Noteworthy News Articles on Mental Health Topics, May 1-5, 2006 The hope is that while exposing some to drugs unnecessarily, preemptive treatment may help others ward off or even prevent psychosis, sparing them the agonizing flights of paranoia and confusion that torment the three million American who suffer schizophrenia. Yet the findings from the first long-term trial of early drug treatment, appearing today in The American Journal of Psychiatry, suggest that this preventive approach is more difficult to put into effect — and more treacherous — than scientists had hoped. Daily doses of the antipsychotic drug Zyprexa, from Eli Lilly, blunted symptoms in many patients and lowered their risk of experiencing a psychotic episode in the first year of treatment, the study found. But the drug also caused significant weight gain, and so many participants dropped out of the study that investigators could not draw firm conclusions about drug benefits, if any. The long-awaited study, which was financed by Eli Lilly and the National Institute of Mental Health, raised more questions than it answered, experts said. "The positive result was only marginally significant, and the negative result was clear," said Dr. Thomas McGlashan, a professor of psychiatry at Yale and the study's lead author. "This might discourage people, and legitimately so, from using this drug for prevention because of the weight gain, but hopefully it won't discourage study" of other drugs. Critics have charged that treating people for a disorder that has not yet been diagnosed is not only premature but stigmatizing, especially for adolescents. The new study was intended in part to clarify the trade-off between the risks and the potential benefits of preemptive treatment. "Unfortunately, the study's numbers are so small that it cannot be decisive on the key issue, which is whether it's prudent to treat people early when there are uncertainties about the diagnosis and given the effect of stigma and adverse effects," said Dr. William Carpenter, director of the Psychiatric Research Center at the University of Maryland, who was not involved in the study. The study was plagued by recruitment problems from the beginning, in 1997. Mild, psychosis-like symptoms are rare in adolescents, and families often wait until symptoms are pronounced before seeking treatment, Dr. McGlashan said. Good candidates trickled in slowly; and the researchers added several recruitment sites along the way to increase the numbers of people in the study. They eventually enrolled 60 people, most of them adolescents, who scored highly on a scale that assesses risk for psychosis. The scale rates severity of more than a dozen symptoms, including suspiciousness, grandiosity and bizarre thoughts. From 20 to 45 percent of people who score high on the scale go on to develop full-blown psychosis, in which these symptoms become extreme, researchers have found. The researchers split the participants into two groups, one that received drug treatment and one that took placebo pills. In the first year of a two-year trial, 5 of the 31 of those on medication developed full-blown psychosis, compared with 11 of 29 of those who were taking dummy pills. But by then, more than two-thirds of the young people in both groups had dropped out, making it difficult to interpret differences between them. Some left the study without explaining why; others moved; and 10 of those on medication quit the study because they felt the drug was not working, could not make the appointments or did not like the side effects, among other reasons. Those on medication gained an average of 20 pounds during the study. Weight gain is a common side effect of Zyprexa. "It's a pessimistic trade-off, the weight gain and other side effects for what looks like a modest delay in the acute psychotic episode," said Dr. Steven Hyman, a professor of neurobiology at Harvard. "It's clear we need more efficacious drugs with milder side effects." The doctor's recommended treatment? A series of vitamins, abstaining from sexual intercourse in future pregnancies and, most notably, psychotherapy, intended to explore childhood conflicts and other anxieties. The patient, according to her physician, Dr. Carl T. Javert, an obstetrician at Cornell University Medical College, subsequently had three successful pregnancies. The diagnosis and the treatment fit the era in which they occurred. It was the early 1950's, and the field of psychosomatic medicine — based on the notion that many diseases have their origins in emotional distress — was in its heyday. Was Dr. Javert onto something or was he hopelessly misguided? Do his psychosomatic theories retain any currency today? Throughout history, many doctors and patients have posited that emotions influence health. But it was not until the middle of the 20th century that efforts to prove an association accelerated. A driving force behind psychosomatic medicine was Dr. Franz Alexander, a Hungarian-born psychiatrist trained in the teachings of Freud. Dr. Alexander, who taught at the University of Chicago, drew connections between specific personality types and diseases like hypertension, stomach ulcers and asthma. Chronic emotional disturbances, he believed, led to tissue changes in various organs and thus a series of diseases. Followers of Dr. Alexander devised quite evocative phrases to describe the emotional attitudes of people with certain diseases. The typical hypertensive patient, for example, felt "threatened with harm and has to be ready for anything," they said. Patients with ulcers felt deprived of what was due to them and wanted to get even. A second group of psychosomatic medicine advocates, the psychobiologists, focused on specific emotional events in people's lives, like the deaths of loved ones or the loss of employment, arguing that these traumas led to biological changes. By the 1950's, the emotional issue most closely associated with disease was stress — a factor all too prevalent a decade earlier, especially for soldiers, their families and concentration camp prisoners. The cold war caused further anxieties. Dr. Javert believed that this increasingly stressful world was contributing to miscarriages, usually called spontaneous abortions, among his patients. And, not unlike his fictional namesake, Inspector Javert, who relentlessly tracks Jean Valjean throughout "Les Misérables," the New York obstetrician made it his personal mission to fight miscarriages, which he called "the country's foremost