purveyors of pop culture have come to consider just about any of life's shocks -- divorcing, losing a job, even failing a test -- as triggers for PTSD. Though veterans officials say rising awareness has driven most of their growth, they are also reviewing whether some cases have been diagnosed too readily. ''Anything that happens to you that's remotely icky now qualifies,'' says psychologist J. Gayle Beck, at the University at Buffalo-State University of New York. ''It's been culturally overdiagnosed.''
     This psychiatric illness has carried cultural baggage since its birth in the social turmoil over the Vietnam War. The new disorder tied to external events meshed with a Kafkaesque view of society inherited from the 1960s: Outside forces constantly threaten peace of mind. Since 2001, PTSD has tapped into another source of anxiety: terrorists who can inflict mass death in an instant. A survey found highly elevated rates of PTSD in the New York metropolitan area, where the smoking towers of the World Trade Center could be seen for miles. Afterward, some companies sent reassuring notices to workers listing PTSD symptoms and saying they were common responses. One compared them to a minor flu. ''It speaks to dangerous times and threats, and that certainly defines our era,'' says Dr. Robert Jay Lifton, a Harvard University psychiatrist who helped define PTSD as a condition. ''There is bound to be widespread PTSD and an awareness of it.''
     Even so, many people with PTSD still do not come forward for help, caregivers say. And even experts may miss the signs. ''My father dropped dead in front of my mother. She developed PTSD for two years, and I was completely unaware of it. I knew something was wrong, but I didn't know it was PTSD,'' says psychologist Terence Keane. Yet he is director of behavioral science at the federal PTSD center. The good news is this: Even untreated, PTSD goes away in about half of the cases within six months, research indicates. The bad news: When it doesn't, it can last for decades.
     Puglisi had never needed therapy before and didn't think of treating her embarrassing automotive anxiety. ''I would say I'm all right,'' she recalls. But she wasn't. Her doctor told her she'd soon get over it, but her physical therapists knew better. After several months, they persuaded her to look for help.
     She found Edward Hickling, a former veterans psychologist who now specializes in road-accident PTSD. ''I came to private practice, and I saw motor-vehicle accident victims that looked a lot like ... the post-traumatic stress responses I saw in the veterans hospital,'' says the therapist based in nearby Albany. Like many PTSD therapists, he relies on cognitive behavioral therapy. A common psychological treatment, it teaches how to replace negative mental monologues (''I could die on the way to work'') with positive, rational ones (''I'll probably get there just fine, as usual''). It can be carried out one-on-one or in groups.
     Like many PTSD therapists, Hickling re-exposes participants to memories of the terrifying situation, while desensitizing them over a few months or longer. They start by telling what happened and graduate to driving back to the crash site. One woman was able to drive back and gaze at the place where her car plunged down a hill, trapping her for more than two hours. Later, she felt as though she had ''removed a cloud from her brain,'' according to Hickling. The therapy can work in up to 75 percent of road-accident survivors with chronic PTSD, research suggests. Some patients, though, can't tolerate thoughts of their ordeal. ''It's just too painful,'' says psychologist Charles Figley, at Florida State University. Lesser symptoms persist in many people.
     Psychiatrists often treat PTSD with drugs. The federal government has approved two depression medicines, Zoloft and Paxil, for PTSD. Research suggests they help at least a quarter of PTSD patients. Other researchers are experimenting with potential PTSD drugs like anti-adrenaline agents and the antibiotic D-cycloserine. In theory, they might disrupt the consolidation of long-term PTSD memories or help the brain forget them later.
     Psychological therapy alone conquered Puglisi's symptoms, though it took a year. She still hasn't gone back to work but doesn't feel so alone. Now she knows of many others like her: ''The mind does this sometimes.'' What happened to her, she has learned, is normal.


This Johnny Appleseed Is Wanted by the Law
Clifford Krauss, New York Times- 8/13/2005

VANCOUVER, British Columbia- Freshley released on bail, Marc Emery faced the camera of his Pot-TV.net Web site the other day to make an urgent appeal for money to finance his legal struggle to avert extradition to the United States for trafficking marijuana seeds south of the border. Let me be the light that shines on the American gulag," he said, stern-eyed, pointing into the camera. Without notes, Mr. Emery sermonized for a half-hour about everything from the marvelous medicinal and spiritual qualities of pot to the greatness of Thomas Jefferson, "who gave America on hemp paper the Declaration of Independence." "Marijuana made me a better parent, a better lover, a better businessman," he solemnly told his supporters. Immediately after the broadcast, he was quick to add, "a better driver, too."
      At 47, Mr. Emery is known as the Prince of Pot, even in his recent federal indictment in Seattle for charges of conspiring to manufacture marijuana, launder money and traffic millions of marijuana seeds into the United States. At the time of his arrest, on July 29, he and his business were on a United States attorney general list of the 46 most wanted international drug traffickers, and the only one in Canada. But his clownish nickname provides a clue that Mr. Emery is not your typical drug kingpin from the movies who deals in the shadows.
     A lanky Canadian with a taste for bland T-shirts and chinos, he proudly promotes himself as the leader of the sizable Vancouver marijuana counterculture that is condoned by the municipal government and much of the city's population. He postures as just a regular guy who loves the Vancouver Canucks, and rarely smokes more than a joint or two a day. But he also freely says that, outside the Netherlands, he has sold more marijuana seeds and offered the largest selection of any seed bank in the world. He adds that the amount of seeds he has sold south of the border "qualifies me for the death penalty in the United States." (The first claim, of ubiquity, is accepted by American prosecutors, while the second, of a looming death sentence, is met with guffaws.)
