Noteworthy News Articles on Mental Health Topics, September 10-18, 2007

The emerging science suggests that decades-old ''quit for your baby'' messages are too simplistic an approach for many women -- and that perhaps prenatal checkups should include screening pregnant smokers for mental health disorders that themselves require care.

''These ladies all know, I promise you, about the health risks. That's not what it is,'' says Dr. Jan Blalock of the University of Texas M.D Anderson Cancer Center, which has begun a first-of-a-kind study, Project Baby Steps, to test whether non-drug depression therapy helps pregnant smokers quit.

''We should at least understand more about why these ladies don't quit. We should be looking more carefully instead of just saying, 'Whoop, got this group of hard-core smokers.'''

Nearly 45 million Americans, or one in five adults, smoke. Quitting takes on average three to five attempts, and scientists know it's harder if the smoker has depression or anxiety disorders. In fact, one prescription anti-smoking pill is actually the old antidepressant Wellbutrin sold under a different name, Zyban.

Certainly learning how dangerous smoking is to their developing baby can prompt women to try to quit. It increases the risk of miscarriage, premature birth, low birthweight, death from SIDS, and learning and behavior disorders.

But only recently have researchers begun to delve into why, despite the enormous stigma, so many pregnant smokers don't quit. The government estimates about 12 percent of pregnant women smoke.

Dr. Renee Goodwin, a Columbia University epidemiologist, tracked more than 1,500 pregnant women who took part in a larger study of Americans' health. A surprising 22 percent smoked at some point during pregnancy, and about 12 percent were classified as nicotine-dependent.

Pregnant smokers were typically poor, less educated and had less access to health care.

But strikingly, 30 percent of the smokers had a mental health disorder, as did more than half who were nicotine-addicted -- and the vast majority suffered depression. The smokers were about three times as likely to have a disorder as pregnant nonsmokers, Goodwin recently reported in the journal Obstetrics and Gynecology.

Smaller studies also have linked depression to smoking during pregnancy.

Nicotine and other chemicals in cigarette smoke can act in the brain like weak antidepressants, says Dr. Nora Volkow, director of the National Institute on Drug Abuse.

''They are not just smoking to get the habit-forming aspects,'' Volkow explains. ''On top of that, they are seeking the therapeutic effect. It comes at a very, very high cost.''

It can be hard for the depressed to realize when they need help. And chances of relapse increase when would-be quitters feel worsening sadness, lethargy or other depression symptoms.

That makes the smoking more ''a disease instead of a choice,'' Volkow says. ''Society's responsibility is to provide a treatment. Because here you have two individuals that will be affected.''

But how to treat pregnant smokers?

While many smokers turn to medication to ease quitting pangs, doctors hesitate to prescribe even nicotine patches during pregnancy. Studies so far haven't proven the patches' role in pregnancy, and some suggest pregnant women metabolize nicotine faster and thus need higher doses, raising fetal safety questions. A major study is beginning in Britain to try to settle those questions.

What about alleviating depression to help them quit?

Antidepressants haven't been studied specifically in pregnant smokers. Generally, those drugs are reserved for severe symptoms during pregnancy, although recent studies suggest the risk of birth defects is low.

Enter Texas' Project Baby Steps. More than 250 pregnant smokers, and counting, are testing whether a form of cognitive therapy for depression helps them kick the habit better than anti-smoking counseling alone.

The psychological therapy is intense, teaching women to problem-solve so they can improve dysfunctional relationships that can fuel both the depression and the smoking, Blalock explains.

This is a high-risk group of poor, inner-city women. Almost half are currently suffering major depression, and Blalock says many also have a history of abuse or other trauma. But they volunteered for the study because they want to quit smoking.

It's not clear yet if depression plays a role for pregnant smokers in general, or is an added risk mostly for the poor, Blalock stresses.

Still, NIDA's Volkow says it's crucial to develop ways to help this uniquely vulnerable group.

''There's a lot of social disdain'' for pregnant smokers, adds Columbia's Goodwin. ''There aren't a lot of treatment programs. There's just advice ... not to smoke, but that's not going to do the job.''

When a ‘Duplicate’ Family Moves In
Carol Berman, M.D., New York Times- 9/11/2007

My patient, a 37-year-old homemaker, gazed at the man in the red plaid shirt as he sat on the couch in her living room. “Who are you?” she asked.

There was something familiar about him. He wore her husband’s boots, but the shirt made him look like a truck driver.

“Yeah, and who are you?” the man replied with a laugh. “Come here and give me a kiss.”

She gave the man a peck on the cheek, but she felt guilty, fearing that her husband would arrive at any moment and admonish her. Not only did the man want a kiss — he also wanted sex!

Discouraging him, she sat down to talk. The man spoke just like her husband and knew personal facts about her. It occurred to her that her husband had been mysteriously replaced by this fellow. How it happened she had no idea; she knew only that it had.

My patient had a history of schizoaffective disorder, similar to schizophrenia, but with more emotional range. And when she told me of this incident at her weekly visit the next day, I worried that her psychosis was recurring. “Have you been taking your medicine?” I asked.

