“I get there and I sit him down and relax his mind,” Mr. Kaplan said. “I ask him ‘What brought this on?’ It’s always something.” Once they figure out the trigger, “It’s over.”

“It” is the drug craving. The businessman is a drug addict, and Mr. Kaplan is a sober companion, a combination big brother, baby sitter and spiritual guide who uses motivation, prayer and exercise to keep his clients away from alcohol and drugs.

Mr. Kaplan, who sports a goatee and shaved head, is an ex-user and ex-convict, a former gang member and muscle man whose skin — hands scarred from a prison fire, head-to-toe tattoos of naked women, four-letter expletives and green flames shooting upward from the corner of both eyes — documents a previous tough life.

Mr. Kaplan now makes a living gaining the trust of wealthy clients like the young businessman, who allows him into his home, his social circle and his innermost thoughts, paying him fees that can reach $1,000 or more a day. He’s not beyond searching the premises for illegal substances to help a client stay clean.

Sober companions who, like Mr. Kaplan, charge daily rates comparable to the most expensive rehab facilities, have mostly been known as members of a celebrity’s entourage, akin to a personal trainer or a life coach. The profession gained some notoriety when companions accompanied actors like Robert Downey Jr. and Matthew Perry as they struggled with substance abuse problems while shooting a movie or television show.

But, in recent years, sober companions say demand for their services has come from outside Hollywood as well: from the chief executive officer who needs to avoid taking a drink while entertaining clients to the lawyer who needs to stay away from the airport bar while on a business trip.

“Anybody who’s returning to their life after rehab needs added structure and support in that transitioning phase,” said Nanette Zumwalt, owner of Hired Power, a company in Huntington Beach, Calif., that in four years has grown to 70 companions, from 10, working in 15 states.

Even if rehab works in the short-term, “What doesn’t always work is translating the skills learned at rehab to the home,” she said.

THERE are no hard data on sober companions because the occupation is not regulated, but there is evidence that these minders are emerging as a lucrative corollary business to the growing substance abuse treatment industry. Ron Hunsicker, president of the National Association of Addiction Treatment Providers, said his group alone has grown to 318 members, from 200, in the last five years. He said most of the growth has come from high-end treatment centers serving the affluent “self-pay market” in California and Florida (insurance coverage for the cost of treatment facilities is uneven and it does not cover companions, he said.).

Some treatment centers now refer clients to sober companions when they are sent home, incorporating the helpers in their discharge plans and follow-up care, Dr. Hunsicker said.

“It’s another option, particularly for high risk, relapse people,” he said.

Sober companions vary wildly in credentials and style. Some work informally, like Mr. Kaplan, a former bodyguard for entertainers and business people who uses his own recovery as training and word-of-mouth references as his ads; others work for companies like Sober Champion and Hired Power, businesses that have been founded in the last three or four years.

Individual support has been a critical component of recovery programs like Alcoholics Anonymous, which provide “sponsors,” mentors and role models who have gone through the programs themselves, for free. Sober companions have a more intense relationship with their clients, as do sober or recovery coaches, members of a related specialty, who function much like a counselor or therapist, meeting with clients or talking on the telephone in sessions that focus on issues such as building life skills, like devising a budget. Both are carving out their own niche in the substance abuse treatment industry for those who can pay.

Demand for sober companions — who are usually paired with recovering addicts of the same sex and work for a few days or a few months, and for shifts that last just for a few hours or are around the clock — sometimes comes from those who want to deal with their addiction on their own or can’t stand a residential treatment center.

That was the case for Mr. Kaplan’s client, who left one such center 33 days short of a planned 90-day stay for addiction to heroin, cocaine and painkillers, unable to stand what he says was the lack of privacy and the cliques that develop among patients.

“It was driving me crazy,” said the man, Nathan, who used only his first name to protect his privacy.

Mr. Kaplan loosely follows the spiritual foundation laid out by the Alcoholics Anonymous 12-step program. He meets Nathan at his house each morning for an hour of prayers, meditation and reading from self-help books like “Addiction and Grace.”

While Nathan is at the office, Mr. Kaplan conducts “feeling checks” to find out how his client is feeling before they meet again for lunch or for a walk, hike, session at the gym or a noon A.A. meeting.

They get together again at the end of the workday, for another A.A. meeting and dinner, followed by prayers at Nathan’s house before he goes to bed.

For a recent meeting, the two drove in separate cars but, in the parking lot, they put their arms around each other’s shoulders and bowed their heads.

“Lord, I ask that you open Nathan’s mind so that he can receive the message he’s about to receive,” Mr. Kaplan intoned.

Nathan, whose family staged an intervention last December and who found Mr. Kaplan for him, said he couldn’t recover alone. He said he had seriously considered suicide.

“He speaks to the part of my brain that can trick me into thinking ‘this is a good excuse to do drugs,’ ” Nathan said of Mr. Kaplan, whom he passes off to friends and associates as “a friend of mine.”

Robert Tyler, president of the California Association of Alcoholism and Drug Abuse Counselors, said companions can serve an important role in setting up those freshly out of rehab in “the sober community” — accompanying them to A.A. meetings, for example.

But Mr. Tyler said he’s also wary of the profession. “There’s no regulation, no accountability,” he said.

Jerry Schoenkopf, a treatment center administrator who runs the Telesis Foundation, a nonprofit organization that sponsors free detox services, said the sober companions can add “an extra layer of protection” between the client and the world but noted that the occupation is “more art than science.”

One client of Hired Power, a 30-year-old lawyer from Boston, said a companion should be viewed as temporary insurance “to protect you from yourself.”

“I don’t think you need a sober companion for six months,” she said. “You have to take responsibility for your own recovery.”

But the lawyer, a recovering alcoholic and cocaine addict who withheld her name to protect her privacy, said that for her, while the cost of a companion is a downside — she spent $650 a day plus expenses for four days — it is worth it. After treatment in Utah earlier this year, she said she couldn’t have flown back home alone after treatment and trusted she would not engage in her usual ritual: sitting in business class taking Valium and drinking the equivalent of two bottles of wine.

“If you don’t have your sobriety you’re going to end up in a hospital, in jail or dead,” said the lawyer, who said she had had legal troubles, car crashes and “many” close calls before she sought treatment. “You can’t put a price on that.”