     "I have a master plan," Mr. Emery said in an interview in the offices of his magazine, Cannabis Culture. "I've wanted to be the Johnny Appleseed of marijuana, so if we produced millions and millions of marijuana plants all over the world, it would be impossible for governments to eradicate or control all of it." In other words, he added, he wants "to overgrow the governments" that punish marijuana users.
     In his crusade to make marijuana completely legal everywhere, not just in Canada, where anti-pot laws are already more lenient than in the United States, Mr. Emery has marketed his seeds and anti-prohibition message on his Web site and magazine and traveled around the country smoking marijuana in front of police stations. As leader of the British Columbia Marijuana Party, he has run candidates across the province and has himself run for mayor twice in Vancouver on the platform of disbanding the police force and remaking it from scratch. Armed with a speaking style that resembles a tommy gun firing off sound bites, he came in a respectable fifth out of 16 candidates in the last mayoral election, in 2002.
     To the growing annoyance of American law enforcement, he has been openly selling seeds to American growers and counseling them how best to cultivate his product and avoid the attention of the police - all with only minor harassment, until now, from Canadian law enforcement. According to the United States Drug Enforcement Administration, Mr. Emery has sold millions of dollars worth of seeds to growers in California, Florida, Indiana, Michigan, Montana, New Jersey, North Dakota, Tennessee and Virginia. "He operated his business very efficiently, making a lot of money at the expense of our kids and the American public," Rodney Benson, special agent in charge of the D.E.A. field division in Seattle, said in an interview.
     Now, his master plan is in serious jeopardy. In July, the Canadian police, working with D.E.A. agents, arrested Mr. Emery and raided his headquarters at the request of the American government, so that he might be extradited for trial in Seattle. Last week, he was freed on bail; the extradition process could take years. It is bound to stir a debate in Canada about whether it should permit a Canadian to stand trial in the United States for an offense that is essentially tolerated here.
     But for the time being, Mr. Emery's empire is in tatters. He has been forced to lay off workers at his magazine and Web site, and because he can no longer sell seeds, his ability to finance marijuana-legalization causes has dried up. He says he must move to a smaller apartment, give up his car lease and live on the equivalent of $32 a day from donations. "Lets face it," Mr. Emery said in an interview. "I've sold millions of seeds and I've been doing it every day of my life the last 11 years. I'm so transparent that everyone from the prime minister to the guy on the street knows it."
     He says he has made $4 million in profit since 1996 selling seeds in his Vancouver store, by mail and on the Internet. But he says he has not saved a dime, does not own a share of stock or bonds, does not even own a piece of property. All the money he has made, he says, has gone into his magazine, his Internet Pot-TV news channel, his British Columbia Marijuana Party, various referendum initiatives for marijuana legalization in the United States, legal fees for marijuana growers in several countries and support for his wife, various ex-lovers and four adopted children. He also claims to have paid nearly $600,000 in taxes from the proceeds of his seeds, noting openly on his tax returns that he worked as a vendor of marijuana seeds.
     Mr. Emery describes himself as "a responsible libertarian, not a hedonist," who extols the virtues of capitalism, low taxes, small government and the right of citizens to bear arms. He said he grew up a social democrat, influenced by his father, who was active in trade union work. But he said his life changed in 1979 when he began reading the works of Ayn Rand, who championed individual freedom and capitalism. "The right to be free, the right to own the fruits of your mind and effort now all made sense," he recalled. Only a few months after discovering Rand, his girlfriend at the time offered him a joint and he smoked marijuana for the first time.     It was an epiphany," he said. "I had a sixth sense added to my five senses. The silence sounded different, smells were more nuanced and the brightness of the moon made it look bigger and more substantial in the sky."
     The combination of Rand's philosophy and the marijuana set him on a course of advocacy in which, he said, "I decided to dedicate my whole life to repudiate the state." Then living in London, Ontario, he sold banned marijuana and pornography books and magazines, contested laws limiting the right of stores to open on Sundays and led a municipal tax revolt. He even resisted a municipal garbage strike, by renting a truck and picking up the garbage himself. After traveling for a while in Asia, however, he has dedicated his efforts to promoting marijuana and its culture. "Now the Goliath, now the evil empire has made its move on me," Mr. Emery told his Web site audience. But he promised that his crusade would continue "till liberty or till death."


After Suicide, Shaken Family Rallies, Wonders
Sally Jacobs, Boston Globe- 8/14/2005

The letter is written in girlish, excitable script. It is an appeal from a scared young woman to her father. In it, she confides that she has ''a little problem." The problem is a baby. But amid all the run-on sentences and exclamation points, Danielle M. Jones could not quite bring herself to write the word ''baby." Instead, she enclosed a copy of her ultrasound. When she wrote the letter in January she was seven months pregnant with her second child. She was not married. ''Please, please forgive me," Jones, 25, wrote.
      On St. Patrick's Day, Jones gave birth to a baby boy named Deryn. He was placid and perfect, and she paraded him proudly around the Medford streets of her childhood. Three weeks later, on a brisk spring evening, she strapped her two sons into her white Pontiac Grand Am and made her way out onto Route 1 headed north. As her car crested the lower deck of the Tobin Bridge, she abruptly pulled to the left and jumped out. She stood for a second at the railing, then rolled herself over. When the boys' father reached the bridge an hour later, Deryn was sound asleep. His other son, 16-month-old Aidan, was staring silently ahead. ''He was very calm, not crying," said Derek Lanphere. ''Just looking." In the note that State Police found on the dashboard of her car, Danielle had written Lanphere's cellphone number and these words: ''I'm sorry. I love you."
