Noteworthy News Articles on Mental Health Topics, October 1-9, 2007

Recent studies show that how often couples fight or what they fight about usually doesn’t matter. Instead, it’s the nuanced interactions between men and women, and how they react to and resolve conflict, that appear to make a meaningful difference in the health of the marriage and the health of the couple.

A study of nearly 4,000 men and women from Framingham, Mass., asked whether they typically vented their feelings or kept quiet in arguments with their spouse. Notably, 32 percent of the men and 23 percent of the women said they typically bottled up their feelings during a marital spat.

In men, keeping quiet during a fight didn’t have any measurable effect on health. But women who didn’t speak their minds in those fights were four times as likely to die during the 10-year study period as women who always told their husbands how they felt, according to the July report in Psychosomatic Medicine. Whether the woman reported being in a happy marriage or an unhappy marriage didn’t change her risk.

The tendency to bottle up feelings during a fight is known as self-silencing. For men, it may simply be a calculated but harmless decision to keep the peace. But when women stay quiet, it takes a surprising physical toll.

“When you’re suppressing communication and feelings during conflict with your husband, it’s doing something very negative to your physiology, and in the long term it will affect your health,” said Elaine Eaker, an epidemiologist in Gaithersburg, Md., who was the study’s lead author. “This doesn’t mean women should start throwing plates at their husbands, but there needs to be a safe environment where both spouses can equally communicate.”

Other studies led by Dana Crowley Jack, a professor of interdisciplinary studies at Western Washington University in Bellingham, Wash., have linked the self-silencing trait to numerous psychological and physical health risks, including depression, eating disorders and heart disease.

Keeping quiet during a fight with a spouse is something “we all have to do sometimes,” Dr. Jack said. “But we worry about the people who do it in a more extreme fashion.”

The emotional tone that men and women take during arguments with a spouse can also take a toll on their health. Utah researchers have videotaped 150 couples to measure the effect that marital arguing style has on heart risk. The men and women were mostly in their 60s, had been married on average for more than 30 years and had no signs of heart disease. The couples were given stressful topics to discuss, like money or household chores, and the comments made during the ensuing arguments were categorized as warm, hostile, controlling or submissive. The men and women also underwent heart scans to measure coronary artery calcium, an indicator of heart disease risk.

The researchers found that the style of argument detected in the video sessions was a powerful predictor for a man or woman’s risk for underlying heart disease. In fact, the way the couple interacted was as important a heart risk factor as whether they smoked or had high cholesterol, says Timothy W. Smith, a psychology professor at the University of Utah, who presented the study last year to the American Psychosomatic Society.

For women, whether a husband’s arguing style was warm or hostile had the biggest effect on her heart health. Dr. Smith notes that in a fight about money, for instance, one man said, “Did you pass elementary school math?” But another said, “Bless you, you are not so good with the checkbook, but you’re good at other things.” In both exchanges, the husband was criticizing his wife’s money management skills, but the second comment was infused with a level of warmth. In the study, a warm style of arguing by either spouse lowered the wife’s risk of heart disease.

But arguing style affected men and women differently. The level of warmth or hostility had no effect on a man’s heart health. For a man, heart risk increased if disagreements with his wife involved a battle for control. And it didn’t matter whether he or his wife was the one making the controlling comments. An example of a controlling argument style showed up in one video of a man arguing with his wife about money. “You really should just listen to me on this,” he told her.

What’s particularly notable about the study is that the men and women filled out standard questionnaires about the quality of their relationships, but those answers were not a good predictor of cardiovascular risk. The difference in risk showed up only when the quality of the couple’s bickering style was assessed.

“Disagreements in a marriage are inevitable, but it’s how you conduct yourself,” Dr. Smith said. “Can you do it in a way that gets your concerns addressed, but without doing damage at the same time? That’s not an easy mark to hit for some couples.”

The study, which followed for a year more than 600 adolescents being treated for chronic depression, found that four in five recovered entirely, or nearly so, when treated over nine months with medication, talk therapy or a combination of the two.

Patients taking medication showed significant signs of improvement up to six weeks earlier than those who received talk therapy alone, but were about twice as likely to report feeling suddenly suicidal. The combination of the two therapies, the authors found, produced the most rapid recovery and protected against sudden suicidal urges.