The total number of Americans with substance dependence has remained stable since 2002, federal statistics show, but binge drinking is up for adults over 18 and illicit drug use is increasing among some baby boomers. The chance of relapse is significant — as high as 40 to 60 percent, according to some studies.

SOBER companions say they have clients who fall back into old habits. Mr. Kaplan, who said he’s been clean of drugs and alcohol for more than 10 years, frankly admits that “sometimes you can’t help people.”

“They think they can still drink a little bit, still smoke some marijuana, because they’re not doing their drug of choice,” he noted.

Mr. Kaplan, who never married but has three grown children, grew up in East Los Angeles the son of heroin addicts. He said he started his downward spiral as a teenager, including 17 years of prison stints for drug- and gang-related crimes.

He said he evolved from bodyguard to sober companion eight years ago, when he became tired of watching his clients use drugs.

Mr. Kaplan added that more competition prompted him this week to to start his own Web site, Mama-Tried.net, named after the Merle Haggard song about a son who ends up in prison despite his mother’s efforts to steer him right.

In his spare time, which he said isn’t much, he is also writing book about his life.

“I sleep, eat and play when I can,” he said.

Mr. Kaplan, who said he lives in a modest two-bedroom apartment with a roommate, is also saving his money to open his own rehab center. He said he has traveled the world because of the needs of his rich clients, but downplays the perks of the job.

“The lifestyle, most of it is a facade,” he said. “Most of them are miserable. I try to bring meaning to their life.”

Many Parents Admit They Bribe Their Kids
Associated Press, 4/16/2007

CHICAGO -- Call it a reward, or just ''bribery.'' Whichever it is, many parents today readily admit to buying off their children, who get goodies for anything from behaving in a restaurant to sleeping all night in their own beds. Often, the rewards are for behaviors their own parents would have simply expected, just because they said so.

The new dynamic -- sometimes seen as a backlash to that strictness -- has some parenting experts wondering if today's parents have gone too soft.

''It's definitely more our generation,'' Kirsten Whipple, a 35-year-old mom in Northbrook, Ill., says with a quiet laugh. ''I'm sure our parents would be appalled if they knew how much we bribe our children.''

She can see why they might be -- but she and her husband try not to overuse rewards and have found they work best for smaller things. For instance, they might offer their boys, ages 5 and 8, a special dessert or a chance to rent a video game if they listen to their baby sitter. A good report card might earn a dinner out to celebrate.

Whipple has noticed a downside though -- what she calls a ''sense of entitlement.''

''Often times, it leads to good behavior with a question attached: 'What are you going to give me?''' she says.

That's part of what worries parenting experts.

''I think that reward systems have a time and a place and work really well to help develop capacities -- if we need them to go above and beyond,'' says Marcy Safyer, director of the Adelphi University Institute for Parenting.

She remembers how, as a child, her own parents promised her an ice cream if she could sit quietly through religious services.

''But what often gets lost for people is being able to figure out how to communicate to their kids that doing the thing is rewarding enough,'' Safyer says.

Feeling rested in the morning, for instance, could be seen as the reward for not getting up at night.

''Instead, parents are paying their kids to get good grades; they pay their kids to go to sleep, pay their kids to be toilet trained,'' Safyer says, meaning payment as a material reward.

Parents and experts alike agree that the dynamic is partly a reflection of the world we live in -- where many families have more than previous generations.

It's unrealistic to think a parent wouldn't reward their children with material things sometimes, says Robin Lanzi, a clinical psychologist and mother of four who's the research director at the Center on Health and Education at Georgetown University.

''But you want to make sure that they match the behavior, so it's not something huge for something small,'' Lanzi says.

She recalls hearing about a father who offered his child a Nintendo Wii game system for scoring a couple goals in a soccer game.

''There's always this upping the ante,'' Lanzi says. ''What was a reward 20 or 30 years ago is a whole lot different than it is now.''

Elizabeth Powell, a mother of two young daughters in Austin, Texas, knows what she means.

''You want to raise them in a way that they're respectful and appreciate things,'' Powell says of her children. ''But sometimes, you wonder now if kids appreciate even a new pair of shoes.''

That was something she remembers being a big deal to her as a kid -- as were the ice creams and 45 rpm records, or very occasional trips to McDonald's.

These days, she sees children negotiating to get things in a way she never would've dreamed of. ''A lot of my friends, I see them cave, just like I have a tendency to do -- just to get them to be quiet,'' Powell says.

She and other parents agree that striking a balance with rewards -- and not giving them so often that they mean nothing -- is the goal.

Powell sometimes lets her 5-year-old daughter shop at a store she likes, if she behaves for an entire trip to the mall.

She doesn't want it to become an expectation. But she also concedes that having two kids has made it more difficult to stick to the ideal, especially in public settings.

''There are times when you have a second child, and you've got to change a diaper. And you find yourself telling your (older) child that 'I will do anything you want if you will just stand here and behave,''' says Powell, who's 34.

''Sometimes, desperate situations call for desperate measures.''

Those who specialize in child behavior say they hear those kinds of stories from parents all the time -- and often try to suggest methods that don't involve material rewards.

Sometimes, ''because I said so'' is still a valid tactic. But for something like sleeping in their own bed, Safyer suggests putting stars on a chart for each night the child is able to stay in his or her room -- and then making a big deal about the progress.

''Parents' pride in their children goes a long way,'' she says.

Claire Lerner -- director of parenting resources for the Washington, D.C., nonprofit Zero To Three -- also recalls a couple whose child would only brush his teeth if he got a reward.

She suggested the parents emphasize the benefits of just getting it done.

''To have a power struggle takes up a lot of time and eats into the bedtime routine,'' Lerner says. ''So you can tell them that if they brush their teeth, 'We have time for an extra book or an extra lullaby or five more minutes in the bath' -- whatever it is they really love. ''That's a real-life consequence.''

On the Net:
Adelphi: http://www.adelphi.edu/parentinginstitute/
Zero to Three: http://www.zerotothree.org

Last year a Westchester County lawyer — a 57-year-old husband and father of two, Boy Scout leader and churchgoer — left the garage near his office and disappeared. Six months later he was found living under a new name in a homeless shelter in Chicago, not knowing who he was or where he came from.