health problem." Of particular concern to Dr. Javert were women who had "habitual abortions" — three or more miscarriages. The chief conflict experienced by such patients, he believed, was "fear of pregnancy and of the baby." These fears, in turn, led to "abortion neurosis," vividly depicted in Dr. Javert's 1957 book, "Spontaneous and Habitual Abortion," as a black octopus enveloping a woman. How could fear and neurosis lead to a miscarriage? To explain this, Dr. Javert turned to psychobiological theory, arguing that stress caused increased secretion of adrenaline. That hormone, in turn, produced premature uterine contractions that then caused spontaneous abortions. Central to Dr. Javert's theories was a holistic view of medicine of the sort that today's medical schools try to teach. "The sciences of somatology and psychology," he wrote, "are employed in treating the patient as a complete individual." Women who successfully gave birth after undergoing psychotherapy were fiercely loyal to him. But Dr. Javert's paternalism, typical of the predominantly male medical profession of the 1950's, would not go over so well today. The "doctor-priest," he wrote, should capitalize on the dependency of his patients when providing advice. Kathleen M. Dixon, a philosopher at Bowling Green State University who has studied Dr. Javert's career, argues that his focus on women's fears and anxieties unfairly blamed them. Also, Professor Dixon says, Dr. Javert's data were suspect. His retrospective assessments of stress levels are probably inaccurate, and he never tested his regimen of vitamins and psychotherapy in any sort of unbiased, controlled clinical trial. Subsequent research has failed to confirm the findings of Dr. Javert, who died in 1981. A study published in The Annals of Epidemiology in 2003 by Deborah B. Nelson, an epidemiologist at the University of Pennsylvania, found no relationship between psychosocial stress and the risk for spontaneous abortion. But this issue will surely generate more studies. Even though psychosomatics no longer has the cachet it once did, research into the mind-body interaction in medicine continues, seeking to prove a quotation attributed to Hippocrates: "It is more important to know what sort of person has a disease than to know what sort of disease a person has." 'Teachable' 9/11 Moment Helped Smokers Quit Nicholas Bakalar, New York Times- 5/2/2006 Starting a smoking-cessation program for New York City firefighters in the months after the Sept. 11 attacks on the World Trade Center might have seemed ill timed. But that is what the Fire Department did, and a study reports that it was a success. Not unexpectedly, the stress of work at ground zero caused many smokers to smoke more and prompted others who had quit to start again. "Tobacco calms your nerves, increases awareness, allows you to stay up," said Dr. David J. Prezant, the Fire Department's chief medical officer. "These are all things that people want in the middle of a disaster. It's not their fault that they start smoking more." At the same time, the disaster provided what Dr. Prezant called "a reachable, teachable moment," when the message about the dangers of smoking could come through. "We know that in every prior environmental disaster, the cancer effects are found in the smokers," he said. "So it would have been a shame to not make a difference here, especially when the stress of the W.T.C. increased smoking." Dr. Prezant is a co-author of an analysis of the program in the April issue of the journal Chest. Ninety-eight percent of the department's rescue workers, whether they used tobacco or not, reported respiratory problems during their exposure to dust and debris at the disaster site. Of almost 12,000 workers screened (including firefighters, health care workers and officers), 15 percent said they regularly smoked tobacco. Of the 1,767 smokers, 29 percent said they increased their daily tobacco use after the disaster, and 23 percent said they were ex-smokers who started again after it. The program was free and voluntary, and 164 rescue workers enrolled — 9 percent of those who said they smoked. Fifty-six family members also participated. At the end of 12 months, 33 percent of the participants were abstinent, compared with the usual 20 to 27 percent abstinence rates for other programs cited in the study. The results were confirmed with biochemical assays and the testimony of family members. Smoking can be confirmed by testing carbon monoxide in exhaled breath. The researchers used the number of cigarettes smoked per day as one measure of the severity of addiction. They also administered a questionnaire to determine feelings of dependency. A few participants smoked fewer than five cigarettes a day. These smokers were treated with up to six cartridges of a nicotine inhaler daily, which together deliver less than 24 milligrams of nicotine. About half of the participants smoked 20 to 30 cigarettes a day, and they were given nicotine patches and nicotine inhalers. Five percent of the group smoked more than two packs a day, and they were given two patches, an inhaler and a nicotine nasal spray. Long-acting Wellbutrin, an antidepressant useful in smoking cessation, was also available, but only a few people chose to use it. The study participants used the patches for maintenance, then added inhalers or nasal spray for acute cravings. The important factor, Dr. Prezant said, was the use of multiple medicines in varying doses depending on the severity of the smoker's addiction. Participants met with tobacco treatment specialists every three to four weeks for group discussions, carbon monoxide breath tests and individual sessions with addiction specialists to discuss cigarette use and get answers to questions. Bill Brennock, a firefighter in the Bronx who works as an aide to the deputy chief, signed up for the program at the beginning, in August 2002. "I used the nicotine patch," he said, "which for me was the biggest thing. It takes away the cravings." But Mr. Brennock needed more than that. "I also used the inhalers, which again were very good because using them simulates opening the pack and puffing on a cigarette. Those were highly beneficial to me." Still, he went on, the personal support may have been most important. "The guys involved with the program were great, always there to prod you, tell you it's going to be O.K.," he said. "They give you moral support and a lot of tools." Mr. Brennock said he had smoked for 30 years and had tried