     Her suicide seemed unaccountable, astonishing. Even veteran practitioners in the medical examiner's office, seasoned in tragedy, were left wondering, why? The only thing that seems certain is that Danielle had left nothing to chance -- post-mortem tests showed that she had taken a fatal overdose of oxycodone, a prescription painkiller, shortly before she jumped.
     Her family now believes she suffered an extreme form of postpartum depression, although none of them sensed her to be suicidal before that day. A more complex explanation may be rooted in the murky thicket of her childhood. Danielle Jones did not want children. But when she got pregnant she set out to do her best, to be all the things that her own neglectful mother and sometimes-absent father had not been. In doing so, she found herself face-to-face again with feelings she had spent most of her short life trying to escape. ''My sister didn't jump off a bridge," said Christopher Jones, 29, Danielle's brother. ''She jumped off a mountain of stress and pain and a mother she couldn't get at. It all just ate her up."

Telltale symptoms
A sweltering July day is just fading into dusk and Danielle's eldest son, Aidan, now a burly19-month-old, is poised, rigid with excitement, at the end of a diving board ''Come on Bo Bo," someone shouts from the pool, using the abbreviated form of 'Big Boy' that was Danielle's favored nickname for her son. ''You can do it!" At last, Aidan leaps into the water clutching his green flotation tube as relatives on the patio clap.
      Bo Bo and his brother, nicknamed Squiggles, live in a small, olive-green house in Medford behind the pool along with the uncommon, extended family that formed in the wake of their mother's April 7 suicide. There's Uncle Christopher and his new wife, Susan Mitchell, as well as her parents who own the house. One of Mitchell's brothers also lives there. On the night of Danielle's death, Lanphere, her fiance and boyfriend of nine years, moved out of the East Boston apartment they shared and into the house, too.
     They all pitch in. Mary Mitchell, Susan's mother, did not know Danielle well, but she cares for the boys during the weekdays. When ''the guys" get off work -- Chris is a letter carrier in Medford and Lanphere works for a towing company in East Boston -- they take over. On weekends the children sometimes visit their grandfather's New Hampshire cabin. They call it ''Camp Grampy."
     Sometime this fall, the boys will probably move into a new home. Lanphere and Christopher and his wife are buying a two-family house in which they plan to raise the boys together. Lanphere and the boys will live on the bottom floor. Christopher and Susan on the top. ''Danielle was the most important person in my life," said Christopher. ''Now, Derek and the boys are my connection to her. So I am going to go to the ends of the earth to make it easier for him to be their father."
     Everyone's thoughts are on the person missing from the poolside scene: Danielle, with her electric smile, permanent suntan, spotless white Keds sneakers (she kept up to 30 boxes of replacement pairs), and boundless devotion to her boys. ''Oh, my God, she loved those children," exclaimed Elaine Lanphere, 46, the boy's paternal grandmother, who cared for Aidan while Danielle worked. ''I wish I'd had her for a mother. No one saw it coming. No one."
     It is only now that some among Danielle's extended family realize that there were signs they wish they had heeded. Always somewhat moody, Danielle withdrew even more in the months when she was pregnant with her second child. She stopped bleaching her brown hair to complement her tan. So rarely did she answer the phone, it became a sort of family joke. ''When Aidan was born, she shut off the phone," said her father, Chuck Jones, 48, of Weirs Beach, N.H. ''When Deryn was born, we figured she'd just throw it out the window." It was Christopher who most clearly sensed her darkening mood. ''She just wasn't the same," said Christopher, tears running down his face. ''She was just very hard to reach. But I didn't know what it was."
     Danielle never uttered the words ''postpartum depression" to anyone in her family. But her fiance said she did bring it up with her obstetrician. Not long after Deryn's birth, Lanphere recalled, the couple met with Dr. Matthias Muenzer in Medford, and Danielle said that she'd been depressed after her first son's birth ''but that she'd never told anyone." ''But she told the doctor that she was doing excellent now," explained Lanphere, 26, who works for Todisco's Towing. ''She said that she'd say something if she felt it coming on again. ''We never discussed it after that," he added. ''It was like a dead subject."
     Although postpartum depression has been in the news lately with the publication of Brooke Shields's book, ''Down Came The Rain," it is a disorder that many women's advocates believe is underdiagnosed and easily dismissed. Characterized by mood swings, lack of energy, and suicidal feelings, it is believed to affect 1 in 10 new mothers. Danielle faced several risk factors for the disorder. Women with low self-esteem and low confidence in their parenting are considered to be at risk, according to Shoshana Bennett, president of Postpartum Support International. And those who have had postpartum depression have up to an 80 percent chance of a recurrence after the birth of another child, according to Bennett.
     Jones's family members, who have read extensively on the subject, suspect she may have suffered a rare disorder known as postpartum psychosis. Affecting only about 1 in 1,000 women, its symptoms, which manifest within the first four weeks after childbirth, include delusions and hallucinations that can lead the mother to harm herself or her children. While Danielle exhibited several telltale symptoms, including fatigue and feelings of inadequacy, it is not clear whether she had either disorder. Dr. Muenzer declined, through his attorney, to be interviewed even though Danielle's father authorized him to speak about her case. All that is obvious to the family is that she must, somehow, have been out of her mind when she went over the bridge and landed in the parking lot of US Gypsum Co. in Charlestown. The proof, for them, is the children in the car. ''If my daughter had been in her right mind, she would never, ever have taken the kids with her that day," said Chuck Jones. ''Danielle would never have done anything to hurt these children."

