Noteworthy News Articles on Mental Health Topics, December 20-22, 2006




Schizophrenia Drug Wins Federal OK
Associated Press, 12/20/2006

WASHINGTON -- Johnson & Johnson won federal approval Wednesday for a schizophrenia drug derived from another top-selling anti-psychotic medicine. The Food and Drug Administration said Invega will add to the treatment options for the disabling mental disorder, which affects about 2 million Americans. It also could add to the bottom line for J&J, which faces the loss of patent protection in December 2007 for the No. 3 anti-psychotic drug, Risperdal. Risperdal, also called risperidone, had $2.3 billion in sales in 2005, according to the pharmaceutical data company IMS Health.
      Confronted with the prospect of competition from generic versions of the drug, the New Brunswick, N.J.-based company seeks a further six months' patent protection for Risperdal by studying its use in children. Invega, also called paliperidone, is derived from Risperdal. The body breaks down Risperdal to form paliperidone. Unlike Risperdal, Invega will be sold in extended-release tablet form. The company didn't disclose the drug's cost, saying only that it would be priced competitively with other anti-psychotics.
     Schizophrenia is marked by hallucinations, delusions, disordered thinking and movements and cognitive deficits, the FDA said.
     On the Net: Food and Drug Administration: http://www.fda.gov

As a Mother Falters, a Father Strengthens His Resolve (#3 of six articles)
Mary Otto, Washington Post- 12/20/2006

"Mr. Cromwell," Judge Martin P. Welch asks, "how are you?" "One hundred percent better than I was last week," Keith Cromwell replies. "Everything is fine." But he is alone. His girlfriend, Stacy Coleman, is not in court with him. She wasn't there the week before, either. She has relapsed again. After a relapse in November, she was placed in a new inpatient drug treatment program. She made it through the holidays clean -- clean enough to visit 6-month-old Keyona, the couple's baby in foster care. Then, a week ago, Coleman had an argument with the house manager and left her program. She headed straight back into her old life: stealing, hustling and smoking crack.
     Since New Year's, however, Cromwell has been in a month-long treatment course at Mountain Manor, near Camp David, a religious shrine and a ski resort. The bare trees, rolling hills and cold, fresh air seem a world away from Baltimore, where Cromwell grew up in housing projects, the third of 10 children. In a constant round of therapy sessions, the quiet Cromwell has been encouraged to open up and confront facts about his life, his addiction and the people he has hurt. Keyona.
     "I've seen you up; I've seen you down," the judge is saying. "But you are always showing up." Cromwell is the rare father in the Family Recovery Program. Every Friday, the courtroom fills with mothers. A few have won back their children, but others come and go as they struggle to quell their addictions. "The women are getting all the glory," Cromwell announces to the court that day. "I want to be the first man to get my daughter back."
     The following Friday, when Cromwell returns for another hearing, clean for more than two months, there is a hard look of resolve about him. But Coleman is waiting for him. Her face seems swollen, her hair tangled. She is wearing a heavy jacket and heavy boots. She seems to panic in the hall outside the courtroom. "I want to give up my parental rights," she tells him. Small, solid Janet Neale, the program's manager, is standing by. She sees the wild look in Coleman's eyes and tries to enfold her in a motherly hug. "I don't want her," Coleman mutters in an exhausted monotone. Neale walks Coleman up and down the hall, making soothing sounds.
     Cromwell goes into the courtroom. Coleman slips in after him, trying to catch his eye. He refuses to look her way. Court starts late this morning. The judge's wife had an accident, and he had to take his children to school. He hasn't even had his cup of tea. But when Welch, the Circuit Court judge who leads the program, hurries to the bench, he is as fastidiously dressed as usual, with a yellow bow tie showing above the collar of his black robe, and smiling. Cromwell fingers the cross he wears around his neck as the judge turns to Coleman, her head hanging down. "Ms. Coleman," the judge says, "I'm glad to see you. We missed you these two weeks."
     The court, he says, is ready to give her another chance. The judge knows that relapse is often part of recovery. The weeks of sobriety that Coleman had achieved before she faltered can be building blocks for another try. He wants her caseworker to reassess her needs, to see whether another treatment program would work better. "We will meet you where you are. Are you going to let us try?" No, she answers. "Even if you want to give up, you can't," the judge tells her. "You've had a lot of ups and downs. We want you to take a deep breath. Are you ready to be reassessed?" "No." "I will order that you be reassessed. You had an altercation with your house manager. If you end up in another program where you don't have those issues, will you try again?" "Maybe," she whispers. Cromwell gives her a long, severe look and shakes his head.