Library searches and contact with the Chicago police did not help the man. His true identity was uncovered through an anonymous tip to “America’s Most Wanted.” But when he was contacted by his family, he had no idea who they were.

On the fictional side is a play called “Fugue,” now on stage at the Cherry Lane Theater in New York. In it, a woman found wandering homeless in Chicago is interviewed by a psychiatrist. She does not know her name and can recall nothing about her life before landing in Chicago. The rest of this most interesting play by Leonora Thuna is an exploration of a rare but intriguing emotional disorder, known technically as dissociative fugue or dissociative amnesia.

A Sudden Change
People with this problem suddenly and unexpectedly take leave of their usual physical surroundings and embark on a journey that can last as little as a few hours or as long as several months. During the fugue state, individuals completely lose their identity, later assuming a new one. They don’t know their real names or anything about their former lives, and they do not recognize friends or family. They may not even remember how they got to where they are.

While loss of memory can occur for many reasons, dissociative fugue has no direct physical or medical cause. Rather, it is precipitated by a severe stress or emotionally traumatic event that is so painful the mind seems to shut down and erase everything, like a failed computer hard drive.

But unlike a computer whose unsaved information is lost forever, most if not all patients suffering from dissociative fugue eventually recover their memories, typically just as suddenly as the memories disappeared.

While in the fugue state, people are unaware that their identity and memory have been lost, said David Schacter, professor of psychology at Harvard. They wander off, often traveling far from home. It is only when they are forced to reveal some piece of biographical information that they realize they do not know who they are, which may lead to a desperate search to uncover their identity.

In a telling case detailed by Berton Roueché first in The New Yorker and later his book “The Medical Detectives, Volume II” more than a half-century ago, a man who felt increasingly trapped in his father-in-law’s business one day failed to show up at the store in Boston and later found himself in New York. Not until he had to provide his name for a hotel did he discover he did not know who he was.

After many failed attempts to uncover his identity, his past revealed itself while he was being quizzed by a doctor at Bellevue Hospital, he recalled. “All of a sudden, I knew, I remembered. I jumped up and shouted. I yelled, ‘I know — I can remember! I remember my wife’s name. It’s Mildred. We live in Boston. I can even tell you the address. And my name is Uhlan. Walter Uhlan.’ ”

A Diagnostic Challenge
Elkhonon Goldberg, clinical professor of neurology at New York University and the author of three books on the human mind, says that some underlying neurological problem is the usual cause of amnesia. When amnesia has a physical basis, memory loss is usually not complete, but rather covers a part of someone’s life. The more recent memories are often lost, while memories of more distant events are preserved.

When examining a patient with memory loss that has no obvious physical cause, the first step, Dr. Goldberg said, is to look for a neurological cause like a head injury, stroke, viral encephalitis or temporal lobe epilepsy. In such cases, in addition to incomplete memory loss, there is usually a loss of individual facts like biographical information. However, when memory loss includes generic knowledge about whole classes of things, like how many wings birds have, the underlying cause is more likely to be psychogenic, Dr. Goldberg said.

When amnesia has an organic cause, people’s memories of who they are usually are not disrupted, Dr. Schacter said. Nor are memories usually lost of events that occurred before the physical problem. But such people may be unable to form new memories.

And sometimes cases of fugue have a precipitating psychological cause along with some form of underlying brain damage that is revealed, say, through a functional M.R.I. or PET scan, according to Morris Moscovitch, a psychologist at the University of Toronto.

Another challenge clinicians face in diagnosing amnesia, Dr. Schacter said, is to differentiate between genuine cases of lost memory and the concocted amnesia of malingerers — people who are fleeing financial problems, for example, who have committed a crime or who simply wish to gain notoriety. Neuropsychological tests performed by experts can often pinpoint the malingerers who may do so poorly on certain tests that they are obviously faking their answers.

Other checks for malingering include assessing whether patients are making a genuine effort to answer questions correctly and whether there are apparent motives for pretending they do not know who they are.

Misplaced Files
In the case of the Westchester lawyer, who had lost all memory of his former life, his wife provided background information suggesting that his amnesia may have resulted from prolonged post-traumatic stress. He was a Vietnam War veteran who happened to have walked between the twin towers of the World Trade Center on Sept. 11, 2001, minutes before the first plane hit. He subsequently experienced a return of painful memories of his war experience and required treatment for depression.

The playwright, Leonora Thuna, was first attracted to the subject of fugue after seeing an article in The Los Angeles Times. An attractive blonde woman was picked up by the police after she was found wandering the streets of Los Angeles with no idea of who she was or how she got there. After her picture appeared in the paper, her family recognized her and came to get her, but when they arrived she had no idea who they were, either.

Similar cases have occurred elsewhere, like the 40-year-old man from Olympia, Wash., who somehow made his way to Denver, where he wandered the streets alone and confused until he finally asked doctors and the police to help him discover his identity.

In researching fugue states, Ms. Thuna learned something reassuring: “You never lose your memory. It’s always there. It just falls out of the file cabinet.”

Revolving Door for Addicts Adds to Medicaid Cost
Richard Perez-Pena, New York Times- 4/17/2007

With grim humor, some doctors in New York call them “frequent fliers” — addicts who check into hospital detoxification units so often that dozens of them spend more than 100 nights a year in those wards.

Through its Medicaid program, New York spends far more than other states on drug and alcohol treatment, including more than $300 million a year paid to hospitals for more than 30,000 detox patients. One reason for the high cost is that $50 million is spent just on the 500 most expensive patients, at a cost of about $100,000 a person. These patients check in and out of detox wards, on average, more than a dozen times a year — a practice that experts say would not be tolerated in most states.

In the state’s 2004 fiscal year, one patient was admitted to such units 26 times at 17 different hospitals around New York City, spending a total of 204 nights, Medicaid records show. In fiscal year 2005, there was one patient who spent 279 nights in detox wards, at a cost of about $300,000.

New York State spends more than enough money to provide all the needed treatment, but “the dollars are being spent in the wrong settings,” said Deborah S. Bachrach, the state’s Medicaid director. In Gov. Eliot Spitzer’s campaign to overhaul Medicaid, she said, “this is very high on our agenda.”