For several years experts have been debating the risks to children and adolescents who take antidepressants like Prozac and Paxil. In 2004, health regulators required that all labels for antidepressants carry prominent warnings that the drugs were associated with increased risks of suicidal thinking and behavior in young patients, a link that many psychiatrists say has been blown out of proportion, scaring off patients who could benefit from drug treatment.

In this study, antidepressants lowered the risk of suicidal thoughts and actions over all, but significantly less so than talk therapy.

“What this study shows, convincingly and for the first time, is that there are very good options for a child who is thought to be at risk for suicidal thinking,” said Kevin Stark, a psychologist at the University of Texas, who was not involved with the research. “Psychosocial therapies do work on their own, with time. But they also help prevent relapse, and this shows that they can help make drug treatment safer.”

In the study, which began in 1999, researchers recruited 654 youths ages 12 to 17 who had been moderately to severely depressed for up to a year or longer. The adolescents were randomly assigned to be treated with Prozac, the antidepressant made by Eli Lilly; cognitive behavioral therapy for a weekly hourlong session; placebo pills; or a combination of Prozac and talk therapy.

After 12 weeks, about three in four of the patients receiving both talk therapy and medication were rated as “much better” or “very much better,” and two-thirds taking just the drug fared just as well. Talk therapy by itself was no better than the placebo.

After four months, about two-thirds of those receiving any treatment were rated as much or very much improved — significantly better than a typical response to placebo pills.

By nine months, 8 in 10 adolescents had shaken off their depression, entirely or almost entirely, no matter the treatment.

Talk therapy was a safer alternative. Almost 15 percent of the patients taking just Prozac reported what were described as “suicidal events,” mainly talk and thoughts of suicide so alarming that doctors called in the patients and, often, altered dosages.

The rate of such events for those receiving just cognitive behavior therapy was 6 percent. The results for combination therapy were about the same.

“The message is that medication accelerates recovery, but cognitive therapy protects against these bad reactions, and the combination is the best option,” said Dr. John March, chief of child and adolescent psychiatry at the Duke University Medical Center and the principal investigator for the study.

The talk therapy promoted changes in behavior like getting patients out of bed and doing something that they enjoy, like playing basketball or going to a party. It also provided cognitive therapy, in which patients are taught to diffuse poisonous assumptions like “I’m a loser” or “I’ll never get a girlfriend.”

Experts say it is not easy to find specialists in this therapy outside large cities. The techniques have been widely published in manuals and books, and Dr. March said a good therapist could usually work such techniques into a treatment plan.

“The trick,” he said, “is to be an intelligent consumer and find a skilled therapist who’s willing to work with you on these methods.”

Yet relationships in which close friends begin having sex come with their own brand of awkwardness, according to the first study to explore the dynamics of such pairs, often called friends with benefits, or F.W.B..

The relationships tend to have little romantic passion, but stir the same fears that stalk lovers: namely, that one person will fall harder than the other.

Paradoxically, and perhaps predictably, the study suggests, these physical friendships often occlude one of the emotional arteries of real friendship, openness. Friends who could once talk about anything now have an unstated taboo topic — the relationship itself. In every conversation, there is innuendo; in every room, an elephant.

The research, conducted among Michigan State University students, confirmed previous findings that most college students report having had at least one such relationship. Although that is undoubtedly true of many couples throughout history, “friends with benefits” have become a cultural signature of today’s college and postcollege experience.

“The study really adds to the little we know about these relationships,” said Paul Mongeau, a professor of communications at Arizona State University who was not involved in the research. “One of the most interesting things I get from it,” he said, “is this sense that people in these relationships are afraid to develop feelings for the other person, because those feelings might be unreciprocated.”

In the study, appearing in the current issue of Archives of Sexual Behavior, Melissa Bisson, a former graduate student at Michigan State, and Timothy Levine, a professor in the communications department, surveyed 125 young men and women and found that 60 percent reported having had at least one friend with benefits.

One-tenth of these relationships went on to become full-scale romances, the study found. About a third stopped the sex and remained friends, and one in four eventually broke it off — the sex and the friendship. The rest continued as friends-with-benefits relationships.

In a follow-up study, the researchers gave 90 students who reported having at least one such relationship a battery of questionnaires asking about passion, commitment and communication.

“We found,” Dr. Levine said, “that people got into these relationships because they didn’t want commitment. It was perceived as a safe relationship, at least at first. But also that there was this growing fear that the one person would become more attracted than the other.”

Yet, he added, the overall qualities of the relationships appeared to be true to the name. On standard psychological measures, they appeared more like friendships than romances.