Drugs, Therapy or Both?
“It’s obvious that medication has been more effective than behavioral modification in treating the core symptoms of A.D.H.D., but behavioral treatments can produce real improvement, and for certain kids the combination of the two treatment appears to be best,” said Dr. Oscar Bukstein, a child psychiatrist at the University of Pittsburgh School of Medicine who is helping the American Academy of Child and Adolescent Psychiatry write treatment guidelines. “Children with other behavior problems in addition to A.D.H.D., for instance, seem to do best with both treatments.”
      The Popczynskis found that a brand of family therapy by itself was sufficient to put Peter on track at school and at home. Their experience helps illustrate how a family can, in effect, treat a child’s psychiatric disorder — and for whom such an approach can be practical. One thing the family had going for it was location. When Peter’s mother began scouring the Internet for resources in the spring of 2003, she quickly learned that they lived only a few miles from the University of Buffalo, which runs one of the country’s most comprehensive behavioral modification programs.
     In a study involving 128 families, psychologists at the university had found that about a third of parents who completed the program saw enough improvement in their children that they had decided that medication was unnecessary. The other two-thirds put their children on stimulant medication at school but at doses significantly lower those typically prescribed, said William Pelham, a psychologist who is director of the Center for Children and Families at Buffalo and the senior author of the study. Eighty percent of the families who participated in the program, with follow-up parent training, decided that their children did not need medication at home. “Most parents seeking help for a child with a psychiatric disorder never hear about programs like this,” Dr. Pelham said. “The only option they’re given is medication. Now, it may be that the best treatment for that child is medication. But how do you know if you never try anything else?”
     Behavior modification for A.D.H.D. and for related problems, like habitually disruptive or defiant behavior, is based on a straightforward system of rewards and consequences. Parents reward every good or cooperative act they see: small things, like simply paying attention for a few moments, earn an “attaboy.” Completing homework without complaint might earn time on a Gameboy. Parents remove privileges, like television and playtime, or impose a “time out,” in response to defiance and other misbehavior. And they learn to ignore annoying but harmless attempts to win attention, like making weird noises, tapping or acting like a baby.

Tracking Behavior
These skills are hardly unknown to seasoned parents. But most also know that stress or anger, even when dealing with a child who has no serious problems, can sour the best instincts. That is why family-based programs insist that parents try to maintain a clear, neutral tone when instructing their children, or penalizing them. Bluntness, for example, is a virtue. Saying to a child, “Would you put your toys back in the box, please?” turns a command into a question. Saying, “Let’s put your toys back in the box,” implies collaboration. An unadorned “Put your toys back in the box” is clearer for everyone, psychologists say, especially so for a child who is highly distractible.
     However it is dressed up, family therapy like this teaches parents to provide what many critics say children these days are missing — discipline. But therapists make a careful distinction between corrective action and cruelty, between firmness and frostiness. Overly punitive parents increase the likelihood that a child will develop mood problems, some studies suggest. So parents learn not to become scolds, but to bring their children into line without demeaning them.
     In some programs, parents play-act situations in front of their peers, who critique the performance for emotional tone and the clarity of parents’ statements. As a result, the parents say, they become immediately more deliberate at home. “You end up constantly saying things like, ‘That’s not an appropriate behavior,’ using this unnatural language,” said Ms. Popczynski. “But the point is you don’t get into it with them. The first thing I noticed was that I wasn’t yelling all the time. The house got a lot quieter right away.”
     Their instructions to Peter and Scott became more precise, as well. Saying “Clean your room” is too vague and covers a half-dozen tasks, Roman Popczynski, the boys’ father, said. Peter might wonder where to start, or just decide it was too much to worry about, and give up, his father said. “Put your laundry in the hamper” is much more likely to get results, he said, and lead to the next clear step, like “Put your toys where they belong.”
     Multiple commands are also confounding: “Put away your crayons, clear away the table, and organize your homework, please” leaves a child wondering which to do first, and whether it is too much work to finish. “It overloads a kid, and then he feels like he’s failing, which only makes it worse,” said Mr. Popczynski, who is a UPS driver.

