Noteworthy News Articles on Mental Health Topics, May 1-6, 2007

Such is the criminal parade in the country’s first and only gambling treatment court. Following the model of about 2,000 “therapy courts” devoted to drugs and spousal abuse that have opened nationwide in the last two decades, the setup here allows defendants to avoid jail time if they follow a court-supervised program that includes counseling sessions, credit checks and twice-monthly meetings with Justice Farrell.

“I realize this is demanding,” the judge said the other day as he ordered Andrew Hallett, 19, who forged his father’s checks to feed a bingo and lottery addiction, to attend Gamblers Anonymous meetings twice a week. “If you continue to apply yourself to the program, and you continue to go to the self-helps, we’ll get you through it.”

Mirroring the rise in gambling nationally and the opening of two new casinos near this suburb of Buffalo, the court’s caseload has grown steadily since it opened in 2001, to several dozen cases a year from a handful. And as gambling has become more popular, with the growth of online poker and with New York State lottery revenues nearly doubling to $6.8 billion over the past six years, Justice Farrell’s docket includes middle-aged parents with college degrees and steady jobs as well as young drug users with criminal records.

“Gambling has become almost a genre in our society,” said Justice Farrell, who lectures defendants with a stern voice and a no-nonsense tone. A majority of the gamblers he sees can hold their own, he said, “but it’s the 5 percent that have problems, and we’re seeing an expression of it in gambling court.”

The gambling court is too small and too young to show statistically significant results, but its staff members say that more than half the 100-plus defendants so far have completed the treatment program, and only one has been arrested again — on an offense not connected to gambling. But drug courts have shown some impressive results: a 2003 study in Washington State found that participants were 13 percent less likely to become repeat offenders than defendants who went through the regular criminal system, saving $3,759 per participant in potential administrative costs and $3,020 in costs to victims.

The idea of expanding therapeutic courts to problem gamblers seems to be gaining momentum. Judges and lawyers in Buffalo have recently started steering gambling-related cases toward Amherst, and Justice Farrell has been in demand on the speaking circuit, talking about the program to prosecutors, counselors and other officials in 15 states since 2002.

Don E. Dutton, commissioner of the New Mexico Gaming Control Board, said a statewide task force there plans to recommend the start of such a diversion program by year’s end.

Jeffrey J. Marotta, who manages the Oregon Problem Gambling Services in that state’s Department of Human Services, said his agency expects to start a pilot program soon.

And in Louisiana, the state attorney general in 2004 set up a diversion program in which gamblers charged with nonviolent crimes can avoid trial if they get treatment.

Keith S. Whyte, executive director of the National Council on Problem Gambling, said California and Illinois have expressed interest in starting gambling courts. Also, Arizona trains its probation officers to watch for problem gamblers.

Justice Farrell, a 59-year-old lawyer, has spent about 35 hours a week since 1994 running Amherst Town Court. With 43,000 cases a year, it is one of the larger of New York’s approximately 1,250 town and village courts, which handle two million criminal, domestic-violence, landlord-tenant, traffic and other cases each year. Justice Farrell started a diversion program from drug crimes in 1996, and for domestic violence in 1999.

Justice Farrell, who said he will visit local casinos a few times a year, “lose $100 and figure out what kind of idiot I was,” noticed the spike in gambling-related crime by looking for warning signs similar to those he saw with drug addiction and domestic violence.

In a two-and-a-half-week span a few years ago, he said, he saw a dozen cases of car theft, larceny and other crimes committed by otherwise unlikely suspects, and called in experts who determined that gambling was the common theme. Soon, the gambling court was born.
As with drugs and domestic violence, the gambling defendants must plead guilty to be eligible for the diversion program, which gives Justice Farrell broad discretion to defer punishment for up to a year and dismiss charges for those who complete the prescribed treatment regimen. But he said gambling can be more complicated, because the connections to the crimes are indirect. For example, there is no urine test to identify gamblers, and society generally treats addiction to cards or dice as a character flaw rather than a psychological disorder.

“People are more likely to admit they are a heroin addict than a gambling addict,” Justice Farrell said.

So the judge and his staff members screen defendants after arraignments by asking those accused of, say, check forgery, why they needed the money. Court-appointed counselors look for signs of impulsiveness and weak self-control.

The gambling court meets every other Tuesday for an hour — just before the much busier drug court session — and on one recent afternoon it started by distributing leaflets on gambling addiction to all the defendants. Then the defendants heard from Karreen Kelly, a graduate of the drug court program after an arrest for driving while intoxicated, who said she spent “two years drinking in my bedroom” to deal with her husband’s compulsive betting.

Mrs. Kelly, who is 45 and works in retailing, said that constant calls from loan sharks and credit-card companies, and the loss of more than $160,000, led her to consider suicide with a bottle of tranquilizers and a 12-pack of beer.

“When he started gambling, I didn’t think anything of it,” she said between sobs. “I had no time because I was working and with kids.”

Over the hourlong session, a young woman numbly admitted that she had relapsed, both using drugs and buying daily scratch-off lottery tickets. A man in sweat pants told a story about “replacing one addiction with another,” explaining that he had recently been in jail and found himself losing $400 gambling with cellmates.

In another case, a man whose habits included sports betting, dice and animal fights had missed a scheduled counseling session.

“You need to be where you’re scheduled to be,” Justice Farrell warned him. “You play ball with me, I’ll play ball with you.”

Mr. Hallett, pencil-thin under a puffy ski jacket, started playing bingo at church before he turned 12, experimented with slot machines while on a cruise and soon was buying 15 to 20 lottery tickets at a time while also sneaking out for bingo.

“It was like a rush of adrenaline,” he recalled. “You’re hooked on that feeling.”

Mr. Hallett said he drained his bank account, then manipulated accounts at the doctor’s office where he worked, to keep finding the money to gamble. When he was fired, he took a job at Target and soon was caught stealing gift cards. He sold his stepsister’s DVDs, prompting his father to put locks on the bedroom doors.

Then his father had him arrested this year for forging checks.

Judith Munzi, a gambling recovery counselor at Jewish Family Service of Buffalo and Erie County, stood with Mr. Hallett in court and told Justice Farrell that the young man was a motivated patient, but that he suffers from attention-deficit hyperactivity disorder and may need to change his medication.

“The judge makes you not want to do something,” Mr. Hallett said afterward, vowing to stay out of trouble.

The three therapeutic courts, run under the broader auspices of the town court system, which pays the judge’s $69,500 annual salary, receive about $50,000 a year in grants and donations to cover the cost of urine tests, educational materials, computers, travel expenses and overtime for police officers who search for defendants with outstanding warrants. Treatment costs are separate.

While Justice Farrell’s court handles only misdemeanors involving $1,000 or less, or felonies in which charges were reduced through plea bargains, the authorities here have also seen a rise in more serious offenses rooted in gambling.

John C. Doscher, chief of the white-collar crime bureau in the Erie County district attorney’s office, said his group has convicted nine people of stealing $100,000 or more in gambling-related crimes since 2005.

Among them was Judith Ann Scheitheir, who pleaded guilty in January to stealing $350,000 from the plant nursery where she worked to cover her credit-card debts and losses at casinos in Niagara Falls and Ontario. And Kenneth Mangione, chief financial officer at a boarding school for troubled children, was sentenced in March to six months in jail and ordered to repay $50,000 after he confessed to stealing almost $200,000 from the school to cover gambling losses.