to quit many times. This time it worked. He has now been smoke-free for almost four years, and his wife and his mother-in-law have joined the program. Is there a "reachable, teachable" moment in the life of the ordinary smoker? Yes, Dr. Prezant said. "But unlike the firefighters at the W.T.C., they don't carry a placard that tells you about it. Health care professionals have to find the moment. They have to keep asking." He added: "Maybe a relative just died of cancer. Maybe a child was just admitted to a hospital after an asthma attack. Maybe events like this present the opportunity to quit. It's this constant quest for the moment that we need to understand." Matthew Bars of the Fire Department's bureau of health services drew an analogy with asthma treatment. Like asthma, he said, tobacco addiction "is a chronic, remitting, life-threatening disease." "You give an asthmatic a bronchodilator," he said, "and all of a sudden his son brings home a puppy, and he has a flare-up. No one would say that the asthma meds have failed. You look at the problem and make adjustments to customize the treatment." Mr. Bars is the lead author of the analysis. The program is continuing, and Dr. Prezant says it continues to work. "We have similar if not better quit rates," he said. "We're now in the 40 percent range at six months, because we're concentrating on the severity of cravings and titrating the medicine up accordingly."
The findings suggest a variety of options can help if drinkers are determined to quit and if they regularly meet with a doctor or nurse for guidance, researchers said. They said the study also indicates drinkers can make strides without going to a costly alcohol treatment center. That could vastly expand access to care for a problem that affects some 8 million Americans -- most of whom never seek help. The 1,383 alcoholics studied were assigned to get 16 weeks of treatment -- either counseling, medication or fake pills -- most with the help of a doctor or nurse. All badly wanted to quit, a factor that led some outside experts to question whether the results apply to the real world. And one critic said getting alcoholics to drink less over just four months doesn't prove they've kicked the habit. But the researchers argued that cutting back is an important step and said the results should help convince skeptics that alcoholism isn't hopeless. The study ''really does open up the possibility of people having more choice and it could significantly expand access,'' said Dr. Mark Willenbring, director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism, which funded the research. The findings appear in Wednesday's Journal of the American Medical Association. The most effective treatments were naltrexone, a drug that reduces alcohol craving, and specialized counseling. When each was combined with medical management, abstinence days increased from about 25 percent to about 80 percent. Combining fake pills was almost as effective. Unexpectedly, a newer alcoholism drug called Campral, used more often in Europe than in the United States, was no more effective than dummy pills. The researchers aren't sure why and said more study is needed. A 58-year-old Charleston, S.C., artist said taking a placebo every day helped her ''stay focused on what the goal was, to get rid of this habit.'' Sylvia, who asked that her last name not be used, said counseling with doctors and nurses also helped, teaching her common-sense tips, such as keeping alcohol out of the house and finding healthy substitutes -- for her, tea. That kind of advice is similar to that given newly diagnosed diabetics, the researchers said, and involved nine 20-minute sessions with a doctor or nurse. ''I've had some backslides,'' Sylvia said, but added, ''the longer you stay sober, the easier it gets.'' Among the participants, lapses occurred during a yearlong follow-up but overall, they continued to drink far less than the daily nine- to 10-drink average at the start. Several study authors have industry ties, including lead author Dr. Raymond Anton, a Medical University of South Carolina researcher who has consulted for the makers of a long-acting form of naltrexone and for the U.S. distributor of Campral. Dr. Stuart Gitlow, an addiction specialist at Mount Sinai School of Medicine in New York, said the study used ''worthless'' short-term measures to define success. Alcoholism is a lifetime disease, said Gitlow, who was not involved in the research. ''Either you drink or you don't. Alcoholism is like pregnancy: you are or you're not. No middle ground.'' Dr. Lynne Kirk, president of the American College of Physicians, called the research potentially promising for primary-care doctors faced with alcoholic patients. But she said real-world treatment might be more challenging because those in the study were clearly ''ready to abstain from alcohol. That's a big step in and of itself.'' On the Net: JAMA: http://jama.ama-assn.org
It's a cartoon profile of the frowning father of psychoanalysis, with nose and eyebrows blending into the image of a naked woman. ''What's on a man's mind?'' reads a wry inscription in English, but the real question might be: What would your mother think? Mirth and melancholy, hubris and humor -- it's how the world likes its Freud, whose legacy is still being celebrated and scorned as the 150th anniversary of his birth arrives Saturday. For every sober and scholarly discussion about his groundbreaking theories on neurosis, narcissism or Oedipus complexes there's a New Yorker cartoon, a Woody Allen clip, a ''Seinfeld'' rant or a memorable Freudian slip of the tongue that springs to mind. The English poet W.H. Auden foreshadowed all this after Freud's death in 1939 when he said Freud had already become ''no more a person now but a whole climate of opinion.'' ''There are only a very few personalities who have had such a significant, fundamental impact on today's cultural history as Sigmund Freud,'' said Austrian President Heinz Fischer, a law scholar who says he ''always loves'' to read Freud's works and who is the official overseer of his country's anniversary events. A special exhibition titled ''The Couch'' is being mounted at his apartment at Berggasse 19, now the Sigmund Freud Museum. There are also plans to display paintings by psychiatric patients, screen films about Freud and hold an international symposium on psychoanalysis. His face, bearded and brooding, is on the covers of magazines comparing him to Copernicus and Darwin -- an