Noteworthy News Articles on Mental Health Topics, December 13-20, 2006



FDA May Expand Antidepressant Warning
Associated Press, 12/13/2006

WASHINGTON -- Antidepressants increase the risk of suicidal behavior for people up to age 24, the government said Wednesday. It plans new warning labels, and says users of all ages should be closely monitored. The label change proposed Wednesday would expand a warning now on the antidepressants that applies only to children and adolescents.
      The Food and Drug Administration presented its plan to update the drug labels at a meeting of outside advisers on the issue. They endorsed the plan. The FDA also stressed that patients of all ages should continue to be carefully monitored for signs of suicidal tendencies when they are beginning treatment on the drugs.
     Public reaction was split, with some saying the changes were overdue and others arguing they could keep drugs from those who need them. In emotional testimony illustrated at times by slides of family photos, relatives of suicide victims pleaded for the new warnings. Suzanne Gonzalez, shouting and in tears, goaded the panel to action, telling the experts that her 40-year-old husband who had been taking Paxil shot himself. ''I wake up every morning thinking, 'Oh my God, he's dead. He is freaking dead.' Do you wake up and think, 'How many people are going to die today because I am doing nothing?''' Gonzalez asked.
     Still, mental health experts worry that additional warnings could curtail use of the drugs and ultimately do more harm than good. Dr. John Mann, a Columbia University psychiatrist, suggested simply replacing the proposed expanded warnings with the recommendation that doctors more closely monitor their patients. ''We can do more good by providing more treatment for depressed children and adults,'' Mann said.
     The FDA proposed the changes after completing a review that found use of the drugs may increase the risk of suicidal thoughts and behavior among young adults 18 to 24, as well as among younger patients. Psychiatrists testified Wednesday that the 2004 addition of a warning for children led to a falloff in antidepressant prescriptions being written for patients under 18 -- and an increase in suicides in that age group. Still, overall use of antidepressants continues to grow, with nearly 190 million prescriptions dispensed in the United States last year, according to IMS Health, a health care information company. That suggests doctors have placed more weight on the long-term benefits of the drugs than on any short-term risks, said Dr. Thomas Laughren, director of the FDA's division of psychiatry products.
     Expanding the ''black box'' or other warnings on the drugs could dissuade patients from seeking or starting treatment, mental health experts said. They warned that people with untreated depression -- about half of those who suffer from the disease -- face an estimated 15 percent greater likelihood of death by suicide. Dr. Joseph Glenmullen, a Harvard Medical School clinical instructor in psychiatry and author of ''Prozac Backlash,'' said expanding the warnings wouldn't scare off patients, but instead would allow them to make informed choices.
     The FDA recently completed a review of 372 studies involving about 100,000 patients and 11 antidepressants, including Lexapro, Zoloft, Prozac and Paxil. When the results were analyzed by age, it became clear there was an elevated though small and short-term risk for suicidal thoughts and behavior among adults 18 to 24, the FDA said in documents released ahead of Wednesday's meeting of its psychopharmacologic drugs advisory committee. The FDA's analysis of the multiple studies suggests an age-related shift in the risk of suicidal thoughts and behavior associated with treatment with the drugs. For instance, antidepressants seem to protect against suicidal thoughts and behavior in adults 30 and older, with the effect most pronounced in patients over 65. The FDA said the increased risk could mean as many as 14 additional cases of suicidal thoughts or behavior in every 1,000 children treated with antidepressants. For adults 18 to 24, there could be four additional such cases per 1,000.
     In May, GlaxoSmithKline and the FDA warned Paxil may raise the risk of suicidal behavior in young adults and added that to the drug's label. ''Anytime suicide is involved it is a tragic outcome. It is one of the things that keeps us motivated to search for better treatments because depression can be a fatal illness,'' GlaxoSmithKline spokeswoman Mary Anne Rhyne said.
     On the Net:
FDA on the use of antidepressants in children, adolescents and adults: http://www.fda.gov/cder/drug/antidepressants/default.htm



Sleep a Problem in Alcohol Recovery
Ann Arbor News, 12/13/2006

New research by a team from the University of Michigan's Department of Psychiatry provides further evidence that insomnia and other sleep problems can impede recovery from an alcohol problem. In addition the researchers found that people's perception of how bad their sleep problems are may be as important as the actual sleep problems themselves.
     The results show how important it is for alcohol-recovery patients, and those who are helping
them through their recovery, to discuss sleep disturbances and. seek help. Often, sleep isn't discussed in alcohol-recovery programs, the researchers say.
     The team has launched a new study that aims to help those who have just entered treatment for alcohol problems. Instead of using sleep medications, which can carry their own risk of addiction, the treatment is based on a series of "talk, therapy" sessions with a trained sleep therapist who can help patients change behaviors and patterns of thinking that contribute to sleep problems.