Friends with benefits scored in the middle on a scale assessing intimacy and low on passion and commitment, the study found. “When scores were compared to previous findings with romantic couples, scores on all three dimensions were lower, with the largest differences observed in commitment followed by passion,” the authors wrote.

The relationships may be less common than reported. “Friends with benefits” appears to have become an umbrella term for a wide variety of sexual arrangements, some of which are quite familiar, Dr. Mongeau said.

In addition to budding romances, he said, the “friends” may also be former lovers who occasionally see each other or they may be people who hang out at the same places and now and then end up wrapped around each other, even though they are not really friends.

Dr. Mongeau said the study seemed to have captured the dissonant, circular thinking that characterized what it felt like for a friendship to enter treacherous territory.

“There’s clearly a strong desire to be with this other person, who fills important needs,” he added. “But at the same time, it’s as if I’m saying, ‘O.K., I’m not going to get passionately involved — because then it’s at risk of being a real romance.’”

Mental Disorders Cause 1/3 of Sick Days
Denise Gellene, Los Angeles Times- 10/3/2007

Mental disorders account for about one-third of all sick days, more than those caused by back pain, according to the most comprehensive report yet on the effect of illness on disability. Adult Americans with depression, anxiety or other psychological disorders annually miss 1.3 billion days of work, school or other daily activity, according to a report published Tuesday in the Archives of General Psychiatry. Back and neck pain cause sufferers to miss 1.2 billion days.
     Mental disorders had a bigger effect than expected, researchers said, yet they often are left unrecognized and untreated. "If we treated the mental disorders, we could wipe out a lot of the impairment," said senior author Ronald C. Kessler, a professor of healthcare policy at Harvard Medical School.
     Lead author Kathleen Merikangas, an epidemiologist with the National Institute of Mental Health, said more funds should be allocated to the study and treatment of musculoskeletal conditions and depression and psychiatric disorders. "It is ironic we spend the least on musculoskeletal disorders and depression when they have the most impact on people's lives and disability," she said.
      The study was based on the National Comorbidity Survey Replication, a nationwide survey of 9,282 people over age 18 that was sponsored by the National Institute of Mental Health. Participants reported the number of days they had been completely unable to work or carry out normal activities within the previous month. They also said which of 30 mental and physical conditions, including such illnesses as cancer and heart disease, they had had during the past year Transient illnesses, such as influenza, were not included.
     Taken together, all chronic conditions, including cancer, heart attack, ulcer and vision loss, sideline adults for a total of 3.7 billion days a year researchers said. Researchers found that more than half of American adults have chronic health conditions. Some go to work every day, while others are severely impaired and no longer work. The study found that those with chronic conditions take an average of 32 sick days a year.
     Among mental disorders, depression accounted for the most sick days, at 387 million. Other reasons included: social phobia, at 214 million days; post-traumatic stress disorder, 113 million; generalized anxiety disorder, 110 million; bipolar disorder, 103 million; panic disorders, 101 million; substance abuse, 93 million; agoraphobia, 37 million; and separation anxiety disorder, 20 million.
Besides back and neck pain, other physical conditions that led to missed days at work included arthritis, at 375 million days, and stroke, at 221 million days. Cancer patients missed a total of 71.5 million days, and heart attack victims 204 million days. Although the diseases are devastating, cancer and heart attacks accounted for a relatively low number of lost workdays.




Adults Being Given Juvenile Protections In Sex Abuse Cases
Ernesto Londono, Washington Post- 10/7/2007

They were both children more than 25 years ago when Sona Gandhi and her neighbor had the encounters that she would later call sexual abuse. They were certainly adults the day Gandhi confronted the man in a Rockville courtroom last winter.

But the man, now 40, was charged as a juvenile because of his age at the time of the alleged offenses, in a type of case that is becoming more common as women increasingly report being molested as children.

"I deal with this every day of my life," Gandhi, 33, told the man in court, according to a copy of her prepared remarks. "I hope that's something you think about every day of yours."

Cases such as the one prompted by Gandhi's report to police last year have ignited a legal debate about whether adults can and should be tried in juvenile court and whether labeling adults as sex offenders for things they did as teenagers is fair and necessary.

Gandhi says the criminal justice system let her down. Montgomery County prosecutors dropped the charges against her former neighbor after clinical experts concluded that he is unlikely to offend again. The man had admitted the abuse in a telephone conversation recorded by police last summer, according to a police report.