inspired genius who developed the science that would fundamentally change mankind's understanding of the mind. Dr. Peter Kramer, an American psychiatrist writing a biography of Freud, puts it succinctly: ''He made psychology popular.'' Freud, he said, made it easier for people to talk about sex and aggression, and his ideas spurred a surge of public interest in personal and sexual fulfillment around the time of World War I. Many of Freud's ideas have been modified or discarded, and even psychoanalysts differ on how closely to follow the father of their profession. But they all basically accept Freud's notions that human behavior is unconsciously motivated and that people all struggle to keep their underlying motivations out of their consciousness, said Elisabeth Young-Bruehl, a New York City psychoanalyst. More specifically, Freud's hand can be seen in the popularity of such notions as being a supportive parent rather than just a strict disciplinarian, and the idea that a person's childhood experiences will influence how he or she turns out as an adult, said psychologist James Hansell of the University of Michigan. The very idea of talking to a therapist is a Freud legacy. ''Every form of (talk) therapy out there today rests on the foundations that he laid,'' Hansell said. Even today, Kramer added, ''it helps tens of thousands of people.'' An early user of cocaine who thought it might have cure-all properties, Freud believed psychoanalysis might someday be replaced by medication. But today, talk therapy in general has not given way to drugs. In fact, it has formed a useful partnership. One form of talk therapy, called cognitive-behavioral therapy, coupled with an antidepressant, works better for depression than just the pills alone, says Harvard psychiatrist Dr. Joseph Coyle. It's not psychoanalysis, but Freud ''did, I think, lay the foundations for future clinicians to develop talk-therapy type of interventions that are quite effective,'' Coyle said. Millions of others worldwide channel the good doctor with the kind of ''Freud Lite'' pop psychology chatter so often overheard at cocktail parties. Who among us has never indulged in a little armchair analysis of our dreams or childhoods, or snapped up a self-help book laced with Freudian ideas? ''Everybody jokes that the taxi drivers in Argentina read Freud, and they do,'' said Young-Bruehl. Some of his signature work has inspired generations of comedians and cartoonists -- the Oedipus complex, penis envy, infantile sexuality, the anal phase, the meaning of dreams. Bookstores from Boston to Berlin sell impish, white-bearded Freud ''action figures'' that say, in guttural German-accented English, ''Tell me about your mother.'' Even at the Freud Museum in Vienna, which displays his ''Prof. Dr. Freud'' nameplate, degrees, fedora and cane, ''Analyze Me'' T-shirts are on sale in the gift shop. Would Freud be offended? Maybe not. He clearly had a sense of humor, as evidenced by one of his more droll quotes: ''Sometimes a cigar is just a cigar.'' Not all women are fond of Freud, who once referred to them as ''a dark continent.'' ''My grandfather was a good and loving man, but he understood nothing about a woman's sexuality,'' Freud's granddaughter, 82-year-old Sophie Freud -- who emigrated to the United States in 1942 and became a social worker -- said in an interview with the Austrian news magazine Profil. Freud was also ambivalent about homosexuality; though some scholars say he regarded it as a perversion, he once described it as ''assuredly no advantage, but nothing to be ashamed of.'' A Jew by birth but an avowed atheist, Freud was born in what is now the Czech Republic in the former Austro-Hungarian Empire on May 6, 1856. He spent most of his life in Vienna but fled Nazi persecution in 1938 for England, where he died at 83 of cancer on Sept. 23, 1939. His love of cigars was his undoing. In what might have been a macabre example of his own theory of oral fixation, he is said to have smoked a box a day even after a malignancy forced the surgical removal of his jaw. On the Net: Sigmund Freud Museum: www.freud-museum.at Jamie Talan, Chicago Tribune- 5/2/2006 Scientists call it "psychosis in miniature" and have completed a study that suggests that treating young people with the earliest signs of schizophrenia may prevent or push back the mind-altering condition. But the study, published in the latest issue of the American Journal of Psychiatry, raises concern from some in the field that it may be too early to correctly identify people at risk for schizophrenia, the most severe form of mental illness, affecting one in every 100 people. "While it would be great to find people at risk, you don't want to put people on these medicines if they don't need to be," said Dr. Daniel Weinberger, director of genes, cognition and psychosis at the National Institute of Mental Health. The anti-psychotic medicines have been linked to weight gain, type-2 diabetes and cognitive problems. "There is a lot of concern in the field," Weinberger said. But Dr. Thomas McGlashan, a professor of psychiatry at Yale School of Medicine and principal investigator of the new study, said that it's time to figure out whether doctors can pick out affected young people before their "first break," which is marked by hallucinations or delusions, and can be traumatic for the patient and family. The young people recruited for his study had not lost their grip on reality but knew what they were thinking was not right, McGlashan said. The study found 60 such young people with what they thought were early signs of altered thinking and assigned them to an anti-psychotic medication or a placebo for a year, then watched them for another year. McGlashan and his colleagues found that 38 percent of those on placebo developed psychosis--delusional thinking or hallucinations--compared with 16 percent of those taking olanzapine, made by Eli Lilly & Co. The study was financed by Lilly and the National Institute of Mental Health. Researchers at Long Island Jewish Medical Center also have been trying to identify these at-risk patients and offer early treatment. Dr. Anil Malhotra, director of psychiatric research at LIJ's Zucker Hillside Hospital, has identified strong evidence that a gene called dysbindin, recently implicated in schizophrenia, has a direct effect on cognitive ability. About 12 percent of people with schizophrenia have this particular form of the dysbindin gene.