Panel Wants Broader Antidepressant Labeling
Benedict Carey, New York Times- 12/14/2006

SILVER SPRING, Md., — Strong warning labels about the suicide risk associated with antidepressants, which now include children and adolescents, should be extended to adults under 25, a federal advisory panel concluded Wednesday. The panel, which voted 6 to 2 to recommend the warnings after a daylong hearing, also advised the Food and Drug Administration to require including information in the drugs’ labels highlighting the risks of untreated depression.
      Since 2004, antidepressants have carried black-box warnings — the strongest the F.D.A. can require — about the risk of suicidal thinking and behavior for children and adolescents. The warnings appear in bold type set off by black borders, usually at the top of the prescribing information provided by drug makers to doctors and patients. “I really feel we have an obligation to warn the public when we have new information, and we do,” said Jean Bronstein, a consumer representative and panel member from Sunnyvale, Calif., referring to a recent F.D.A. analysis that found a link between suicidal behavior and antidepressants in young adults, but not in older people.
     The recommendation followed hours of emotional public testimony on both sides of the issue, and comes amid a long-running debate about the safety of the drugs, which include medications like Prozac, from Eli Lilly, Paxil, from GlaxoSmithKline, and Effexor, from Wyeth. Some psychiatrists said expanded warnings could lead to more suicides. Dr. Carolyn B. Robinowitz, president-elect of the American Psychiatric Association, said the labels might cause a “black-box panic.” “We’re talking about a devastating, chronic and recurrent disorder, and a black-box warning may serve as another barrier to care that people need,” Dr. Robinowitz said. But other psychiatrists said the labeling might make doctors be more cautious about how they prescribe the drugs, reserving them for patients who are seriously depressed.
     The panel also heard from many patients and family members who told stories of devastating loss. One woman said her niece set herself on fire and died just after having stopped the drug Effexor. Another woman, shaking, her daughter at her side, described how her 44-year-old husband had shot himself while he was on Paxil, and said, “I hold you responsible for this and always will,” pointing at the panel members. Other patients, however, said they had done well on the drugs.
     The panel based its decision in part on a recently completed analysis by F.D.A scientists of data from studies involving about 100,000 patients. Men and women under 25 who took the drugs were twice as likely as those given placebo pills to attempt suicide or prepare for a suicide attempt, the analysis found. For every 1,000 patients given the drugs, about 4 will act on suicidal urges who would not have done so had they not been taking the medications, the analysis suggested. “It’s about as unequivocal a result as you can get,” said Dr. Marc Stone, a senior F.D.A. reviewer and an author of the report. The analysis found that the drugs did not increase the risk of suicide in adults from 25 to 65, and significantly lowered suicide risk in people over 65.
     The F.D.A. does not have to follow the recommendations of its advisory panels but usually does, and did so after a panel recommended similar warnings for minors in 2004. Since then, researchers have found that antidepressant prescription rates to children and adolescents have dropped in the United States and elsewhere. And the Centers for Disease Control and Prevention said last week that suicide rates in teenagers increased slightly in 2004, for the first time in more than a decade.
     Several psychiatric researchers at the hearing argued that these trends suggested, in effect, that the agency’s previous warning for children had led to the deaths of people who were scared away from treatment. “I recommend that the committee reverse its previous warning for children and adolescents and instead encourage careful monitoring” of side effects, said Dr. John Mann, a professor of psychiatry and radiology at Columbia University and director of psychiatric research at the New York State Psychiatric Institute.
     But others said extending the warnings to include young adults was essential so patients could make informed choices. “Had my son been told about this risk, had any of us been told, we wouldn’t be here,” said Jayne Richner, whose 22-year-old son, Sean, hanged himself in August just after he stopped taking the antidepressant Celexa. “It’s only been four months since he killed himself, and we’re still trying figure out how to get through every day because of this.” Some former patients said the drugs had saved their lives. The apparently stark contradictions in the testimony and in studies might suggest the drugs increase suicidal urges in some and reduce them in others. “It’s possible for a drug to opposite effects over time, even within same domain,” said Dr. Thomas Laughren, director of the division of psychiatry products at the F.D.A.