She admitted that she had not taken her antipsychotic, Clozaril, for a few days because of a side effect, excessive salivation.

“With your condition, it’s important to take your medicine every day,” I said gently.

She liked and respected me, but she could not stand it when I gave her orders. “If you knew how embarrassing it is to drool all over yourself, you wouldn’t make me take that medicine,” she told me.

As I tried to extract a promise that she would restart her medicine, she suddenly sat back and stared at me. “What’s wrong?” I asked.

There was a pause. I saw her composing herself before she spoke. “You have the same voice, but your nose is bigger and your face longer.”

She excused herself 10 minutes early. I allowed her to go, because I knew she could not stand being with me any longer.

Days later, her husband called to say she was going “crazy” again, believing that I and, now, her parents had been replaced by duplicates. I had to hospitalize her and restart her medication.

My patient suffered from a variation of Capgras syndrome, in which people are replaced by inexact duplicates. It has been considered rare, but the more I work with geriatric patients, the more I am diagnosing it.

The disorder was first described in 1923 by the French psychiatrists Joseph Capgras and Jean Reboul-Lachaux. They treated a 53-year-old who believed that her husband, her children, her neighbors and even she had been replaced by exact “doubles” in a plot to steal her property.

In Capgras, there is an uncoupling of perception and recognition that leads many investigators to theorize that there may be a neurological, organic cause that remains unknown. Psychoanalysts have seen Capgras as an unusual form of displacement in which the patient rejects the loved one whenever negative features have to be attributed.

Yet guilt and ambivalence prevent the patient from becoming conscious of the rejection. The bad feelings are displaced to a double, who is an impostor and may safely be rejected. Anna Freud thought this delusion allowed patients to defend themselves against loss and distress about changes in close relationships.

After resuming her medicine, my patient quickly lost her belief that her husband, parents and psychiatrist were doubles. When she was healthy enough to return to outpatient treatment, I asked whether she had ever seen the movie “Invasion of the Body Snatchers.” She said no.

I thought I’d better not explain the plot to her.

Experts Question Study on Youth Suicide Rates
Alex Berenson & Benedict Carey, New York Times- 9/14/2007

Last week, leading psychiatric researchers linked a 2004 increase in the suicide rate for children and adolescents to a warning by the Food and Drug Administration about the use of antidepressants in minors. The F.D.A. warning, the researchers suggested, might have resulted in severely depressed teenagers going without needed treatment.

But the data in the study, which was published in The American Journal of Psychiatry and received widespread publicity, do not support that explanation, outside experts say.

While suicide rates for Americans ages 19 and under rose 14 percent in 2004, the number of prescriptions for antidepressants in that group was basically unchanged and did not drop substantially, according to data from the study. Prescription rates for minors did fall sharply a year later, but the suicide rates for 2005 are not yet available from the Centers for Disease Control and Prevention.

“There doesn’t seem to be any evidence of a statistically significant association between suicide rates and prescription rates provided in the paper” for the years after the F.D.A. warnings, said Thomas R. Ten Have, a professor of biostatistics at the University of Pennsylvania.

In the report published last week, the authors analyzed data on suicides and antidepressant use over several years in the United States and the Netherlands. They argued that drug regulators may have created a larger problem by requiring pharmaceutical companies to place warnings on antidepressants, scaring away patients and doctors. The F.D.A. warning label says that a potential side effect in young people is an increase in suicidal thoughts and behavior.

“The most plausible explanation is a cause and effect relationship: prescription rates change, therefore suicides change,” said Dr. J. John Mann, a psychiatrist at Columbia University and a co-author of the study.

But Dr. Ten Have and other experts, while noting that it may still turn out that a reduction in prescriptions is leading to increased suicides among young people, said that the new study neither proved nor disproved this. Instead, some experts say, the study illustrates why suicide trends are so difficult to understand — and why this debate has been so polarizing and confusing.

In an interview, Robert D. Gibbons, a professor of biostatistics and psychiatry at the University of Illinois at Chicago and the lead author of the journal article, acknowledged that the data from the United States that he and his colleagues analyzed did not support a causal link between prescription rates and suicide in 2004. “We really need to see the 2005 numbers on suicide to see what happened,” he said.

But Dr. Gibbons defended the paper, saying that when taken in the context of previous studies that linked falling antidepressant use to increased suicide rates, “this study was suggestive, that’s what we’re saying.”

Other experts, however, said that the problem with such studies is precisely that they are suggestive rather than conclusive and are open to interpretation. Suicides are rare and uniquely personal events that can be driven by many factors: worsening depression or other mental illnesses, breakups or job loss, lack of drug or psychiatric treatment, even easy access to guns.

In calling for the labeling change on antidepressants, F.D.A. scientists based their decision on data from drug makers’ clinical trials, considered the gold standard in medical research. Those trials have shown that young patients who took antidepressants were about twice as likely than those on placebos to report suicidal thoughts or attempts, though the numbers in both groups were small.

Yet none of the youngsters in the trials, most of which ran for no more than a month or two, actually committed suicide. And most psychiatrists with long experience using antidepressants in children say the benefits far outweigh any risk.