Although Gandhi was given an opportunity to confront him in court the day the case was dropped, she says the main goals of her decision to come forward -- accountability and public safety -- remain unfulfilled. The case file is not open to the public because it was handled in juvenile court. Her former neighbor was not found to have committed the offense, and he was not subjected to the scrutiny of adult court. "It shouldn't be a secret he gets to keep," Gandhi said. "If you have a child, do you want this man as your child's teacher, soccer coach, taking him on a camping trip?"

The Washington Post is not naming the man because it generally doesn't publish the names of juveniles charged with crimes. It also usually does not print the names of victims of sexual crimes, but Gandhi asked that her name be printed because she said she wants to draw attention to the issue. Her former neighbor declined to be interviewed. His attorney, Alan L. Fishbein, said that prosecuting his client as an adult would have been unfair. "My client had an exemplary life and never had any difficulties" with the law, he said.

Montgomery Assistant State's Attorney Kathy Knight said she is barred from discussing the case because it was handled in juvenile court. Speaking generally, she said, old sex cases involving people who were juveniles at the time present a tough balancing act.

Beyond the ages of the offender and the victim at the time of the crime, the nature of the offense and the evidence at hand, prosecutors look for signs that the offender remains a threat to children, and they weigh the potential ramifications of a conviction. Prosecutors also rely heavily on expert assessments of the threat level of offenders and the extent to which they have sought roles of responsibility around minors, Knight said. "We have to look at each one and try to be fair," she said. "To have all the sanctions and consequences of adult court for something they did when they were 13 or 14 -- that's huge."

The disposition of Gandhi's case appears to be an exception among the dozen or so such cases that have been investigated in the area in recent years, according to lawyers involved in them. Most cases started in juvenile court but were transferred automatically because prosecutors argued that the juvenile system doesn't have jurisdiction over people 21 and older.

Some lawyers have recently argued that Maryland's highest court has ruled that judges have the discretion to keep some cases in juvenile court. However, the Department of Juvenile Services has refused to conduct assessments or make recommendations on which court the cases belong in.

In the District and Virginia, prosecutors generally charge adult offenders in regular court regardless of how old they were when the offense was committed, according to lawyers who have researched the issue.

Rockville lawyer Stephen Mercer has a client who is appealing the transfer of his case, without a substantive hearing, to adult court. Mercer said that adults who molested younger children as teenagers should be prosecuted in juvenile court -- if at all.

His client, a 26-year-old Olney man, was fired as a Prince George's County police officer after being accused in December 2005 of molesting a child he babysat for in 1996 and 1997, according to court records. The case began as a juvenile proceeding but was transferred to Circuit Court. The case has not gone to trial; prosecutors agreed to await the results of the appeal.

The following account of Gandhi's case is supported by an interview with Gandhi, a copy of the police report and e-mails between Gandhi and Knight, the prosecutor, which Gandhi provided to The Post.

The incidents occurred when Gandhi was about 7 and living in Montgomery. A neighbor, then about 14, was a friend of one of Gandhi's older brothers, and she went to his house frequently. On some of those occasions, he fondled her, she said. She told no one.

For years, Gandhi said, she suppressed memories of the abuse. But they resurfaced. "I remember feeling very frightened, trapped, sort of paralyzed," she said. In March last year, she contacted police. "It was empowering: Finally I'm the one making decisions over some of this," she said.

Detectives took Gandhi's statement and told her that they would arrange a phone sting. During a conversation that detectives recorded in June 2006, the man apologized profusely. "I knew it was wrong, but it was something I knew I could do," he said, according to the police report. "I couldn't stop myself."In the conversation, he also told Gandhi that he had been molested by a female cousin when he was a child and that he had molested another child, according to Knight's e-mails. "I so regret how I hurt you," he said, according to the police report. "I wish I could take your pain away."

The remarks led detectives to charge the man with three counts of third-degree sex offense. The man agreed to undergo a clinical risk assessment evaluation. Gandhi was not shown the evaluation, but prosecutors told her that it did not suggest that her former neighbor was likely to abuse children or that he had done so as an adult.

Research on juvenile sex offenders shows they are more likely than adults to respond to treatment. And experts say many juveniles who commit sex offenses don't do so as adults.