When asked where the stolen money was, Mr. Doscher recalled that Mr. Mangione told prosecutors, “It’s at the casino.”

In gambling court, where Justice Farrell presides in front of a floor-to-ceiling mural that includes the American flag and a bald eagle, the numbers are smaller, but the stories are similar.

Experts said that therapeutic courts remain a rarity because many judges consider them an administrative burden, lawyers are often wary of letting their clients admit to an addiction on top of any particular crime, and financing is scarce.

“The easier thing to do is to sit back and see if it works elsewhere,” said Carson Fox, director of operations at the National Association of Drug Court Professionals.

It seems to be working for an up-and-coming boxer identified in court as Leslie R. After being arrested for petty larceny, he recently completed a year of treatment.

Justice Farrell gave the boxer a certificate and a key chain with the inscription, “Amherst Court: Where Treatment and Justice Meet,” along with a copy of “The Little Engine That Could,” the classic children’s book.

“I think Judge Farrell is very strict, but he’s fair,” Leslie R. said. “I don’t plan to be back here again.”

It was among the officers' first encounters with ''Strawberry Quick,'' the latest version of methamphetamine, a drug authorities say manufacturers are constantly remaking to keep their customer base growing.

From lollipops to high-sugar sodas, law enforcement officials say they've found meth cut with a variety of candies, drinks and other materials over the years. Officials say the ''designer meth'' can smooth the ingestion of the drug, making it easier for first-time users to try.

''It's really a bitter substance ... so if you're going to try to make it more consumable for the masses, then you're going to want to try to take that edge off whichever way you can,'' said Chris Harrison, chief illicit laboratory chemist at the Arkansas State Crime Laboratory.

''Strawberry Quick'' came to prominence in January, after the Nevada Department of Public Safety issued a bulletin describing the type of meth there, said Steve Robertson, a Washington-based spokesman for the Drug Enforcement Administration. DEA agents have since heard reports of flavored meth appearing in Missouri, Texas, Washington state and Wisconsin -- though Robertson stressed it was not a nationwide phenomenon.

''Traffickers are out there and are trying to sell it to customers, whether they are young customers or older, brand-new customers by changing the color or the taste or just giving it a less-intimidating name, they are trying to make it seem less dangerous and lure this new customer base,'' Robertson said. ''If someone was completely terrified of trying it, it might diminish the threat.''

''Strawberry Quick'' uses powdered drink mix to give the drug a pink coloring. The sweetness of the powder can make meth more palatable and partially masks its harsh chemical taste.

Cutting the meth also may soften the burning sensation some have when snorting the powdered drug, Harrison said.

''It's a different spin, like a marketing thing,'' said William Bryant, assistant special agent in charge of the DEA's office in Little Rock.

Methamphetamine is found in powder and in a crystalized form similar to broken glass. Its low boiling point allows for it to be smoked or injected easily.

Because of its chemical properties, meth easily mixes into any water-based liquid. Caffeinated, high-sugar energy drinks and sodas often litter areas where meth cookers manufacture the drug, sometimes used as a chaser to the stimulant, Harrison said.

FDA Seeks Antidepressant Suicide Warning
Associated Press, 5/3/2007

WASHINGTON -- Young adults face an increased risk of suicidal thoughts and behavior when they first begin taking antidepressants and should be warned about the danger, federal health officials said Wednesday.

The Food and Drug Administration asked makers of the drugs to expand its warning labels to include adults age 18-24. The labels already include similar warnings for children and adolescents.

Eli Lilly and Co., the maker of Prozac, Zoloft manufacturer Pfizer Inc. and other pharmaceutical companies said they would comply with the FDA's request.

''We believe this step will help ensure that the millions of people with depression who are young adults age 24 and under and their families can make informed treatment decisions while minimizing the fear and stigma associated with depression,'' Eli Lilly said in a statement.

Pfizer spokeswoman Shreya Prudlo said the company would update its label, which she said already calls for close monitoring of patients when they begin taking Zoloft. She added, however, ''There is no established causal link between Zoloft and suicide in adults, young adults or children.''

The proposed labeling changes would note that studies have not shown this increased risk in adults older than 24 and that adults 65 and older taking antidepressants have a decreased risk of suicidal thoughts and behavior.

The expanded warnings would emphasize that depression and certain other serious psychiatric disorders are themselves the most important causes of suicide.

''Antidepressant medications benefit many patients, but it is important that doctors and patients are aware of the risks,'' said Dr. Steven Galson, the FDA's drugs chief.

The FDA advises that patients of all ages starting on antidepressants should be ''monitored appropriately and observed closely'' for worsening symptoms, suicidal thoughts or behaviors or unusual changes in behavior.

Still, any risks are small. For every 1,000 patients 18-24 treated with antidepressants, the FDA would expect there would be five additional patients who have suicidal thoughts or exhibit suicidal behavior, said Dr. Thomas Laughren, who oversees psychiatric drugs for the FDA. The FDA analysis was based on studies of 11 antidepressants in more than 77,000 patients.

The proposed changes came with the endorsement of FDA expert advisers. Some experts have argued that the changes are overdue while others maintain they could keep drugs from those who need them.

Last month, a comprehensive analysis of antidepressants for children and teenagers found the benefits of treatment trump the small risk of increasing suicidal thoughts and behaviors in some patients. The Journal of the American Medical Association study also found that risk is lower than what the FDA identified in 2004, the year the agency warned the public about the risks of the drugs in children.

After that warning, doctors wrote children fewer prescriptions for antidepressants, and U.S. youth suicides increased.

That suggests the warnings could have a net effect that is harmful if they keep the drugs from patients who would benefit from them, said Dr. David Brent, a University of PittsburghSchool of Medicine psychiatry professor and co-author of the JAMA study.

''When you have a black-box warning and within it you caution people that the biggest risks are from the disease and not being treated, people will still pay attention to the headline and not the small print,'' Brent said.

Laughren said the FDA's doesn't know if the previously strengthened warnings led to the decrease in prescriptions or the increase in youth suicides.

''These are data that are hard to reach any conclusion about in terms of causality, but obviously it is something we are concerned about,'' Laughren said.

On the Net: http://www.fda.gov/cder/drug/antidepressants/default.htm

Ex-Stripper Guilty as Unlicensed Psychologist
Megan Tench, Boston Globe- 5/5/2007

A former Boston stripper who advertised herself as a psychologist was found guilty yesterday of fraud and larceny after she treated young patients without a license on the South Shore for seven years.

Louise Wightman, 47, of Hull was found guilty of five counts of filing false healthcare claims, 13 counts of larceny over $250, and one count of practicing psychology without a license.

Calling Wightman's behavior egregious, Attorney General Martha Coakley praised the verdict, saying that the former stripper's practice preyed on a vulnerable group.

"This should send a message," said Coakley. "It is a chance for consumers . . . of medical care to make sure that the practitioner they visit has the requisite skills and experience."

Each offense carries a maximum term of five years in prison, except for the last offense, which carries a maximum of three months.

Wightman was found not guilty of five counts of insurance fraud and one count of larceny of over $250.

"The evidence showed that there were victims involved who depended on her purported skills and experience," Coakley said. "It was a double hit for people who were seeking emotional help and did not get it."

Wightman practiced psychology from 1998 to 2005, when she treated hundreds of adolescents for eating disorders and other serious problems.

Wightman's lawyer, Katie Cook Rayburn, said that she and her client were "certainly disappointed" by the verdict, but that she is not sure whether Wightman will appeal.