Difficult childhood
Danielle knew something of how children can be hurt. She was the child of teenagers: Chuck Jones and Karen Tipton Jones were 18 and 16 and just married when they had Christopher, their first child. Danielle came three years later in 1979. They divorced when Danielle was 5, and Christopher and Danielle saw little of their father for years, Chuck Jones acknowledges. There were times when they didn't see much of their mother, either. By the mid-1980s, Karen Jones, according to her two sisters and her mother, began to use drugs and sometimes left her children at home alone. Christopher recalls that, by the time he was about 10, he and his sister could, ''bathe ourselves and feed ourselves and pretty much do everything for ourselves." And when it got too cold in the apartment, he added, ''we'd turn on the dryer and turn the exhaust vent back into the apartment to keep ourselves warm."
      Their maternal grandmother, Anne Anzalone, was so worried about the children that when she finished her shift as a cook at Children's Hospital in Boston, she would often take milk and cereal and leftovers and slip them between the screen door and front door of her daughter's apartment as she drove home at dawn. ''I worried to death that those children would go hungry," said Anzalone, now 70. ''The children never said a word. They never complained."
     Karen Jones, who remarried and now goes by the name of Karen Correia, has a record in Somerville District Court stretching over two decades. Most recently, she was charged in June of 2004 with two counts of possession of cocaine and two other drug-related offenses after police raided her Medford apartment. She failed to show up for a hearing on the case in March and a warrant was issued for her arrest. After the raid, the state Department of Social Services took custody of Correia's 13-year-old daughter by her second marriage. Correia declined through a friend to be interviewed by the Globe. Her lawyer, Jacqueline Ellis, said she had not heard from Correia in five months. But you can read her words in the online bereavement guest book she maintains for her daughter at www.legacy.com. ''I LOVE YOU DINKA YOU ARE IN MY THOUGHTS MY HEART MY SOUL. MA," Correia wrote, using Danielle's childhood nickname.
     Christopher and Danielle always watched out for each other, but childhood was a painful period of want and uncertainty. While a student at Medford Vocational Technical High School, Danielle took on a host of after-school jobs. But she often had to borrow clothes. Melissa Ziobro, who dated Christopher, remembers Danielle once asking her quietly if she could borrow a dress for the prom. ''It was cherry red and she loved it, and of course I said 'Yes.' But I think it was always hard for her to ask."
     Danielle, by all accounts, loved her mother deeply. But her mother's behavior gnawed at her self-confidence. When she got older, Danielle would refuse to talk to her mother until she stopped using drugs. When her mother was injured in a car accident in 1998, for example, Danielle moved in with her to help her out. But when she found a crack pipe in the bathroom several months later, she moved out that afternoon, according to friends and family. ''She felt like she was always trying to get her mother's love and attention but she just couldn't get it," said Christine Welch, one of Karen Correia's sisters. ''It made her feel she didn't matter. So, Danielle became a people pleaser. If you look at pictures of her, you will see she is always smiling. There is not one sad picture."
     When she was 15, something came along to really smile about. His name was Derek and he was funny and mellow in all the ways that she was not. Shortly after she graduated from high school in 1997, she and Lanphere and Christopher shared an apartment together in Everett. Danielle and Lanphere agreed they did not want children. But when Danielle took a break from birth control in 2002, she quickly became pregnant. ''I said, 'If it's OK with you, it's OK with me,' " shrugged Lanphere. Danielle told him it was OK with her.
     They vowed to get married as soon as they could afford it. Danielle stopped smoking. She gained 60 pounds. She even cut back on her cherished visits to the tanning salon. And when Aidan arrived in November 2003, she was beside herself. ''She loved that baby to death," said Ziobro. ''She would say, 'He's a new start for all of us, for me and Derek and Christopher.' " Added Lanphere, ''She did everything for him. As soon as he moved an inch, she jumped."
     Chuck Jones, who reentered his children's lives in the early 1990s, says that when Danielle visited him in New Hampshire, she would often get herself up in the middle of the night, well before Aidan awoke, so she could be ready with his bottle.
     When Danielle returned to her job at the Dodge Co., a Cambridge vendor of funeral supplies, co-workers say the stress showed. The ever-sunny Danielle had drooped. ''She didn't think she was a good mother," said Patty Cahill, 36, Dodge's supervisor and a mother of three children. ''But she was great. She would say, 'I'm sorry, I'm sorry, I'm sorry.' It was sorry about everything. But that was Danielle."
     In the fall of 2004, less than one year after Aidan was born, Cahill noticed that Danielle was wearing large T-shirts to work. As the shirts grew larger, Cahill bought Danielle some prenatal vitamins and urged her to go to the doctor. Danielle refused. But finally, when she was almost five months pregnant, she agreed to have an ultrasound. Cahill went with her. ''They told her it was a boy," recalled Cahill. ''And she seemed pretty excited. It made it like a person and not just a problem."
     Danielle did not talk much about her condition and few could have guessed: she gained just 20 pounds in her second pregnancy, according to Lanphere. And when she finally did tell people, she did not elaborate. 'When she told me, she was very aggravated," recalled Christopher. ''She just said, 'I'll do it.' " Sylvia Belcastro, 26, one of Danielle's closest friends, says that when Danielle told her, ''she was worried about everything. She didn't want to tell her father because she didn't want to upset him."
