Noteworthy News Articles on Mental Health Topics, April 24-30, 2007

It occurred, oddly enough, during the appearance of a hostile witness, Dr. Robin Hamill-Ruth, one of the experts who was paid by the federal prosecutors to analyze Dr. Hurwitz’s prescriptions for OxyContin and other opioids.

Dr. Hamill-Ruth, who noted that she never prescribed the highest-strength OxyContin tablet, said some of Dr. Hurwitz’s actions were “illegal and immoral” because he prescribed high doses despite warning signs in patient behavior that the opioids were being resold or misused.

Then, during cross-examination by the defense, Dr. Hamill-Ruth was shown records of a patient who had switched to Dr. Hurwitz after being under her care at the University of Virginia Pain Management Center. This patient, Kathleen Lohrey, an occupational therapist living in Charlottesville, Va., complained of migraine headaches so severe that she stayed in bed most days.

Mrs. Lohrey had frequently gone to emergency rooms and had once been taken in handcuffs to a mental-health facility because she was suicidal. In 2001, after five years of headaches and an assortment of doctors, tests, therapies and medicines, she went to Dr. Hamill-Ruth’s clinic and said that the only relief she had ever gotten was by taking Percocet and Vicodin, which contain opioids.

Mrs. Lohrey was informed that the clinic’s philosophy “includes avoidance of all opioids in chronic headache management,” according to the clinic’s record. The clinic offered an injection to anesthetize a nerve in her forehead, but noted that “the patient is not eager to pursue this option.” Mrs. Lohrey was referred to a psychologist and given a prescription for BuSpar, a drug to treat anxiety, not pain.

“You gave her BuSpar and told her to come back in two and a half months?” Richard Sauber, Dr. Hurwitz’s lawyer, asked Dr. Hamill-Ruth. Dr. Hamill-Ruth replied that unfortunately, the clinic was too short-staffed at that point to see Mrs. Lohrey sooner. Under further questioning Dr. Hamill-Ruth said that she was not aware that BuSpar’s side effects included headaches.

Mrs. Lohrey looked elsewhere for help. Having seen Dr. Hurwitz on television _ — “60 Minutes” and other programs had featured his controversial high-dose opioid treatments — she sent him a letter describing her pain and the accompanying nausea and vertigo.

“I have lost hope of retrieving my life as it was,” she wrote, because she could find no doctor to take her seriously. “I currently have a physician who has said that I am psychologically manufacturing my headaches, and that I am addicted to narcotic pain relief. This of course is not the first time that I have been treated as a ‘nut’ or a ‘junkie.’ ”

It was the kind of letter Dr. Hurwitz received from people across the country. His office in the Virginia suburbs of Washington was like a Lourdes for people with pain, one of the most widespread health problems. Surveys have found that one in five adults deals with chronic pain, and that it is treated adequately only about half the time.

Prescribing opioids was once taboo because of concerns over patients’ becoming addicted. But medical opinion gradually shifted over the past two decades as researchers concluded that high doses of opioids could sometimes be safer and more effective than alternatives like surgery or injections.

Two of the leading pain experts, Dr. Russell K. Portenoy of Beth-Israel Medical Center and Dr. James N. Campbell of Johns Hopkins University, testified without pay as experts for the defense. They said Dr. Hurwitz was widely known as a knowledgeable physician and passionate advocate of giving patients full pain relief, unlike many doctors who were reluctant to prescribe opioids because they feared legal repercussions, particularly when dealing with patients who sometimes used illegal drugs.

Such “problem patients” consumed so much time and energy that most doctors refused to treat them “regardless of what the consequences would be for the patient,” Dr. Campbell testified. He said that he had been initially skeptical of some of Dr. Hurwitz’s high-dose treatments, but was then impressed by the results in patients he sent to Dr. Hurwitz.

He said some doctors might argue that Dr. Hurwitz was guilty in some instances of negligence that would make him liable for damages in a civil case. But Dr. Campbell contradicted the prosecution’s experts by testifying that all the prescriptions were clearly within the “bounds of medical practice.”

That legal phrase is the crucial distinction in this criminal case, which the jury was deliberating as this column went to press: Did Dr. Hurwitz knowingly prescribe drugs to be used for nonmedical purposes? (For updates on the case, see www.nytimes.com/tierneylab.)

When Dr. Hurwitz testified last week, he spent hours going through the histories of those he called his “misbehaving patients,” telling why he believed they all had genuine problems. “Ultimately, pain is what the patient says it is,” he told the jury, contrasting his approach with what he called the traditional “Father Knows Best” approach of old-school doctors.

In retrospect, he acknowledged, he should have been more suspicious of patients who asked for early refills, reported losing prescriptions and tested positive for illegal drugs. He did get rid of the worst patients, he said, but he believed others were reforming, and he feared they would not get help anywhere else if he dismissed them.

“I felt that I had a duty to the patients,” he said. “I hated the idea of inflicting the pain of withdrawal on them.” After the closure of his practice in 2002, he said, two of his patients committed suicide because they gave up hope of finding pain relief.

The most moving testimony came from Mrs. Lohrey and other patients who described their despondency before finding Dr. Hurwitz. They said they were amazed not just at the pain relief he provided but at the way he listened to them, and gave them his cellphone number with instructions to call whenever they wanted.

“I felt like I was his only patient,” Mrs. Lohrey testified. “I think he truly understood the nature of what I was going through.” When she lost her health insurance, she said, Dr. Hurwitz continued treating her at no charge, and helped her enroll in a program that paid for her opioid prescriptions. After Dr. Hurwitz’s practice was shut down, she could not find anyone to treat her for seven months. Eventually, she found a doctor willing to prescribe small numbers of low-dose Percocet, but she said she was not getting enough medicine to consistently blunt the headaches.

“The last two weeks, I was pretty much in bed and sick with the headaches and the nausea and the whole nine yards,” she said, explaining that she had deliberately undergone the two weeks of pain in order not to use up any of her pills.

“I had to save up medication,” she testified, “so I could be here today.”

And sure enough, from bombs to clones, the ethicists have generally kept to the rear of the scientific parade: they are the ones with the big brooms trying to restore order after the floats and the elephants go by.

Those brooms sweep slowly. Often, by the time the ethicists finish laying out facts and weighing relevant moral values, the worst of any given crisis has passed. But recently, those who work in medicine have moved closer to the fray: they staff acute-care hospitals and monitor events in real time, aiming for a little less retrospective philosophy and a little more damage control.

In this proactive spirit Howard Brody, a medical ethicist, has brought his discipline’s tools to the relationship between the medical profession and the pharmaceutical industry. This problematic tangle of moral compromise (or triumphant health-promoting collaboration, depending on your point of view) has inspired several polemics by physicians in recent years, all of them straightforward indictments of the pharmaceutical industry and its for-profit webs.

Dr. Brody is also a physician, but he aims for the measured cadences of the ethicist instead, calmly laying out the relevant facts and then reasoning from basic principles to determine whether the medicine-pharmaceutical relationship, as it stands now, is an ethical one or not.

That Dr. Brody manages to deliver a hundred-odd pages of determinedly objective analysis before he, too, lets the righteous indignation roll should not really be called a failure of methodology: even as he carefully lays out the facts in this impressively comprehensive book, those facts begin to speak damningly for themselves.

The small-time operations that grew up into modern medicine and Big Pharma joined together back in the late 19th century, allied in the name of scientific medicine against a variety of dubious health-care entrepreneurs. The A.M.A. actually called the early pharmaceutical companies the “ethical” drug makers, to distinguish them from unscrupulous patent-medicine peddlers.

Over time, this casual alliance has been reinforced with such complex and often invisible bonds that, in Dr. Brody’s title metaphor, medicine and pharma are now “hooked” like two pieces of Velcro, tethered by a million barbs and as dependent on each other as any addicts are on their substance of choice.

Dr. Brody systematically analyzes the levels of connection, from the lowly drug salesman buying lunch for a roomful of medical students (future customers all) to the lucrative contracts and patents that simultaneously fuel medical research, fill corporate coffers and give us, as the industry doggedly and quite correctly points out, dozens of truly miraculous life-saving drugs.

Many of these interactions are probably now familiar to most readers: the omnipresent logo-bearing trinkets festooning medical offices, the free samples of the latest, most expensive drugs, the “ask your doctor” television ads.

Less familiar may be some of industry’s other friendly overtures: the lavish junkets and cash rewards for some “high-prescribing” doctors; the subtle manipulations of research data; the way-too-generous financing of postgraduate medical education; the very cozy relationship with the Food and Drug Administration and its physician consultants; and a casually Orwellian interference with the average physician’s prescription pad.

A drug salesman recalls for Dr. Brody the time his company asked a local doctor to evaluate various sales presentations for a particular drug: “He’d been selected because our data showed that he was a relatively low prescriber. ...Basically, the company was willing to bet $500 or $750 that if he heard the same drug pitch all day, by the end of the day he’d be so brainwashed that he could not possibly prescribe any other drug but ours.”

All this mutual back-scratching would be fine if patients’ interests were indeed being served. But ample data indicates quite the reverse. Patients, after all, are the ones who pay for expensive drugs when cheaper would do as well, and the ones who swallow dangerous drugs nudged to market by their manufacturers.