George Epps, 59, was a heavy user of alcohol, cocaine and heroin and says he went through detox programs around New York City 20 to 25 times over several years. “I would come out of detox and rent a room, squander my money on drugs and women, be homeless again for a while, and check back into detox,” said Mr. Epps, who added that he had been clean for more than six years.

He was far from being one of the most extreme examples, but he says he understands the thinking of the repeat patient.

“I would tell myself I was just a brother who needed a rest, not somebody who had a problem,” he said. “I could mimic what they said with such grace and conviction, they would swear I was cured.”

Among state officials, doctors who treat addiction, service groups dedicated to helping the homeless and mentally ill, even the addicts themselves, there is remarkable agreement on why the treatment system in New York is overpriced and inefficient.

In other states, most addicts who go through detox programs do so on an outpatient basis, while in New York the vast majority are inpatients. Medicaid rules in New York also encourage hospitals to provide the most expensive kind of inpatient detoxification, though it is often not medically necessary, while many other states favor a less expensive form of inpatient treatment.

And in New York, when patients are discharged — typically after about five days — the needed transition to an outpatient treatment program often never occurs. That is one reason many patients do not fully recover from their addictions and return to detox wards, experts say.

The system suits the most frequent patients — most of them homeless, mentally ill, or both — who see the programs as a source of shelter and food. And the most expensive treatment, which usually involves some sedation, can reduce the discomfort of withdrawal better than other methods.

Some drug users, especially those on opiates, also set out to clean their systems so they can reduce the dose needed to get high, according to addicts and those who treat them. For a homeless addict, the cost of each dose is a major concern.

But at its core, experts say, the overuse of costly inpatient programs is connected to the lack of housing for homeless people. People are less likely to admit themselves to hospitals, and more likely to adhere to treatment programs, when they are not living on the streets. For more than a decade, the city and state have invested in such housing, including some that accept residents who are not yet drug-free, but demand for housing still far exceeds supply.

“For this small group of what are basically professional inpatient detoxification users, it’s really a whole series of linked problems, and none of the parts of the system work very well,” said Dr. Richard N. Rosenthal, an addiction specialist and chairman of psychiatry at St. Luke’s-Roosevelt Hospital Center in Manhattan. “There’s been some progress on each element, but not enough.”

The most intensive form of treatment, “medically managed” withdrawal takes place in a hospital, usually involves some sedation, and requires a great deal of care by doctors and nurses. The next level, “medically supervised withdrawal,” can be done in a hospital, or sometimes on an outpatient basis, and requires less medical intervention and less staff.

In New York, Medicaid pays an average of more than $100 a day for outpatient medically supervised withdrawal, and close to $400 a day for the inpatient version.

But it pays more than $1,300 a day for medically managed detox — and state officials estimate that more than 40 percent of that is profit for the hospitals. Hospital executives say the margin is not that high, but they concede that the most expensive form of detoxification is a significant money-maker.

As a result, many hospitals offer that program, but not the cheaper ones. By law, hospitals cannot turn away emergency patients, and drug or alcohol withdrawal is considered an emergency. So about 80 percent of the detox patients handled by hospitals in New York are treated at the most expensive level — often because it is the only one available.

Federal officials say they do not keep state-by-state Medicaid records, but experts and state officials say it is clear that New York spends far more on drug treatment than any other state, because other states mostly provide outpatient treatment. Figures compiled by the Department of Health and Human Services support that claim, showing that New York has more hospital admissions for drug or alcohol abuse — whether paid by Medicaid or someone else — than California, Texas and Florida combined.

Of the patients in medically managed detox in New York, “about 80 percent of them are uncomplicated and could be provided with a lower service,” said Karen M. Carpenter-Palumbo, commissioner of the state’s Office of Alcohol and Substance Abuse Services.

Spitzer administration officials say the state needs to pay less for the top level of care, and possibly pay more for the others, to spur the development of those services. That fits with the governor’s plan to review what Medicaid pays for all services, with an eye to encouraging less expensive forms of care.

But those officials also know that when George E. Pataki tried twice as governor to change the detox payment system, the hospital industry, which has been losing money over all, persuaded the Legislature to protect one of its few sources of profit.

Everyone in the field agrees that drug treatment would be more effective and less expensive if a patient consistently went to the same hospital and the same set of doctors.

But in New York, a hospital has no way of checking a patient’s history at other hospitals. The state has talked for years of making that information available right away, and requiring that patients be transferred to their “home” hospitals, but to no avail.

Beyond medically managed and medically supervised detox, there is the least intensive form, called medically monitored withdrawal, which is often done in a residential treatment center, to remove addicts from the influences that contribute to their drug use. The cost per day is comparable to outpatient detox, but patients can stay for weeks.

But under rules laid down decades ago by the federal government, which pays half of New York’s Medicaid bills, Medicaid will not pay for drug treatment in a residential center, as opposed to a hospital. The state pays for a limited amount, using non-Medicaid funds.

In interviews, several current and recovering addicts who have also been homeless said they would happily accept less expensive forms of treatment, as long as they were given shelter. Sam Tsemberis, executive director of Pathways to Housing, a nonprofit group based in Manhattan, works with many such people.

“People use it instead of the shelter system,” he said. “It’s safer, you get three hots and a cot, the meals are better than a shelter, the beds are better, you get a clean change of clothes.”

When patients are discharged from hospital detox wards, the hospitals are supposed to refer them to follow-up treatment, usually through other organizations.

“The handoff doesn’t happen,” said Shari Noonan, who was the acting commissioner of the state substance abuse office last year. “There are no incentives for the hospital to make sure it happens.”

Medicaid records show that in New York State, 80 percent of patients do not have any form of outpatient treatment soon after leaving hospital detox. For almost half of them, the next drug treatment they get is another detox admission.

Ms. Carpenter-Palumbo said the state is looking into ways to correct those failings, providing incentives to hospitals to follow up, and assigning case managers to track patients. But again, such steps might require getting stable housing first.