     Money worries had long plagued Danielle, who handled the couple's finances. Over the past year, she had borrowed nearly $10,000 from her father and $3,000 from family and friends. Lanphere says he was unaware of the loans. But Belcastro and some family members say that in recent years, Danielle often secretly bought her mother food and cigarettes and posted her bail. Lanphere says that Danielle took $500 out of their bank account to pay her mother's bail last year. It was, he says, the only time they fought. ''I just wanted her to tell me she was taking it," sighed Lanphere. ''Danielle just said, 'It's my mother. My mother.' "
     By early this year, not only was Danielle's pregnancy beginning to show but she was agitated by other things. She and Lanphere had moved to a two-bedroom apartment in East Boston so that Lanphere could be closer to his job, but she felt cramped and alone. Her mother had moved in for a month, but Danielle ordered her to leave after she didn't make it to Danielle's 25th birthday dinner but showed up the next day and devoured the rest of the cake. And then there was the fact that her cherished brother Christopher was going to get married in the spring. ''Here was Christopher going to get married and leave her -- not that he would," said Anzalone, Danielle's grandmother. ''I think she just felt forsaken."
     Deryn Lanphere arrived by C-section on March 17, one week before he was due. He was tiny and good-natured and liked to sleep. During the surgery, Danielle had her fallopian tubes tied. She would have no more children.

Culminating factors
Thursday, April 7, was going to be special. It was the day of the final fitting for the latte brown satin bridesmaids dresses for Christopher and Susan's wedding. The plan was for Danielle and the five other bridesmaids to be fitted and then gather for dinner. But Aidan had a fever. By late that morning Danielle was cranky and worn down. ''Danielle was highly aggravated," said Belcastro, who talked to her on the phone at about 11 a.m. ''Aidan was just on her, on her, on her. She'd say, 'Aidan, I just need five minutes. Five minutes to go to the bathroom, please.' And then Deryn was crying." At about 3:30 pm, Danielle called Mary Mitchell, Susan's mother, and told her she could not come to the fitting because of Aidan's fever. ''She must have said 'I'm sorry,' three times," said Mitchell. ''I offered to take Deryn, but she said no."
      Sometime in the afternoon, Danielle talked to Lanphere on the phone. He says they discussed why their bank account was short a couple of hundred dollars. Danielle, he said, ''had paid some bills, and I was like, 'Whatever.' Everything was fine." But late in the afternoon he called his mother. ''He said, 'I don't know what the hell is going on, but money is missing again,' " recalled Elaine Lanphere. ''He said Danielle must have taken the money out again for her mother. He was very upset. He told me they were going to talk about it that night."
     Shortly before 6 p.m., Danielle stopped her car on the Tobin Bridge. As she stood rigidly at the railing, another driver jumped from her car and called to her. Danielle did not turn her head. Lanphere's cellphone rang at about 6:30 pm. ''It was a stranger. A foreign guy. And he shouted something like, 'You car, you car on bridge,' " said Lanphere. ''I almost hung up because I thought it was a joke. But then he said, 'White car.' And then it clicked. He said, 'Two kids. Two boys. Alone.' And then I was lost."



Marketers, Peers Drive Younger Girls to Drink
Barbara Meltz, Boston Globe- 8/15/2005

Girls are moving further and further away from sugar and spice and everything nice. Last year, researchers and teachers reported an increase in bullying behaviors among kindergarten and preschool girls. Recently, a survey released by the American Medical Association says teenage girls are more likely than boys to obtain alcohol illegally. That girls are laying claim to behaviors once the exclusive domain of boys is not entirely bad, but turning to violence and alcohol probably is not anyone's idea of progress. "This is a wake-up call," says AMA president Edward Hill, a family physician from Tupelo, Miss.
     The survey also shows that girls are more likely than boys to get alcohol from parents, including from parents of friends. Hill speculates that it's harder to turn down a request from a girl. "Parents see it as more innocuous," Hill says.
     Psychiatrist/psychologist Duncan Clark, director of the Adolescent Alcohol Research Center at the University of Pittsburgh, says the AMA findings are consistent with a trend that has largely gone unnoticed:. Girls and boys are becoming more similar in their alcohol use. He cites a 2004 nationwide survey of eighth- and ninth-graders showing girls were more likely than boys to binge, that is, drink at least five drinks, usually beer, within a two-hour period.
     The AMA commissioned the survey of 701 teens in the wake of research that shows the human brain doesn't stop growing until about age 21 or 22, and that alcohol consumption can alter or retard that growth, including memory and test-taking ability. 'Think SATs," says David Jernigan, research director for the Center on Alcohol Marketing and Youth at Georgetown University (camy.org).
     Damage to the brain is real for boys and girls, but a girl who drinks is at greater risk, and not just for the obvious reasons of tarnished reputation, sexual misconduct, unwanted pregnancy, or sexually transmitted disease. The way the female body processes alcohol makes girls more susceptible to alcohol poisoning, hepatitis B, and liver and heart disease, and also affects menstrual cycles and fertility, says Hill. "A reasonable goal ' for parents is to delay that first drink for as long as possible: 16 is better than 14, 18 is better than 16, and 21 is better still," says Jernigan.
     Many parents apparently doubt their influence. At least that's one explanation Clark offers for the finding, which surprises him, that parents are more likely to supply alcohol to girls. "Parents seem to think the only choice is between supervised drinking and unsupervised drinking. That's a fallacy, and it's dangerous," he says, because it leads girls to conclude there's, such a thing as "safe" drinking.
     The findings also raise a critical question: Why are girls today more interested in alcohol than they used to be? There's no research on this yet, but there is speculation: Girls start getting messages about drinking at very young ages. Colby College gender researcher Lyn Mikel Brown says girls grow up thinking drinking is normal and glamorous because messages about alcohol are all around them from a young age: toys like Bratz dolls and My Scene Barbie, which feature pool- and bar-side drinking scenes; reality shows where alcohol is prominent; alcohol product placements in video and films that young girls watch; and alcohol ads that appear on programming popular among preteens, such as "Seventh Heaven" and "Gilmore Girls."