Starting Slowly
Like most who try to use behavior modification techniques, the Popczynskis relied on a daily report card to keep a running tally of Peter’s specific problem behaviors, like wandering attention, ignoring commands or defiance, and his efforts to correct them. For instance, at the beginning, Peter, then 7, would get a check mark every time he ignored more than two commands to do his homework, put away his toys or brush his teeth, but he would earn immediate praise if he got started. He received check marks when he slid off his chair at dinner, and earned approval if he stayed seated. At bedtime he accumulated marks if he pulled delay tactics. A tantrum resulted in instant punishment: a timeout of 5 to 10 minutes, shortened for good behavior. The report card was posted on the refrigerator.
     The Popczynskis started slowly. They measured how many marks Peter recorded in a normal day, and at first rewarded him if he reduced the number by even one: with an extra 15 minutes on Game Cube, for example. If he had more good days than bad ones over the course of a week, he got to choose from a bag of toys from the $1 store. Mr. and Ms. Popczynski continued to raise the standard, one checkmark at a time, until Peter hit zero consistently. “You want them to be able to succeed,” Mr. Popczynski said. “If you make it too hard, they’ll just give up, and so will you.”
     The Buffalo program is more comprehensive than most: psychologists run a summer camp here, employing the same principles, and, during the school year, regularly visit the teachers of every child in the program. Those teachers who agree to cooperate — most do — keep daily behavior report cards for the child too, in effect providing full coverage for a child’s every waking hour.
     Even then, the therapy is far from a silver bullet or an automatic replacement for treatment with Ritalin or other drugs that are routinely prescribed for attention disorder based on many studies showing their effectiveness. The constant tallying and reminding is too exhausting for some parents, especially those raising children on their own and juggling outside jobs. The Popczynskis did well in part because Peter’s difficulties were not severe, he was a capable student and his most disruptive behavior came out at home, Mr. Popczynski said. And the couple were able to share the many duties.
     Yet most parents in the program have found that their children do best with a combination of the medication and family treatment, albeit with significantly lower doses of the drugs than typically prescribed. Dawn Van de Wal, a single mother of three in Buffalo, said that over the last six months she has learned to contain and redirect the behavior of her exuberant 9-year-old, TJ, who has received a diagnosis of attention-deficit disorder. TJ can still become extremely frustrated when required to sit for long periods and concentrate on schoolwork, in the absence of his mother. “I still give him medication for school, because the fact is that right now he needs it to get through the day, but it’s a low dose,” Ms. Van de Wal said while TJ practiced headstands on the couch. “He doesn’t take it at home, though, and I plan to reduce the dosage in time as much as I can.” She added, “I don’t want him to look back and think the successes he’s had are all due to a drug.”
     In surveys and in dozens of interviews, most parents of children with psychiatric diagnoses say that they prefer to avoid using medications, if possible. It is not so easy to do. Insurers as a rule do not fully cover behavior modification therapies because they cost substantially more than drugs. The therapies require an enormous commitment from already overloaded parents, and some children are too severely troubled to respond. Many clinics do not even offer the programs. Psychiatrists, pediatricians and family doctors also tend to be more comfortable writing prescriptions for psychological reasons.

Shifting Perceptions
“It’s a tremendous relief for the physician to prescribe something, because these kids are very tough, and it feels horrible to sit there and not be able to help,” said Dr. Jennifer Mary Harris, a child psychiatrist practicing in Arlington, Mass., who has argued for more caution in using medication. At every level, she said, the mental health system strongly favors drug treatment.
     Yet the increasing number of studies that support family-based behavioral treatment is shifting perceptions. The largest study comparing medication with behavioral modification therapy for attention deficit problems, released in 1999, found that drugs were more effective in improving children’s ability to focus and keep still. But more than three-fourths of those treated without medication did well enough that their parents were able to keep them off drugs. And behavior therapy significantly improved children’s reading performance and their relations with parents and teachers when combined with medication, the study found.
     Researchers have also studied a different approach to behavior treatment, called cognitive behavior therapy. This approach engages children directly, and signs up parents as helpers. The children meet in groups to speak with a therapist, and learn elementary ways to identify and manage their anger, frustration and hopelessness. The parents learn in sessions how to reinforce those lessons at home. Studies find that up to three quarters of children who suffer from depression, anxiety or obsessive-compulsive disorder find relief of their symptoms with the help of this kind of therapy, which usually involves once-a-week sessions for a few months or so.
     Alicia Brzycki, a freelance editor who lives in Lawrenceville, N.J., said she noticed several years ago that her son was struggling more than usual with Tourette’s syndrome, a neurological disorder that causes involuntary facial tics and limb movements. The condition did not stop him from making friends or doing well in school, Ms. Brzycki said, “but I think it was first grade, I realized that he was stifling the tics at school, and it created this boomerang effect, and they came out like mad at home.”
     At the urging of a doctor, she took the boy, by then 9, to a program at Temple University in Philadelphia that specializes in treating childhood anxiety, which can exacerbate Tourette’s. Therapists teach children to identify the thoughts that amplify their worries, and then defuse or moderate them. Ms. Brzycki and her husband attended sessions, too, and Ms. Brzycki learned she was unwittingly contributing to her son’s anxiety. “The main thing that came out for me was that I was being overprotective,” she said. She added: “As a parent you want to protect a child from stressful situations, but by doing that you’re creating an avoidance mechanism that can turn a minuscule anxiety into the big, bad wolf. I had to loosen my grip” and let him face his fears.
     Now in fourth grade, her son has helped make a DVD about Tourette’s syndrome that he has shown to classmates. He has a close circle of friends, his mother said, and his tics seem to have diminished lately. But he sometimes still feels self-conscious and will talk himself through it, with his parents’ help if needed.
     Family-based therapy for a difficult childhood disorder is in almost all cases a way of life, not a weeks-long or months-long cure. If parents are serious about finding alternatives to drug treatments, experts say, they have to be willing to make difficult, and long lasting, changes to their behavior and the home environment, and to allow the child to progress at his or her own pace. “You can’t let your foot off the accelerator with something like behavioral modification for A.D.H.D., for example,” said Dr. Gabrielle Carlson, director of child and adolescent psychiatry at Stony Brook University School of Medicine, who used the treatment for her own son. “It’s like making changes in diet and exercise to lose weight: you don’t lose 20 pounds and then you’re home free and can eat ice cream and cake again. No, it’s a complete lifestyle change, and when you have a child with any of these psychiatric difficulties you have to stay on the program, for as long as it takes.”