Giving Troubled Families a Say in Child Welfare
Lynette Clemetson, New York Times- 12/16/2006

McMINNVILLE, Tenn. — In an effort to correct dysfunctional foster care systems, a growing number of child welfare agencies around the country are reaching outside their ranks to involve troubled families and the people in their lives in wrenching decisions about where endangered children should live. Some agencies find that by enlisting help from grandparents, church members, school counselors and sports coaches, they can reach faster, safer and more lasting decisions that result in fewer children languishing in foster care. Under the practice, known as team decision making, a group is assembled within 24 to 48 hours after a state agency is called into a crisis situation.
      Programs exist in at least 21 states. Indiana, Michigan and Tennessee have adopted the team-approach statewide, while other programs are run at the county level. Officials in Denver County, Colo., credit the team approach for a 32 percent drop in out-of-home placements since 2002. In Cuyahoga County, Ohio, the program has reduced the number of children in foster care by more than half since 2001. Tennessee has reduced the number of children in state care by more than 1,000 since March 2004, when there were 10,600 in the system. Methods differ, but the philosophy is the same: that even families under scrutiny from state agencies can help make positive decisions for their children.
     Some advocates for children say the strategy gives negligent parents too much sway. But many child welfare officials believe the team process works. Historically, “agencies called all the shots and told families everything that was wrong with them,” said Viola P. Miller, commissioner of the Tennessee Department of Children’s Services, who instituted her state’s new model. “But kids don’t exist in isolation,” Ms. Miller said. “If we are really going to keep families safe, we need to do that in the context of communities and family.”
     In this rural outpost between Nashville and Knoxville, 12 people gathered recently to decide whether Misty N., a 26-year-old single mother of four, whose children were taken into state custody last February, deserved to get them back. “Let’s start by acknowledging Misty’s strengths,” said Carrie McCrary, a group facilitator with the state, welcoming “Misty’s team.” The group included Misty, her mother, the children’s court-appointed guardian, a local Head Start coordinator, her older children’s school psychologist and several social workers. One by one they offered affirmations.
     Misty (who asked that her family members’ last names be withheld to protect their privacy) had moved from a homeless shelter into a two-bedroom trailer with her mother. Though Misty has mild retardation, she was absorbing newly learned parenting skills, yelling at her children less and offering more positive reinforcement. She was also providing nutritious food during visits with her children. And it was clear, everyone agreed, that she loved her children: Ramon, 6; Domiann, 5; Roberto, 4, and Pedro, 2.
     “We need to talk about the sex offenders,” Rachel Kirby, the children’s court-appointed guardian, said, shattering the mood. Misty had been living with a sex offender when her children were taken away. She had a brief involvement with another. “We just need to be clear,” Ms. Kirby said to Misty. “When you’re standing in court, if there is a sexual offender in the home, that throws all the other good work out the window.”
     Around the country, where similar strategies are in place, a group can meet for as long as two years, helping social workers assess whether families can be reunited or whether children should be moved toward adoption or legal guardianship, with relatives or an outside family. Groups sometimes continue to meet after a placement to monitor children’s progress. Child welfare agencies maintain ultimate power of approval, but deference is given to the collective wisdom and recommendation of the team.
     No comprehensive long-term studies have been conducted to assess whether the team approach reduces incidents of child abuse. But in Cuyahoga County, Ohio, which instituted its program in 1994, Jim McCafferty, director of the county’s Department of Children and Family Services, credits team meetings with helping reduce the number of children in the system to 2,702 this month from 6,237 in 2001, when the county’s largest city, Cleveland, was rebounding from a crack epidemic. The number of children re-entering the system within 18 months dropped to 9 percent in 2004 from 16 percent in 1996. Roxane White, manager of the Denver Department of Human Services, said that in addition to reducing out-of-home placements, team meetings had reduced incidents of new abuse to just over 2.6 percent from 6 percent in 2002.