During the trial, the former stripper known as Princess Cheyenne testified that she never purported to be a licensed psychologist when she treated hundreds of patients, most under the age of 18, at a practice called South Shore Psychology Associates.

Massachusetts state law requires psychologists to have a doctoral degree in psychology from a program recognized by the state and to be licensed with the state Division of Professional Licensure.

Wightman acknowledged, however, that she adver tised as having a doctorate in psychology, despite withdrawing from the Massachusetts School of Professional Psychology after completing five years of course work without earning a degree.

Wightman, who has a master's degree in counseling psychology from Lesley University, told the jury she dropped out of the doctoral program when a dean, whom she did not identify, confronted her about her storied career as a stripper in Boston's Combat Zone in the 1970s and '80s.

Feeling that she had earned her doctorate, Wightman told the jury, she turned to the Internet and paid about $1,300 for what she thought was a bona fide degree from Dominica-based Concordia College & University. She said she later discovered that the online degree was bogus.

Under cross-examination, Wightman acknowledged that the Massachusetts School of Professional Psychology began proceedings in March 2001 to kick her out for operating what a school official described in a letter as an "independent private practice" without a license.

She also conceded that she applied to the state for a license as a mental health counselor in August 2005, six months after "Fox 25 Undercover" aired a report about her past.

But before the church could intercede late last summer, Seung Hui Cho had to return to Virginia Tech to start his senior year, said the Rev. Dong Cheol Lee, minister of the Presbyterian congregation.

College might have been the worst place for Cho, according to interviews with classmates, church members and other acquaintances. At home, he had his parents, his sister and some structure and discipline. At Westfield High School in Chantilly, where he graduated in 2003, he was studious and had joined the science club.

Now, new details have emerged suggesting that Cho's mental condition worsened at Virginia Tech, especially in his senior year after his mother had sought to step in back home. His isolation grew, and his attention to schoolwork and class time dropped, according to numerous interviews. On April 16, he killed 32 people and himself in the deadliest shooting rampage by an individual in U.S. history.

Cho's family has said nothing publicly about his medical history, his academic performance or anything else that might explain what drove him to kill. Nevertheless, Hyang In Cho knew last year that her son was troubled. Before finding One Mind, she had gone to several other congregations of various denominations seeking help, according to officials at several Northern Virginia churches.

"His problem needed to be solved by spiritual power," said Lee, whose congregation met with Cho and his mother. "That's why she came to our church -- because we were helping several people like him." Those churchgoers told Hyang In Cho that her son was afflicted by demonic power and needed deliverance, Lee said. He would not say what they would do to accomplish that.

At first, Cho seemed to have tried to fit in at Virginia Tech. He had started out in college attending classes and studying faithfully. He wore a Virginia Tech baseball cap, jeans and T-shirts to class. When funny things were said in his Advanced Fiction class last fall, he would smile along with everyone else, recalled a classmate, J.D. Medlock, 22.

Cho had also reached out to female classmates, including one venture on Facebook, but it only served to upset some women enough for them to contact police. By senior year, his suitemates never saw him with a book or heading to class.

"He would just sit there," said Karan Grewal, one of five students who shared a three-bedroom suite in Harper Hall with Cho. Grewal added that Cho, who was assigned the suite randomly, would sit in a wood rocker by the window and stare at the lawn below.

What Cho was thinking remains a mystery; so many who knew him say they never heard him speak until the video he mailed to NBC News was aired on television. One clue exists in Cho's final selection of courses. He was taking a sociology class called Deviant Behavior, according to interviews. The class met on the second floor of Norris Hall, where most of the shootings occurred.

Relatives say Seung Hui Cho had suffered from a mental disability from a young age. Kim Yang Soon, a great aunt in South Korea, said Cho exhibited violent anger even as a child. It remains unclear whether his parents sought psychiatric or other professional help for their son in addition to the religious assistance.

Before coming to the United States, Cho's father ran a secondhand bookstore that didn't make much money, relatives said. The family had rented a three-room basement in a suburb of Seoul that was no larger than 430 square feet. Now unoccupied and full of mildew, it was the least-expensive rental in the building, according to Korean news reports.

The Chos told friends that they came to the United States for the sake of their children's education. They arrived in Detroit, where the family had relatives, before moving to Northern Virginia. Cho's father, Seung Tae Cho, worked long hours pressing pants in at least four dry cleaners in Manassas, Leesburg, Herndon and Centreville. Cho's sister, Sun Kyung Cho, entered Princeton University in 1999. Despite his silence, Cho was academically capable as well.

Taylor Van Buskirk, who was in the science club with Cho at Westfield High, recalled that Cho seemed to get irritated when other club members tried to talk to him. But Van Buskirk said he had no doubts that Cho was smart. During a science competition his sophomore year, Cho played the key role in helping his club win a first-place prize when he figured out the right formula to use during an experiment.

"He seemed to be a math whiz," Van Buskirk said. "He just kept to himself. He studied by himself. He got good grades; he didn't have any tutors."

Two other members of the club said that Cho was in honors classes and at least one Advanced Placement class at Westfield.

Cho started at Virginia Tech with high ambitions. He declared his major as business information technology, according to the 2003-04 university directory. A combination of computer science and management coursework offered by the Pamplin College of Business, BIT is one of Virginia Tech's most challenging undergraduate disciplines -- and No. 6 on the university's list of majors with the highest median starting salary after graduation.

Cho's freshman roommate, Francis Virtudes, said Cho seemed to study all the time, sitting at his desk or by himself in the dining hall, an open book in front of him.

But by December 2005, Cho was exhibiting signs of trouble. Two female students he tried to contact found his behavior disturbing and contacted campus police. He was sent to a mental health facility that month, and a judge ordered him to receive outpatient treatment.

And by his senior year, Cho appeared to never go to class or read a book, said Grewal. He would type on his laptop, go to the dining hall or gym and clip his hair in the bathroom (and clean up the mess). During one period last fall, he rode his bicycle in circles in the parking lot of their dorm, Grewal said.

Cho was an English major at the time of the shootings, no longer studying business. Virginia Tech officials, citing privacy laws, would not discuss Cho's academic record, including why he changed his major, what his grades were or whether he attended class in the months before his rampage. Mark Owczarski, Virginia Tech's director of news and information, noted that the school offers many programs to help students deal with campus life.

Any college campus hours from home would have been a difficult place to fit in for someone who struggled to communicate as much as Cho did.

Cho was close to none of the other Westfield graduates who entered Virginia Tech in 2003. He made no friends his freshman year, Virtudes recalled. He did not have visitors to his room on the second floor of Miles Hall. Cho moved in with Virtudes partway through freshman year, but only after inquiring whether Virtudes played loud music.

The aloneness could have only grown worse for Cho on an enormous campus where for many students social contact is at least as important as academics. Sixty-four fraternities and sororities are active on campus. And there are 600 registered student organizations -- from the Boxing Club to the Romanian Student Association.

"Nobody ever shuts out anybody here on purpose," said Alia Ghannam, 22, an English major who belongs to a sorority and an a cappella group and was part of the homecoming court this year. "You have to try hard to live in that kind of solitude here."

Solitude came naturally for Cho.

He played video games, but students from the gaming club never met him. He came from a Christian family, but the campus ministers don't remember him. He knew something about video editing, but the regulars at the student television station had not heard of him. Grewal never heard his voice, didn't know what classes he took. Those in the suite next door, he said, never knew of Cho until April 16.