Many individual problematic drugs make an appearance here. Chloromycetin, a toxic antibiotic from the 1950s, was relentlessly promoted by its manufacturer for routine use until the day its patent expired. (Still available in generic form, it is now used only as a last resort.) Thalidomide never caused an epidemic of birth defects in this country, as it did in Germany, only because a single stubborn F.D.A. officer was dissatisfied with the drug’s safety profile, despite the manufacturer’s repeated assurances that everything was fine.

The epitaph of the recently withdrawn painkiller Vioxx, whose virtues were subtly spun to the medical community in prestigious research journals, is still being written in litigation around the country.

“Research that is driven by marketing rather than by scientific aims would seem, in the end, to be low-quality research,” Dr. Brody comments mildly about the Vioxx fiasco.

His overall conclusion is similarly low-key: “A profession is not just a way of making money; it’s a form of public trust. ...Medicine has for many decades now been betraying this public trust.”

It is not a particularly surprising conclusion, and, in fact, there is relatively little in this book to surprise anyone familiar with the territory. Rather than new material, it provides a meticulously referenced compendium of all the relevant history and commentary (including, for full disclosure, excerpts from one of this reviewer’s columns in this newspaper).

Its breadth translates into a lack of depth in some areas, especially the final section, in which Dr. Brody tries to outline a feasible solution to the mess. His suggestions are cogent but a little skimpy, given that absent an act of God, it will probably take an act of Congress to pry medicine and industry apart someday, preferably as part of thoroughgoing health care reform.

Still, for a detailed overview of this very jagged terrain, if not for a map of the pathway out, a better general guide than this one is hard to imagine.

How could I possibly understand or help her, she seemed to be asking, if I had not personally experienced her pain?

Her question caught me by surprise and made me pause. O.K., I’ll admit it. I’m a cheerful guy who’s never really tasted clinical depression. But along the way I think I’ve successfully treated many severely depressed patients.

Is shared experience really necessary for a physician to understand or treat a patient? I wonder. After all, who would argue that a cardiologist would be more competent if he had had his own heart attack, or an oncologist more effective if he had had a brush with cancer?

Of course, a patient might feel more comfortable with a physician who has had personal experience with his medical illness, but that alone wouldn’t guarantee understanding, much less good treatment.

Still, many patients want their doctor to be someone with whom they can identify, not just a technically competent professional who can alleviate their pain.

As a psychiatrist, I’ve met many patients who have made requests for a specific type of therapist: African-Americans who want a black psychiatrist, Orthodox Jews who insist on a Jewish psychotherapist, women who ask for a feminist therapist and so on.

Not long ago, a gay man in his 30s called me to ask for a referral to a gay therapist. He was adamant about seeing only a gay clinician. “I can’t take the chance of getting a homophobic shrink,” he said.

His assumption was that if a therapist shared his sexual orientation or ethnic group, there would be a kind of guaranteed basis for understanding or acceptance.

I did, in fact, refer him to an excellent colleague who happens to be gay, but the brief conversation left me troubled. All these patients who were searching for understanding had a misconception, I think, of what empathy is all about.

What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex.

Contrary to what many people believe, being empathic is not the same thing as being nice. In fact, empathy can sometimes be put to a very dark purpose.

When the Nazis were bombing Rotterdam in World War II, for example, they put sirens on the Stuka dive-bombers knowing full well that the sound would terrify and disorganize the Dutch. The Nazis imagined perfectly how the Dutch would feel and react. Fiendish, but the very essence of empathy.

In the right hands, empathy has tremendous positive therapeutic force and can narrow what looks like an unbridgeable gap between patients and therapists.

A few years back, I saw an elderly woman who had just lost her husband to cancer. “Oh, I hadn’t realized you were so young!” she exclaimed. “No offense, but maybe I need to see someone who’s a bit older.”

I asked her, “Are you worried that I can’t know what it feels like to lose someone you love and face life without him?”

True, I had never lost a partner, but it wasn’t hard to imagine her grief and anxiety about her future. That must have done the trick, because she stayed in treatment and never again mentioned my age.

Sometimes, though, patients should get exactly what they ask for in a therapist. One of my residents once saw a young woman from Africa who had survived hideous torture and rape and said that she didn’t think she could see a male therapist.

That struck me as entirely appropriate. Given her trauma, she simply could not have put her trust in a male therapist, no matter how empathic he might actually be.

What about patients whose demand for a particular therapist springs from nothing more than everyday prejudice? I remember a patient who once stormed into my office and demanded a white therapist to replace his therapist, who was black.

That’s a request I turned down, even knowing that this patient’s biased beliefs were an appropriate target for treatment. To do otherwise would have vindicated his prejudice and fundamentally compromised the therapy from the start.

In the end, empathy is what makes it possible for us to read each other. And it is the reason your doctor can understand your problem without actually having to live it.

Richard A. Friedman is director of the psychopharmacology clinic at the Weill Medical College of Cornell University.



American Indian Women Face More Assaults
Associated Press- 4/24/2007

WASHINGTON -- American Indian women are more than twice as likely to be raped as other U.S. women, and the suspects often go free because of confusing police jurisdictions and a lack of nurses, Amnesty International reports.

The human rights group said Tuesday that at least one in three Indian women will be raped or sexually assaulted, compared with fewer than one in five U.S. women overall.

Confusion about whether state, federal or tribal police should respond means victims might not see a police officer or a nurse for hours or days, if at all. Even if a rape victim is taken to an Indian Health Service clinic, almost half lack staff trained to provide emergency services to victims of sexual violence, researchers said.

''What this amounts to is a travesty of justice for the tens of thousands of indigenous survivors of rape,'' said Larry Cox, executive director of Amnesty International USA. He contended the U.S. government's treatment of Indian rape victims is a violation of human rights.

At a news conference Tuesday, Cox said the group will press Congress to fully fund the Violence Against Women Act at $683 million. Tribes would get about 10 percent of various grant programs under the act. Members also will push for money for more sexual assault nurse examiners at tribal clinics.

State and federal officials have pledged to fight skyrocketing crime rates on Indian reservations related in part to methamphetamine and other drug abuse.

Indian reservations, which are often rural and poor and lack large police forces, have long struggled with drug and alcohol abuse and related crimes. Meth has made the problem worse in recent years.

Amnesty International used sexual violence statistics from a Justice Department survey. The group focused on three locations: Alaska, Oklahoma and the Standing Rock Sioux Reservation in North and South Dakota.

The report indicated at least 86 percent of the reported rapes or sexual assaults of Indian women are by non-Indian men.

State, tribal or federal police might be responsible for investigating, depending on the seriousness of the crime and whether the perpetrator is an Indian.

The maze of law enforcement jurisdictions on Indian reservations has created ''areas of effective lawlessness which encourages violence,'' according to the report.

During Tuesday's news conference, Renee Brewer, a domestic violence worker from Oklahoma, said rape victims sometimes must wait for help while tribal and local police hammer out who should respond to the crime.

''Imagine having to tell your story multiple times to authorities in multiple systems that may or may not be working in collaboration,'' Brewer said.

Tribes ultimately want the resources and ability to provide public safety themselves, said Sarah Deer, a tribal law specialist from Minnesota and a member of the Muscogee Nation.

But the book that prompted her to write a 1,200-word post on her blog, www.mommiesparadise.com, was “The Feminine Mistake” by Leslie Bennetts, which Ms. Moen has not read and has no intention of reading.

Having seen an article from HuffingtonPost.com by Ms. Bennetts and a review of the book, which argues that mothers who stay at home with their children are financially, emotionally and medically at risk, Ms. Moen believes that she knows enough about it to debate its premise.

“I really think she laid out what she wrote about in the book in the article,” Ms. Moen said. “The whole article rubbed me the wrong way, so I’m not inclined to read the book.”

Ms. Moen is one of dozens of women online who have tangled with what they perceive as Ms. Bennetts’s message. Fueled by the author’s appearance on the “Today” show, an excerpt in Glamour magazine, and reviews or interviews in Parade and People, these women are giving Ms. Bennetts the kind of cocktail-party stature (if these women, mostly mothers, had time for cocktail parties) to which many writers aspire.

The explosion of commentary on blogs and elsewhere about “The Feminine Mistake” joins a growing list of similar fracases stirred up by books that touch on the perennial dilemma of mostly upper-middle-class women: return to work or stay at home with the kids. But the truth is that, with rare exceptions (and it’s too early to say whether Ms. Bennetts’s book may be one of them), these so-called mommy books fail to transform their talk-show and blogosphere buzz into book sales. Talk, it turns out, is much cheaper than the $24.95 cover price.

“There is a lot of discussion out there about this issue and that’s why we’re having these books,” said Nancy Sheppard, vice president of marketing at Viking, which last year published “Get to Work: A Manifesto for Women of the World” by Linda R. Hirshman. “But it’s mostly just a discussion.”

Ms. Hirshman, who also argued that women should work outside the home to fulfill their human capacities and avoid economic dependency, appeared on “Good Morning America” and “The Colbert Report” after the book’s release in June, and the blogosphere went wild. But her book sold only 4,000 copies, according to Nielsen BookScan, which accounts for about 70 percent of sales in stores and online.