     But some advocates for children say the team system may be keeping children with parents when they would benefit more from foster care. “The pendulum may have swung too much in the opposite direction,” said Cyndy Bailes, executive director of CASA of the Tennessee Heartland, part of a national group of court-appointed special advocates for children. Ms. Bailes’s organization works in five counties in East Tennessee. She says her volunteers have complained that the team system there is poorly organized, that families do not cooperate and that participants have felt pressured by the Department of Children’s Services to support family reunification over foster care or termination of parental rights. Some social workers disagree. “I have really bought into it, because it is not so much about blaming, so there is less resentment all around,” said Ms. McCrary of Children’s Services.
     Cheryl McGuire, the caseworker who leads Misty’s team, said the system relieved pressure on overworked case managers. Misty and her mother, Geraldine, have seen the change in the system, they said, from the inside out. Geraldine took Misty in as a foster child when she was 5 weeks old. Geraldine, who tacked down beltloops in a garment factory, and her husband adopted Misty and her older brother, Chris, when they were 2 and 3 years old. After Geraldine’s husband died in 1983, she was unable to cope. Misty and Chris went back into state care. Now Misty’s four children are in the system. Of the three known fathers, only one has been tangentially involved. It was Geraldine who called Children’s Services in February, because Misty, she said, “was running wild.” At 64, Geraldine said, she was too old to care for the children on her own. “It scares me half to death to think that she might not get her kids back,” said Geraldine, who is now retired. “But at the time it was best for the children. I hoped it would straighten her out.”
     Geraldine said the team approach offered families more support than in years past when decisions were made by a single caseworker. “When I was a foster parent, they just dropped off the kids and came back once a month to make sure they were clothed and fed,” she said. Misty, too, said the experience differed from her past memories. “It ain’t the first time I’ve been in here,” she said, referring to the county office of the Department of Children’s Services. “But this way here, it’s helping me more. Helping me to get my kids back.”
     Teams around the country adhere to tight timelines for determining permanent placements, typically within a year or two. Placements with relatives are preferred, but sometimes so-called kinship placements are not with biological relatives, but with people whom the child considers family.
     In Rutherford County, southeast of Nashville, a 13-year-old girl was recently placed in foster care after her mother’s suicide. She responded poorly, acting out and wetting her bed. She asked to be with her mother’s boyfriend’s mother, whom she called Granny. The girl’s participation in the team resulted in her adoption, last month, by her grandmother figure.
     With no similar possibilities for Misty’s children, the stakes of her team’s decision are higher. By the one-year mark in February they must recommend reunification or make the children available for adoption. The children are in a rare situation in which the foster parents, a stable family in a nearby town, have agreed to keep all four long term. Misty and Geraldine are living on Geraldine’s $789-a-month Social Security check, plus food stamps. Where would the children sleep in the two-bedroom mobile home and could the women’s limited resources provide for them? asked Ms. McGuire, the team leader, in the hour-and-a-half meeting on Misty’s case. “It don’t leave a lot of room for extras, but it can sustain us,” Geraldine said, adding that they would get extra food stamps with the children.
     The discussion turned to the children. Roberto has continuing problems with aggression. Domiann, one person suggested, had taken on a “dominant mother role” among the sibling group. Pedro, someone mentioned, might suffer from an attachment disorder. Ramon, participants observed, has been gorging during visits with his mother, a nervous behavior he does not engage in at his foster home.
      Next, the group laid out goals for Misty to reach before February: She must have a psychological evaluation and continue training with social workers. She must stop associating with criminals. After she and Geraldine left the room, the team members discussed the weight of the decision yet to come. “The tough fact is that she may do everything we tell her to,” Ms. Kirby said. “She may work as hard as she can, and still not be able to get her children back.”