"They were like, 'That guy lived here?' " Grewal recalled.

Others, though, said they tried to be friends with Cho.

Charlotte Peterson, a former Virginia Tech student, said she shared a British literature class with Cho in fall 2005. She regarded him as a loner but had spoken to him during class. At some point during the semester, she said, "he friended me" on Facebook, meaning that he invited her to his Web page as a participant. His name on Facebook was "?" -- a way Cho often identified himself.

But two weeks later, a friend of Peterson's gave her a warning: Stay away from him. The friend told Peterson that Cho had bothered her and that she had gone to police. Peterson deleted herself from Cho's page.

It is a familiar exchange: I step up to the counter at a convenience store and order my daily ration of Camel cigarettes, which I have been smoking since the Reagan administration and, as it happens, am smoking as I type this. Sliding the pack across the counter, the clerk — female clerks, typically; male clerks are more laissez-faire — sighs and says to me, “You know you need to quit.” My response, well honed over the years, goes like this: “I know I should quit,” I say, “but there’s one problem. I enjoy it.” On rare occasions, the clerk startles and smiles — that’s how it played out this morning — as if tickled by this forbidden admission. Far more frequently, however, I find myself at the receiving end of a uniformly bemused, pitying and faintly disgusted stare. I cannot possibly mean what I have just uttered, the stare says to me. The victim cannot confess to the crime. The cash register rings its tinny ring as the clerk slides the drawer shut and sadly wags her head.

Allan M. Brandt’s “Cigarette Century,” a fat chronicle of the rise and fall of the cigarette in the 20th century, delivers that same ruthful stare. Brandt, a professor of the history of medicine at Harvard Medical School, canvasses giant chunks of terrain here — the culture, science, politics, law and global spread of the cigarette, to cite just his section headings — without ever pausing to examine the central, vexing paradox of smoking: that in return for death, cigarettes give pleasure. Justifiable pleasure? Of course not. What Kant deemed “negative pleasure”? Perhaps. But pleasure nonetheless. Smokers, in Brandt’s view, are midwifed by an array of potent forces: ferocious tobacco advertising; peer pressure; cultural aesthetics (i.e., the imitable artfulness of Humphrey Bogart cupping a smoke); the addictive properties of nicotine; the tobacco industry’s pernicious campaign to obfuscate the perils of smoking; youthful longing for easy rebellion; and even, as evidenced by the boom in smoking after World War I, the scalding stress of trench warfare. But the cigarette itself, outside of its chemical components, gets scant credit. “One must not forget,” Jean Cocteau once wrote, “that the pack of cigarettes, the ceremony that extracts them, lights the lighter, and that strange cloud which penetrates us and which our nostrils puff, have with powerful charms seduced and conquered the world.” To be immune to those charms is naturally Brandt’s prerogative. To refuse or fail to acknowledge them in a history of the cigarette, however, is more problematic, and suggests the question: Is a cigarette sometimes just a cigarette? Or does the totality of its meanings — up to and including its flavors, fragrance and neurological kick — stem from a cultural moment, a peculiar and corporate-engineered hinge in time and place?

“It seems striking,” Brandt writes, “that a product of such little utility, ephemeral in its very nature, could be such an encompassing vehicle for understanding the past. But the cigarette permeates 20th-century America as smoke fills an enclosed room.” The cigarette came of age with, and thanks to, dramatic advances in manufacturing technology and marketing tactics, and was further helped along by the tectonic shifts in consumer culture and social mores that followed World War I. It was, pun intended, a breathtakingly fast rise. In 1904, cigarettes accounted for only 5 percent of the domestic tobacco market. By midcentury, nearly half of all adults smoked. Cigarettes were ubiquitous, with ashtrays freckling every room: nurseries, doctors’ offices, TV news studios. The tobacco industry — a bad seed from the beginning, as Brandt shows (as early as 1908, the American Tobacco Company was battling the feds, this time over antitrust regulations) — nurtured and exploited that ubiquity. If the health hazards of smoking were not “proven” until midcentury, they were readily apparent. Yet scientists, early on, found themselves lumped together with antitobacco moralists in the public mind, which imbued their cautions with the shrill taint of Victorian finger-wagging. Carcinogenesis sounded a lot like degeneracy, and America was happy to blow a collective stream of smoke in the face of that charge.

ll that changed in the early 1950s, when the causal relationship between smoking and lung cancer was finally “proven,” in scientific terms, and more formally “alleged,” in tobacco industry parlance. Faced with damning evidence, the industry devised a cagey defense: rather than denying the harms of smoking, it insisted there were “two sides” to the story, and corralled skeptical scientists — perennially available on any subject — to rebut or at least cast doubt upon the medical consensus. Journalists were urged to consider “fairness” and “balance” in covering the invented “controversy.” The industry’s public relations arm, Brandt writes, was “adept at taking a single dissenter and assuring widespread media coverage of his views.” This purposeful agnosticism, which served the tobacco industry well, will sound eerily familiar to anyone following the global warming “debate” — another case in which a few pedigreed skeptics, whose views align with those of a powerful industry, are framing consensus as controversy. “The industry,” Brandt writes, “insisted on scientific criteria that it knew full well could not be attained then, or ever.”

From this point on, “The Cigarette Century” morphs into combat history, into a meticulous record of the myriad courtroom clashes that defined the life of the cigarette in the latter years of the 20th century. Brandt’s admirable skills as a researcher and analyst are in full flower here, though readers searching for courtroom drama and more human scale should refer to Richard Kluger’s Pulitzer Prize-winning “Ashes to Ashes,” a silkier, smoother narrative that tracked the tobacco wars up through the mid-1990s. If the tobacco trials have yet to extinguish the industry, as antismoking advocates have been hoping for years, they’ve certainly delivered mortal wounds — most effectively, perhaps, in the discovery process, which unearthed decades’ worth of slimy industry documents (including one industry idea Brandt quotes, from a 1987 brainstorming session, to deal with health concerns: “Create a bigger monster (AIDS)”) that has made every cigarette purchase since feel like a deal with the devil, on top of a dance with death. Additional tort action, and ramped-up regulation now that tobacco support has become more of a political liability than an advantage, seems likely to further chip away the number of domestic smokers until just a few of us will remain, huddled in the rain 500 feet away from any possible contact with others, impoverished from taxes and life insurance premiums and the inability to pass a nicotine-finding blood test in order to get a job. Yet the essential conundrum, succinctly stated in a 1961 tobacco-industry memo, will remain: “There are biologically active materials present in cigarette tobacco. These are: a) cancer causing; b) cancer promoting; c) poisonous; d) stimulating, pleasurable and flavorful.”

Sifting Through the Ruins of Infidelity
Milreya Navarro, New York Times- 5/6/2007

The client said all he got was a massage, the kind that comes from an escort service and costs about $300. The owner of the escort service maintains all she offered was sexual fantasy, the kind that prompts a federal prosecution for running a prostitution ring.

In the latest sex scandal from the nation’s capital, the efforts to gloss over a sexual encounter failed to spare one of the first exposed: Randall L. Tobias, 65, who is married. Mr. Tobias, a top foreign aid adviser in the State Department, was listed on the phone records of Deborah Jeane Palfrey’s “high-end erotic fantasy service.” He denied he had sex with prostitutes, and then he quit his job, which entailed requiring foreign recipients of AIDS funds to condemn prostitution.