     Girls are specific targets of marketing. Jernigan says that girls under 21, and especially 13 to 15, get a heavier exposure to alcohol marketing than girls of legal age and see 95 percent more alcohol advertising than the typical 35-year-old. Much of it is in the magazines girls read, especially Cosmopolitan, In Style, Vibe, Entertainment Weekly, and Vogue, he says, but radio ads are also huge. "It flies under parents' radar because we don't listen, watch, or read the same things. Surprise, surprise," says Jernigan. "Studies show that the more alcohol advertising teens are exposed to, the more likely they are to drink."
     Alcopops make girls feel safe: About 6 years old, alcopops are a new genre of spirits, much as wine coolers once were. Sweet, fizzy, and brightly colored, they mask the flavor of alcohol and come with names such as Skyy Blue from Skyy Vodka ("It comes in a, pretty blue bottle and ... citrus flavors which really takes away the aftertaste ... It has less of a bite" is the comment in one chatroom); Smirnoff Ice; and Bacardi Silver.
     Most parents don't even know about alcopopsi Hill says, although many girls prefer them because they think they are safer. "They aren't," says Jernigan. "They have 5 to 7 percent alcohol, same as most beer." Raspberry flavored Tllt is the newest, announced recently by Anheuser Busch.
     Koren Zailckas blames alcopops for the rise in underage girls' drinking, along with the advertising girls are exposed to. The 25-year-old author of "Smashed: The Story of a Drunken Girlhood" (Viking), she grew up in Bolton, took her first drink at 14 (Southern Comfort, or So-Co, as she calls it in the book) and nearly died before she took her last two years ago. "I took my first drink because my best friend offered it to me. I took it because I was looking for a way to bond with her," she says. She kept drinking because she was "bored and unhappy. Girls in middle school are so insecure about their appearance and looking for acceptance. You're trying on so many different roles at that age. Drinker/party girl is just one."
     Her advice to parents is not to wait to talk to daughters about alcohol. "Studies show a girl has, often had her first drink by eighth grade," Zallckas says. "If a daughter is old enough to go to a coed dance, she's old enough for a conversation about alcohol," even if that's sixth grade.
     Brown urges parents to be more aware and involved in girls' media. "It's not about turning off TV or forbidding magazines," she says. "It's about watching the shows and reading what she reads, having conversations about what makes you uncomfortable, and letting her put the pieces together." For instance:
Mom: "I notice that on this reality show, it's often a guy in a hot tub with a lot of girls in bikinis with drinks. What, do you think about that?"
Daughter: "Oh, mom..."
Mom: "In a toy store, I saw the same kind of images on the packaging for a Bratz doll. Do
you think there's a pattern?"
Daughter: "Mom, you're so wrong about this."
Mom: "Well, I'm noticing it all the time now. I just wondered if you were, too."
     Be careful not to put your daughter down, and not to impose your own morality, says Brown. Rather, "Open her brain too see things differently." Brown's book, "Packaging Girlhood, Rescuing our daughters from marketers' dreams" (St. Martins), is due out next spring.
     Jernigan and Clark promise that parents do make a difference. "It's a matter of persistence. This is not a conversation you have once or twice or even three times," whether you have a son or a daughter, says Hill. And while there are known to be greater risks for daughters and therefore greater worries for parents, Hill says there is at least one way in which parents of girls can take comfort. "I'll be criticized for saying this," he says, "but girls are easier to talk to."
     Facts to share with daughters:
• Because women have less of a stomach enzyme that breaks down alcohol, girls become intoxicated on less, alcohol than do boys.
• Teen girls who drink more than five times a month are almost six times more likely to attempt suicide than girls who never drink.
• Heavy-drinking girls are more likely than heavydrinking boys to be depressed.
Actions parents can take:
• Lobby the alcohol industry to back off advertising that targets' girls.
• Work within your community: if you're in a college town, back zoning regulations that prevent bars within a block of campus. Ensure bartenders are trained to check IDs carefully.
• Lobby the government to do more. The federal government spends $100 million a year on anti-tobacco education for teens, but only $850,000 on an underage drinking campaign.
• Be aware: States may have social hosting laws that hold parents responsible for underage drinking in their house.
• Be in touch with other parents.


A Whiff of 'Reefer Madness' in U.S. Drug Policy
Sally Satel, M.D., New York Times- 8/16/2005

Patients arrive broke, busted or abandoned at our methadone clinic in a raw section of Northeast Washington. They are opiate addicts, primarily dependent on heroin, though some take vast doses of street-bought painkillers like OxyContin. Drinking the pink methadone solution every day prevents withdrawal sickness. About half of our patients have also spent years on crack or alcohol. Not all have stopped, but at least they have cut back. We see almost no methamphetamine users, but that is a simple accident of geography -- the corrosive drug hasn't yet reached epidemic proportions in this part of the country. The personal ravages of hard-core addiction are enormous, and they translate into vast social costs -- crime, violence, incarceration, homelessness, unemployment, hepatitis C, H.I.V./AIDS.
      Such an immense burden makes me wonder about the wisdom of federal priorities. Why is marijuana, of all drugs, the main target of the White House Office of National Drug Control Policy? Answer: the gateway theory of addiction. Start with marijuana, the idea is, and progress to methamphetamine or heroin or cocaine.
