Noteworthy News Articles, September 21-30, 2005

Smokers who hope to avoid serious illness by limiting their intake to a few cigarettes a day may be making a big mistake. Writing in the current issue of Tobacco Control, researchers report that even people who smoke as few as one to four cigarettes a day significantly increase their risk of death from lung cancer or heart disease.
      The study, led by Dr. Kjell Bjartveit of the National Health Screening Service in Oslo, found that the risk of dying from heart disease for light smokers was three times higher than it was for nonsmokers. Women who were light smokers were found to have a five times higher risk of dying from lung cancer. Men and women who were light smokers had a one-and-a-half-times higher risk of dying prematurely from all causes than nonsmokers did. "Health educators," the researchers wrote, "should emphasize more strongly that light smokers are also endangering their health."
     The findings were based on a long-term study of more than 40,000 men and women in Oslo and in three Norwegian counties. Participants were given health screenings in the early 1970's, when they were 35 to 49 years old. The study then tracked their health until 2002, with many of the participants getting a second screening 10 years after the first one.
     A complication, the researchers said, was that the amount the study participants smoked often changed over the years. About 20 to 24 percent of those questioned in the second screening reported smoking the same amount. But 25 percent of the men and 40 percent of the women said they smoked more. Many others said they had quit.

Bosses dismiss employees. Spouses divorce each other. Patients leave their doctors. But can doctors ever fire their patients? This is not a topic most doctors like to talk about openly. Sure, many physicians I know, myself included, have occasionally wanted to fire a difficult or abusive patient, but no one really knows how often it happens.
      Of course, people are generally not on their best behavior when they are sick. Illness can make people demanding, anxious and needy -- something most doctors understand and abide as a part of everyday medical care. I once had a patient with a generalized anxiety disorder who failed to respond to antidepressants and cognitive therapy. The patient had accidentally discovered that opiates relieved her anxiety after she received them for a minor surgical procedure. From then on, she insisted on being treated with opiates. I didn't doubt the anti-anxiety effects of opiates, but the drugs are not a safe or reasonable treatment for anxiety. And I was not about to compound an anxiety disorder with an opiate addiction in this patient who had a history of drug and alcohol abuse. Because I would not give her a treatment that I deemed harmful, I terminated our relationship. I referred her to another colleague but later learned that she had also rejected his treatment recommendation.
     While the American Psychiatric Association does not have specific guidelines for ending a relationship with a patient, the American Medical Association's ethical guidelines state that a doctor is obligated to provide for continuity of medical care. Under the guidelines, a doctor may withdraw from a case only if the doctor notifies a patient, the patient's relatives or responsible friends with enough advance notice for the patient to secure another physician.
     A physician, under the guidelines, can decline to treat a patient who requests a treatment that is known to be scientifically invalid or that is incompatible with the physician's personal, religious or moral beliefs. But noncompliance with treatment is not a reason to fire a patient. "Patients often didn't do what I told them," said Dr. Richard C. Hughes, a retired internist in Wisconsin. "But I never thought it made much sense to refer them to a colleague, because they would probably do exactly the same thing with a different doctor." He added, "At least I knew them and could try to work things out with them."
     In his 32 years of practice, Dr. Hughes said he fired only one patient. "This was a patient who chronically screamed at my secretary, who was very seasoned," Dr. Hughes said. "He once even brought her to tears. I could have handled him, but he really upset my staff and other patients." He continued: "I finally told him that if he continued his abusive behavior, he'd have to find another doctor. The next time he came in, he did the same thing, so we said, 'We'll take care of you until you have another physician,' and I referred him to several other colleagues."
     Sometimes a doctor dislikes a patient. If the physician is a psychiatrist, then a patient's unpleasant or obnoxious behavior is likely to be a focus of treatment. In those cases, psychiatrists have to understand their own emotional reactions and use that knowledge to help their patients. "Any physician who is thinking of firing a patient should first speak to a colleague," said Dr. Robert Michels, a professor and former chairman of psychiatry at Weill Medical College of Cornell University. "This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action." Countertransference refers to a doctor's emotional reactions to a patient that are based on his own unconscious needs and conflicts.
     Years back, we had a patient in the clinic who verbally taunted several female residents in an overtly sexual manner. He was repeatedly confronted but showed no interest in understanding or changing his behavior, which was clearly within his control. I finally discharged him from our clinic. I like to think that experience possibly helped him; last I heard, he was still in the treatment I referred him to.