As more names in Ms. Palfrey’s circle begin to trickle out (she says she needs her powerful clients to prove she did nothing illegal), she may cause more shame and may ruin more careers. But outside the public glare, what about all the wives and girlfriends of those receiving massages? In that case, is an erotic massage, or sex with a prostitute, as much of a threat to a marriage or relationship?

“What I coach my clients to consider is, what is cheating and what is the ranking order of the violation to their agreement as a couple?” said Patti Britton, president of the American Association of Sexuality Educators, Counselors and Therapists. “They may consider it cheating or not.”

She added: “Is an erotic massage sex? What is sex? The Bill Clinton question of all time.”

Many of those who have been cheated on say there’s no such thing as ranking when it comes to infidelity. Having sex with a prostitute. Sleeping with the nanny, a co-worker or a neighbor. Getting a massage from a naked masseuse. Touching the naked masseuse.

Those nuances seem to escape users of survivinginfidelity.com, a site for the betrayed that recently featured a posting by a woman who wrote that her boyfriend had just being arrested at a massage parlor with a prostitute.

“I slapped him several times,” the woman wrote. “Then I kicked him out.”

Another user replied: “My opinion is to keep him kicked out and thank your lucky stars” you are not married to him.

At the heart of the matter, those commiserating with the woman said, were the lying, the betrayal of trust and even the risk of getting a sexually transmitted disease. But couples’ therapists and other experts say many mates make allowances when it comes to impersonal, anonymous, businesslike sex (or almost sex). A tryst for pay, for example, may be more forgivable than a long affair or emotional infidelity, such as the kind carried on by e-mail and instant messaging.

“It’s the idea of having an emotional or intellectual mind meld over the long term that’s hardest to recover from,” said Carrie Sloan, the editor in chief of Tango, a magazine on relationships.

A woman, 55, who is a loan officer in Kansas forgave her husband of 18 years after an affair of three months with a woman in her town, but said that she would have much preferred that he had hired a sex worker. It took her almost two years, she said, to believe him when he said that he wasn’t in love with the other woman.

“With a prostitute I wouldn’t have to get over that,” said the woman, who was not identified to protect personal details of her marriage. “I’d ask him what more would he desire sexually as opposed to ‘Are you in love?’ ”

Another woman, 40, who is a secretary in Detroit, said her two-year marriage broke up largely over her husband’s affairs with co-workers and women he met at business conventions. She agreed that a single night with a prostitute would have been easier to accept. At least that, she said, could be chalked up to “a momentary lapse.”

“An affair involves more lying and more manipulation,” said the woman, who was not identified to protect her privacy.

But the secretary said that now, six years after her divorce, she would not tolerate any cheating. “Now I’m like, ‘If you really want to go out and cheat, let’s end it,’ ” she said.

Pamela Druckerman, the author of “Lust in Translation,” about the global rules of infidelity, said that men cheat more than women worldwide. But while Japanese men who pay for sex may consider the practice purely recreational — rather than a firing offense — Americans try to find acceptable excuses for the cheating.

“He could blame sexual addiction, that you can’t control yourself,” Ms. Druckerman said.

Men know they are cheating when they pay for sex, but “there’s a lot of rationalization that goes on,” said Russell J. Stambaugh, a clinical psychologist in Ann Arbor, Mich., who has helped patients deal with the issue. Some men believe they are entitled to sex with many women because of biological needs or because their partner doesn’t satisfy them in bed, Dr. Stambaugh said.

Marie H. Browne, a marriage therapist in Westfield, N.J., who treats couples struggling with infidelity, said that in cases where men engage prostitutes while out of town, “they often feel it’s very private. It’s not hurting anyone.”

But there are consequences. Once caught, therapists say, men can succeed in saving their relationships only if they are penitent.

“It’s harder to forgive if he says, ‘You’ve gained 50 pounds, what do you expect?’ ” said Dr. Browne,who was an author for the book “You Can’t Have Him, He’s Mine: A Woman’s Guide to Affair-Proofing Her Relationship.”

Public humiliation can hamper healing, and it is not only high-powered men in Washington who risk widespread exposure. To deter the use of prostitutes, so-called “johns laws” nationwide resort to arrests and public shame, including posting pictures on local government sites.

Some places have gone the way of San Francisco, which offers a rehabilitation program to first offenders to reduce recidivism. Replicated in more than two dozen locations, the “john school” confronts participants with the effects of their actions, including testimony from ex-prostitutes and information about venereal disease.

Norma Hotaling, a former prostitute, runs the Standing Against Global Exploitation Project, which helps prostitutes, and helped found the First Offender Prostitution Program with the San Francisco Police Department and the district attorney’s office. She said most participants are younger than 35, married and have a degree.

“They have a very healthy sense of denial,” she said. “They blame the people they’re in relationships with. ‘My girlfriend won’t do this. My wife is a bitch.’ ”

As Ms. Palfrey exposes her clients — according to ABC News, the list has thousands of phone numbers, including those of a Bush administration economics official and assorted lobbyists — advocates like Ms. Hotaling say the names should be released. Protecting patrons only leads to more sexual exploitation, she said.

“Prostitution is about lying,” Ms. Hotaling said. “It’s not about people liking each other. It’s living a double life.”

“They go home and have dinner with their families and everything is normalized,” she said of prostitution clients. “Let’s put it all out there.”