Ronald I. Weiner, director of Clinical and Forensic Associates, a Washington-based agency that evaluates sex offenders in criminal proceedings, said his office has been asked in recent years to assess the risk level of about a half-dozen adults charged in sex offenses they allegedly committed as juveniles. "There was no evidence of subsequent abuse into adulthood," he said, noting that the low number makes it impossible to draw solid conclusions.

Still, Gandhi thinks authorities failed to cast a wide net in part because investigators must protect the privacy of juveniles in delinquency proceedings.

"It's a tough balance between privacy concerns and what's best for the general public," said Frank Darley, a Montgomery family crimes detective. Before the case was dropped, Gandhi told prosecutors she was upset by their decision. She said they told her they took into account that the former neighbor had been forthcoming and apologetic.

"I know it took a lot of courage to finally come forward," Knight wrote to her in an e-mail. "But circumstances are very unusual in this case. We are not talking about punishing someone for something they did as an adult. We are looking at the behavior of a 14 year old boy. He was just a kid too. And while what he did was horrific, we cannot lose sight of the fact that he was a kid when he did it."

Massachusetts Tracks Children on Psychiatric Drugs
Scott Allen, Boston Globe- 10/7/2007

Following the death of a 4-year-old Hull girl from an overdose of psychiatric drugs last December, state officials have set up a unique early-warning system to spot preschoolers who may be getting excessive medication for mental illness. In just the first three months, the system has flagged the cases of at least 35 children for further investigation, and the number is sure to rise.

The state Medicaid program is analyzing records of 82,900 children under age 5, looking for those taking at least three psychiatric drugs or a single prescription of a powerful antipsychotic drug. Mental health professionals will review the care of these children and, if necessary, contact the prescribing doctor for an explanation, say officials of the state insurance program for lower-income families, known as MassHealth.

Although cases like the overdose of Rebecca Riley are rare, the prescription of psychiatric drugs to young children is not. Doctors last year prescribed Clonidine - a drug sometimes used to treat hyperactivity that was found in lethal quantities in the Hull girl's bloodstream - to 955 children under age 7 in MassHealth. Doctors also prescribed antipsychotic drugs, which raise the risk of diabetes and obesity, to 536 children under age 7, according to MassHealth records. MassHealth could not say how many of these cases involve children under age 5 and might be subject to review.

Some psychiatrists have been concerned for years about the rise of psychiatric drug treatment of young children, largely because few preschoolers are old enough to show clear signs of mental illness and there are almost no studies on how the chemicals affect their developing brains. But until Riley's death from three drugs she was taking to treat bipolar disorder and hyperactivity, the state provided little oversight of doctors' prescribing practices.

Riley's death "was a wake up call," said Dr. John Straus, vice president for medical affairs at the Massachusetts Behavioral Health Partnership, one of the organizations that manage mental health care for children in MassHealth. He said MassHealth managers want to make sure that doctors have good reason for prescribing psychiatric drugs to such young patients and that they are not relying solely on the parents or guardians for information about each child's condition. Riley's parents have been charged with deliberately giving her a fatal overdose.

"If the behavior is extreme enough to require this level of medication, we ought to make sure that the behavior exists," said Straus, by checking with day-care providers and other independent observers.

The oversight system is too new to say how many cases will merit contacting the prescribing doctor, officials said, but the largest provider of mental health services for MassHealth - Massachusetts Behavioral Health - identified 35 preschoolers in the first three months of the system who were taking three psychiatric medications or one antipsychotic drug. Four other managed-care organizations have also begun reviewing children's MassHealth prescription records, but their findings have not been released.

Nonetheless, Straus said he hopes that fewer than 100 children under age 5 enrolled in MassHealth will trigger the early-warning system in the course of a year.

Deputy Mental Health Commissioner Robert J. Keane, who led the effort to create the tracking system, stressed that it isn't meant to punish doctors or second-guess their judgment. He noted that some children, such as those who are extremely self-destructive, may need multiple medications. However, he said MassHealth's outreach could help some doctors make more informed decisions when they prescribe drugs for very young children.

"Clinical decision making often happens in isolation. It's a problem in healthcare," said Keane, suggesting that some doctors may not realize they are overprescribing psychiatric drugs to preschoolers.

Until the 1990s, children under age 5 were rarely treated with psychiatric drugs for mental illness, in part because the conditions are hard to diagnose in children too young to discuss their feelings or control their impulses. But by 2000, Dr. Joseph T. Coyle of McLean Hospital in Belmont was warning of a "growing crisis in mental health services to children" amid reports that the number of preschoolers taking drugs for attention deficit/hyperactivity disorder had doubled in four years. Writing about a major study of preschool psychiatric drug prescriptions in the Journal of the American Medical Association, Coyle argued that disturbed children were getting drugs as a "quick fix" instead of more time-consuming therapy and other family services.