Nobody has matched the success of “The Feminine Mystique,” Betty Friedan’s bombshell that exposed the dreariness of women’s domestic lives and has sold about three million copies since it first appeared in 1963. Judith Warner’s “Perfect Madness: Motherhood in the Age of Anxiety” has been described as a recent success because it sold 37,000 copies in hardcover and hit the New York Times hardcover nonfiction best-seller list for three weeks. (After publication, Ms. Warner became a columnist for TimesSelect, the paid Web site of The New York Times, and a contributor to the Op-Ed page.)

Recent mommy books that have not lived up to the promise of their publicity include Sylvia Ann Hewlett’s “Creating a Life: Professional Women and the Quest for Children,” which sold only 11,000 copies in hardcover and 2,000 in paperback, according to BookScan, despite the book’s appearance on “60 Minutes,” “The Oprah Winfrey Show” and the covers of Time and New York magazines.

And last year Caitlin Flanagan’s “To Hell With All That: Loving and Loathing Our Inner Housewife,” a collection of essays that said, among other things, that when a woman works, something is lost, generated a media and Internet frenzy, but sold only 9,000 copies in hardcover, according to BookScan.

What is striking about these limp sales figures is that these books cover a topic that raises fierce passions, as anyone who has spent time on a playground or near an office water cooler knows. But that may get at the heart of why women are not buying books about these subjects.

“I always felt it was something that women didn’t want to look at too closely,” said Jonathan Burnham, publisher of HarperCollins, who was editor in chief at Talk Miramax Books when Ms. Hewlett’s book, which suggested that women who pursued high-powered careers could end up childless, was published five years ago. “It was a problem that touched very complicated feelings, so while they read a magazine article or watched a segment on ‘Oprah,’ they didn’t want to read a whole book about it because it was such a difficult subject.”

It also may be that in the absence of any policy changes making the lives of mothers easier, people are more interested in venting their frustrations than in reading another book. Because it’s such an unresolved issue, women have a “desperate need to express their feelings and have a discussion,” Naomi Wolf, the feminist writer, said. “You don’t really need to buy a book to do that.”

Ms. Bennetts, who interviewed hundreds of people, including mothers, economists and sociologists, and marshaled a broad array of statistics for “The Feminine Mistake,” said she didn’t understand why the people who have posted inflammatory comments about the book weren’t willing to buy it and find out what she has to say. Some have even taken to personal attacks, with one blogger discrediting Ms. Bennetts because of her weight.

“Among full-time homemakers, this overdeveloped capacity for denial is often accompanied by a highly combative sense of indignation about views that challenge their own,” Ms. Bennetts wrote in a HuffingtonPost.com article.

In an interview Ms. Bennetts, who worked at The New York Times for 10 years before moving to Vanity Fair, where she is now a contributing editor, added that the negative blog posts do not reflect the many positive responses she has personally received. “We’ve got this incredible response from working women who are just about euphoric about the fact that somebody has finally written that not only are you not a bad mother, but you are providing for your kids in really crucial ways,” Ms. Bennetts said.

Ms. Bennetts said she even received a call early one Saturday morning from a stay-at-home mother who told her: “ ‘I didn’t realize how depressed and unhappy I’ve been until I read your book.’ She said, ‘I swear to God, I think you’ve saved my life.’ ”

At Barnes & Noble, Mike Ferrari, a director of merchandising, said the book is “selling extremely well.”

Still, some booksellers say sales have not taken off. “I really expected more than what we’re seeing,” given the publicity, said Cathy Langer, lead book buyer for the Tattered Cover bookstores in Denver. “We bought, thinking it would move a little faster, a little bigger.” So far, according to BookScan, “The Feminine Mistake,” which went on sale on April 3, has sold 5,000 copies.

Ellen Archer, publisher of Voice, a new imprint of Hyperion directed at women that published “The Feminine Mistake,” said the book is already in its fourth printing, with 42,000 copies. “This is a book that’s going to build over time through word of mouth,” Ms. Archer said. “There are many business books that sell hundreds of thousands of copies that never hit any best-seller lists, but they endure over time and become classics in their category.”

Some authors say that book sales are not the only goal. Ms. Hirshman, who wrote a shortened version of her book for the online site of American Prospect magazine six months before the book’s release, said the book was just a platform for getting her ideas into the ether.

“I guess the media world has changed in such a way that a book is just a pretext for television appearances and blogging and writing for The New Republic,” Ms. Hirshman said. “If the world is divided into people who don’t need my message and women who don’t want to hear it, it’s a miracle I sold any books.”

But for many busy mothers, it is simply the only-so-many-hours-in-the-day factor. “I’m home-schooling, I have three children, and my reading time is limited,” said Heather Cushman-Dowdee of Los Angeles. With many of the mommy books, she said, “I think I get their points through the articles that they’re writing without needing to delve in.” Declining to buy the books, she said, is a way to “protect your sanity a little bit.”

New York State would more closely scrutinize its use of solitary confinement for mentally ill prison inmates under the proposed terms of a legal agreement scheduled for review by a federal judge on Friday.

New York is one of several states that have faced lawsuits over the means used to punish mentally ill prisoners, and, under a settlement reached last week, it has agreed to consider changes in how it uses solitary confinement as a disciplinary measure with the mentally ill.

Many advocates hail the agreement as a watershed in prison reform because of the effects long sentences in isolation have had on the most vulnerable prisoners, including suicide and self-mutilation.

Some mentally ill inmates serve months to years in punitive segregation, locked up for 23 hours a day and sometimes restricted to a diet of cabbage and a pasty flour loaf three times daily for up to 30 days for misbehaving.

Disability Advocates Inc. and the Legal Aid Society of New York sued the state over the practices five years ago, and the resulting agreement goes before Judge Gerard E. Lynch of the Southern District of New York on Friday for final review.

If the agreement is approved, as expected, the state will not be barred from the use of solitary confinement, or punitive segregation, to discipline mentally ill prisoners, but it would have to provide far more assessment and services for mentally ill inmates in solitary. In addition, the state would be required to review the reasons for and the length of proposed segregation sentences.

Many mental health advocates believe that the New York settlement will create pressure on other states to review their policies of confining mentally ill prisoners.

Others, including state lawmakers and advocates, said the agreement was only a small step toward stopping inhumane treatment of these prisoners. Many of those advocates were particularly disheartened last fall when Gov. George E. Pataki vetoed a bill that would have banned the use of solitary confinement for the mentally ill in New York.

“We see the settlement as a step in the right direction because it provides additional resources and services for treating the mentally ill in prison,” said Robert Gangi, executive director of the Correctional Association of New York, an advocacy group that is now lobbying the new administration in Albany to stop sending mentally ill prisoners into isolation. “But it falls far short of the policy changes that are needed to ensure humane and appropriate treatment for all the mentally ill people in prison.”

In New York, with one of the largest prison populations in the country, mental illness has been diagnosed in about 8,400 of the 63,000 inmates, according to the State Office of Mental Health. The number of inmates has decreased significantly in the last few years, but Mr. Gangi said the number of mentally ill prisoners was rising, possibly because the condition is being more accurately diagnosed.

Under the agreement, mentally ill prisoners sent to solitary confinement would be entitled to leave their cells for therapy and treatment for two to four hours daily. Their placement in solitary confinement would have to be preceded by extensive reviews, all prisoners entering the system would be screened for mental illness, and the state would be required to provide some mentally ill prisoners with alternative residential housing.

State officials said that because of both the agreement and their own budgetary priorities, they had set aside an additional $9 million in the 2007-8 fiscal year for programs within existing prisons and new or renovated facilities to accommodate mentally ill inmates, a total of $57.5 million dedicated to mentally ill inmates.

The agreement also stipulates that New York prisons, which local and national advocates say are unique in using restricted diets to punish prisoners already in segregation, cannot use the cabbage-and-loaf punishment for more than seven days with mentally ill prisoners without “exceptional circumstances.”

Lawyers who brought the suit and national prisoner rights advocates said the New York settlement was unique in covering all mentally ill prisoners, from the time they enter the system until they leave, whereas some states have merely stopped sending prisoners with major mental illnesses to prisons with especially harsh conditions.

“The proof of the pudding is in the eating,” said David C. Fathi, senior staff counsel with the American Civil Liberties Union’s national prison project, who has handled several cases around the country regarding the treatment of mentally ill inmates. “We will have to see how this is implemented. But on paper, it is very significant, a victory and a step forward.”

He added, “Now we can point to New York and say, if New York can do it, why can’t you do it?

Brian had been a kind of star on campus, with a 3.7 grade-point average, and a lively wit that shone through his roles as sports editor of the newspaper, president of an a cappella group and actor in the annual student-written musical.

The death of her only brother, and the discovery that he had hidden his struggles with mental illness from his friends and family for years after he began hearing voices, rocked Ms. Malmon’s world, and by her junior year led her to start the student group that evolved into Active Minds Inc., a nonprofit organization with student-run chapters on 65 campuses, devoted to increasing awareness of mental illness.

She started small. Very small. Only three people showed up for the first meeting at Penn of what she initially called Open Minds.