Self-Nonmedication
Bruce Stutz, New York Times Magazine- 5/6/2007

Seven years ago, not long after my father died, with my editing job lost, my finances frail, my 26-year marriage failing, a child in college and a mortgage to pay, my brain seemed to lose its way. Sometimes it could barely think at all. Sometimes it tortured a single thought for hours. And sometimes, in desperation and without aim, it released a barrage of anger upon itself.
      I could come up with a hundred descriptions of how I felt — as if the train I’d been riding had gone off track, as if the ground beneath me had given way and swallowed me up, as if I were in a black hole being compressed to nothingness — none of them very original, I suppose, because this was not, for a man just past 50, a very extraordinary midlife situation. But it was mine, and I saw no way out of it. Immobilized by indecision or agitated to the point of exhaustion, I could enumerate every stressful circumstance, but I was simply unable or unwilling to resolve any of them. Instead, I dithered miserably while I staved off creditors, struggled to write, sparred with marriage counselors and rued the emotional havoc I was wreaking on myself and everyone around me. Frustrated, I felt angered and at times utterly hopeless. I needed help.
     At our first meeting, I told the psychiatrist that what I thought I needed was something to enable me to focus my thinking, something like the amphetamines I used to take in college to study. He demurred but said that an antidepressant might prove worthwhile and accomplish the same thing. He prescribed Prozac, but after only a few days on it, I began having nightmares that verged on the hallucinatory. So he suggested a switch to Effexor, and without much thought as to what this was or how it worked, I took the prescription and the handful of blister-packed capsules he offered (I had, when I was younger, tried many things given me by far lesser authorities) and agreed that we should meet regularly. The medication, he said, would begin working after a few weeks of gradually increasing dosage. I had no adverse reaction to it.
     We met weekly and, like engineers examining a weakening structure, began to analyze each point of stress and how I might deal with it. This was not easy since, in the course of living, working and rearing children, I had developed many ways of specifically not dealing with many things — especially those that involved determining who I was and what I thought without reference to my being son, father, husband, lover or friend. I was not breaking new psychoanalytic ground here, but if one of the characteristics of depression —as it has been said of insanity — is thinking the same thing over and over and expecting to get different results, then I was depressed. I found little pleasure in anything; I couldn’t sleep. Each day seemed to drag on forever, and yet I never seemed to have enough time to accomplish even the simplest tasks.
     After several weeks of sessions, my brain began to clear. Whether this was because of the drug or from just taking the time to consider my circumstances, I don’t know. Still, it took nearly three years of therapy before I began to lose my fear of thinking about things differently and accepting the fact that change held possibility along with uncertainty. But change was still hard — on everyone. My marriage did not make it through. I was living alone in a 17-by-6-foot below-ground studio in Brooklyn that my kids called “the Batcave,” still challenged by money and work. But the siege had lifted, the panic had vanished and I felt older, wiser and abler.
     My last session with my psychiatrist lacked drama. I thanked him. We shook hands. He wished me luck. There was no mention of going off my antidepressant, and satisfied with the way things were going, I continued to take my 150 milligrams once a day. I still struggled with work and money, but I stayed focused. Over the next several months, I wrote a proposal for a book that would, in examining the nature of spring, consider the nature of change. In March of the following year I began my travels, heading north across the country for four months, following the increasing hours of daylight, seeking to reach spring’s climax and complete my spiritual renewal when I reached the Arctic at the summer solstice. But there, I also came to another realization: exhilarated by the 24 hours of Arctic daylight, hoping for a transformative escape from time, I had removed my watch. I was watching the timeless sight of caribou herds crossing the vast Arctic plain — and found myself worrying that I had no way of knowing when I should take my next dose of antidepressant.
      In the past I experienced what happened if I didn’t take it on time. When I missed my morning dose, by 2 p.m. I would begin to space out. A prickliness in my neck would give way to a restless agitation that left me edging toward panic. All I would be able to think of was how far away I was from home, my pill, relief. Within 20 minutes of taking the pill, I would feel better. I would feel better just knowing I’d taken it.
     But what I was experiencing 4,000 miles away from New York felt absurd. Why, more than two years after leaving therapy, feeling fine, able to work, write and face setbacks and frustrations without panic or depression, was I still taking an antidepressant? I decided that being in the middle of writing the book was no time to stop, and stayed on for another two years. But once the book was published, I began to wonder again whether I needed to keep taking this pill.
     Since the time I had stopped seeing my psychiatrist, other doctors had, with no questions asked, written prescriptions. My G.P. was the prescriber of the moment.
     “I was thinking of getting off Effexor,” I told him.
     “Do you feel O.K. on it?” he asked. I said I did.
     “Then why go off it?”
     Well, for one thing, this fear of forgetting my pills. And for another, I was beginning to suffer some undesirable sexual side effects.
     “There are other drugs with fewer sexual side effects,” he offered. “And there’s always Viagra.”
     Didn’t it seem strange to have to counteract the effects of one drug with another drug? Why not just get off the antidepressant?
     “In my experience,” he said, “most people who go off eventually go back on.”

Somehow I couldn’t believe I had to take this pill for the rest of my life. I was feeling fine. At least I thought I was feeling fine. The image that came to mind was of Dumbo the elephant believing that what allowed him to fly was the feather the crows had given him. Only when he drops the feather does he realize that he truly has the gift of flight. Could I let go?
      Friends had plenty of stories of trying to go off antidepressants. One said her medication made her lose interest in sex, so that soon after she began taking it she quit but felt guilty telling her therapist, who went on thinking she was on it. Another said she kept trying to get off because she couldn’t deal with the amount of weight she’d gained. But she kept returning to it. One said that within two weeks of quitting, she and her husband both found her unbearable, and she went back on.
    All of them questioned my decision to go off. Didn’t I understand that depression was caused by a chemical imbalance? It was a disease, they insisted, like diabetes, and antidepressants were like insulin. But a diabetic knows what will happen if he goes off his insulin. I was in a psychopharmacological Catch-22: the only way to know whether my depression would return if I went off of my antidepressant was to go off my antidepressant and risk depression.
     My friends and I are children of the modern drug age; we never knew a time before antibiotics or antipsychotics, so our working assumption is that every disease has its cure. Sooner or later, as in the movies, an Erlich, a Pasteur or a Salk, working late in the lab, has a eureka moment, and the magic bullet is found.
     When it came to depression, serotonin was deemed that magic bullet. One of life’s most venerable chemicals — plants were making use of it long before humans evolved — serotonin is one of several chemicals, including norepinephrine and dopamine, called neurotransmitters, which nerve cells release into the tiny gaps among themselves and their neighbors to allow signals to pass among them. Once a message has been sent and received, the sending cell absorbs (“reuptakes” is the scientific term) the leftover neurotransmitter.
     During the 1960s and 1970s, researchers recognized that some drugs that improved patients’ moods had the ability to inhibit the sending cell’s reuptake process, thereby leaving more neurotransmitter lingering in the synapses. Inductive reasoning led them to conclude that what must have caused these patients’ mood disorders in the first place was an insufficiency of these same chemical neurotransmitters. Restore the brain’s “chemical balance,” the thinking went, and depression could be alleviated. The antidepressant age was born.
     Early antidepressants worked on a number of neurotransmitters. In 1987, Prozac became the first selective serotonin reuptake inhibitor (S.S.R.I.) introduced in America, followed by Paxil and Zoloft. Effexor (generically, venlafaxine hydrochloride), the drug I was taking, focused on both serotonin and norepinephrine (and so is referred to as an S.N.R.I), inhibiting their reuptake, increasing the amounts in my synapses and thereby presumably enabling my brain to keep depression at bay.
     It has long been known that the body’s chemistry responds to stress. Recent studies suggest that when stress becomes chronic, the persistence of the chemicals that respond to it may damage or reduce the number of serotonin receptors, inhibit the production of proteins that mobilize serotonin receptors and even shrink neurons in the hippocampus, the part of the brain involved most with memory. How the chemistry of chronic stress results in depression is uncertain. It’s also uncertain whether a deficiency of serotonin might lead to chronic stress. But the presumption is that antidepressants, by increasing serotonin, reduce the effects of chronic stress and thereby arrest depression.
     Since I was no longer feeling depressed, the experiment I was about to embark upon would test whether without the drug to keep my serotonin up, my depression would return. A risky proposition, considering all I’d gone through to get well, but if I really was well, perhaps my serotonin levels might adjust on their own. Or perhaps I was well enough to live with a chemical imbalance, if that’s what I had.
     Drug-company brochures and Web sites reported that the symptoms of going off antidepressants were usually mild and short-lived — a week or two. They all recommended tapering off, preferably by half-steps, in consultation with a doctor. I thought about calling my psychiatrist, but it had been four years, and I didn’t want to return to the place, physically or mentally, where I had gone through so much pain. I also knew my psychiatrist well enough to know that he didn’t take his job lightly and would have most likely asked me to come in. But I couldn’t afford more sessions.
     While I was still undecided whether or when to begin, serendipity came into play. Instead of prescribing a month’s worth of 150-milligram capsules to be taken once a day, my doctor mistakenly prescribed 75-milligram capsules to be taken twice a day. I took it as an omen. This would make it easy for me to halve my dose. So I began.