Once the water recedes, mud is hauled away and families are reunited with those who survived Hurricanes Katrina and Rita, most of the displaced residents will be focused on finding new places to live and work. But it will be equally important to pay attention to the effects of these vast disruptions on the mental health of children whose lives were torn apart.
In an almost prophetic coincidence, in the September issue of the journal Pediatrics, experts from the American Academy of Pediatrics published a 10-page report to help pediatricians deal with the psychosocial effects of traumatic events -- natural disasters and acts of terrorism -- on children of all ages. The report, by the academy's Committee on Psychosocial Aspects of Child and Family Health, and its Task Force on Terrorism, was compiled in response to the terrorist attacks on Sept. 11, 2001. But it could not have come out at a more appropriate time.
Dr. Joseph F. Hagan Jr., a pediatrician in Burlington, Vt., headed both the committee and the task force. In his view, the job ahead is similar to that faced by those trying to address the needs of children after Sept. 11, even though the catastrophes resulted from an act of nature, not a deliberate act of terrorism, and there are many child survivors to care for.

'Profound Sadness'
"The children will have post-traumatic stress disorder, anxiety and depression, and some will have bereavement issues," Dr. Hagan said in an interview. "They've lost their homes, neighbors, pets, friends and some have lost parents and grandparents -- all factors that can lead to profound sadness."
      At the same time, parents whose lives were affected may themselves experience emotional problems that can make it difficult for them to recognize and cope with the mental health needs of their children. "If a parent has a sense of hopelessness, that parent's ability to attend to a child's needs is compromised," Dr. Hagan noted. And parents who will have to find a new life for themselves and their families "are not as likely to be available to their children and sensitive to their needs," he said. The report states: "Any effect of trauma on key or trusted adults can result in magnified psychological effect on the children they care for. An adult's emotional problems can add to a child's fear. Distressed adults may fail to recognize a child's distress."
     Under these circumstances, he said, "We wouldn't want parents to have to figure it out. It's the role of communities, family doctors, pediatricians and schools to anticipate the mental health needs of children," he explained. And they must prepare to deal with these needs, he said. "We lack a cohesive health care system in this country, particularly with regard to mental health," Dr. Hagan said. "We have inadequate mental health services for children, and it's much harder for children to access these services than it is for adults."
     Dr. Hagan said the first task was to get shelter for families and the second was to get parents jobs so they could have some sense of autonomy and control over their lives. "This is important to a child's sense of safety," he said. "If parents are frantic because of their own losses and needs, it's pretty hard for children to be protected." Equally important is to get children in school as quickly as possible. "School is what's supposed to happen in September," Dr. Hagan noted, and returning to school restores a sense of normalcy for children.
     Even in the best of circumstances, children who have been the victims of devastating natural disasters like the back-to-back hurricanes are likely to experience emotional distress that can affect their behavior and mood for months to come. "Parents and caregivers can expect children to respond to disaster in distinct stages," the report states. "The first stage, immediately after the disaster, includes reactions of fright, disbelief, denial, grief, and feelings of relief if loved ones have not been harmed." The second stage comes a few days to several weeks after the disaster. It might include regression to an earlier stage of development, anxiety, fear, sadness and depression, hostility and aggression toward others, apathy, withdrawal, sleep disturbances, psychosomatic symptoms like stomachaches, a pessimistic view of the future and play acting that recreates aspects of the event.
     Children with marked distress are in urgent need of counseling, the report notes. Professional help is also needed for children with stress reactions that persist for longer than a month, or who are at risk for developing a persistent post-traumatic reaction or "violent or delinquent behaviors later in life," the report notes. Even infants and toddlers can be adversely affected by disasters. For infants, the reaction can be an increase in crying and irritability, separation anxiety and an exaggerated startle response. For toddlers and preschoolers, signs of trouble may include sleep terrors and nightmares, helplessness, clinging behavior and temper tantrums.
     School-age children may re-enact the trauma in play, behave aggressively, become withdrawn or apathetic, develop psychosomatic symptoms or behavior problems, and experience sleep disturbances and regressive behaviors like separation anxiety. Traumatized children may become hypervigilant, always on the alert for possible danger, Dr. Hagan said. They may be afraid to go to go to sleep or to school lest they get washed away while their mothers are somewhere else. Even young children distant from the trauma can be adversely affected, thinking a hurricane will next hit where they live, Dr. Hagan said. "They need to be reassured that Katrina was far, far away."