The risk they found is lower than the one the Food and Drug Administration identified in 2004, the year the agency warned the public about the drugs' risks in children. After the warning, U.S. youth suicides increased and some mental health experts said reluctance to try antidepressants might be to blame.

The new analysis includes data from seven studies that were not part of the previous FDA analysis, including two large pediatric depression trials that were unavailable three years ago.

Researchers analyzed data on 5,310 children and teenagers from 27 studies. They found that for every 100 kids treated with antidepressants, about one additional child experienced worsening suicidal feelings above what would have happened without drug treatment. In contrast, the FDA analysis found an added risk affecting about two in 100 patients.

There were no suicides in any of the studies. The antidepressants included Prozac, Paxil, Zoloft, Celexa, Lexapro, Effexor, Serzone and Remeron.

''The medications are safe and effective and should be considered as an important part of treatment,'' said study co-author Dr. David Brent of the University of Pittsburgh School of Medicine. ''The benefits seem favorable compared to the small risk of suicidal thoughts and behavior.''

Antidepressants worked best when used to treat anxiety, the analysis found. They worked moderately well treating obsessive-compulsive disorders. They worked less well, but were still effective in treating depression.

Adolescents responded better than children to treatment for depression and anxiety, the researchers found. They also found that only Prozac worked better than dummy pills in depressed children younger than 12.

In the studies involving depression, 61 percent of patients improved while on antidepressants. But 50 percent of depressed patients taking dummy pills also improved.

Among young patients with obsessive-compulsive disorders, 52 percent improved on antidepressants, compared to 32 percent who improved on dummy pills.

And in the studies of anxiety disorders, 69 percent improved on antidepressants and 39 percent improved on dummy pills.

Effectiveness of the drugs was measured in the studies using widely accepted rating scales. The analysis appears in Wednesday's Journal of the American Medical Association.

Dr. John March, chief of child and adolescent psychiatry at Duke University Medical Center, welcomed the study as ''the most comprehensive analysis of the data yet put together.'' He said the suicidal behavior risk, although lower than found by the FDA, demands that doctors and families watch for warning signs.

''You can't treat kids with these drugs without taking this information into account,'' said March, who was not involved in the study, but does similar research. ''You can't say, 'Take these and call me in six weeks.' You have to monitor carefully the benefits and adverse events.''

The study didn't measure the effects of talk therapy, March pointed out. He said cognitive behavioral therapy used with antidepressants can lower suicide risk and speed up recovery for depressed youth.

The study was supported by grants from the National Institute of Mental Health and the Robert Wood Johnson Foundation.

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

Mr. Cho’s eruption of violence, in which 32 victims and himself were killed on the Virginia Tech campus here in a rampage of gunfire, was never directly signaled by his actions or words, several of his acquaintances said Tuesday. But those acquaintances were frequently disturbed by his isolation from the world and his barely concealed anger.

Joe Aust, who shared Room 2121 at Harper Hall with him, said he had spoken to Mr. Cho often but had received only one-word replies. Later, Mr. Aust said, Mr. Cho stopped talking to him entirely. Mr. Aust would sometimes enter the room and find Mr. Cho sitting at his desk, staring into nothingness.

“He was always really, really quiet and kind of weird, keeping to himself all the time,” said Mr. Aust, a 19-year-old sophomore, who, though finding Mr. Cho strange, had not thought him menacing.

Yet there were signs that his behavior was more than just bizarre.

Lucinda Roy said that in October of 2005 she was contacted as head of the English Department by a professor who was disturbed by a piece of his writing. Ms. Roy, rebuffed by Mr. Cho, contacted the campus police, counseling services, student affairs and officials in her department. Ms. Roy described the writing as a “veiled threat rather than something explicit.”

University officials told her that she could drop Mr. Cho from the class. Or, they said, she could tutor him individually, and she agreed to do so three times from October to December 2005. During those sessions, she said in an interview, he always wore sunglasses and a baseball cap pulled low.

“He seemed to be crying behind his sunglasses,” she said.

Ms. Roy said she had been so nervous about taking him on as an individual student that she worked out a code with her assistant: if she mentioned the name of a dead professor, her assistant would know it was time to call security.

In another writing class, Mr. Cho submitted two profoundly violent and profane plays. Ian MacFarlane, a classmate who now works for America Online, posted the plays on the company’s Web site Tuesday, saying they had horrified the rest of the students.

“When we read Cho’s plays, it was like something out of a nightmare,” Mr. MacFarlane wrote. “The plays had really twisted, macabre violence that used weapons I wouldn’t have even thought of.”

As a result of them, Mr. MacFarlane added, “we students were talking to each other with serious worry about whether he could be a school shooter.”

In one play, called “Richard McBeef,” Mr. Cho wrote of a teenage boy who accuses his stepfather of murdering the boy’s father and of trying to molest the boy himself.

“I hate him,” the boy says of the stepfather in a copy of the play on the Web site. “Must kill Dick. Must kill Dick. Dick must die.”

Though the level of anger was clear to those who knew Mr. Cho, there is little that points to a precise motive for Monday’s events. Or, as a federal law enforcement official who spoke on condition of anonymity put it: “What was this kid thinking about? There are no indications.”

There are just the snippets of a lonely young life: prescription medicines, ominous words and two newly bought handguns.

Mr. Cho was a 23-year-old senior, skinny and boyish-looking, his hair cut in a short, military-style fashion. He was a native of South Korea who grew up in Centreville, Va., a suburb of Washington, where his family owns a dry-cleaning business. He moved with his family to the United States at age 8, in 1992, according to federal immigration authorities, and was a legal permanent resident, not a citizen.

In the suite in Harper Hall where he lived with five other students, he was known as a loner, almost a stranger, amid a student body of 26,000. He ate his meals alone in a dining hall. Karan Grewal, 21, another student in the suite, recalled that when a candidate for student council visited there this year to pass out candy and ask for votes, Mr. Cho refused even to make eye contact.

On Tuesday, investigators were examining a note Mr. Cho had left behind in his dorm room, a rambling and bitter list of the moral laxity he found among what he considered the more privileged students on campus.

Centreville is an unincorporated community of 48,000 about 20 miles from Washington in Fairfax County. Mr. Cho graduated in 2003 from Westfield High School in nearby Chantilly, a large school that sends dozens of its students to Virginia Tech. At least two of Mr. Cho’s victims had also attended Westfield.