“I asked them to help me figure out what we should do, ” said Ms. Malmon, now 25. “There’s so much talk about sexual identity and racial relations on college campuses. It was ridiculous in my mind that mental health wasn’t right up there with them, since it’s an issue that touches so many people.”

The prevalence of mental illness on campus is stunning, she found when she began researching the topic: Suicide is the second leading cause among death for college students. Almost one in 10 college students has made a suicide plan. Nearly half of all students report having felt so depressed that they could not function in the previous year. Most people with schizophrenia develop the disease before they are 25.

And yet, Ms. Malmon said, mental illness like her brother’s is so stigmatized that it is often kept secret.

“Mental illness is such an isolating thing,” she said. “It’s not something that’s easy to tell your family and friends about. That is the impetus for this. I firmly believe that Brian took his life because he didn’t know how to live with mental illness. It’s terrifying, because there aren’t positive role models, there’s just the people you see on the streets.”

Now, with the Virginia Tech shootings, Ms. Malmon is concerned about a resurgence of the stigma against mental illness. “I worry that as a society we’re going to look toward everybody with mental illness as being violent, and that stigma will build right back up,” she said. “We want to emphasize the need for students to talk about what they’re going through, and share their experiences. ”

Active Minds is one place where students can do that. While each chapter is different, the membership blurs the lines between students with mental illness; students with friends or family members living with mental illness; and a smattering of psychology students, social workers and nurses.

“When we have panel discussions, some are about what you can do to help a friend you’re concerned about, that you should go and say, ‘I’m worried about you, is everything O.K.?’ and walk them over to the counseling center,” Ms. Malmon said. “Others are about how to live with mental illness, where people discuss their own experiences with anxiety disorder or depression. It may sound a little mushy, but all these things help get the word out,” whether it is showing ”A Beautiful Mind,” sponsoring a Stamp Out Stigma run or having a speaker.

When a college student develops a mental illness, she said, friends are often the only ones who notice. Active Minds seeks to ensure that everyone on campus knows what mental health services are available and when to use them. On each campus, Active Minds has tables offering materials on mental health — often the same materials available at the counseling center, Ms. Malmon said, but more visible. In some cases, a chapter has worked even more closely with the counseling center, providing student interviewers to sit in when candidates are interviewed for counseling jobs.

Ms. Malmon, a sunny and impressively composed young woman who was a gymnast as a child and a varsity cheerleader at Penn, grew up in Potomac, Md., with her mother, Joanne, a social worker, and her father, Stuart, a lawyer. They separated when she was 8 and divorced when she was 12. “That’s really when Brian and I bonded, traveling back and forth from one to the other,” she said. “It was very important having a brother with me.”

Ms. Malmon was always interested in psychology. As a freshman, she studied historical perspectives on mental illness, and abnormal psychology. Brian’s death focused her interests further. Her senior thesis was “Attitudes Toward Mental Illness Among Ivy League Undergraduates.”

In 2003, Ms. Malmon graduated Phi Beta Kappa from Penn, incorporated Active Minds, and became the youngest recipient of the Tipper Gore Remember the Children Award from the National Mental Health Association.

Now, financed by a combination of individual donations and foundation grants, Active Minds is her full-time job. She shares the headquarters, a crammed one-room office in Washington, with two other women who coordinate the campus chapters. And soon, she expects, they will need more space. Every week brings inquiries about starting chapters, most recently from students or staff members at Arizona State University, Luzerne County Community College in Pennsylvania, the University of Central Florida and Humboldt State University in California.

“We just got a $100,000 three-year grant to do outreach,” Ms. Malmon said. “The goal is a chapter on every campus, but more realistic is that we’ll have about 300 chapters in the next three years. Mental illness is such an important issue. I expect to grow, not stay a little nothing nonprofit.”

However, Chief Stephen Farmer of the Tahlequah police says the department had received permission to destroy the evidence after Ms. Rozell initially declined to press charges.

Human rights advocates say such troubled cases involving Indian victims are common. And, American Indian women are voicing growing anger at what they call their disproportionate victimization in crimes of sexual assault, most often committed by non-Indians, and attitudes and laws that they say deter many from even reporting an attack.

“Indian women suffer two and a half times more domestic violence, three and a half times more sexual assaults, and 17 percent will be stalked — and I’m a victim of all three,” said Pauline Musgrove, executive director of the Spirits of Hope Coalition, an advocacy group in Oklahoma.

Now Amnesty International has taken up the issue, calling on Congress to extend tribal authority to all offenders on Indian land, not just Indians, and to expand federal spending on Indian law enforcement and health clinics.

In a report released yesterday, the American arm of the organization said sexual violence against American Indians had grown out of a long history of “systematic and pervasive abuse and persecution.”

Chris Chaney, deputy director of the office of justice services at the Bureau of Indian Affairs, and a member of the Seneca-Cayuga tribe of Oklahoma, said that Indians fell victim to crime at a higher rate than members of any other ethnic group and that domestic violence was on the rise because of methamphetamine abuse.

But Mr. Chaney said that the bureau recognized the problem and that the new federal budget proposed an increase of $16 million to aid Indian law enforcement agencies.

With just over 4 million American Indian and Alaska Native people in 550 federally recognized tribes scattered over Indian and non-Indian lands throughout the United States, jurisdictional questions often throw cases into limbo, Amnesty International found. In cases where tribal courts have jurisdiction, they can only impose punishments of up to a year in jail and a $5,000 fine. The report cited Justice Department figures suggesting that more than one in three American Indian and Alaska Native women would be raped in their lifetime, almost double the national average of 18 percent.

In 86 percent of the cases, the report said, the perpetrators were non-Indian men, while in the population at large, the attacker and victim are usually from the same ethnic group.

Larry Cox, executive director of Amnesty International USA, said the organization had been studying violence against women worldwide “and then somebody said why not look at what’s happening here.”

The 73-page report focused on Indian communities in Alaska, Oklahoma and South Dakota.

Alaska has the highest incidence of forcible rapes of all women, the report said, and Native Alaskans in Anchorage were nearly 10 times more likely to be victims of sexual assault than non-natives. Oklahoma’s 401,000 American Indians (according to 2005 Census estimates that include people listing mixed racial heritages) share 39 tribal governments and a patchwork of Indian and non-Indian lands; there are no reservations in Oklahoma, which is second only to California in its Indian population.

At Help in Crisis, a shelter for Indian women and their children in Tahlequah in eastern Oklahoma, many told of suffering assaults, often by husbands, without filing complaints.

Among them was Kendra Hunter, 25, who said she had been raped by three white men who held her captive for three days in 2001. Ms. Hunter said that she did report it, but that police officers turned away the complaint, saying that the sex was consensual and that with three witnesses against her, there was no chance of a case. “I had cigarette burns on me, and they called it consensual,” she said.

Deana Franke, director of the shelter, showed off an exercise room she had built for the women but added, “I should be building a shooting range.”

Nearby in Tahlequah, at offices of the United Keetoowah Band of Cherokee Indians in Oklahoma, the director, Sonya K. Cochran, and two advocates, Lois Fuller and Sue Gaytan, displayed the legal records of a local Indian woman who complained of having been raped and sodomized by a brother-and-sister team of attackers in Fort Smith, Ark., in 2004, only to have the charges dropped after a prosecutor said the woman had repeatedly missed court dates. The woman contends she was in court.

Culturally, some advocates said, Indians, fearing humiliation, are often reluctant to press a complaint, seeing it as a test of faith or preferring to “let the creator take care of it,” as one said.

The jurisdictional complexities were evident outside the offices of the Citizen Potawatomi Nation in Shawnee. A nearby fast-food drive-in stands on state land, the north lane of the road is on city land and the south lane is Potawatomi land, where Jason O’Neal, chief of the Lighthorse Police of the Chickasaw Nation, has jurisdiction.

Chief O’Neal said that increasingly, Indian and non-Indian police departments are recognizing each other with cross-designations of authority.

But even on Indian land, if a crime is committed by, or suffered by, a non-Indian, federal law applies — except in states (not including Oklahoma) where such jurisdiction has been ceded to the state. Yet tribal courts enjoy concurrent jurisdiction when the crime is committed by an Indian, regardless of the victim, on Indian land. And the federal government retains jurisdiction over 14 major crimes, including rape, committed by Indians in Indian country. Another problem is figuring out just who is an Indian — an enrolled member of a tribe, for sure, and less certainly, anyone a tribe considers Indian, but beyond that definitions blur.

“I can’t get a U.S. attorney to take a domestic violence case unless there’s severe physical harm or use of a deadly weapon,” said Kelly Stoner, director of the Native American Legal Resource Center at the Oklahoma City University School of Law. “If you just knock a tooth out it’s not enough.”

Renée Brewer, a child welfare and family violence counselor at the Potawatomi Nation and a member of the Creek Muskogee tribe, said she recently had four agencies arguing over jurisdiction after a woman from the Absentee Shawnee Nation called 911 to say she had been raped.

“The D.A. was so confused,” Ms. Brewer said. The woman eventually left the state. And the accused rapist? “Oh, he walked,” Ms. Brewer said.

Experts say the findings are unsettling because rural addicts have limited access to treatment facilities and health professionals.