Exceptionally Vulnerable
Adolescents, who are already going through a difficult period of development, are particularly vulnerable to the effects of a disaster, the report states. They may become withdrawn, apathetic and depressed. They may also engage in risk-taking behaviors like drug abuse and sexual behaviors as a means of coping with trauma-induced distress. On the other hand, some adolescents may try to mask or withhold symptoms of distress and even try to protect other family members who are upset. As a result, parents may underestimate the effects of the disaster on adolescents and fail to get them the help they need.
The report also points out that boys and girls tend to react differently to a disaster. Girls commonly develop symptoms like anxiety and mood disturbances, while boys are more likely to show behavioral symptoms and take longer to recover than girls.
Most important, the report concludes, is to "allow our children to have hope." "Even children living in unsafe communities or those affected by prejudice, racism, or violence depend on trusted adults to feel safe or protected so that they might anticipate a less stress-laden future," it says. Achieving this goal will depend on the actions taken in the coming weeks by federal, state and community governments, schools and health care professionals, not just by parents who themselves have been traumatized.

A drug commonly prescribed for attention deficit disorder as an alternative to stimulants may increase suicidal thinking in children and adolescents, federal drug regulators warned yesterday.

The warning stemmed from a finding of a large-scale government effort to examine whether psychiatric drugs had previously unrecognized side effects.

The drug, Strattera from Eli Lilly, will carry a prominent "black box" warning - the Food and Drug Administration's most serious alert - on its label, said F.D.A. officials and Lilly representatives.

The drug agency instructed Lilly to add the warning based on the company's findings from a search of its data from clinical trials of the drug. The search, which analyzed reports of suicidal thinking among patients taking the drug, was conducted at the agency's request, said Dr. Thomas Laughren, who directs the psychiatric products division at the drug agency.

Dr. Laughren said the evidence of suicide risk for Strattera was not strong enough for doctors to change the way they prescribe the drug. But the finding is likely to fan the debate over whether drugs for attention deficit disorder are overprescribed for children, and whether the risks are fully understood.

Doctors who have reviewed the Lilly data said that the risk for suicidal thinking appeared remote, but that it was important to inform parents whose children are taking the drug or might take it.

"It's important for both families and physicians to make a judgment based on the risk-benefit ratio, which is still quite favorable," said Dr. Laurence Greenhill, a professor of psychiatry at the Columbia University School of Medicine, who has worked as a consultant to Lilly on Strattera.

The drug helps about one in four people who take it; in the Lilly data, about one in 270 reported suicidal thinking, he said.

Some 3.4 million children and adults have taken Strattera, the only nonstimulant drug approved for the treatment of attention deficit hyperactivity disorder, or A.D.H.D., a condition characterized by distractibility and hyperactivity. The disorder affects 3 percent to 5 percent of children, mostly boys, according to the American Psychiatric Association.

"We believe Strattera is a safe and effective treatment option, and attention deficit disorder has its own risks for people who stop taking the medication based on something they hear," said Dr. John Hayes, vice president for Lilly Research Laboratories. "We are advising people who have concerns to consult their physician."

In its analysis, Lilly researchers reviewed data from 12 trials involving 2,208 children and adolescents. They found that of 1,357 taking the drug, 5 - or 0.4 percent - had suicidal thoughts serious enough to report to their doctor. One child attempted suicide but survived. None of the 851 minors taking dummy pills in the trials reported suicidal thinking or attempted suicide, the analysis found.

Dr. William E. Pelham, director of the Center for Children and Families at the State University of New York at Buffalo, said, "This and other label changes for A.D.H.D. drugs only reinforce the notion that parents and clinicians should be conservative in treating the disorder and use drugs after trying other things, like psychosocial techniques, not before."

But other psychiatrists say that suicidal thinking is so common, especially among adolescents, that it is not clear what, if anything, a 0.4 percent difference means.