Drug Files Show Lilly Promoted Unapproved Use
Alex Berenson, New York Times- 12/18/2006

Eli Lilly encouraged primary care physicians to use Zyprexa, a powerful drug for schizophrenia and bipolar disorder, in patients who did not have either condition, according to internal Lilly marketing materials. The marketing documents, given to The New York Times by a lawyer representing mentally ill patients, detail a multiyear promotional campaign that Lilly began in Orlando, Fla., in late 2000. In the campaign, called Viva Zyprexa, Lilly told its sales representatives to suggest that doctors prescribe Zyprexa to older patients with symptoms of dementia.
      A Lilly executive said that she could not comment on specific documents but that the company had never promoted Zyprexa for off-label uses and that it always showed the marketing materials used by its sales representatives to the Food and Drug Administration, as required by law. “We have extensive training for sales reps to assure that they provide information to the doctors that’s within the scope of the prescribing information approved by the F.D.A.,” Anne Nobles, Lilly’s vice president for corporate affairs, said in an interview yesterday.
     Zyprexa is not approved to treat dementia or dementia-related psychosis, and in fact carries a prominent warning from the F.D.A. that it increases the risk of death in older patients with dementia-related psychosis. Federal laws bar drug makers from promoting prescription drugs for conditions for which they have not been approved — a practice known as off-label prescription — although doctors can prescribe drugs to any patient they wish.
     Yet in 1999 and 2000 Lilly considered ways to convince primary care doctors that they should use Zyprexa on their patients. In one document, an unnamed Lilly marketing executive wrote that these doctors “do treat dementia” but “do not treat bipolar; schizophrenia is handled by psychiatrists.” As a result, “dementia should be first message,” of a campaign to primary doctors, according to the document, which appears to be part of a larger marketing presentation but is not marked more specifically. Later, the same document says that some primary care doctors “might prescribe outside of label.” Ms. Nobles said that the company had never promoted its drug for any conditions except schizophrenia and bipolar disorder. Older patients who seem to have dementia may actually have schizophrenia that has gone untreated, Ms. Nobles said. Several psychiatrists outside the company said yesterday that they strongly disagreed with Lilly’s claim. Schizophrenia is a severe disease that is almost always diagnosed when patients are in their teens or 20s. Its symptoms could not be confused with mild dementia, these doctors said.
     Zyprexa is by far Lilly’s best-selling product, with $4.2 billion in sales in 2005, 30 percent of its overall revenues. About two million people worldwide received it last year. Based in Indianapolis, Lilly is the sixth-largest American drug company.
     The issue of off-label marketing is controversial in the drug industry. Nearly every company is under either civil or criminal investigation for alleged efforts to expand the use of its drugs beyond the specific illness or condition for which they are approved. Lilly faces federal and state investigations over its marketing of Zyprexa. In its annual report for 2005, Lilly said that it faced an investigation by federal prosecutors in Pennsylvania and that the Florida attorney general’s office had subpoenaed the company “seeking production of documents relating to sales of Zyprexa and our marketing and promotional practices with respect to Zyprexa.”
     Since Lilly introduced Zyprexa in 1996, about 20 million patients worldwide have received the drug, which helps control the hallucinations and delusions associated with schizophrenia and severe mania. But Zyprexa also causes weight gain in many patients, and the American Diabetes Association found in 2004 that Zyprexa was more likely to cause diabetes than other widely used drugs for schizophrenia. Lilly says that no link between Zyprexa and diabetes has been proven.
     As part of the “Viva Zyprexa” campaign, in packets for its sales representatives, Eli Lilly created the profiles of patients whom it said would be suitable candidates for Zyprexa. Representatives were told to discuss the patient profiles with doctors. One of the patients was a woman in her 20s who showed mild symptoms of schizophrenia, while another was a man in his 40s who appeared to have bipolar disorder. The third patient was “Martha,” a widow with adult children “who lives independently and has been your patient for some time.” Martha was described as being agitated and having disturbed sleep, but without the symptoms of paranoia or mania that typically marked a person with schizophrenia or bipolar disorder.