''Rural methamphetamine is worse in a lot of respects,'' said lead researcher Dr. Kathleen Grant, who works at the Omaha VA Medical Center and the University of Nebraska Medical Center.

Meth is an addictive stimulant that can be prepared or ''cooked'' in makeshift labs with over-the-counter cold tablets, common household chemicals and fertilizers.

According to the 2004 National Survey on Drug Use and Health, about 11.7 million Americans ages 12 and older said they've tried methamphetamine and 1.4 million said they'd used it in the past month.

The study, funded by the state, compared addicts from a 20,000-square-mile region who sought help at the nearest treatment facility in Grand Island with those living near and seeking help in state's two largest cities, Omaha and Lincoln. In all, 172 meth abusers were interviewed between July 2004 and July 2005.

The study showed that rural addicts began using meth at a younger age, were more likely to use the drug intravenously and were more likely to also be dependent on alcohol or cigarettes. They also exhibited more signs of psychosis than urban addicts -- 45 percent vs. 29 percent, according to the study.

Grant said the findings, released in the March/April edition of The American Journal on Addictions, suggest rural addicts are at higher risk for psychiatric and medical problems such as infectious diseases and lung and liver cancer.

That's troubling, she said, because addicts living in rural areas have less access to care -- because of distance and transportation issues -- than those living in cities.

''These people continue to slide into addiction and are not able to get the treatment they need,'' said Dr. Jennifer Sharpe Potter, an opiate specialist at Harvard-affiliated McLean Hospital in Belmont, Mass.

She said meth addiction is difficult to treat because there are few treatment options available, and often the options that work best are not available in rural areas. That points to what she calls a long-standing problem that reaches beyond drug treatment: the availability of health care services in rural areas.

Recovering meth addict Barry Schmidt, 49, said he had to move from Fort Dodge, Iowa, to Omaha in order to get the help he needed to overcome a lifetime of drug and alcohol abuse. He left his wife and gave up seeing his father, who lives in a nursing home there.

''I changed my playground, playmates and playthings,'' he said.

It was hard, but something he said was necessary to get over his addictions.

Schmidt said he's been in treatment 19 times over the past 30 years, the first time when he was 19. His environment and a lack of recovery support were obstacles to staying clean, he said.

But things have been different in Omaha. Schmidt said he's graduated from the VA hospital's treatment program and attends six to seven recovery meetings a week.

He credits those meetings and the people he meets there with his success so far.

''I know that if I called any one of them at any given time and said I'm thinking of using and I'm in a bad place, they'd be there for me.''

On the Web: University of Nebraska Medical Center: www.unmc.edu

The average amount of THC in marijuana seized last year reached 8.5 percent, continuing an almost yearly uptick, the White House drug-control policy office said Wednesday. The THC level has doubled since the 1980s.

The government estimates that 4.1 million Americans use marijuana. Use by teenagers has declined recently, but federal officials worry that marijuana is being cited more often in emergency room visits.



Psychiatrist Accused of Molesting Child Patients
Associated Press, 4/26/2007

REDWOOD CITY, Calif. -- Dr. William Ayres' specialty was child psychiatry, which meant it was perfectly routine for him to be alone and behind closed doors with boys.

During a more than 40-year career in which he rose to the top of his profession, he took advantage of that to molest numerous patients, authorities say.

Ayres, 75, is charged with 18 counts of lewd and lascivious behavior involving five boys, ages 9 through 12, under his care. Prosecutors believe there were dozens more victims and plan to bring additional charges. Ayres, who was arrested earlier this month, is free on $750,000 bail.

''His reputation is being destroyed by unsubstantiated leaks and innuendoes,'' said his lawyer, Doron Weinberg. ''He unequivocally denies that he committed any of the acts of sexual misconduct of which he's been accused.''

The earliest allegations of wrongdoing against him are from 1969.

If Ayres is guilty, how did he get away with so much for so long?

''It's the perfect storm,'' prosecutor Melissa McKowan said. ''He has a stream of potential vulnerable victims coming through his office, all of whom have a built-in reason for not being credible if they come forward. This is a psychiatrist who's seeing kids with some emotional, behavioral problems.''

Ayres worked at a home for troubled boys in Boston before moving in the 1960s to Northern California, where he began counseling children, mostly adolescents. His patients were a mix of patients from wealthy families who were referred to Ayres by their pediatricians, and juvenile delinquents ordered to undergo therapy by the courts.

The abuse always began the same way, McKowan said, with a ''physical.''

Ayres asked the boys to undress, then ''examined'' their genitals, according to his accusers.

''I felt creepy. I felt like I had allowed it or consented. That's why I didn't tell anyone,'' said one alleged victim, now a 43-year-old writer in Los Angeles. He sued Ayres and settled for an undisclosed sum in 2005. Authorities were thwarted in an attempt to bring criminal charges in his case, because of a court ruling in an unrelated case that prevented many decades-old cases from being prosecuted.

The man's mother said her then-12-year-old son told her the doctor had given him a physical, which struck her as odd given Ayres' specialty.

''I remember thinking, `That's strange,''' said the woman, a 76-year-old retired mental health professional. ''But I didn't follow up on it.''

Another alleged victim, who was 11 when he first went to see Ayres, told his mother that he was abused, but she didn't believe him, the mother said.

''You didn't believe that priests, doctors and teachers would do that,'' said the woman, a 77-year-old retired school employee from San Mateo whose son died in a car crash in 1995. ''If we had only known and taken action at that time ... who knows?''

The first documented complaint against Ayres was filed in 1987. Police decided the claim was unfounded. Another complaint was lodged in 1994, but the alleged victim refused to cooperate.

Meanwhile, Ayres rose to prominence in his field. In the late 1960s, he hosted ''Time of Your Life,'' a sex education series broadcast locally on public television. The series, aimed at fourth- through sixth-graders, was criticized at the time by some parents, who said it was too explicit and undermined parental authority.

In a 1969 interview with The New York Times, Dr. Ayres defended the program. ''For many years, kids have been coming into my office knowing some of `the facts of life,' but with many facts left out,'' he said. ''They wind up being bewildered, with a great many concerns and anxieties from their lack of knowledge.''

He was elected president of the American Academy of Child and Adolescent Psychiatry, serving from 1993 to 1995, and received accolades from county officials for his ''tireless effort to improve the lives of children.''

In 2002, the U.S. Supreme Court struck down California's practice of allowing victims of sexual abuse to come forward and press charges at any time. Because of that, California established a statute of limitations for long-ago cases. Now, victims must be younger than 29, or the crime must have occurred after 1988.

In 2006, after confiscating Ayres' records, investigators found a victim who fit within the statute. Nearly 40 alleged victims have since come forward, but most of them claimed they were abused in the 1960s and '70s, and cannot press charges, McKowan said.

Ayres estimated he has seen 2,000 patients in 40 years of practicing in San Mateo County. Prosecutors seized his records on his 800 private patients.

But because of confidentiality rules and other complications, McKowan said authorities may be unable to obtain the records of his court-referred patients.



Drugmakers, Doctors Get Cozier
Christopher Lee, Washington Post- 4/28/2007

Despite efforts to curb drug companies' avid courting of doctors, the industry is working harder than ever to influence what medicines they prescribe, sending out sales representatives with greater frequency and plying physicians with gifts, meals and consulting fees, according to several new papers.

One study published in the New England Journal of Medicine last week found that 94 percent of doctors have some type of relationship with the drug industry -- most commonly accepting free food or drug samples, which about 80 percent of physicians did. More than one-third of the 1,662 physicians who responded to a survey conducted from November 2003 to June 2004 reported being reimbursed by the drug industry for costs of going to professional meetings or continuing medical education, and 28 percent said they had been paid for consulting, giving lectures or signing up patients for clinical trials.

Two other papers examined in detail the strategies that pharmaceutical representatives, or "detailers," use and how effective the industry is at influencing doctors.

"We now know that virtually every doctor in the United States has some form of relationship with the pharmaceutical industry," said Eric G. Campbell, lead researcher of the New England Journal of Medicine study and an assistant professor of medicine at Harvard Medical School. "They are common. A quarter receive honoraria or some form of payment for their services, and that was much higher than we expected."

Contacts between doctors and drug salespeople have jumped from the average of 4.4 per month reported in 2000, Campbell and other researchers found. In the survey period, drug representatives met with family practitioners an average of 16 times a month, with cardiologists and internists nine or 10 times a month, with pediatricians eight times a month and with surgeons four times a month. Only anesthesiologists, who saw the representatives twice a month, appear to be meeting with the industry less often than before, the study found.

As those numbers suggest, the companies shower more attention on certain doctors, the researchers said. Cardiologists -- whose prescribing patterns tend to influence primary care doctors -- were more likely to be paid for consulting and other services than were family practitioners, pediatricians, anesthesiologists and surgeons, the study found.

"When I send somebody to a cardiologist, if he puts somebody on a medicine, I'm not going to change it," said co-author David Blumenthal, a general internist and the director of the Institute for Health Policy at Massachusetts General Hospital in Boston. "If they use a particular agent, I'm more likely personally to prescribe that agent because I figure the guy is an expert and he has got some reason for picking that brand as opposed to some other brand."