The F.D.A. has also asked the makers of other drugs used to treat attention deficit disorder, like Ritalin and Adderall, to scrutinize their data for adverse reactions.

But experts said there was no reason to think that these drugs, which are stimulants, carry the same risks as Strattera, which acts more like an antidepressant. Psychiatrists said they typically prescribed Strattera to patients who refused to take stimulants, who reacted badly to them, or who had anxiety along with attention deficit problems.

The drug agency began asking the makers of a wide range of psychiatric drugs to review their data for adverse reactions last year, after an international debate over the risk of suicidal thinking and behavior in children and adolescents from antidepressants.

The agency determined that about 4 percent of minors taking most antidepressants reported suicidal thoughts, compared with 2 percent of those taking dummy pills, despite assurances from some drug makers and researchers that there was no increased risk. Last year, the agency required the products carry their own black box warnings about suicide risk.

Abuse of Electroshock Found in Turkish Mental Hospitals
Craig S. Smith, New York Times- 9/29/2005

Turkey's psychiatric hospitals are riddled with horrific abuses, including the use of raw electroshock as a form of punishment, according to a human rights report issued in Istanbul on Wednesday, just days before Turkey begins formal talks to join the European Union.

The report, by Mental Disability Rights International, a Washington-based group, came after several visits in the past year by the group's investigators to psychiatric hospitals and other facilities for people with developmental or mental disabilities.

While the report details many types of abuses, it said the most disturbing involved the use of electroconvulsive therapy without anesthesia to treat a wide range of illnesses in adults and children. The World Health Organization has called for a ban on "unmodified" or "direct" use of the treatment and states that children should never be subjected to it in any form.

The therapy, in which an electrical current is passed through the brain, was developed in the 1930's and continues to be used in mainstream psychiatry to treat a limited number of ailments. But it is normally administered with anesthesia and muscle relaxants.

Without them it can be painful, terrifying and dangerous. Patients can break jaws or crack vertebrae during the induced seizures. The report quotes a 28-year-old patient at Bakirkoy Psychiatric Hospital in Istanbul as saying, "I felt like dying."

The Health Ministry, which is responsible for psychiatric hospitals, said it had not yet read the report and declined to comment, other than to say that the director of the electroconvulsive therapy center at Bakirkoy denied administering unmodified electroshocks there.

But on one day in April when the rights group's staff visited the center, 24 people received such treatments, the report said. Technicians at the center told the group that only patients who had broken bones, presumably from previous treatments, were given anesthesia.

The human rights group estimated that unmodified shock treatment was used on nearly a third of patients undergoing psychiatric crises at the government-run hospitals, including children as young as 9. The treatment is also administered for many illnesses, like postpartum depression, that are not generally considered by the international psychiatric community to warrant electroshock.

The investigators also found that the treatment was used as punishment. The report describes patients being dragged to electroshock therapy in straitjackets and forcibly held down during the procedure.

"If we use anesthesia the E.C.T. won't be as effective, because they won't feel punished," the report quotes the director of the electroconvulsive therapy center as saying.

Referring to that statement, Eric Rosenthal, the founder of the rights group, said in a telephone interview from Istanbul, "That was one of most horrifying statements I've ever heard in 12 years of doing this work."

Turkey has been criticized for using unmodified electroshock before. In 1997 the European Committee for the Prevention of Torture called on Turkey to stop the practice, and the Health Ministry promised to do so.

Now, the new report is likely to complicate Turkey's talks with the European Union, because of the organization's strict human rights requirements for membership.

"There's no question that what's described in the report counts as torture under the European convention and shouldn't exist in Turkey or anywhere in Europe," said Richard Howitt, a British member of the European Parliament who sits on the joint European Union-Turkish parliamentary committee.

He said he would bring up the report as part of the membership negotiations, because to join, a nation must be judged to follow democratic principles, respect human rights and be on its way to meeting certain economic and institutional standards.

The report, which includes testimony from former patients and videos taken inside some institutions, reported other abuses as well.

Much of the documented abuse took place in orphanages and rehabilitation centers for children with developmental or intellectual disabilities. Investigators saw emaciated and neglected children, many of whom had behavioral problems that were likely to have been the result of mistreatment rather than pre-existing illness, Mr. Rosenthal said.