Riley's death focused attention on the growing use of drugs among preschoolers for another condition, bipolar disorder, which is characterized by wide mood swings and was once thought to begin in late adolescence. Her doctor, Kayoko Kifuji, diagnosed the girl with the condition when she was 2 1/2 years old. Kifuji has voluntarily given up her license to practice medicine while regulators investigate her treatment of Riley, and the girl's mother, Carolyn Riley, said on "60 Minutes" last Sunday that she no longer believes her daughter was bipolar. The parents blame Kifuji for their daughter's death, though she denies wrongdoing.

Despite unease over the amount of psychiatric drugs being prescribed to preschoolers, few states have tried to rein in prescriptions beyond drug educational programs for doctors or other forms of doctor assistance, such as Massachusetts' popular network of psychiatrists who are available for instant phone consultations concerning young patients.

However, one state's experience is instructive: Texas officials adopted an early-warning system last year for mental health care of children in state foster care, and they saw an immediate drop in prescriptions of psychiatric drugs for children under 18 once they started contacting doctors who prescribe large amounts of psychiatric medication. Since 2004, the percentage of foster children receiving at least one psychiatric drug prescription has fallen from 29.9 to 24.4 today.

"Just the fact that doctors are being asked to get involved in this discussion, they are going to be a little more reflective about what they are doing," explained Ted Hughes, spokesman for the Texas Health and Human Services Commission. He added that foster children tend to have a higher rate of medication than others because they often face complex emotional problems.

MassHealth officials said it's unclear whether Massachusetts needs to reduce the rate of drug prescriptions to young children: their records show that the number of young children receiving antipsychotic drugs began declining in 2005.

Keane said that most psychiatric drug prescriptions for preschoolers are written by child psychiatrists rather than pediatricians or family doctors, meaning that trained specialists are making the drug decisions. Riley's doctor was a child psychiatrist at a Boston teaching hospital, Tufts-New England Medical Center.

Under the early-warning system, managed care organizations are reviewing prescription records for all children under age 5 who are receiving mental health treatment paid for by MassHealth. They are expected to keep a closer eye on those who are taking drugs and to conduct a case review of children receiving an unusual quantity or an antipsychotic.

The reviewers will be looking to make sure that the high rate of prescriptions is not an error caused by more than one doctor writing them, and checking to make sure the drugs don't have dangerous side effects when taken together, Straus said. They will also look at the child's history for signs of abuse, evidence of emotional problems, and other issues aside from mental illness that could explain behavior problems. The point is to make sure doctors try other forms of treatment or social services before turning to drugs, Straus said.

Straus said he is encouraged by results of the early-warning system. He said the behavioral health partnership has only contacted a handful of doctors so far to discuss prescriptions for at-risk children, but they had reasonable explanations for the children's treatment plans. "They were being thoughtful about it," he said.

Keane said the new system is an experiment since apparently no other state has done something quite like it before. But, if the tracking system works, he said, it could be expanded to many of the 300,000 Massachusetts children under age 5 who are not in the MassHealth program. "This is really the start of this process," he said.