Use of the new class of drugs known as atypical antipsychotics by people 19 and younger skyrocketed 80 percent in the same time period, according to the pharmacy benefit manager. Antipsychotic drug prescriptions for that age group comprise a relatively small amount of the total for such medicines, Medco said. In 2005, 15 percent of prescriptions for such drugs were for children while 85 percent were for adults. Still, the sharp increase is noteworthy because the powerful drugs are for individuals with serious psychosis such as schizophrenia so there is some concern the medicines may not always be prescribed appropriately, said Dr. Amita Dasmanapatra, senior director of medical affairs at Medco. She said it is possible that some doctors are prescribing the drugs for children with behavioral problems, which would be better controlled by other means. Medco's analysis of over 2 million insured Americans didn't explore the reasons for the increase. Additionally, the atypical antipsychotics aren't approved for use in children although doctors are free to prescribe drugs as they see fit. The number of children on antipsychotics rose to 6.6 per 1,000 in 2005 from 3.81 per thousand in 2001. In contrast, 11 adults per 1,000 were taking one of the drugs. The increase in the number of adults taking antipsychotics rose 13 percent in the four years ended in 2005. However, the rate of prescription growth in children has been slowing although the analysis was not designed to determine the reason. For example, the rate of prescription growth in all antipsychotics was 3.38 percent last year, down from 14 percent in 2004 and 22 percent in 2003. Meanwhile, last year prescription growth for atypical antipsychotics was nearly 5 percent, down from nearly 13 percent in 2004 and 24 percent in 2003. In adults, the number of prescriptions fell 7 percent. Dr. David Kessler, a child and adolescent psychiatrist in Burlington, Vt., speculated that the decrease in growth is tied to concern about atypical antipsychotics link to diabetes. In 2003, The U.S. Food and Drug Administration asked manufacturers of atypical antipsychotics to add warning labels describing the increased risk of high blood sugar and diabetes. The drugs include Eli Lilly & Co.'s Zyprexa, AstraZeneca PLC's Seroquel, Bristol-Myers Squibb Co.'s Abilify and Pfizer Inc.'s Geodon. Also, last year the FDA determined that elderly patients with dementia that were being treated with atypical antipsychotics had an increased risk of death. The FDA asked manufacturers to include a warning on the drugs' label about the risk, and note that the drugs are not approved to treat behavioral problems in patients with dementia. John Keilman, Chicago Tribune- 5/3/2006 When Victoria Squire, 17, was on the prowl for high-powered narcotic painkillers, she had little trouble finding a pharmacist willing to hand them over. Using a fake name and a prescription forged on a computer, the Villa Park teen went into one drugstore after another and emerged with a bottle of Vicodin, usually with no questions asked. On the rare occasions when pharmacists detected her scam, she said, they'd tell her to leave rather than call police. Squire, a recovering crack and heroin addict who said she was obtaining the painkillers for another person, was finally caught in February after as many as 30 successful forays. Sitting in a DuPage County Jail cell, she is still amazed at what she was able to pull off. "I think it's really ridiculous how easy it is," she said. "The government, the state, they practically let you get away with it." Though you need to show a photo ID to buy cold medicine in Illinois, addictive medications can be obtained with nothing more than an easily faked prescription slip. Pharmacists aren't legally obligated to verify an order is genuine, and tamper-proof prescription pads, a security measure used in other states, are not required here. It's a system some say is easily gamed, contributing to a plague of painkiller abuse. According to federal estimates, more than 11 million people--almost 5 percent of those ages 12 and older--used the drugs outside of a doctor's care during the last year. "Filling prescriptions has become such a big business now that I believe at times they're overwhelmed," said Lt. Terry Lemming, statewide drug enforcement coordinator for the Illinois State Police. "Because of that, perhaps, they're not as vigilant on reviewing the prescription as they should be." There are many ways, experts say, to fraudulently obtain prescription painkillers, from enlisting the aid of corrupt doctors, pharmacists or pill-pushing Web sites, to swiping prescription pads or simply buying the drugs on the street. Squire began with a ploy known as "doctor shopping." She visited a series of emergency rooms in the western suburbs complaining of a toothache or migraine, and though she didn't ask for narcotics, knowing that would tip off the physician, she usually got them anyway. "I knew how to play it up so they didn't really get suspicious," she said. Squire, whose own drug problems had caused her to leave her parents' home, said she wasn't getting the medication for herself, but for a housemate addicted to Vicodin. In time, Squire said, the housemate came up with a new strategy, taking a legitimate prescription written by a Naperville internist and in a few simple steps, producing near-perfect forgeries with a home computer. Squire said that to her surprise, even an underage girl dressed in baggy jeans and rock band T-shirts roused little suspicion. She said that she visited pharmacies like Target, Wal-Mart, Osco and CVS, and that the druggist almost always filled her order. When employees did check with the doctor's office, they would warn Squire, allowing her to escape. The Drug Enforcement Administration says 1 in 4 cases of illegally obtained prescription drugs involves forgery. Under Illinois law, however, pharmacists are required only to act in good faith when dispensing a controlled substance. They don't have to confirm the authenticity of the prescription. A spokesman for Walgreens, where Squire said she took most of her prescriptions, said the chain's pharmacists use "professional judgement" when assessing the veracity of an order. Marlin Weekley, president of the Illinois Pharmacists Association, said most druggists are savvy about recognizing bogus prescriptions. He added that phoning a doctor to check every narcotics order would be impractical. A pharmacy fills dozens of them every day and callbacks already can take hours, imposing a