I expected that for the first couple of days I would feel the muscle-twitching anxiety that came when I missed a dose, but it was not so bad, and I had hopes that I might taper off quickly. On the third day, however, I began to find it difficult to focus and was unable to sit at my desk for more than a half-hour at a time. I was agitated, restless and hyperaware of sounds. When I read, sentences seemed to run into one another on the page, and I realized that this was not just because of difficulty focusing my mind but also my eyes. By early evening on that day, I felt so jittery and anxious that I decided I needed more medication. Somewhere, I recalled, a couple of years earlier I stashed a blister pack of 37.5-milligram capsules, a sample my doctor had passed on to me. But where? Although I could have split open a 75-milligram capsule, in my anxious state I became bent on finding those 37.5’s. An hour or more later, after manically scavenging through everything in the apartment, I found them — six remaining in the blister pack. I took one and felt as if I could now go on. I felt relieved to have them. I would stay with my reduced dosage as long as I could, but they would be my backup if I found that I absolutely needed them.
      Over the next several days they came in handy, especially at night, when I would wake up feeling dizzy, almost seasick, disoriented and in a heavy sweat, the pillow soaked. One night, awake and not eager to go back to lying restlessly in bed, I went online, typed in “Effexor withdrawal” and found bulletin boards full of pained, plaintive and sometimes angry posters who had quit taking their medication and were suffering a broad but surprisingly consistent range of symptoms: dry mouth, muscle twitching, sleeplessness, fatigue, dizziness, stomach cramps, nightmares, blurred vision, tinnitus, anxiety and, weirdest of all, what were referred to as “brain zaps” or “brain shivers.” While there were those who went off with few or no symptoms at all, others reported taking months to feel physically readjusted. In the face of those symptoms, many despaired, gave up and returned to the drugs.
     By the end of the second week, I felt confident that I could continue on 75 milligrams a day. But then my symptoms became more physical: the chills at night and the cold sweats continued. I felt tingling in my shoulders and hands, spasms in my legs. These came and went, seemingly with no reason. And then one night as I lay back to go to sleep, I felt a quick spasm in my head as if an electrical current had suddenly been sent through a circuit somewhere inside my brain. Two more followed in quick succession. With each came a wave of nausea. I sat up. They seemed to disappear. They returned. I realized these were the brain zaps, and over the next few weeks they would come, with no distinguishable pattern, several times a day.
     Coping with the ever-changing and seemingly capricious symptoms was beginning to exhaust me. I couldn’t stick to any sleep schedule. I couldn’t think clearly. I was becoming unfocused, agitated and unable to sit long enough to read or work. The stress of anxiety and sleeplessness that I’d almost forgotten seemed to be returning. And that scared me. Was my depression returning, or could getting off this drug actually cause so many and various symptoms? I spoke with neuroscientists, research psychiatrists and practicing therapists. All of them knew of the difficulties some people had in getting off not only Effexor but other antidepressants as well. They also all agreed that most of these symptoms were caused by a deficiency of serotonin.
     What was happening was this: When I started taking Effexor, the drug began inhibiting my brain cells’ process of reabsorbing “excess” serotonin — that is, the serotonin that had gone unused in sending signals across the synapses from one neuron to another. This was the purpose of taking the drug — to increase the amount of serotonin my cells had to work with and therefore, in theory, enable me to cope with my stress and depression. I say “in theory” because even 20 years since the introduction of drugs like these, every researcher with whom I spoke was cautious about presuming a direct relationship between increased serotonin levels in neural synapses and a decrease in depression. First, no one has ever measured the amount of serotonin in the synapses between anyone’s brain cells. No one knows what constitutes a low, high or even standard level. Second, for reasons unknown, only a little better than half the people treated with antidepressants respond to them. Third, studies have shown that placebos have only a slightly lesser rate of effectiveness than the drugs. Fourth, serotonin levels are affected by many things — exercise, light, sleep, diet and even time of day. And finally, serotonin has so much influence on chemistry and functions in so many places in the body and brain relating to mood, sleep, sexual desire, appetite and body temperature that to say that it acts in any one particular way is impossible.
     Research suggests that as the effects of the drug set in, my cells became more receptive to serotonin and the brain compensated to ensure that there wasn’t a serotonin overflow. This function is important, because an excess of serotonin can not only cause severe psychological effects but can also, in rare cases, be fatal. During the first weeks of taking an antidepressant, then, until the drug’s ability to inhibit reuptake of serotonin matches the brain’s ability to withhold it, the brain apparently has less serotonin to work with than it had before. During this period patients can suffer a range of uncomfortable side effects, from sleeplessness to anxiety, that make many patients quit taking the drug before they ever reach an effective dose. It’s also the period during which some patients suffer such severe agitation that the chances that they will attempt suicide increase significantly enough that the F.D.A. requires what is known as a “black box” warning on the labels of S.S.R.I.’s for pediatric patients and is considering extending this warning to adults.
     What I was doing now by decreasing my dose of Effexor was essentially reversing the process that I went through when I began taking it. As the amount of the drug in my system declined, my neurons once again began to take up the excess serotonin. But while the reuptake mechanism may respond quickly, the serotonin system can take weeks or months to readjust. In the meantime I was going to be short on serotonin and would have to suffer the effects. And because serotonin is so ubiquitous in the nervous system, the effects might be almost anything. They might even feel like depression. Or worse, they might even be depression.