When Reality TV Gets Too Real
Jeremy Peters, New York Times- 10/8/2007

On a recent episode of “Intervention,” A&E’s documentary series about addiction, no one was stopping Pam, an alcoholic, from driving. As she made her way to the front door — stopping first at the refrigerator to take a swig of vodka for the road — viewers could hear a producer for the show speak up. “You have had a lot to drink,” the voice from off camera said. “Do you want one of us to drive?” Pam was indignant. “No, I can drive. I can drive,” she mumbled. She then got into her car, managed a three-point turn out of the parking lot and drove off. The camera crew followed, filming her as she tried to keep her turquoise Pontiac Sunfire between the lines.
      Perhaps more than any other program on television now, “Intervention” highlights the sticky situations that reality-show producers can find themselves in as they document unpredictable and unstable subjects or situations. In recent years, producers and networks have increasingly pushed the boundaries of television voyeurism in search of another ratings hit. At times, this has proved problematic for television networks. There have been several lawsuits related to shows like “Big Brother” and more recently, CBS found itself facing accusations that it had created dangerous working conditions for children in its reality program “Kid Nation,” in which children aged 8 to 15 toiled in the New Mexico desert to build a working society on their own. In the case of reality-TV documentary shows like “Intervention” and the various incarnations of “The Real World” and “Road Rules” on MTV, producers can be witnesses to crimes, raising the question of when they are obligated to step out from behind the camera and intervene. And legally, producers are treated like witnesses: they bear no responsibility to intervene. “The law in the United States doesn’t require you to step in and save people,” said David Sternbach, counsel for litigation and intellectual property matters for A&E Television Networks. “And it doesn’t require you to stop a crime that’s in the works.”
     A&E said “Intervention,” has never been sued. And legal experts said that making a case against it or other documentary programs like it would be difficult because the subjects were being filmed in their own homes, engaging in activities that they would be pursuing regardless of whether a camera crew was there. “This is their life with me or without me,” said Sam Mettler, “Intervention’s” creator and executive producer. The program takes other steps, like requiring potential subjects to undergo psychological evaluations and keeping a family member of the addict on call 24 hours a day during filming, to avoid being negligent.
     To make a case for negligence, legal experts said, the accusing party would need to prove that the reality program created a situation that put its subjects in jeopardy. A “Big Brother” cast member sued CBS, for example, in 2002 after another cast member with a criminal record held a knife to her throat. CBS settled the case for an undisclosed amount.
     Being absolved of legal responsibility for his documentary subjects, however, does not make shooting the program any easier. “I’ve had children of alcoholic parents there watching their mother in a drunken stupor, watching their mother pass out, watching their mother throw up,” Mr. Mettler said. “Those innocent children as casualties of their mother’s addiction was just emotionally heart-wrenching. The trauma of that is horrible, just horrible.”
     “Intervention,” which ends each episode with an actual intervention, has arrangements with substance-abuse rehabilitation centers across the country that provide free in-patient treatment for addicts on the program. “Morally and ethically, none of us can feel good watching someone hurt themselves or hurt someone else. And I’m not going to stand by and have someone who is drunk get behind the wheel of a car and kill someone,” Mr. Mettler said.
     Mr. Mettler himself has had to step out from behind the camera on a number of episodes to prevent someone from driving drunk. In one case, he followed a crack addict named Tim through a swamp. Tim had crawled into a drainage pipe and threatened suicide, so Mr. Mettler had to talk him out. And in another episode, Mr. Mettler’s field producers called paramedics after an alcoholic they were filming overdosed on the sedative trazodone. Laney, a wealthy divorced woman who drank half a gallon of rum a day and traveled long distances in limousines because she did not like putting her cat on commercial jets, swallowed the pills while the cameras were off. She told producers what she had done after they saw her chugging a bottle of juice to wash the pills down. “Our first position is that this is a documentary series, we are there capturing real people in their real lives,” said Robert Sharenow, A&E’s senior vice president for nonfiction and alternative programming. “If there was an immediate danger, that was sort of our line. If the person was putting themselves or anyone else in immediate danger, then we’d cross the line.” He added: “It’s a very, very delicate balance.”

Panic Attacks Seen as Risk in Postmenopausal Women
Nicholas Bakalar, New York Times- 10/9/2007

Postmenopausal women who have panic attacks appear to be at higher risk for cardiovascular disease and death. Researchers who followed 3,300 women ages 51 to 83 found that a history of full-blown panic attacks over six months was associated with a more than fourfold risk for coronary heart disease. They also found a 75 percent increase in mortality from all causes, compared with women who did not have panic attacks.

The women were enrolled in the larger Women’s Health Initiative Observational Study, which is looking into the risk factors for heart disease, cancer, fractures and other causes of mortality among postmenopausal women. The current study, published in the October issue of The Archives of General Psychiatry, was partly financed by Glaxo Wellcome, now called GlaxoSmithKline.

The researchers found that women who had panic attacks were also more likely to smoke, and to have high blood pressure, diabetes and symptoms of depression, as well as a history of cardiovascular problems. The increased risk for women who had had even one panic attack during the six-month period was still present.

“This is consistent with previous studies that have suggested that certain negative emotional states can be associated with adverse medical outcomes,” said Dr. Jordan W. Smoller, the lead author and an associate professor of psychiatry at Harvard. But he added, “We can’t say whether the association with panic attacks is a direct causal connection or whether the panic attacks are a proxy for some other factor.”