     Ms. Nobles said that Lilly had actually intended Martha’s profile to represent a patient with schizophrenia. But psychiatrists outside the company said this claim defied credibility, especially given Martha’s age. Instead, she appeared to have mild dementia, they said. “It’d be very unusual for this to be a schizophrenic patient,” said Dr. John March, chief of child and adolescent psychiatry at Duke University medical center. “Schizophrenia is a disease of teenagers and young adults.” Dr. March serves on Lilly’s scientific advisory board. Diagnostic criteria for schizophrenia include delusions, hallucinations, disorganized and incoherent speech, and grossly disorganized behavior. They also include so-called negative symptoms like social isolation and a flattening of the voice and facial expressions.
     The documents also show that Lilly encouraged primary care doctors to treat the symptoms and behaviors of schizophrenia and bipolar disorder even if the doctors had not actually diagnosed those diseases in their patients. Lilly’s market research had found that many primary care doctors did not consider themselves qualified to treat people with schizophrenia or severe bipolar disorder.
     The campaign was successful, the documents show. By March 2001, about three months after the start of Viva Zyprexa, the campaign had led to 49,000 new prescriptions, according to a presentation that Michael Bandick, the brand manager for Zyprexa, gave at a national meeting of Lilly sales representatives in Dallas. Mr. Bandick did not say how many of those new prescriptions were for older patients with dementia. Over all, sales of Zyprexa doubled between 1999 and 2002, rising from $1.5 billion to $3 billion in the United States. In 2002, the company changed the name of the primary care campaign to “Zyprexa Limitless” and began to focus on people with mild bipolar disorder who had previously been diagnosed as depressed — even though Zyprexa has been approved only for the treatment of mania in bipolar disorder, not depression. In a 2002 guide for representatives, Lilly presented the profile of “Donna,” a single mother in her mid-30s whose “chief complaint is, ‘I feel so anxious and irritable lately.’ ” Several doctors’ appointments earlier, she was “talkative, elated, and reported little need for sleep.”
     Lilly’s efforts to promote Zyprexa to primary care doctors disturbed some physicians, the documents show. In August 2001, a doctor in Virginia sent an e-mail message to Lilly and the F.D.A., complaining about a presentation from a Lilly sales representative who had discussed the hypothetical Martha with him. The representative “presented an elderly female patient who was presented to her physician by her family complaining of insomnia, agitation, slight confusion, and had no physical finding to explain her state,” the doctor wrote. The representative then suggested that the doctor prescribe Zyprexa. “I inquired what Zyprexa was indicated for; she then indicated that many physicians might prescribe an antipsychotic for this patient. I then asked for her package insert and read to her that her product was indicated for schizophrenia and bipolar mania — neither of which the presented patient had been diagnosed with,” the doctor wrote. He added that he had never contacted the F.D.A. before but was “genuinely concerned about the promotion of this powerful drug to my peer community of primary care physicians outside of its approved and intended purpose.” Tara Ryker, a spokeswoman for Lilly, said the company no longer uses “Martha” or “Donna” in its marketing. “We are constantly developing new promotional materials and new profiles,” she said.
     The Zyprexa documents were provided to The Times by James B. Gottstein, a lawyer who represents mentally ill patients and has sued the state of Alaska over its efforts to force patients to take psychiatric medicines against their will. Mr. Gottstein said yesterday that the information in the documents should be available to patients and doctors, as well as judges who oversee the hearings that are required before people can be forced to take psychiatric drugs. “The courts should have this information before they order this stuff injected into people’s unwilling bodies,” Mr. Gottstein said.
     Lilly originally provided the documents, under seal, to plaintiffs lawyers who sued the company claiming their clients developed diabetes from taking Zyprexa. Last year, Lilly agreed to pay $700 million to settle about 8,000 of the claims, but thousands more are pending. Mr. Gottstein, who is not subject to the confidentiality agreement that covers the product liability suits, subpoenaed the documents in early December from a person involved in the suits.
     The “Viva Zyprexa” documents also provide color about Lilly’s efforts to motivate its sales force as they marketed Zyprexa — whose generic name is olanzapine — to primary care doctors. At the 2001 meeting in Dallas with Zyprexa sales representatives, Mr. Bandick praised 16 representatives by name for the number of prescriptions they had convinced doctors to write, according to a script prepared in advance of the meeting. More than 100 other representatives had convinced doctors to write at least 16 extra prescriptions and thus “maxed out on a pretty sweet incentive,” he said. “Olanzapine is the molecule that keeps on giving,” Mr. Bandick said.