heavy burden upon honest, suffering patients, he said. Even so, some states have tried to curb doctor shopping with electronic prescription tracking, which allows physicians, pharmacists and law enforcement to check a patient's history of obtaining controlled substances. Illinois has been tracking prescriptions since 2000, but only so-called Schedule II drugs, such as the powerful painkiller OxyContin. Vicodin and some other narcotics, classified as Schedule III medications, are not reviewed. A bill pending in Springfield would expand monitoring to all controlled substances, but the measure has yet to leave the House Rules Committee. Electronic systems can raise an alert if phony prescriptions or a doctor's DEA license number are in circulation. Yet while the number, used to confirm a physician's authority to prescribe narcotics, helps track down doctors who abuse the privilege, it is less useful for nailing forgers with a slew of aliases. "It's like people using bad checks. You have to start somewhere with some real information," said Susan Hofer, spokeswoman for the Illinois Department of Financial and Professional Regulation. Some states have tried a further safeguard with special prescription slips for controlled substances. Forms used in Kentucky, Indiana and elsewhere include such features as watermarks, heat-sensitive ink and paper that displays the word "VOID" if the form is copied, scanned or faxed. Squire's pill-gathering spree lasted until Feb. 11, when she went to a Jewel-Osco in Lombard with a prescription slip bearing a bogus name. She had gotten Vicodin there before, she said, but this time sensed the pharmacist's suspicion. She swallowed her unease and stuck around to get the drugs. But Lombard police said the pharmacist checked the order with the doctor's office, and upon learning it was a fake, called authorities. "When I went to pick it up, they said it would be another 15 or 20 minutes," Squire said. "I went to go find [the housemate] and two cops stopped me and arrested me." Charged with forgery and unlawful possession of a prescription form--felonies carrying a penalty of up to five years in prison--Squire is now behind bars, hoping to get into a drug court program that would let her avoid incarceration in exchange for treatment. Meanwhile, Squire's mother, Liz Cunneen, who lives outside St. Charles, has been writing to elected officials in Washington, looking for changes in a system she said has proven all to easy to cheat. Above all, she wants pharmacies to check IDs when filling prescriptions for controlled substances, something a growing number of states require. Squire said that would have complicated but not derailed her plot. However, if all the defenses adopted by other states were in place, she said, the plan would have been too complicated to attempt. "There might always be a way around the system, but I think it would diminish it 99 percent," she said. "I don't think being able to do what I was doing was right." Placebo Just as Effective as Alcoholism Drug Denise Gellene, Los Angeles Times- 5/3/2006 The drug Campral, approved two years ago to treat alcoholism, works no better than a placebo in reducing the craving for alcohol, according to a study released Tuesday. The report in the Journal of the American Medical Assn. compared several treatments for alcoholism and found the older generic drug naltrexone offered the clearest benefits. The study of 1,383 patients at 11 medical centers in the U.S. should spur increased use of naltrexone, which is not widely prescribed, researchers said. The dominant treatment now is counseling and behavioral therapy, including Alcoholics Anonymous. "I think results of this kind show that medication has an important place in the treatment array," said Dennis Donovan of the University of Washington and one of the study's 20 authors. The finding that Campral had no effect was a surprise because the pill seemed to work in other clinical studies. Scientists said more research was needed to sort out the conflicting results. In a statement, Campral marketer Forest Laboratories Inc. said the study should be viewed as "a single data point." About 8 million Americans have alcohol dependence, but a minority receive treatment for the disorder. Fewer than 150,000 receive medication for alcoholism. About 75,000 Americans die each year from complications related to alcoholism. The study looked at various combinations of Campral, naltrexone, behavioral therapy sessions and a placebo pill. Patients received treatment for 16 weeks and were followed for a year after the treatment ended. All the participants said they wanted to quit drinking. Patients taking either the drugs or a placebo also attended up to nine 20-minute counseling sessions focused on the use of their medication. Patients assigned to behavioral therapy attended as many as 20 50-minute sessions for intensive motivational support. In addition, all patients were encouraged to participate in Alcoholics Anonymous. After 16 weeks, researchers assessed the groups based on the ability to abstain from alcohol and avoid heavy drinking, defined as four to five drinks a day. Patients in all groups, including those taking a placebo, substantially reduced their drinking. Researchers attributed the so-called placebo effect to the optimism on the part of patients about the potential benefits of receiving pills and the effects of regular meetings with doctors and nurses. Patients taking Campral showed no reduction in craving or the length of time before a relapse involving heavy drinking compared to a placebo, according to the study. But patients who received naltrexone with counseling showed significant improvement in both of those areas. The patients had twice the chance of achieving a "good outcome" — meaning they were able to abstain or drink in moderation — compared to those on a placebo. Naltrexone patients also did better than those receiving intensive behavioral therapy. When researchers looked at patients one year after treatment ended, they found that those who had received naltrexone continued to show a small advantage in preventing a relapse. In an editorial accompanying the study, Dr. Henry R. Kranzler of the University of Connecticut School of Medicine said the finding suggested treatment should extend beyond 16 weeks for patients to achieve sustained benefits.