The ties between doctors and drug companies are deepening despite voluntary guidelines to curb excesses, adopted in 2002 by the American Medical Association, the American College of Physicians, the Accreditation Council for Continuing Medical Education and the Pharmaceutical Research and Manufacturers of America. The inspector general of the Department of Health and Human Services issued similar guidance in 2003.

Under the industry code, gifts must be worth less than $100 and should primarily benefit patients -- items such as stethoscopes or medical dictionaries. Meals should be "modest" in cost, and a physician's spouse should not be included. Gifts of cash or tickets to sporting events are inappropriate. Consulting arrangements must be for real services, and doctors should not be paid for listening to marketing pitches.

"Clearly, adequate safeguards are already in place," Ken Johnson, senior vice president of the drug industry association, said in a statement. "The goal is to make sure the focus of conversations between company representatives and physicians remains providing accurate information about medicines."

A former industry insider, however, painted a different picture in an article last week in PLoS Medicine, a journal published by the Public Library of Science. Shahram Ahari, a former drug company representative, and physician Adriane Fugh-Berman wrote that the estimated 100,000 representatives who visit doctors' offices look for details such as family photos or hobbies that they can use to forge a relationship. They use food, gifts and money to make often-overworked doctors feel more appreciated -- and more loyal to the company's drugs. If a physician will not meet with them, the representatives often woo the office staff with flattery and meals.

"Pharmaceutical gifting . . . involves carefully calibrated generosity," Ahari and Fugh-Berman wrote. "Many prescribers receive pens, notepads, and coffee mugs, all items kept close at hand, ensuring that a targeted drug's name stays uppermost in a physician's subconscious mind. High prescribers receive higher-end presents, for example, silk ties or golf bags."

Drug companies also purchase prescription records from pharmacies and, with the help of an American Medical Association database, identify individual physicians' prescribing patterns and rank doctors based on how many prescriptions they write, the authors wrote.

The tactics work. Another study in PLoS Medicine last week found that visits by detailers prompted nearly half of 97 physicians to increase prescriptions of gabapentin, a drug approved to treat seizures. In many cases, the drug representatives were pushing non-approved, or "off-label," uses of the drug, the study found.

A study in the Journal of General Internal Medicine in February found that physicians in focus groups said that they understand the potential conflicts of interest but that they still view their meetings with drug detailers as informative and appropriate. Such findings suggest that voluntary guidelines are inadequate, researchers wrote.

In an interview, one District-based physician, orthopedic surgeon Peter E. Lavine, said that drug representatives used to visit his office daily but have cut back in recent years to stopping by about twice a week. The conduct guidelines have eliminated most excesses, Lavine said, and many doctors view the sessions as a way to learn about side effects and how drugs compare.

"The vast majority of physicians appreciate the information but find them [detailers] as a nuisance," said Lavine, chairman of the Medical Society of the District of Columbia.

"They always tend to come in the middle of the day when you are busy seeing patients, and it's very difficult to break away and talk to them. And if they've bought lunch for the staff, then you are sort of obligated to give them a little bit of your time. I think they certainly have a valuable educational benefit. I don't think that physicians are going to change their prescribing patterns for free samples."

Both retinas were puckered and clouded red. And there was acute bleeding outside and beneath the brain's outer membrane -- the kind of bleeding most often associated with a burst aneurysm.

To forensic experts, these were classic signs that Natalie was shaken to death.

The common wisdom in such ''shaken-baby'' cases was that the last person with the child before symptoms appeared was the guilty party, and a Wisconsin jury convicted baby sitter Audrey Edmunds of first-degree reckless homicide.

Edmunds is now 10 years into her 18-year prison sentence, and she's seeking a new trial.

In the decade since her conviction, her attorneys say, many experts have studied the physics and biomechanics of shaken-baby syndrome and have concluded that shaking alone could not have produced Natalie's injuries without leaving other evidence of abuse.

Among those now questioning the diagnosis is Dr. Robert Huntington III, the forensic pathologist who examined Natalie's body and whose testimony helped put Edmunds away.

If the trial were held today, Huntington told The Associated Press recently, ''I'd say she died of a head injury, and I don't know when it happened ... There's room for reasonable doubt.''

Some judges in other cases have broadly agreed.

Last year, a judge in Manatee County, Fla., barred use of the term ''shaken baby syndrome'' because of its possible prejudicial influence on jurors.

A Kentucky judge subjected shaken-baby to a ''Daubert'' test -- a kind of mini-trial to determine the validity and admissibility of certain evidence. Circuit Judge Lewis Nicholls decided he could not admit expert testimony on a theory whose foundation may amount to ''merely educated guesses'' about the cause of death.

''The best the Court can conclude is that the theory of SBS is currently being tested, yet the theory has not reached acceptance in the scientific community,'' Nicholls ruled.

But the syndrome does not lack official recognition.

''Shaken baby syndrome is a serious and clearly definable form of child abuse,'' the American Academy of Pediatrics declares on its Web site.

According to the National Institute of Neurological Disorders and Stroke, SBS bears a ''classic triad'' of signs -- brain hemorrhaging, retinal hemorrhaging and brain swelling. Because of a baby's relatively heavy head and weak neck muscles, shaking ''makes the fragile brain bounce back and forth inside the skull and causes bruising, swelling, and bleeding, which can lead to permanent, severe brain damage or death,'' the institute says.

An estimated 1,500 shaken-baby cases were reported in the United States last year, says Toni Blake, a San Diego defense attorney who specializes in the cases.

But 3 1/2 decades after the term was first used, there seems to be no middle ground in the debate.

''It doesn't exist,'' contends Dr. John Plunkett, a Minnesota pathologist who began openly questioning shaken-baby following the 1997 involuntary manslaughter conviction of British nanny Louise Woodward, the case that put SBS on the map. ''You can't cause the injuries said to be caused by shaking, by shaking.''

Many pediatricians disagree.

''People confess to it. So it has to be possible,'' counters Dr. Suzanne Starling, director of forensic pediatrics at Children's Hospital of The King's Daughters in Norfolk, Va.

She and her colleagues analyzed 81 cases in which an adult confessed to shaking and/or battering a child. In cases where only shaking was admitted, the children were 2.39 times more likely to have retinal hemorrhages than victims of impact alone, they found, ''suggesting that shaking is more likely to cause retinal hemorrhages than impact.''

Plunkett scoffs: ''What is the No. 2 cause of wrongful convictions? False confessions. ... You don't base scientific conclusions on what people confess to.''

Boston pediatrician Robert Reece is on the international advisory board of the National Center on Shaken Baby Syndrome, and yet he avoids using the term in a courtroom. ''What goes on in the courtroom is up or down, and medicine doesn't work that way usually,'' he says.

In testimony, he refers to ''abusive head trauma'' or ''inflicted traumatic brain injury'' instead, though he still believes shaking alone can cause it.

- Plunkett, in a 2001 article, concluded an infant could suffer a fatal head injury from even a short fall, and that the injury ''may be associated with a lucid interval and bilateral retinal hemorrhage.'' In other words, symptoms might not immediately follow the injury -- which can be an important issue in fixing blame. In addition, there were other, accidental sources for one of the ''classic'' signs of SBS, he wrote in the American Journal of Forensic Medicine & Pathology.

- In a 2003 study, University of Pennsylvania researchers used special dummies to simulate a 1 1/2-month-old baby being shaken or dropped from various heights. The response to a vigorous shaking was ''statistically similar'' to that from a 1-foot fall onto concrete or concrete with carpet pad, they found; a fall from 3 feet produced forces nearly 40 times greater.

- But still-to-be published research using a more advanced infant dummy simulated far greater brain damage than with previous dummies, says Dr. Carole Jenny, a Brown University Medical School professor and chair of the AAP's committee on child abuse and neglect.

''They come into court and they say, `Oh, you can't kill a baby just by shaking it,' and yet they have a dead baby before them,'' she says. ''Did a flying saucer come in from Mars and strike the baby in the head?''

- Other studies cited by SBS opponents have suggested that the hemorrhaging and swelling thought to prove shaking can have myriad causes, from dehydration and infection to oxygen deficiency.

Much of the debate has centered on how quickly symptoms begin after a brain trauma. That question was central to the Wisconsin case.

On Oct. 16, 1995, Edmunds was caring for her two daughters and another child when Cindy Beard dropped off her daughter, Natalie.

Natalie had had an ear infection and had vomited in recent days, but her parents say that appeared to have cleared up. But Edmunds says Natalie was unusually fussy that morning and refused to take a bottle.

Edmunds, who was five months pregnant with her third daughter, says she put Natalie down with a propped bottle and went to tend to the other children. When she went back to retrieve Natalie, the girl was crying and limp, her face slick with regurgitated formula.

At her 1996 trial, Huntington testified it was ''highly probable'' that Natalie was injured within two hours of being treated. That would mean the fatal injury occurred while Natalie was in Edmunds' care.

What changed his mind was a later case involving a child with injuries similar to Natalie's. That child had a ''lucid interval'' of more than 15 hours before the onset of symptoms, leading Huntington to acknowledge that Natalie could have been injured long before she was dropped off at Edmunds'.

Edmunds' attorney cited other studies in which there were lucid intervals of 24 hours between injury and death.