     To me, the "gateway" assumption, which took root in the 1950's, has a nostalgic, "Reefer Madness" feel. But it is still driving federal policy. The drug czar's office made that clear last month in response to a call from the National Association of Counties "to put the same kind of emphasis on methamphetamine abuse as they have on marijuana." The association had just announced that its 500 members were reeling from methamphetamine-related crime, incarceration and child-neglect. The Office of National Drug Control Policy defended its prioritization. Addressing "early marijuana use is an effective way of heading off and preventing subsequent movement into other drug use," said a spokesman for the drug czar on National Public Radio.
     Is this true? Is the gateway argument a valid justification for marijuana policy? No reasonable person disputes that most users of cocaine and heroin have smoked marijuana earlier in life. Likewise, the more frequently people consume marijuana the more likely they are to try hard drugs. But what is the nature of the linkage? Is it actual cause and effect, as the drug czar's office implied, or a correlation based on a common factor that predisposes youth to drug use in general? And how frequently do we observe such a progression?
     One theory is that teenagers who smoke marijuana without incident are emboldened by the experience to try other more risky and exotic drugs. And perhaps buying marijuana brings them in contact with dealers of stronger drugs. Or possibly cocaine and heroin abusers would have developed their drug problems no matter what. As RAND researchers reported in a 2002 article, "Reassessing the Marijuana Gateway Effect," "Marijuana use precedes hard drug use simply because opportunities to use marijuana come earlier in life than opportunities to use hard drugs."
     A relatively newer theory suggests that marijuana sets up the user's brain to be more receptive to harder drugs. A much-publicized 1997 study from the Scripps Research Institute reported that cannabis activates the same reward circuitry in the brain as cocaine, heroin, tobacco and alcohol. But this has dubious relevance to future addiction. After all, almost any normal pleasurable activity, like eating or sex, also stimulates those pathways.
     In any event, a brain activation effect couldn't be too powerful, as most casual marijuana smokers do not graduate to the abuse of hard drugs. Only about 3 percent of monthly cannabis users go on to try a hard drug in the same year, according to data from the National Survey on Drug Use and Health. And roughly one-fifth of those who try cocaine eventually become addicted; perhaps one-third of heroin experimenters do.
     Social scientists have found that adolescents who progress to hard drugs are already quite troubled to begin with. Truancy, failing in school, fighting, stealing and drinking often come before heroin or cocaine involvement. Marijuana use before age 15 is also a red flag indicating psychological turmoil and social instability. By contrast, older teenagers who experiment with marijuana generally function as well as nonusers with respect to school and mental well-being.
     These observations are consistent with my own clinical experience. As staff psychiatrist for the clinic, I have taken over 500 detailed histories of adults with opiate addictions. Marijuana was the least of their problems when they were young. More often, they were staggering under the weight of a chaotic home life and had dropped out school, committed petty crimes and battled depression. These problems, not marijuana, led them to hard drugs.
     Efforts to prevent new generations of addicts are noble, but they should be rational too. It's hard to say whether any one policy a drug czar could devise would have derailed the early trajectories of my patients' lives. But it is clear that such a large investment in the gateway theory has been of little help
     Sally Satel is a psychiatrist and resident scholar at the American Enterprise Institute and a co-author of "One Nation Under Therapy."



A Business Built on the Troubles of Teenagers
Louise Story, New York Times- 8/17/2005

Mary Ann Davies has spent more than $100,000 in the last year to send her 16-year-old daughter to one private counseling and educational program after another. She has just signed up to go further into debt, committing herself to spend another $100,000 over the next two years for a boarding school in New York that she hopes will help her daughter overcome a drug problem. "We're saving this life," said Ms. Davies, who works in advertising in Richmond, Va. "You can't put a price on that."
      More and more parents of troubled teenagers are following the same course and sending their children to special programs -- no matter the cost. At the same time, the number of programs available has soared. They differ from the tough boot camps and the long-term psychiatric stays that were the main options a couple of decades ago. The new "feel good" programs combine therapy and education, often in an outdoor setting, at an average cost of $5,000 a month.
     Those numbers have drawn the attention of some big money investors, who see a growing need for the kind of services these programs provide. Although there have been allegations of abuse within the industry, and those have garnered most of the media attention on the schools, officials at several companies said almost all the incidents had been at a handful of less reputable programs. At the same time, the influx of money from investors seeking a high return on equity is worrying some traditionalists in the field, who are concerned that the bottom line may take precedence over students' needs. So far, they said, the schools are able to charge enough to make solid profits while keeping most customers satisfied.
     "If you've got a child with problems, this is your most precious asset, and I don't think any parent would ever cut corners if they thought there was a way to help their child through the problem they're experiencing," said Joseph Kenary, the president of the corporate finance business at CapitalSource Finance, a lender to the Aspen Education Group, based in Cerritos, Calif., and one of the more prominent providers of programs for troubled teenagers. If the programs are "run well, if they're full, they generate a pretty attractive return on a cash-on-cash basis."
     No one tracks the industry's enrollment, revenues or claims of success or failure, in part because the programs fall through the regulatory cracks and in part because the industry is still so fragmented. But financial analysts and educational consultants estimated that the number of teenagers attending such programs had quadrupled since 1995, to as many as 100,000 this year. They estimate that annual revenues now total at least $1 billion.
     Venture capital firms like Warburg Pincus and the Sprout Group, a division of Credit Suisse First Boston, have found it a promising business opportunity. Two of the larger private companies, Aspen and Three Springs, based in Huntsville, Ala., have been buying up smaller programs and founding new ones. Universial Health Services, a public company that primarily owns hundreds of hospitals, has expanded into teenage behavioral programs.