Therapy and Addiction Drugs Help Heavy Drinkers Benedict Carey, New York Times- 5/3/2006 Careful medical attention, combined with psychotherapy or an addiction drug, is the most effective way to help heavy, chronic drinkers reduce their alcohol consumption, researchers are reporting today from the largest-ever trial to compare treatments for alcohol dependence. In the study, the drinkers who received the best medical attention available reduced the amount they drank by 80 percent, and many controlled their habits for more than a year. The widely anticipated government study is being published in The Journal of the American Medical Association. All told, about three-quarters of the nearly 1,400 people in the study were abstinent or drinking moderately after four months of treatment, and more than half of those were still doing well a year later. Experts said the results were impressive but should be interpreted with caution. The men and women in the study spent far more time with doctors, nurses and other staff members than most people who seek treatment do; such lavish attention itself acts as therapy, they said. And the researchers did not report how many of the participants were entirely abstinent by the end of the trial, an important measure of lasting success for many drinkers. Fewer than 10 percent of the estimated eight million Americans who are dependent on alcohol ever receive specialized treatments, and fewer than one in 100 are ever offered medication, surveys find. "This is a beautiful study, in terms of the way it was designed and executed, in that it gives us a good look at how well a variety of treatments work," said Dr. Edward Nunes, a professor of clinical psychiatry at Columbia, who was not involved in the research. Dr. Nunes added: "What the study shows is that it doesn't seem to matter much what kind of treatment you get, as long as you get an approach with a good rationale. Most people in the study reduced their drinking significantly." Dr. Raymond Anton of the Medical University of South Carolina led a research team that randomly assigned 1,383 problem drinkers to one of nine treatment groups. Some received the drug naltrexone, with or without regular therapy sessions; others took acamprosate, another popular addiction drug, by itself or with therapy; still others received dummy pills, combined with different therapies. All had regular visits with doctors, nurses and staff members working on the study. The talk therapy included up to 20 hourlong sessions, in which people learned to recognize the cues that spurred their cravings, like the sight of a familiar bar, and how to diffuse or ignore them. Therapists engaged family members and friends to help, when possible, and used 12-step techniques, when appropriate. After four months, about three-quarters of those receiving naltrexone, talk therapy or both were abstinent or drinking no more than one or two drinks a day on average, the study found. And these approaches proved more effective than medical management by itself or acamprosate treatment. In previous studies, acamprosate has roughly doubled people's chances of becoming abstinent, and most addiction doctors consider it a useful therapy. The study's authors said they would conduct further analyses to see whether the drug benefited a subgroup of drinkers in the new study. Many researchers expected that naltrexone, which blunts the rush of heavy drinking, and acamprosate, which soothes the drumming irritation of withdrawal, would work better together than alone, as previous research had suggested. Yet combining the drugs did not make any difference in the new study. Taking pills — any pills, whether placebo or prescription — greatly increased people's odds of curbing their habits, the study found. Drinkers who attended talk therapy classes and took placebo pills did significantly better than those who received the same therapy without placebos or drugs. "The act of taking the pills itself reinforces commitment to abstinence," said Dr. Barbara Mason, of the Scripps Research Institute, a co-author of the study. Dr. Mason said that both drugs were given in high doses with very few adverse effects and that "one of the main findings of the study was that the drugs are safe." The differences between the groups disappeared in the year after treatment was completed, the researchers found: about 47 percent of the drinkers still had their drinking under control, regardless of which treatment they had received. "What happens is that, after treatment is over, a certain number of people relapse," Dr. Anton said. "And like many chronic conditions, the farther out you go, the more people relapse." Extending the length of treatment, in some form, might be the best way to preserve drinkers' early gains, the researchers concluded. That means about 5.5 out of every 1,000 school-age children have been diagnosed with autism. Past estimates have ranged from 1 to 9 out of every 1,000 children, based on smaller studies in individual states or cities. The government-run study released Thursday reports findings from national surveys of tens of thousands of families. The study by the U.S. Centers for Disease Control and Prevention also found boys are nearly four times more likely than girls to be identified with the condition. And it found Hispanics had lower autism rates, though it's possible that may be related to health-care access problems. ''There's somewhat of a dearth of information how autism impacts children and their families,'' said lead author Laura Schieve, an epidemiologist with the CDC. Because of its national scope, the CDC report ''is probably one of the best'' studies of how often autism is diagnosed, said Dr. Eric Hollander, an autism expert at New York's Mount Sinai School of Medicine. The study does not attempt to answer whether autism is increasing -- a controversial topic, driven in part by a debate over whether autism is linked to a vaccine preservative. The new research is being published this week in the CDC publication, Morbidity and Mortality Weekly Report. This is the first in a series of autism studies being issued by the Atlanta-based CDC. Future articles will look at autism diagnosis variations across different communities, and at how long it takes for a child to be diagnosed after onset of symptoms. Autism is a complex disorder usually not diagnosed in children until after age 3. It is characterized by a range of behaviors, including insistence on sameness, difficulty in expressing needs and inability to socialize. Schieve's study pulls together results from two surveys done in 2003 and 2004. In both, parents were asked the same