George Nichols, a former Kentucky medical examiner, testified recently on Edmunds' new trial request. It was his conclusion that Natalie had some kind of choking event, and that a lack of oxygen to the brain resulted in fatal brain injury.

Prosecutors dismissed Plunkett, Nichols and others as ''a fringe group of doctors.''

Dr. Thomas Bohan, a forensic physicist and attorney, has tried to get the National Academy of Sciences and the National Institute of Justice to evaluate the medical and legal arguments.

In May, he and other specialists who are members of the self-styled Evidence-Based Medicine Group are meeting in Chicago to present papers on shaken-baby syndrome. Bohan, who is also vice president of the American Academy of Forensic Sciences, says it's not good enough to say you can't really study shaken-baby because you can't shake actual babies to test the hypothesis.

''The point is you don't send people off to prison for 50 years and break up families because you don't want to do the work to validate it,'' Bohan says.

Audrey Edmunds was hoping that science would set her free.

About once a month, the 45-year-old mother and her daughters visit in the prison cafeteria. They talk on the phone several times a week.

''I've lost a part of their life,'' says Edmunds, whose husband divorced her several years ago because he couldn't wait any longer. ''But there's a lot that we stay strong with, too.''

Federal jurors in Alexandria found William E. Hurwitz guilty of 16 counts of drug trafficking, determining that he prescribed massive quantities of medicine to patients in chronic pain. The 12-member jury acquitted Hurwitz on 17 other trafficking counts, but Hurwitz faces up to 20 years in prison for each count on which he was convicted. He will be sentenced July 13.

U.S. District Judge Leonie M. Brinkema dismissed the remaining 12 counts, saying she did not want jurors to have to come back Wednesday to resume deliberations, prosecutors said. The jury would have been unable to deliberate sooner than that because a juror had travel plans.

The verdict marked perhaps the final step in the long legal and medical odyssey of Hurwitz, a major figure in the growing field of pain management who was once profiled on "60 Minutes." He was convicted on similar charges in U.S. District Court in 2004, but an appeals court threw out that verdict. Yesterday's conviction came after a retrial.

In the first trial, jurors convicted Hurwitz on 50 counts -- including trafficking that caused the death of one patient and seriously injured two others. They acquitted him of nine counts and deadlocked on the final three in a 62-count indictment.

Hurwitz was sentenced to 25 years in prison. But the U.S. Court of Appeals for the 4th Circuit overturned that verdict last year and granted Hurwitz a new trial. A three-judge panel ruled that prosecutors had presented "powerful evidence" but that U.S. District Judge Leonard D. Wexler improperly told jurors that they could not consider whether Hurwitz acted in "good faith" when he prescribed the large doses of medicine.

Hurwitz became a symbol in a nationwide debate as cancer patients and others in chronic pain became increasingly vocal about access to successful treatment.

Advocates for patients in chronic pain have portrayed him as a heroic figure, prescribing legal drugs to help suffering patients who have nowhere else to turn. They have criticized the government, saying it criminalized medical decisions that should be left to doctors.

But prosecutors contended that Hurwitz prescribed excessive amounts of Oxycodone and other dangerous narcotics -- in one instance more than 1,600 pills a day -- to addicts and others, some of whom then sold the medication on a lucrative black market.

U.S. Attorney Chuck Rosenberg said the case "is not about the lawful practice of medicine . . . but rather about the unlawful drug trafficking of pain medication. Drug traffickers come in all shapes and sizes. This one just happened to wear a white coat and be a doctor."

Richard Sauber, a lawyer for Hurwitz, said defense attorneys are "disappointed in the verdict. We think that Dr. Hurwitz was a doctor first and foremost and not a drug dealer." He added that Hurwitz "saved a number of lives."

Sauber said he did not know whether the defense would appeal.

Last week, Brinkema dismissed the counts involving the patient who died and the two who were seriously injured, leaving 45 counts for the jury to decide.

During the four-week retrial, prosecutors argued that Hurwitz was a common drug dealer whose McLean waiting room was filled with sleeping and incoherent patients with track marks on their arms. The prosecution presented 41 witnesses, including 12 former patients who had been convicted of drug crimes.

"He crossed the line from a healer to a dealer," Assistant U.S. Attorney Gene Rossi told the jury in closing arguments April 18.

Defense lawyers presented testimony from 10 former patients of Hurwitz. The defense portrayed him as a medical pioneer, a caring and courageous doctor who just wanted to help people in unbearable pain.

There, Leon Tillman says, over there -- the house on the right, a white, two-story building set off by itself. It used to be a big drug house. Now it's shuttered, its owners in prison.

A man dressed in an army green shirt and pants appears on the side of the road, his thumb up, looking for a ride. ''That's a meth head,'' Tillman says. ''He's bumming right now.''

A few more drug houses and Tillman's tour of the despair of methamphetamine ends.

Not long ago, most people here had never even heard of meth. But today, most know someone on meth or in prison because of it. Tillman, 39, knows too many to count.

''It's everywhere,'' he said.

Indeed, American Indians have been especially hard hit by meth. Drug cartels have targeted Indian Country because the people are vulnerable, and law enforcement struggles to keep up.

But the story of how meth came to this remote reservation is really quite remarkable.

Like a cancer, a Mexican drug gang permeated the reservation and its families. It left behind a landscape strewn with broken lives.

Some 12,000 Indians -- members of the Northern Arapaho and the Eastern Shoshone tribes -- live on 2.2 million acres, an area so vast many homes are separated by miles of barren land.

Poverty and unemployment are high, alcoholism is rampant and the police department is so understaffed -- patrolling such a large area -- that the average response time is 15 to 20 minutes.

Jesus Martin Sagaste-Cruz knew that. And he knew the reservation's isolation would be perfect for his business.

Authorities learned of the Sagaste-Cruz drug ring back in 1997. Sagaste-Cruz and his Mexican gang had already been selling around Indian reservations in South Dakota and Nebraska.

But it was an article in The Denver Post that changed the way they did business. The story talked about how a Nebraska liquor store near the Pine Ridge Reservation in South Dakota did millions of dollars in business. Sales were especially high immediately after Indians received their per capita checks -- their share of their tribe's income.

Sagaste-Cruz figured if there were already so many Indians addicted to alcohol, it would be easy enough to addict them to methamphetamine.

So around 2000, the Mexicans moved in and near Wind River Reservation.

''They came to a place where people don't have anything,'' said Frances Monroe, who works in the Northern Arapaho Child Protection Services office.

They started with free meth samples. The men pursued Indian women, providing them with meth even as they romanced them and fathered their children. Eventually, the women needed to support their habit, so they became dealers, too -- and they used free samples to recruit new customers.

It was all part of the plan.

For the next four years, the gang sold pounds and pounds of meth, much of it 98 percent pure. The drugs came from Mexico, then on to Los Angeles; Ogden, Utah (where Sagaste-Cruz lived); and finally Wyoming, where gang members had a handful of local distributors, each with their own customer base.

Customers became dealers and recruiters, and their customers did the same.

Before, meth was barely mentioned on the reservation. Police reported only sporadic arrests.

But now the reservation was saturated with it. Crime soared. From 2003 to 2006, cases of child neglect increased 131 percent. Drug possession was up 163 percent; spousal abuse rose 218 percent.

The Wind River reservation is not alone. The Bureau of Indian Affairs found that methamphetamine was listed as the greatest threat to Indian communities by police departments.

Mexican drug cartels take advantage of the often complicated law enforcement jurisdictions in Indian Country. Isolated communities are hit the hardest, and sometimes even tribal leaders are not immune, said Heather Dawn Thompson, director of government affairs for the National Congress of American Indians.

Here on the Wind River, a tribal judge, Lynda Munnell-Noah, was arrested in a 2005 drug ring bust and accused of trying to assault and murder a Bureau of Indian Affairs law enforcement officer.
Resources are few, and most reservations don't have treatment centers. Between 2000 and 2005, the number of methamphetamine contacts in Indian Health Services facilities increased by almost 250 percent.

''Even if we arrest people for use or sale, there's almost nothing to do with them in order to help them recover,'' Thompson said. ''Where do you go and how do you pay for it?''

In his 2008 budget, President Bush proposed a $16 million increase in law enforcement funding in Indian Country to help combat methamphetamine, a godsend to police departments like Wind River's, which has only 10 police officers.

''The heartbreaking part of it is, it's had this absolutely devastating effect on our community,'' Thompson said. ''I have tribal leaders coming to my office all the time just crying. I mean, how do you fight this? How do you function as a government when 30 percent of your tribal employees are now using meth?''

Inside a tribal office, a bulletin board displays meth's effects: In a series of mug shots, a woman deteriorates -- her teeth rotting, her skin collecting scabs. A nearby poster warns that making, selling or using meth around a child will mean prison time.

This is a place where people mostly keep to themselves. They know meth is a huge problem, but they don't want to talk much about it. They fear retaliation.

A jury found that the Sagaste-Cruz ring had distributed more than 99 pounds of meth -- an amount that had a street value of between $4.5 to $6.8 million, according to the Drug Enforcement Administration. The gang also sold meth on the Rosebud, Pine Ridge and Yankton reservations in South Dakota and Santee Sioux reservation in Nebraska, authorities found.