"We saw children who were essentially abandoned, starving, tied down to their beds," he said, adding that investigators had not been allowed to see the worst wards.

Photographs and videos taken at the Saray Rehabilitation Center, the largest of Turkey's government-run rehabilitation centers, show skeletal children, some with plastic water bottles taped over their hands to prevent them from biting their fingers. Other children with only minor disabilities are mixed in with the rest.

Although the center keeps no mortality records, a footnote in the report notes that the large number of admissions without a corresponding number of discharges suggests that many children die at the center.

"We believe there's a very high death rate in these facilities," Mr. Rosenthal said.

Officials at Turkey's Directorate for Social Services and Child Protection could not be reached for comment.

The report said that there were no enforceable laws in Turkey to protect mentally ill people from arbitrary detention or forced treatment and that there were virtually no community services that might keep them out of institutions. As a result, according to the report, thousands are institutionalized for life.

Mr. Rosenthal founded Mental Disability Rights International in 1993. It now has a staff of nine people, including one in Turkey.

'Mysterious Skin'
Kevin Thomas, Los Angeles Times- 5/27/2005

A poetic fable that takes a subtle approach to an explosive subject, Gregg Araki's "Mysterious Skin" takes the viewer to bucolic Hutchinson, Kan., where one fateful sunny day two 8-year-olds are playing in a Little League game. Dark-haired, self-confident Neil (Chase Ellison), the star player, has become aware that he is different and that the immediate object of his attraction is the team's coach (Bill Sage). Sometime after that the coach takes Neil home and cunningly takes advantage of the situation. Separately, blond, nerdy Brian (George Webster), who lives in the nearby community of Little Run, realizes that "five hours have disappeared from my life. Five hours, gone without a trace."

Years pass and Brian, plagued by nightmares and terrified of the dark, comes to believe that aliens must have abducted him. An introverted, studious teenager, Brian (now played by Brady Corbet) is tormented by a comically obtuse and seriously possessive mother (Lisa Long), who has long since driven away her husband (Chris Mulkey). Neil (now played by Joseph Gordon-Levitt) has grown into a darkly handsome youth, raised lovingly by a single mom (Elisabeth Shue), who casually moves from one boyfriend to another.

Eventually, through a cable program, Brian hooks up with a bright, intense, weird farm girl (Mary Lynn Rajskub), who lives about 30 miles away and claims to have been abducted by aliens many times. While her theories about aliens may be dubious, she does help prod his memory to discover that for some reason he remembers a picture of the Little Leaguers and Neil in particular, without recalling his name. Some amateur sleuthing is in order.

Meanwhile, Neil has discovered he can make a lot of pocket money hustling in a Hutchinson park. As Brian comes closer to tracking him down, Neil in turn follows his lifelong soul mate Wendy (Michelle Trachtenberg) to New York. At this point these 18-year-olds — Neil so foolishly sure of himself, Brian so desperately questing, both so crippled in their ability to interact with others — have embarked upon courses of self-discovery that inevitably will intersect.

The most mature work by the idiosyncratic and gifted Araki, "Mysterious Skin," based on the book by Scott Heim, highlights the director's talent for inspiring the most demanding of portrayals from actors and for richly evoking the world his characters inhabit. The film has a mesmerizing floating quality, heightened by Harold Budd and Robin Guthrie's deceptively serene score, and it has considerable offbeat, deadpan humor to offset its dark undertow.

All these elements ultimately coalesce to create an indirect but stunningly effective approach toward revealing how pedophilia can devastate and scar its victims. "Mysterious Skin" is candid without being graphic but leaves little to the imagination, and its language at times is blunt. But it's hard to imagine a more serious or persuasive indictment of the horrors inflicted on children by sexual abuse than "Mysterious Skin."

Times guidelines: Language, sexuality, disturbing images, adult themes; absolutely not for children
A Tartan Films and TLA Releasing presentation Writer-director-editor Gregg Araki. Based on the book by Scott Heim. Producers Mary Jane Skalski, Jeffrey Levy-Hinte, Gregg Araki. Cinematographer Steve Gainer. Music Harold Budd, Robin Guthrie. Costumes Alix Hester. Production designer Devorah Herbert. Running time: 1 hour, 39 minutes. In selected theaters.