question: Has a doctor or health-care provider ever told you your child has autism? In the first survey, conducted through personal interviews, 102 of the 18,885 children in the sample were identified as autistic. When the numbers were statistically adjusted to account for families that didn't respond and to better represent the U.S. population, the resulting prevalence rate was 5.7 per 1,000. In the second survey, done through random-digit-dialed telephone questioning, 465 of the 79,590 children in the sample were identified as autistic. The adjusted rate was 5.5 per 1,000. Researchers believe some parents may have answered 'yes' for two similar but less severe diagnoses, Asperger disorder and pervasive developmental disorder (which is sometimes called ''atypical autism''). For that reason, the study's prevalence rates may reflect other autism spectrum disorders and not just autism alone, CDC officials said. Kennedy, D-R.I., the son of Massachusetts Sen. Edward M. Kennedy, said he would seek immediate treatment at the Mayo Clinic in Rochester, Minn. His one-car accident about 3 a.m. Thursday was the talk of the capital, with police saying he appeared to be intoxicated but Kennedy saying later that day that he had had nothing to drink. For Kennedy, who said he has suffered from depression and pain-medication addiction for years, the trip to the Mayo Clinic was his second in less than five months. He went there over Christmas and said he returned to Congress ''reinvigorated and healthy.'' ''I've been fighting this chronic disease since I was a young man, and have aggressively and periodically sought treatment so that I can live a full and productive life,'' he said at a Capitol Hill news conference. ''Of course, in every recovery, each day has its ups and downs, but I have been strong, focused and productive since my return,'' Kennedy said. Kennedy said he realized he needed to seek treatment again after he crashed his car. Capitol Police cited him with three traffic violations and said Friday their investigation was continuing. Kennedy promised to cooperate with police. The accident sparked allegations that Kennedy was drinking and had received special treatment by police. He said he could not recall the accident. ''I simply do not remember getting out of bed, being pulled over by the police, or being cited for three driving infractions,'' Kennedy said. ''That's not how I want to live my life. And that's not how I want to represent the people of Rhode Island.'' Kennedy, 38, a nephew of President Kennedy, was elected to Congress in 1994. As he left the lectern Friday, he shook his head no when asked if he might resign. ''I need to stay in the fight,'' he said. He did not take other questions. As a high school senior, Kennedy was treated at a drug rehabilitation clinic before he went to Providence College. He has said he wants to end the stigma of mental health problems, and he has been praised by mental health professionals for being open about his struggles with depression, alcoholism and substance abuse. He also has been diagnosed with bipolar disorder. ''I hope that my openness today and in the past, and my acknowledgment that I need help, will give others the courage to get help if they need it,'' he said Friday. The congressman's father issued a statement saying he was proud of his son for admitting his problem and taking steps to correct it. ''He has taken full responsibility for events that occurred ... and he will continue to cooperate fully with any investigation,'' the elder Kennedy said. According to the police report, Patrick Kennedy drove his green 1997 Ford Mustang convertible into a security barrier near the Capitol. The officer listed alcohol influence as a contributing factor in the crash and noted that Kennedy was ''ability impaired,'' with red, watery eyes, slurred speech and unsteady balance. However, Kennedy said that he took a sleeping pill and another drug that can cause drowsiness before the accident but had not been drinking alcohol. Kennedy told the police officer he was ''headed to the Capitol to make a vote,'' the report said. He was cited for failure to keep in the proper lane, traveling at ''unreasonable speed'' and failing to ''give full time and attention'' to operating his vehicle. Kennedy spokeswoman Robin Costello acknowledged the police report but said in an e-mailed message, ''The congressman has not been presented with those traffic tickets.'' Louis P. Cannon, president of the Washington chapter of the Fraternal Order of Police, who was not on the scene, said the officers involved in the accident were instructed by an official ''above the rank of patrolman'' to take Kennedy home and that no sobriety tests were conducted at the scene. ''I never asked for any preferential treatment,'' Kennedy told reporters as he left his congressional office Thursday night. It was Kennedy's second auto crash in three weeks. His car struck the rear passenger door of a car while he was making a left turn from a roadway into a pharmacy in Portsmouth, R.I., according to a police report on the April 15 accident. No injuries were reported and Kennedy was not cited. In the Capitol Hill accident, police observed Kennedy's car, with no headlights on, swerve into the wrong lane and strike a curb. Kennedy nearly hit a police car, the report said, and did not respond to the officer's efforts to pull him over. He continued at a slower speed before hitting a security barrier head-on, the report said. Kennedy said that he'd gone home Wednesday evening after work and had taken ''the prescribed amount'' of Phenergan, a prescription anti-nausea drug that can cause drowsiness, and Ambien, a sleep medication. The attending physician for Congress had prescribed Phenergan on May 2 to treat Kennedy's gastroenteritis, an inflammation of the stomach and intestines. According to the drug's label, Phenergan can increase the effects of sleep medicines such as Ambien. Kennedy was prescribed Ambien on April 25 for insomnia, according to a statement from Dr. John F. Eisold, the attending physician for Congress. Kennedy's office released the statement. Ambien comes with a warning to patients that it can cause confusion, strange behavior and hallucinations. Also, it is to be taken only when patients have time for a full eight hours of sleep, allowing its effects to wear off, according to its Food and Drug Administration-approved label.
Text of Patrick Kennedy's Statement
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