Sagaste-Cruz and 22 other people were given prison time -- a life sentence, in Sagaste-Cruz' case. His brother, Julio Caesar Sagaste-Cruz, remains a fugitive.

Ask people on the reservation about the Sagaste-Cruz case and most don't know much about it. They seem surprised to learn how sophisticated the operation was.

But mention the Goodman case, and everyone knows. The Goodmans were an entire family, grandparents down to grandchildren, who were dealing meth and prescription drugs here.

Nineteen people, including the tribal judge, were arrested in 2005.

The two cases weren't directly related, but with many Indians already hooked on meth compliments of the Sagaste-Cruz gang, the Goodmans didn't have any trouble finding customers. Assistant U.S. Attorney Kelly Rankin said the Goodmans often had 20 to 50 customers a day come to their house.

Darrell LoneBear Sr., whose sister, Donna Goodman, and her husband, John Goodman, were the ring's leaders, said his relatives fell victim to easy money on a reservation where jobs are hard to find.

He rattles off his family's prison sentences: ''John Goodman, 21 years. My sister Donna, 24 years. My nephew James got 19 years. My nephew Darrell got 8.

''It was all of my family,'' he said.

Thirteen children were sent to live with other relatives. One sister took in six children, another took in three.

''It is a tremendous, added responsibility emotionally and financially,'' said LoneBear, crime prevention and safety supervisor for the Northern Arapaho Tribal Housing. ''All of us have been traumatized by this matter. We all still stay here.''

Police Chief Doug Noseep has a police force that can't possibly keep up with every call. He is grateful for the help from outside law enforcement agencies in the raids over the past few years, and believes it has reduced the amount of meth here.

Noseep knows who is trying to get help, who is still using. Once, his officers encountered a 12-year-old girl who was addicted.

''It's sad as hell,'' he said. ''It's here and it's not going to go anywhere. It's never going to go away.''

Seven years after the Sagaste-Cruz gang arrived, meth rolls on: Last summer, another bust at Wind River resulted in 43 arrests, the largest drug bust in the history of Wyoming.

On a recent night, Partners Against Meth met at a local school. The group struggles to attract volunteers and to keep committees on track. But here families that have been struck hard by the meth epidemic, and those that want to learn more about it, can come together to talk.

Leon Tillman brought his wife, son and daughter. He told the group he has six relatives in prison for meth or alcohol charges. ''That's one of my worst fears, is to have one of my kids on drugs. I want to at least say I tried,'' he said.

A few years ago, John Washakie noticed his daughter, now 27, was losing weight and locking herself in her bedroom at her house. Then, one night, she dropped off her three young children at his house and disappeared into the darkness.

He cared for the kids for three years. It wasn't easy. ''They lose all their energy about life. You spend a lot of time dealing with their emotions,'' he said.

Today, his daughter is clean, and cares for her children, now numbering five, herself.

''I think there are a lot of people that are scared to tell you the truth,'' the grandfather said. ''You don't walk away from this.''

''When I got arrested this last time, I knew it was over,'' Althoff recalled. ''The sad thing was, I didn't even care.''

However, prosecutors agreed to let Althoff enter drug court, an alternative to prison that many states are using to stem the rising flow of drug offenders into prison systems already bursting at the seams.

Over the last three years, at least 22 states have developed initiatives to slow the growth of the inmate population, the most common of which are programs that divert drug offenders into treatment rather than prison cells, according to a March study by the Sentencing Project, a Washington-based think-tank on criminal justice policy issues.

''We've seen a great deal of success in these diversion programs,'' said Ryan King, a policy analyst who authored the study. ''There are a substantial number of drug arrests that occur every year in every state and at the federal level. Even more important than that, they tend to be the type of offense for which there are so many other options available.''

Althoff, now 25, says the rigorous drug court program that included treatment, group therapy, drug testing, a curfew and participation in a 12-step support group was exactly what he needed to help him turn his life around.

''I couldn't do anything, really, except for drug court and work,'' Althoff said. ''At first it was hard, but the alternative was much worse.''

Althoff said he hasn't used drugs or alcohol for more than 2 1/2 years. In that time, he's started his own home remodeling company, gotten married, become a father and completed his associate's degree at a local community college. This fall, he's scheduled to begin his junior year at the University of Oklahoma, where he plans to pursue a degree in geophysics.

The legislation to create a statewide drug court program in Oklahoma was written in the late 1990s by then-state Sen. Dick Wilkerson.

A retired law enforcement officer who worked narcotics for years, Wilkerson says he was skeptical of the idea at first.

However, as Oklahoma's prison population swelled with drug offenders and its operating budget exploded, he saw that Colorado was having success with drug court and thought it might work in Oklahoma.

''You've got to remember that back then, the only answer anyone could think of was to put these people in jail,'' Wilkerson said. ''When we ran that drug court bill, people just said we were being soft on crime and coddling these guys. It's amusing to watch these same people say that they were always in favor of drug court.

''Success has many fathers.''

Although the overall prison population continues to climb, the Department of Mental Health and Substance Abuse Services, the state agency that oversees the drug court program, touts it as a money-saving alternative since it costs the state about $5,000 annually for a drug court participant versus $21,000 to keep an offender locked up in prison.

The recidivism rate for drug court graduates also appears to compare favorably, with a 23.5 percent re-arrest rate, compared to 38.2 percent for standard probation and 54.3 percent for released inmates, according to department statistics.

''This is the most successful program to affect the criminal justice system in history,'' said Jeremy Jarman, Oklahoma's state drug court coordinator.

''The positive outcomes we have we can actually show. These are tangible things,'' he said. ''But there are also the intangibles, the drug-free babies born, the increases in income for participants, the reductions in unemployment.''

Normally, usage rates for illicit drugs such as marijuana and cocaine are much higher for men than women. But for prescription drugs, the reverse is the case for teenage girls, said the White House Office of National Drug Control Policy.

Nearly one in 10 teenage girls reported using a prescription drug to get high at least once in the past year, officials said Monday. For teenage boys, the ratio was close to 1 out of 13.

Federal officials theorized that the trend reversal may be due to unique pressures faced by girls. Men typically abuse drugs and alcohol for the sensation, while surveys indicate women do so to increase their confidence, reduce tension or to lose weight.

''Too many Americans, and increasingly, too many young women simply do not know the addictive potential of these medicines,'' said John Walters, director of National Drug Control Policy.

The usage trends for prescription drugs were pulled from the 2005 National Survey on Drug Use and Health.

Officials said females are involved in 55 percent of the cases of emergency room visits involving prescription drugs. That percentage drops to 35 percent for women when street drugs are involved.

On the Net: Office of National Drug Control Policy: http://www.ondcp.gov

British doctors took brain scans of 15 healthy volunteers given small doses of two of the active ingredients of cannabis, as well as a placebo.

One compound, cannabidiol, or CBD, made people more relaxed. But even small doses of another component, tetrahydrocannabinol, or THC, produced temporary psychotic symptoms in people, including hallucinations and paranoid delusions, doctors said.

The results, to be presented at an international mental health conference in London on Tuesday and Wednesday, provides physical evidence of the drug's damaging influence on the human brain.

''We've long suspected that cannabis is linked to psychoses, but we have never before had scans to show how the mechanism works,'' said Dr. Philip McGuire, a professor of psychiatry at King's College, London.

In analyzing MRI scans of the study's subjects, McGuire and his colleagues found that THC interfered with activity in the inferior frontal cortex, a region of the brain associated with paranoia.

''THC is switching off that regulator,'' McGuire said, effectively unleashing the paranoia usually kept under control by the frontal cortex.

In another study being presented at the conference, a two-day gathering of mental health experts discussing the connections between cannabis and mental health, scientists found that marijuana worsens psychotic symptoms of schizophrenics.

Doctors at Yale University in the U.S. tested the impact of THC on 150 healthy volunteers and 13 people with stable schizophrenia. Nearly half of the healthy subjects experienced psychotic symptoms when given the drug.

While the doctors expected to see marijuana improve the conditions of their schizophrenic subjects -- since their patients reported that the drug calmed them -- they found that the reverse was true.

''I was surprised by the results,'' said Dr. Deepak Cyril D'Souza, an associate professor of psychiatry at Yale University's School of Medicine. ''In practice, we found that cannabis is very bad for people with schizophrenia,'' he said.

While D'Souza had intended to study marijuana's impact on schizophrenics in more patients, the study was stopped prematurely because the impact was so pronounced that it would have been unethical to test it on more people with schizophrenia.

''One of the great puzzles is why people with schizophrenia keep taking the stuff when it makes the paranoia worse,'' said Dr. Robin Murray, a professor of psychiatry at King's College.

Experts theorized that schizophrenics may mistakenly judge the drug's pleasurable effects to outweigh any negatives.

Understanding how marijuana affects the brain may ultimately lead experts to a better understanding of mental health in general.

''We don't know the basis of paranoia or anxiety,'' said McGuire.

''It is possible that we could use cannabis in controlled studies to understand psychoses better,'' he said. McGuire theorized that could one day lead to specific drugs targeting the responsible regions of the brain.

On the Net: www.kcl.ac.uk/phpnews/wmview.php?ArtID1793