The Cho residence in Centreville is on Truitt Farm Drive in a subdivision of attached townhouses called Sully Station II. The family was not at home on Tuesday. But neighbors said three unmarked police cruisers arrived at the house about 10:30 p.m. Monday, and came and went throughout the rest of the evening. The neighbors had only nice things to say about the Cho family; the father sometimes cleaned the snow off his neighbor’s car across the street.

Every 10 years, lawful permanent residents are required to renew their green cards. Mr. Cho did so, and was issued a new card on Oct. 27, 2003. Applicants seeking a green-card renewal undergo a criminal background check through various law enforcement databases, said Chris Bentley, a spokesman for United States Citizenship and Immigration Services. “Nothing showed up in those checks that told us he couldn’t have his green-card renewal,” Mr. Bentley said.

Mr. Cho went to bed early by college standards, about 9 p.m. He often rose early, but in recent weeks he had been doing so even earlier, frequently before dawn, said Mr. Aust, his roommate. Such was the case Monday.

Mr. Cho awoke before 5 a.m., then sat down to work on his computer and awakened Mr. Aust in the process. Mr. Grewal, who shares a room in the same suite, saw Mr. Cho in the bathroom shortly after 5 a.m.

As usual, Mr. Cho did not say anything to Mr. Grewal. No good morning, no hello, Mr. Grewal said. Mr. Cho stood in the bathroom, brushing his teeth, wetting his contact lenses and applying a moisturizer.

He also took a prescription medicine. Neither Mr. Aust nor Mr. Grewal knew what the medicine was for, but officials said prescription medications related to the treatment of psychological problems had been found among Mr. Cho’s effects.

''You have vandalized my heart, raped my soul and torched my conscience,'' he said into the camera, looking down occasionally to read from his manifesto. ''You thought it was one pathetic boy's life you were extinguishing. Thanks to you, I die like Jesus Christ, to inspire generations of the weak and the defenseless people.''

By the time the 23-year-old student had videotaped his suicide message, he knew what was to come. He hoped that a stunned and grieving nation would listen, riveted, to his words. ''I didn't have to do this. I could have left. I could have fled,'' he said. ''But no, I will no longer run.'' ''It's not for me. For my children, for my brothers and sisters. ... I did it for them.''

What was he running from? Of whom did he speak? Was it a last cry of help, or a last show of hate? What was Cho thinking when he compared himself to Jesus? What was he thinking when he glared into the camera and addressed a nation that would still be burying its dead?

The sullen loner known as ''the question mark kid'' by some classmates -- because he entered a question mark instead of his name on a class signup sheet one day -- left his audience with more questions than answers. Questions about killers, and loners, and delusions of martyrdom.

Incongrously, Cho grinned in some sections of his video. Leaning against a car window, his black baseball cap worn backwards, he almost looked like any normal student.

But then there were the photos -- of him grimly pointing two guns at the camera, holding a gun to his temple, wielding a hammer with two hands.

And, always, the invective flowed. ''You had a hundred billion chances and ways to have avoided today,'' he said. ''But you decided to spill my blood. You forced me into a corner and gave me only one option. The decision was yours. Now you have blood on your hands that will never wash off.''

The target of his hatred was fellow students at Virginia Tech, where Cho massacred 32 people Monday.

''Your Mercedes wasn't enough, you brats,'' he said. ''Your golden necklaces weren't enough you snobs. Your trust funds wasn't enough. Your vodka and cognac wasn't enough. All your debaucheries weren't enough. Those weren't enough to fulfill your hedonistic needs. You had everything.''

Cho, it seems, had nothing. He had no friends, no normal college life, no reason to live. Just a death wish. And a desire to show the whole world his disturbed heart.

1 of 4 NYC Men Reported Binge Drinking
Associated Press, 4/19/2007

NEW YORK -- One in four men in New York City reported binge drinking in 2005, or having five or more drinks on one occasion during the previous month, city Health Department said in a report released Wednesday.

The statistics -- the latest available -- are contained in the agency's annual community health survey of 10,000 New Yorkers, who were randomly selected and interviewed by phone throughout 2005.

The survey found that men over the age of 18 were more than three times as likely as women to binge drink.

The report said that about one in four Hispanic and white males indulged in binge drinking, compared to about one in six black men and one in eight Asian men. It also found that white women were more likely to binge drink than black, Hispanic or Asian women, but still half as likely than men.

''Alcoholism is a disease, but recovery is possible,'' Health Commissioner Dr. Thomas Frieden said in a statement. ''Drinking too much can lead to liver damage, injuries, cancer and death.'' He recommended that people who regularly drink in excess seek a doctor's help or call the city's 311 non-emergency hotline and ask for LifeNet.

The Health Department said men should not have more than four drinks on one occasion or 14 in a week. Women should limit their alcohol intake to three drinks on one occasion or seven in a week, it said.

Reports of binge drinking in the city in 2005 were lower than those nationally. The Health Department said 23 percent of New York men reported binge drinking, compared to 31 percent nationally. For all New Yorkers, 14 percent reported binge drinking, compared to 24 percent nationally. For women, the number was the same -- 7 percent.

The margin of error for the portion of the survey related to binge drinking is plus or minus one percentage point.

On the Net: www.nyc.gov/health

School Options Were Few Despite Killer's Troubling Behavior
Raja Mishra & Marcella Bombardieri, Boston Globe- 4/19/2007

BLACKSBURG, Va. -- During a turbulent four-month period in 2005, Seung-Hui Cho repeatedly demonstrated he was a potential threat to himself and other students, according to police, school officials, and faculty.

He harassed two female students in person and with instant messages and phone calls, police said yesterday. English teachers yanked him out of class after persistent antisocial behavior, and gave him instruction in private. And a friend told school administrators that Cho wanted to kill himself.

University police confronted Cho about the harassment complaints, and he was briefly evaluated at a local psychiatric hospital, then pronounced well enough to return to classes and campus life. He never again appeared on the radar screen of Virginia Tech counselors or administrators -- despite continued faculty complaints about Cho's behavior -- until Monday, when the 23-year-old student killed 32 people and then himself.