Baby in the Balance (#1 of five articles)
Mary Otto, Washington Post- 12/18/2006

The small blond woman who slumps before Judge Martin P. Welch seems to have been asleep for the past hour. "Ms. Coleman," the judge says to her, in his gentle way, "I don't want to jump to conclusions, but I have to ask you: Are you high right now?" "I'm tired. I've been up all night," Stacy Coleman says groggily. "My boyfriend kicked me out." Her boyfriend, Keith Cromwell, lean and neatly dressed, is also here before the judge. Welch has their files. He knows their stories. He has taken away so many babies from people like them. Addicts.
      Coleman, 28, is a high school dropout with tousled hair and a careworn face. She grew up in Baltimore's working-class suburbs in a family plagued by cocaine and started using at 13. When she got older she danced in bars, hustled for a living. She has had her brushes with the law. As has Cromwell, 41, a clean-cut high school graduate who grew up in Baltimore public housing, the son of a Vietnam veteran who drank and then disappeared. Cromwell is a steady worker who has had many jobs, a quiet man who struggles with his temper. He started drinking young, got into heroin, then crack. An unlikely couple perhaps, yet bound by their inheritance, the silent absences and secret customs passed down through addicted families. And now bound by a little girl.  Keyona Angel Cromwell is case No. 805206001, born July 19, 2005. Coleman tested positive for cocaine, so the baby was placed in foster care.
     On this day, Coleman and Cromwell find themselves among the first parents to take part in the Family Recovery Program, part of a growing movement of family drug courts throughout the nation. They are here because they want their baby back and know that conquering their addictions is the only way to accomplish that. This is an experimental court, and presiding over it is Welch, one of the first judges in the region empowered to order addicted parents into immediate drug treatment with the goal of dramatically limiting their children's stay in the foster system.
     In more than a decade overseeing the Family/Juvenile Division for the Circuit Court of Baltimore, Welch has taken thousands of neglected and abused children away from addicted parents. He has advised those parents that if they want their children back, they need to get clean and sober. But over and over, he has watched them disappear into anger or denial, or into a system with too few drug treatment slots available, especially for the poor and uninsured. And he has watched their children languish for years in Baltimore's troubled child welfare system.
     Then in August 2005, government, business and philanthropic leaders announced the Maryland Opportunity Compact, a public-private initiative that earmarked $2.5 million to establish the court's Family Recovery Program. When the state takes a child from an addicted parent, the judge refers the parent to the program. A caseworker from a private firm under contract to the court assesses the addict's needs and places the parent in a waiting slot for a drug treatment program paid for by the court. In the first year, 185 people will be referred to the program, 81 of whom will follow through to receive some treatment. The judge meets weekly to discuss their cases with a team of lawyers for the parents and children and with social service providers. Parents appear regularly before Welch in a closed courtroom Friday mornings, maintain steady contact with their case managers and submit urine samples. All the while, the clock is ticking. Decisions must be made.
     This is a year when Coleman and Cromwell's baby will begin to communicate, to walk, to bond, a year in which the parents will stumble repeatedly in their struggle to rise from their addictions. Welch knows relapses are inevitable. He isn't expecting miracles. But if children are to grow up with the capacity to trust and love, they need nurturing families. If Cromwell and Coleman fail to seize this chance, fail to develop the skills they need not only to raise a child but also to live life clean and sober, the state will move to terminate their parental rights. Keyona, with her elfin chin and big brown eyes, will be put up for adoption. "Ms. Coleman, we have to meet each other where we are," Welch tells her. "I'll take your explanation that you are not high, that you are tired. But next month, when you come back, get a good night's sleep. You are right on the cusp."

Sometimes, the Why Really Isn’t Crucial
Sally Satel, M.D., New York Times- 12/19/2006

“Why do I use drugs?” I am asked every few weeks by a patient in our methadone clinic. I take the query as a good sign; curiosity about oneself is usually healthy. But the premise behind the question — that a person can reliably identify the psychic roots of an addiction, or any other act of self-sabotage — is highly overrated.
     Research psychologists have known for decades that it is very difficult to determine causation in mental life and thus, of behavior. For one thing, we can never perform an experiment. Take my patient Karen, 50, who spent most of the 1990s smoking crack. She is certain that the decade-long binge would never have happened had her mother not died when she was 12. We will never know if she is right because we cannot rewind Karen’s life, play it again, and see what would have happened if her mother had lived.
     Reconstructing the story of one’s life is a complicated business for other reasons. What scientists call hindsight bias kicks in when we try to figure out the causal chain of events leading to the current situation. We may well come up with a tidy story but, inevitably, it will contain large swaths of revisionist history. It’s not that we bias ourselves deliberately; it happens because the mind tends to make events in the past appear comprehensible and orderly. We forget the uncertainties that might have beset us as we struggled in real time. Narratives are shaped also by a natural tendency to focus on information that confirms theories we already hold. These theories — for example, that molested children are likely to grow up to have sexual compulsions of their own — may be imbibed from the media, self-help books or therapists.
     If our own accounts of our actions are often so slanted and embellished, is composing them simply a misbegotten quest? Surely not. To a therapist, the attempt signals that patients are aware that they have a problem worthy of attention. And the narratives themselves can help them make sense out of confusion. This, in turn, can diminish anxiety and exaggerated guilt. Such relief might be sufficient in and of itself for some, or, depending on the goals of therapy, it could embolden a patient to make further healthy adjustments.
     But the grail-like search for insight can also backfire when it becomes a way for patients to avoid the hard work of change. This was my experience with Joe, a 24-year-old heroin addict. At every session, Joe would talk about his childhood relationship with his father, seeking new clues for how it damaged him and drove him to heroin. When I tried to change the topic to on-the-job stresses, which he linked to heroin craving, he said he’d rather “do psychotherapy.” Joe was forestalling the need to make practical changes. The many-layered drama with his dad doubled as an excuse for using heroin, absolving him of the responsibility to quit. When I proposed that possibility to him, he said, “Maybe you’re right.” But nothing really changed. He died of an accidental overdose a few months later.
     Finally, insight has no guaranteed relationship to change. A colleague of mine treated a 45-year-old woman, Joan, who came for therapy because she hated her chunky body. Joan firmly believed that once she discovered The Reason for her overeating she would stop. After a few months, Joan told my colleague that her father had developed cancer the year she went off to college. “You know, I never made the connection until now,” she announced triumphantly, “but I started overeating when he began to waste away. It’s like I was trying to nourish him through myself.” A poignant metaphor, yes, but months later she hasn’t lost a pound.
     It is time to retire the myth that insight is a prerequisite for change. For the patients in our clinic, change without hard-won insight is the rule. And who has time to wait? Not Natalie. This past month she and I worked on getting an abusive, shiftless boyfriend out of her apartment; finding tutoring for her son; and building a new social network to replace the drug users that she used to hang out with. At this stage in her treatment, awareness of what she needs to do will get Natalie further than insight. Less chaos in her life means less anxiety and that means less risk of relapse. Down the road she may ask, “Why did I use drugs?” But in the meantime, what’s important for Natalie and her son is that she is determined to stop.
     Frederic C. Bartlett, a British psychologist, coined the term “effort at meaning” to describe the human impulse to make sense of feelings and circumstances. Self-explorers be warned: it is an effort often fraught with distortion and even hazard, when it prevents one from making the changes that need to be made in the present.