Pill Helps Alcoholics Taper Off Drinking
Associated Press, 10/9/2007

CHICAGO -- A migraine pill seems to help alcoholics taper off their drinking without detox treatment, researchers report, offering a potential option for a hard-to-treat problem.

The drug, Topamax, works in a different way than three other medications already approved for treating alcoholism.

Experts said the drug is likely to appeal to heavy drinkers who would rather seek help from their own doctors, rather than enter a rehab clinic to dry out. The drug costs at least $350 a month, plus the price of doctor's visits.

But side effects are a problem, and it's unclear whether the findings will make a dent in an addiction that affects millions of Americans.

Addiction specialists not involved in the study said the findings are promising, although side effects such as trouble concentrating, tingling and itching caused about one in five people to drop out of the study. Drowsiness and dizziness are also problems.

''The size of the treatment effect is larger than in most of the other medications we've seen,'' said Dr. Mark Willenbring of the National Institute on Alcohol Abuse and Alcoholism. ''And all the drinking variables changed in the right direction.''

The study, published in Wednesday's Journal of the American Medical Association, was funded by the maker of the drug, Johnson & Johnson Inc.'s Ortho-McNeil Neurologics. The researchers also reported financial ties to the company. Ortho-McNeil reviewed the manuscript, but did not change the results or interpretation, the researchers reported.

The study followed 371 heavy drinkers for 14 weeks. About half were randomly assigned to take Topamax, also called topiramate, in gradually increasing doses. The others took dummy pills.

All volunteers were encouraged -- but not required -- to stop drinking.

At the start of the study, they drank, on average, 11 standard drinks daily. That's about two six-packs of beer each day, or two bottles of wine, or a pint of hard liquor.

By the end of the study, 27 of the 183 people, or 15 percent, who took Topamax had quit drinking entirely for seven weeks or more. That compared to six out of 188, or 3 percent, in the placebo group.

Others cut back. The Topamax group cut back to six drinks a day, on average, assuming everyone who dropped out of the study relapsed into heavy drinking. That compared to seven drinks a day for the placebo group.

''You can come in drinking a bottle of scotch a day and get treatment without detox,'' said Dr. Bankole Johnson of the University of Virginia, who led the study, which was conducted at 17 U.S. sites from 2004-2006.

The study didn't follow the drinkers long-term, so it's unclear how many relapsed after they stopped taking the pill.

But there were lasting effects for Tom Wolfe, 44, a carpenter from Earlysville, Va., who said he has been sober for two years thanks to Topamax. After years of heavy drinking, he took part in an earlier Topamax study. He felt ''a little lightheaded'' at first until he got used to the drug. Alcohol lost its enjoyment, strengthening his resolve to quit.

''It's been a miracle to me,'' Wolfe said. ''It got the monkey off my back.''

The drug works by inhibiting dopamine, the brain's ''feel-good'' neurotransmitters that are involved in all addictions, said Stephen Dewey, a neuroscientist the Brookhaven National Laboratory, who was not involved in the study but does similar research.

It's a new approach, he said, that ''clearly did work on a very small subset in the population.''

Willenbring, who wrote an accompanying editorial, predicts that a future pill, although probably not Topamax, will do for alcohol dependence what Prozac did for depression: Remove the stigma.

Prozac changed the nature of depression treatment 20 years ago by allowing patients to see their family doctors for help, Willenbring said. An effective drug with few side effects could do the same for alcoholism treatment, he said.

''This is a huge market,'' Willenbring said. ''We're approaching a Prozac moment.''

But Topamax has big obstacles. With the drug maker's patent expiring next year, there won't be any big push to advertise it for alcoholism, Willenbring said.

Doctors are free to prescribe drugs for uses that have not been approved, but drug companies are prohibited by law from marketing drugs for these so-called ''off-label'' uses.

On Tuesday, Dr. Sidney Wolfe, director of Public Citizen's health research group, sent a protest letter to the U.S. Food and Drug Administration questioning the promotion of Topamax for alcoholics by researchers funded by Ortho-McNeil.

''This is a very bad message to send out,'' Wolfe said.

Ortho-McNeil has no plans to seek federal approval for the drug as an alcoholism treatment and promotes it only for its approved uses of migraine prevention and epilepsy, said company spokeswoman Tricia Geoghegan. The company dropped development of new uses for the drug in 2004, but has continued to support some research.

On the Net: JAMA: http://jama.ama-assn.org