School authorities sought yesterday to counter increasing concerns on campus that they mismanaged Cho and failed to act on multiple signs that he might harm others. Administrators and campus police said they lacked enough evidence to expel or institutionalize Cho, and could do nothing more to prevent him from continuing at Virginia Tech after the string of incidents in 2005. The campus police chief said yesterday that police had no contact with Cho after December 2005.

However, faculty in the school's English department complained about Cho's behavior and disturbing writings to university officials into 2006, according to Carolyn Rude , who recently became English department chair.

"There were multiple instances of reports of concerns" about Cho forwarded to school officials, Rude said in an interview with the Globe. "We don't have the authority or the knowledge to do more than report. We are English teachers."

Cho's antisocial tendencies began sending up red flags to professors in September of 2005.

That semester, in poet Nikki Giovanni's creative writing class, he wrote sinister poems about death and took pictures of female students' legs under their desks in class with a cell phone. Giovanni appealed to Lucinda Roy, who then chaired the English department, to remove him from the class. After that, Roy taught him one-on-one, and the sessions so frightened her that she devised a code with her assistant to call for help in case she feared for her safety.

Roy, who also was concerned about Cho's behavior and disturbing writings when she had him in one of her classes, said she brought the concerns to campus police and various other college units. But she said authorities "hit a wall" in terms of what they could do "with a student on campus unless he'd made a very overt threat to himself or others." Cho resisted her repeated suggestion that he undergo counseling, Roy said.

Police said nothing could be done based on the professors' concerns.

"These assignments were for a creative writing course that encouraged students to be imaginative and artistic. The writings did not express any threatening intentions or allude to any criminal activity, and no criminal violation had taken place," said Wendell Flinchum, chief of police at Virginia Polytechnic Institute and State University.

Then, on Nov. 27, 2005, Cho harassed a female student through phone calls and in person, campus officials said. The student called campus police but later refused to press charges. Police officers referred Cho to Virginia Tech's Office of Judicial Affairs, which took no action.

On Dec. 12, 2005, Cho sent harassing instant electronic messages to another female student, who also complained to campus police but then refused to press charges.

Flinchum yesterday said officers had no reason to believe the female students faced a threat to their well-being.

"I'm not saying they were threats. I'm saying they were annoying. That's the way the victims characterized them, as annoying messages," he said. Neither of the two female students was among the shooting victims Monday.

On the same December day as the second incident, police got a call from someone who said he knew Cho and believed that Cho was suicidal, campus officials said. The call triggered the first official action taken with Cho.

Police officers talked to Cho "at length," said Flinchum. Cho agreed to speak to a counselor at the Cook Counseling Center, the mental health facility for the 26,000-student campus in the foothills of the Blue Ridge Mountains.

Dr. Chris Flynn , the center's director, would not discuss his department's dealings with the young man. But he said that he had been prepared to take more serious measures if his staff determined other students' safety were in danger.

" If a danger was known to a mental health professional, they have a duty to act," said Flynn. "And they have a responsibility to act and they will act."

He said his department treats about 2,000 students per school year, about 2 percent of them suffering from serious mental illnesses like schizophrenia and bipolar disorders. Flynn said staff members would have notified authorities if they had determined Cho had violent tendencies. The center is staffed with one psychiatrist, 11 psychologists, three nurses, two counselors, and psychology interns.

"It is very difficult to predict when what someone perceives as stalking is stalking, and then how it might translate into violence later," said Flynn. "Clearly, if anyone had any warning about a violent incident people would have stepped in and acted."

Counselors at the campus center decided in December 2005 that Cho might need further help and sought a temporary detention order from a local magistrate, which Virginia law required to send him to an off-campus facility.

The magistrate signed the order after an initial evaluation by a physician found probable cause that Cho might be a danger to himself or others due to mental problems. On Dec. 13, 2005, Cho was taken to Carilion St. Albans Psychiatric Hospital in nearby Radford, Va.

Within days, Cho was back in classes after being released. St. Albans officials would not discuss Cho's case. But they said they have the power to involuntarily detain anyone viewed as a public threat.

Upon return from St. Albans, Cho faced no sanctions from Virginia Tech's disciplinary system. Students can be suspended or expelled by the school alone for academic misconduct, such as plagiarism. The school also can punish or expel them if they're found guilty by a faculty-supervised five-student panel of violating student life rules, such as hazing and drug use. Because the two female students refused to press any charges, the panel could do nothing, said campus officials.

" You have to have someone who is willing to refer the case, you know, come forward with it," said Edward Spencer , Virginia Tech's associate vice president for student affairs.

In the fall of 2006, nearly a year after Cho had been briefly hospitalized, he wrote plays full of violence and hatred that disturbed his classmates in a playwriting class. At the time, the English department was receiving training on dealing with troubled students because teachers were concerned about the problems some students would bring up in their writing or in person. That semester, one student revealed that she had been raped and a teacher accompanied her to the hospital, Rude said.

According to faculty guidelines, faculty are to contact police if they are concerned a student might be dangerous. The police then contact counseling services, she said. It's unclear what university officials did with the complaints in 2006.

"He was frightening students and frightening the teacher," said Rude. "People have always said he's quiet and he's troubled."

Mental Health A Dilemma For Colleges
Jane Stancill, Hartford Courant- 4/19/2007

BLACKSBURG, Va. -- It seemed like everyone who knew Cho Seung-Hui at Virginia Tech witnessed his odd, disturbing behavior - professors, classmates, roommates and two women he stalked.

Now, the question is, with all the warning signs, should the university have done more to deal with a student who, though troubled, apparently committed no crime and threatened no violence to others? Could something have been done to prevent Monday's massacre?

The painful second-guessing of Virginia Tech's actions could prompt changes in how U.S. college campuses handle students with mental illnesses. It's already a widely debated issue complicated by questions of medical confidentiality, universities' legal liability and a rising population of college students with serious mental illnesses.

It's an acute problem, according to the National Survey of Counseling Center Directors conducted last year. Ninety-two percent said the number of students with severe psychological issues has increased in recent years. They said 40 percent of students seen at counseling centers have severe problems, including 8 percent whose impairments are so serious that they can't remain in school or can do so only with extensive treatment.