None of these symptoms would come as news to most researchers. In 1996, nearly a decade after the introduction of Prozac, its manufacturer, Eli Lilly, sponsored a research symposium to address the increasing number of reports of patients who had difficult symptoms after going off their antidepressants. By then it had become clear that drug-company estimates that at most a few percent of those who took antidepressants would have a hard time getting off were far too low. Jerrold Rosenbaum and Maurizio Fava, researchers at Massachusetts General Hospital, found that among people getting off antidepressants, anywhere from 20 percent to 80 percent (depending on the drug) suffered what was being called antidepressant withdrawal (but which, after the symposium, was renamed “discontinuation syndrome”).
      They also found that the withdrawal effects depend on a given antidepressant’s half-life — that is, the amount of time it takes for half the medication to be washed out of the body. Since this is a measure of the length of time the drug is effective, you will more quickly feel the effects of missing a dose of an antidepressant with a short half-life than of one with a long half-life. If you’re taking your full medication daily, this isn’t relevant. But when, say, you reduce the dosage of a short-half-life drug by half, that half is, by the nature of the drug, quickly halved again. In their studies, Rosenbaum and Fava found that Paxil and Zoloft, with half-lives of one day, proved more difficult to get off than Prozac, with a half-life of four to six days. Effexor, the drug I was on, has the shortest half-life of all: five or six hours. That explained why, if I forgot to take my medication in the morning, by afternoon I was facing a panic attack. It was also why, Rosenbaum and Fava told me, when a patient is having trouble getting off Effexor they might recommend switching to Prozac to ease the transition.
     Still, the symptoms of discontinuation syndrome could be fierce. Fava, in a 2006 paper, cited “agitation, anxiety, akathesia, panic attacks, irritability, aggressiveness, worsening of mood, dysphoria, crying spells or mood lability, overactivity or hyperactivity, depersonalization, decreased concentration, slowed thinking, confusion and memory/concentration difficulties.”
     So I decided to stick with 75 milligrams a day for a while to give my serotonin system time to catch up. But in my third week, I still felt constantly uncomfortable and often irritable. The brain zaps were sometimes blinding. No one seemed to know what caused them. I even went to an ear, nose and throat specialist to see if I was suffering from some sinus problem, but he found nothing. One day, trying to repair a cabinet drawer, I ruined the glide and, suddenly and blindly angered, began pounding my head with my fist. Worse was that my failure at something so trivial triggered more general, undefinable feelings of failure similar to those I suffered when I was depressed.
     Ron Duman, a researcher at the Yale University School of Medicine in the psychiatry department, told me recently that there was no specific mechanism that would explain my symptoms, but that my system was trying to readapt. “Your neurons,” he said, “are literally sensing the lack of serotonin.” That was the bad news. The good news: “That the brain is able to adapt to stress, to environmental impact or pharmacological stimuli and change over time is really a key concept of how the brain works.”
     My choice then, as I saw it, was either to go back to taking the medication or find another way to try and raise my serotonin levels, or at least help the process along. Duman, an athletic-looking guy himself, told me that studies have shown that exercise can improve the serotonin system as much as antidepressants can. So I began a serotonin-boosting regimen — getting out and taking daily walks around Prospect Park, near my home in Brooklyn. No jogger, I completed the three-mile loop in 45 minutes to an hour. After a few days, I noticed that these walks relieved my restlessness. I began to sleep better.
     Sleep, Efrain C. Azmitia of the biology department and the Center for Neural Science of New York University, told me, increases serotonin levels, too. Azmitia, who has conducted research on the serotonin system for four decades, said that light and good nutrition can also increase serotonin. Anything, in fact, that relieves severe stress, which, he has found, is disruptive to the serotonin system. It’s why therapy might work just as well as medication, why placebos may work. The stress is relieved, and the system recovers.
     I was feeling so much better by the end of the fourth week that I decided to cut back on my dosage again. At the bottom of my computer bag I’d found more blister packs of 37.5-milligram capsules, part of my hidden caches of medication. The first day went fine. But that night I screamed so loudly in my sleep that it seemed to echo in the room long after I sat up awake. It was 4 a.m. I was having brain zaps. I decided to take another 37.5 milligrams but then to try to make it last me through the next day. It did.
     Around this time, I began to feel sensations, smells and sounds more intensely. Had the drug, in keeping me focused, also lowered my response to life’s pleasures? When I asked Rosenbaum, the researcher at Mass General, about this, he insisted that there was no evidence that antidepressants have what he called “a dulling effect.” But others disagree. Joseph Glenmullen, a clinical instructor in psychiatry at Harvard Medical School, says he has had many patients describe it. I know that I felt it.
     One evening, sitting in the movie theater and watching “Little Miss Sunshine,” I suddenly found myself welling up with tears. I put my head back and closed my eyes, but the tears came. I wondered for a moment whether it was a sign of depression but realized that I never cried when I was depressed. I didn’t have the focus for it. Over the next weeks, when out walking or listening to music (Count Basie’s “Li’l Darlin’,” in particular), I found myself weeping for no reason at all.
     What I was gradually beginning to feel was the difference between clicking on a book on Amazon.com and wandering through library shelves, allowing my gaze to wander from spine to spine. I imagined that when I allowed myself such pleasures, I was disarming stress and that my serotonin responded accordingly.
     I was now down to 37.5 milligrams a day. It had been two full months since I began getting off Effexor. I decided to see if I could go without. I felt a bit panicked that morning but by noon was still fine. Perhaps, I thought, this was it. But the brain zaps increased throughout the day. Feeling disoriented that night, I took another 37.5 milligrams. I put off taking another dose for 24 hours and then decided to try to make it through the night. By morning I’d gone 36 hours. Should I try to keep going? But the blister pack held another capsule. Maybe just half of it, I thought. I opened the capsule, poured out the tiny white granules, took half into my palm and swallowed it with a glass of water. When I looked down at the counter with the open capsule, the remaining grains of medicine, and the trail of white power where I’d scraped the rest into my hand, I realized that it was time to move on.
     In the months since going off, withdrawing, discontinuing, whatever you want to call it, I’ve been through life’s usual stresses (and some extraordinary ones), felt good, bad, sad, unhappy, glad, even hopeless and helpless. But I’ve yet to feel again the chronic, painful and perspectiveless despair that characterizes major depression and that first brought me to seek help.
      Will I become depressed again? Rosenbaum told me that the answer to that question may depend on the severity of the earlier depression — a major depressive episode as opposed to feeling very down or stressed — and the length of time the symptoms lasted. Sometimes, he said, patients feel better but have residual symptoms. “If you have residual symptoms, you’re at risk for relapse. If you’ve had multiple severe episodes, if you’ve had chronic depression, you’re at risk for relapse.” Studies show that people who go through one bout with severe depression have a one-in-four chance of having another. Two bouts, and your chances double of having a third. Three bouts, and it’s nearly certain you’ll have another.
     I wondered what my future held, since studies show that those who go through long-term therapy in conjunction with antidepressants have less of a chance of their depression returning than those who only take an antidepressant. “I believe that sometimes people can grow while on antidepressants and free up depression in a way that might buffer them to take advantage of psychosocial treatments they couldn’t have taken advantage of when they were depressed,” Rosenbaum told me recently. “But I’ve also seen people who have done hard work in cognitive therapy, but they just can’t sustain it when depression returns.”

What got me back on my feet? Was it the medicine, the therapy or both? Was it just the passage of time? I’m certain that there was much chemistry involved, since our capacities to think, feel and imagine all come out of the chemical makeups of our brains. But did I need the drug to alter that chemistry? If my psychiatrist had told me, “I think you can do this without taking any drugs,” would I have done just as well? If I had been told how difficult it would be to get off the drug, would I have so readily started on it? Even the doctors and researchers who most believe in the effectiveness of antidepressants acknowledge that the “chemical balance” paradigm, the magic-bullet paradigm, makes things seem simpler than they actually are. For some, these drugs may be a lifesaving treatment. But for most of us troubled or even temporarily anguished by life’s difficulties, does our long-term reliance on these drugs become more of a convenience than a cure, allowing us to simply keep going in the midst of very difficult circumstances? And once we start taking them, how do we find the wherewithal to stop?
      Ron Duman told me about one way that scientists try to test the effectiveness of a given antidepressant in the lab. Put a laboratory rat into a beaker of water and see how long it struggles to get out. When it stops, remove it from the beaker and treat it with the drug. Repeat the test. If it struggles for a significantly longer time than before, the drug is considered to have antidepressant potential.
     Is this ability to keep us going altogether good? As Rosenbaum pointed out to me, people under stress can do great harm not only to themselves but also to those around them parents to their children, couples to each other. But when does reliance on a drug keep us from seeking ways to resolve the causes of stress? General practitioners, not mental-health specialists, write most of the prescriptions for antidepressants. For most doctors and psychiatrists, drugs, not therapy, have become the first line of defense. Only some 20 percent of people prescribed an antidepressant ever have even a single follow-up appointment.
     Perhaps it was the difficult time I had getting off my antidepressant, but I never think about going back on. I’m enjoying this revitalized view of my emotional and physical worlds. Having finally dropped the feather that I believed allowed me to fly, I face life’s difficulties without much fear of falling back into depression. I have no illusions about having resolved every issue or that all that happened won’t continue to have repercussions on those who went through it with me. I don’t believe in “closure.” Life, like the brain, has too much interconnected circuitry. But it is also always changing. “The brain has evolved to deal with sadness and grief, and having to deal with them may make the brain more flexible,” Azmitia told me. Maybe dealing with life’s distresses has it’s own chemistry. I know I hated every second of it. I don’t know if the medication helped. But I do know that I’m very glad I’m off.