     John L. Santa, a co-owner of Montana Academy, a school based in Marion, Mont., that he co-founded in 1996, and president of the National Association of Therapeutic Schools and Programs, said he had been approached several times by companies looking to buy the school. But he decided not to sell, even though he said he believed that most large companies had been doing a good job so far. "You're caring for individual kids," Dr. Santa said. "You're not making widgets. There's a fear as you move into a more corporate structure, you will lose some of what we do."
     In contrast with companies focusing on general education -- like Bright Horizions Family Solutions, the day care provider, and Edison Schools, the charter school company -- the behavioral programs are dealing with a population that presents a higher risk. "These kids are difficult," said Andrew E. Kaplan, a partner at Quad Ventures, a private equity firm that has been looking to invest in the field for about four years. "If something bad happens at one, it may be something that's completely out of your control. You may have done everything right, and still something happens."
     Officials at the programs acknowledge that their type of therapy does not work for all teenagers. Even parents who were happy with the programs said they were not sure whether their teenager had simply matured or had changed because of the experience. The teenagers who attend these programs have often been diagnosed with attention deficit disorder or other behavioral problems and are taking medications. Some have used drugs or have been sexually abused. Many have been in trouble at school or in minor trouble with the law. Others have run away from home or stolen from their parents.
     The National Association of Therapeutic Schools and Programs lists 140 schools and programs, about 100 more than it listed in 1999. But educational consultants, who advise parents on these programs, say the total number of programs available is now closer to 300. Since 1990, Lon Woodbury, an educational consultant who has published a newsletter on the industry for 15 years, said he had noticed an increase of 20 to 30 percent in the number of help programs for teenagers. In June, he wrote a column saying that there was still "plenty of room" for new programs. "All indications are that the market is still growing," he wrote. "The consensus is that increasing numbers of children are in trouble and are not growing up very well."
     It is not clear, however, if more teenagers have problems than a generation ago or if more parents are sending their teenagers away for help. Educational consultants said there seemed to be less of a stigma about seeking therapy today. Perhaps most important, more parents have the disposable income or the equity in their homes to pay the typical price of $400 a day for an outdoor program. While most parents have to pay the bills themselves, some also receive help from their school district or insurance company.
     The field began to commercialize in the mid-1990's. In 1998, the Sprout Group and Frazier Healthcare Ventures of Seattle bought the majority of Aspen, a company with a handful of programs at that time but with major plans to expand. In 2002, Warburg Pincus invested $15 million in Aspen; around the same time, the company received at least $48 million in loans from CapitalSource and Caltius Mezzanine, two companies that specialize in lending to small and midsize companies.
     Investors are particularly drawn to the field because it is almost entirely supported by individual payments rather than being dependent on public financing. "I've been in the private equity business for 15 years, and I don't like to invest in companies where, with one strike of a pen, you can wipe out your business," said Nader J. Naini, a general partner with Frazier Healthcare and also the chairman of Aspen's board. Since Frazier invested in Aspen, Mr. Naini said he had been approached several times by other groups wanting to buy the company. Frazier is in no hurry to sell its share, though, he said, because he expects continued growth.
     Aspen and similar companies may go public at some point, company officials said. If Aspen went public, it would have to open its books to investors, allowing them to see its profit margins and operating costs. The company has 31 programs in 11 states, up from 6 programs in 1998. Aspen has recently expanded into the obesity market, offering schools and camps for overweight teenagers. Industry analysts estimate that the companies typically generate profit margins of 10 to 20 percent.
     Kirsten Edwards, an equity research analyst at ThinkEquity Partners, a research and investment banking firm in San Francisco, said larger companies were more efficient because they could spread the cost of their curriculums, marketing and overhead as they expand. Universal Health Services, the hospital management company, acquired 12 properties from Charter Behavioral Health Systems for $105 million in 2000. That acquisition included the Provo Canyon School in Utah, which has been around since the 1970's as a help center for teens. The company is set to take over several therapeutic schools that were run by CEDU Education, the earliest large company in therapeutic teenage help and a branch of Brown Schools, now bankrupt. Brown, which was based in North Palm Beach, Fla., went bankrupt in March largely because of lingering legal costs from lawsuits filed by several former students, said a spokesman for McCown De Leeuw, the private equity firm that owned Brown. Universal Health's bid of $13.35 million for the properties has been accepted by the bankruptcy judge, and the sale is expected to close at the end of the month, said George L. Miller, a partner at Miller Coffey Tate in Philadelphia and the bankruptcy trustee for Brown.
     Another private company, Three Springs, has seized on the market growth in the last five years, adding six new programs. Three Springs now has 25 programs, and may continue to expand. "What we are trying to do is build a continuum," said Sharon Laney, the company's chief operating officer. "If the kid does not fit this model, we have another."
     Many teenager help programs were founded by counselors and therapists wanting to start their own businesses or by people who have had troubled teenagers in their lives. Some parents of graduates of these programs -- among them Joel J. Horowitz, chairman of the board and the former chief executive at Tommy Hilfinger -- have been so impressed by the schools that they have started foundations to help finance the programs for those who have trouble affording them. A new reality television show on ABC this summer, "Brat Camp," which shows a wilderness program in action, could spur even greater interest by giving more parents insights into the programs.
     Ms. Davies, the Richmond mother, said she wished she had found her daughter's new school in New York sooner. The other programs her daughter attended, she said, were not the right matches -- and they cost a lot of money. For now, Ms. Davies said, she is focusing on her hopes that her daughter will have a breakthrough and realize that she needs to change. But she said she was also wondering how she and her husband would meet all the bills. Already, they have dipped into their home equity. "We're going have to reconcile this at some point, and it's going to be tough," she said. "I don't think we have a choice."