College counselors attribute the rise to improvements in psychiatric drugs that allow more people with mental illnesses to make it to college in the first place.

It has created new problems for universities, where counseling centers are often not equipped to deal with serious illnesses and growing numbers of students who need treatment.

Kevin Kruger, associate executive director of the National Association of Student Personnel Administrators, said the Virginia Tech tragedy is likely to influence many colleges' policies about how they identify students who may be dangerous.

"My gut on this is we're going to become more likely to want to remove students from the educational environment," Kruger said.

There are no easy answers.

After a 2002 lawsuit by the parents of an MIT student who committed suicide, more universities began to force suicidal students to withdraw from school, at least temporarily. Another lawsuit by a George Washington University student claimed that the school violated the federal disability law when it suspended him after he sought help for depression.

"Everyone's going to be looking at those threshold points, and [ask] `When do we take more drastic action?'" Kruger said. "It's the classic tension between individual freedom - the right of every individual to stay on campus - with the interests of the community."

Strange behavior is largely a judgment call, and forcing students into treatment isn't usually an option, said Maggie Olona, head of student counseling at Texas A&M University and president of the Association for University and College Counseling Center Directors.

Nor is knowing when to worry about student behavior, and what action to take, always so clear.

“They can’t really kick someone out because they’re writing papers about weird topics, even if they seem withdrawn and hostile,” said Dr. Richard Kadison, chief of mental health services at Harvard University. “Most state laws are pretty clear: you can only bring students to hospitals if there is imminent risk to themselves or someone else, so universities are in a bit of a bind that way.”

But, he said, some schools do mandate limited amounts of treatment in certain circumstances.

“At the University of Missouri, if someone makes a suicide attempt, they mandate four counseling sessions, for example,” said Dr. Kadison, an author of “College of the Overwhelmed: The Campus Mental Health Crisis and What To Do About It.”

Universities can find themselves in a double bind. On the one hand, they may be liable if they fail to prevent a suicide or murder. After the death in 2000 of Elizabeth H. Shin, a student at the Massachusetts Institute of Technology who had written several suicide notes and used the university counseling service before setting herself on fire, the Massachusetts Superior Court allowed her parents, who had not been told of her deterioration, to sue administrators for $27.7 million. The case was settled for an undisclosed amount.

On the other hand, universities may be held liable if they do take action to remove a potentially suicidal student. In August, the City University of New York agreed to pay $65,000 to a student who sued after being barred from her dormitory room at Hunter College because she was hospitalized after a suicide attempt.

Also last year, George Washington University reached a confidential settlement in a case charging that it had violated antidiscrimination laws by suspending Jordan Nott, a student who had sought hospitalization for depression.

“This is a very, very difficult and gray area, when you take action to remove the student from the campus environment, versus when you encourage the student to use the resources available on campus,” said Ada Meloy, director of legal and regulatory affairs at the American Council on Education. “In an emergency, you can share certain information, but it’s not clear what’s an emergency.”

Ms. Meloy estimated that situations complicated enough to involve a university’s lawyers arise, on average, about twice a semester at large universities.

While shootings like the one at Virginia Tech are extremely rare, suicides, threats and serious mental-health problems are not. Last year, the American College Health Association’s National College Health Assessment, covering nearly 95,000 students at 117 campuses, found that 9 percent of students had seriously considered suicide in the previous year, and 1 in 100 had attempted it.

So mental health experts emphasize that, whatever a college’s concerns about liability, the goal of campus policies should be to maximize the likelihood that those who need mental-health treatment will get it.

“What we really need to do is encourage students to seek mental health treatment if they need it, to remove any barriers to their getting help, destigmatize it, and make it safe, so they know there won’t be negative consequences,” said Karen Bower, a lawyer at the Bazelon Center for Mental Health Law in Washington, who represented Mr. Nott.

With the Virginia Tech killings, many universities are planning to remind faculty members of their protocols. “We’re actually going to go ahead and have the counseling service here do a session for all our instructors and faculty on what to look for, what the procedures are, and what the counseling center can do,” said Shannon Miller, chairwoman of the English department at Temple University.

At Harvard, Dr. Kadison said, dormitory resident assistants watch for signs of trouble, and are usually the first to become aware of worrisome behavior — and to call a dean.

“The dean might insist that they get an evaluation to make sure they’re healthy enough to live in a dorm,” he said. “If it’s not thought that they’re in any immediate danger, they can take or not take the recommendation.”

Last month, Virginia passed a law, the first in the nation, prohibiting public colleges and universities from expelling or punishing students solely for attempting suicide or seeking mental-health treatment for suicidal thoughts.

“In one sense, the new law doesn’t cover new territory, because discrimination against people with mental health problems is already prohibited,” said Dana L. Fleming, a lawyer in Manchester, N.H., who is an expert on education law. “But in another sense, it’s ground-breaking since it’s the first time we’ve seen states focus on student suicides and come up with some code of conduct for schools.”

College counseling services nationwide are seeing more use.

“We’re seeing more students in our service consistently every year,” said Alejandro Martinez, director for counseling and psychological services at Stanford University, which sees about 10 percent of the student body each year. “Certainly more students are experiencing mental illness, including depression.

“But there’s also been a cultural shift,” Mr. Martinez said, “in that more students are willing to get help.”

College officials say that a growing number of students arrive on campus with a history of mental-health problems and a prescription for psychotropic drugs. But screening for such problems would be illegal, admissions officers say.

“We’re restricted by the disabilities act from asking,” said Rick Shaw, Stanford’s admissions director. “We do ask a question, as most institutions do, about whether a student has been suspended or expelled from school, and if they have been, we ask them to write an explanation of it.”

Federal laws also restrict what universities can reveal. Generally, the Family Educational Rights and Privacy Act, Ferpa, passed in 1974, makes it illegal to disclose a student’s records to family members without the student’s authorization.

“Colleges can disclose a student’s private records if they believe there’s a health and safety emergency, but that health and safety exception hasn’t been much tested in the courts, so it’s left to be figured out case by case,” Ms. Fleming said.

And the Health Insurance Portability and Accountability Act prohibits the release of medical records. “The interaction of all these laws does not make things easy,” she said.