Sally Satel is staff psychiatrist at the Oasis Drug Treatment Clinic and a resident scholar at the American Enterprise Institute.

Mental Health Parity Stalls Again in Michigan
David Eggert, Associated Press- 12/19/2006

LANSING - Lawmakers swiftly approved scores of bills during the frantic last week of their two-year session. But long and emotional debate was saved for a stalled Senate measure that didn't even get a vote; leaving the term-limited sponsor disappointed and supporters pledging to continue their efforts. The issue is mental health parity, an attempt to require health insurers to give as much coverage to mental illnesses as they do physical ones. "It's not a matter of `if' this is going to come, my friends, it's a matter of `when' it's going to come," said Sen. Beverly Hammerstrom, R-Temperance, who told senators she hopes they "do the right thing" in the next session.
     Hammerstrom has pushed the legislation for years. She had hoped to get it passed before her term runs out later this month, but was unsuccessful. She says a stigma against mental illness has created a discrepancy between physical, and mental health coverage, including fewer therapy visits, inpatient days and, allowable expenses along with higher copays and deductibles.
     By requiring better insurance coverage for depression and other disorders, advocates argue, people could be treated long before their illnesses become severe, allowing them to stay active and be productive citizens. The big obstacle is Michigan businesses, which say the bills would add to their already rising health care costs. Insurance companies also oppose requiring such coverage.
Wendy Block of the Michigan Chamber of Commerce says the group is "extremely sympatetic" to the issues facing the mentally ill, but businesses already are seeing double-digit percentage increases in their health costs. "They find it unacceptable, that government would pass somthing on that would add to those costs," said Block, the chamber's director of health policy and human resources. She said it would be difficult to define what mental illnesses should be covered and how the coverage must be on par with benefits for physical health.
     While the GOP-controlled Legislature has blocked the measure, some of its staunchest backers are Republicans who dispute claims that employers will pay higher premiums. Many Democrats-- including Gov. Jennifer Granholm -- support, mental health parity. "How the business community can claim that this is going to cost them more is just sheer ignorance or stupidity," said Sen. Shirley Johnson, R-Troy, who's also leaving because of term limits. "It's far more costly if that individual is not receiving the necessary care so that individual could lead a productive life," said Johnson, who has a family member with a severe mental illness.
     Michigan Partners for Parity, a Southfield-based advocacy group, says the costs of the legislation would be minuscule, increasing premiums by 1 percent or less. That would be offset by more productivity and less absenteeism by workers who have mental illnesses, according to backers. They say the legislation could help up to half of the 6 million people in Michigan with private health insurance. Large companles that self-insure are exempt from mental health parity requirements under federal law.
     Businesses note that higher health care costs under the legislation and inflationary pressures could cause cutbacks elsewhere in their workplaces. "Government should not be dictating to job providers what should and shouldn't be in their benefit packages," Block said. Thirty-nine states have some kind of a mental health parity law, and 26 are considered to have comprehensive statutes.