In studies of data collected before 2004, Dr. Gibbons, Dr. Mann and others found clear associations between prescription patterns and suicide rates. For instance, prescription rates for patients from ages 10 to 24 rose steadily in the 1990s, while the suicide rate in that age group fell 28 percent from 1990 to 2003, according to a government report released last week.

In another study, researchers at Columbia University, analyzing data from 1990 to 2000, found that for every 20 percent increase in the use of antidepressants among adolescents, there were five fewer suicides per 100,000 people each year. Psychiatric researchers have found similar patterns among some age groups in other countries, including Sweden, Japan and Finland.

But many uncertainties remain. While the suicide rate for adolescents has fallen over the last decade, it has remained largely unchanged for the overall population, though prescriptions for psychiatric medicines have risen sharply in all age groups. Adjusted for the demographic changes, about 11 Americans per 100,000 killed themselves in 2004, the same as in 1994.

Demographics can play a role: White people kill themselves about twice as frequently as African-Americans and Hispanics, so as the population becomes more diverse, the suicide rate ought to drop, all else being equal. And suicide rates also appear to be negatively correlated with economic growth, which was exceptionally strong from 1994 to 2000. Advances in medicine also mean more lives can be saved now.

With so many potentially confounding factors at play, interpreting the relationship between prescription rates and suicides is difficult, said Andrew Leon, a professor of biostatistics at Weill Cornell Medical College who has served on F.D.A. panels studying suicide risk and antidepressants.

“These kinds of studies are very important in giving us a sense of the rates of disease and death in a population and how those may correspond to other things,” Dr. Leon said. “But what they don’t do is tell us whether the two trends are directly related.”

It is a painful tale with two unanswered questions at its heart. The first is, Why? For most of his life Mr. Dully struggled to find a reason for the decision by his father and stepmother to deliver him, in 1960, into the hands of Dr. Walter Freeman, the self-deluded zealot who pioneered the lobotomy as a cure for all manner of personality disorders. In pursuing this quest, he became the first of Dr. Freeman’s patients to retrieve and study his own medical file, with Dr. Freeman’s detailed notes, quoted extensively to chilling effect in the book.

Mr. Dully, now a bus driver in San Jose, Calif., with a wife and two sons, never does find out why. By reconstructing his past, however, he comes to realize that he has been asking an unanswerable question. But it is not clear whether he fully recognizes the other mystery that haunts his story: Was it the lobotomy or his feelings about it that shaped his life?

As he delves into his wretched childhood and the twisted psychology of his father and stepmother, his operation seems less like a turning point than an overcharged symbolic event. In a curious way, this only makes the story more intriguing.

Mr. Dully lost his mother when he was 4. She died giving birth to his younger brother, who was born with severe brain damage. His father, scarred by the Depression and overseas military duty in World War II, was emotionally distant and physically brutal. His stepmother, the cast-off child of a Jazz Age flapper, survived one marriage to an alcoholic and, with two children of her own in tow, came into little Howard’s life like an avenging angel. A harsh disciplinarian and obsessive housecleaner, she took an instant dislike to the boy, whom she regarded as dirty, rebellious and incorrigible.

The truth of what happened next is impossible to determine. “My Lobotomy” presents competing narratives, none of them entirely reliable.

Like any adult looking back on his childhood, Mr. Dully summons up facts mingled with dreamlike images, the grown-up world seen through a child’s eyes and experienced with a child’s emotions. Dr. Freeman’s notes, written in dispassionate style, reflect a synthesis of the parents’ distorted descriptions and his own clinical observations. Court records add a third layer to be interpreted. The past, ultimately, is irretrievable.

By his own admission, Howard was difficult. He stole, he lied, he broke rules. He was constantly in trouble at school. He smoked. Howard’s stepmother supplied a long list of complaints to Dr. Freeman, some serious, many trivial.

“Has monkey-like gestures and mannerisms — i.e., scratching head and body,” Dr. Freeman transcribed. “Won’t move when told time is short. Doesn’t use good judgment. Comprehension not good. Seems useless to convey reasons. Won’t do homework.”

All six of the psychiatrists consulted by Howard’s stepmother before she went to Dr. Freeman told her that her stepson was normal. Four said that she was the problem. Dr. Freeman, after initially finding nothing seriously wrong with his young patient, eventually decided that he was schizophrenic and a prime candidate for a lobotomy.

The operation lasted perhaps 10 minutes. Howard, although initially dazed and disoriented, gradually recovered his faculties, although, Dr. Freeman noted in a follow-up visit, “Howard seems to have no particular depth of feeling about anything.” It is unclear whether the lobotomy changed Howard’s personality or whether it accounts for his subsequent troubles, which were many but seem a direct result of long-established patterns of behavior.

“I’ll never know what I lost in those 10 minutes with Dr. Freeman and his ice pick,” Mr. Dully says in his radio documentary. “By some miracle, it didn’t turn me into a zombie, or crush my spirit, or kill me.”

What it did was put him outside human society. Mr. Dully, regarding himself as a freak, wandered aimlessly through life. Forced from his family home at 14, he spent years in juvenile homes and later state mental hospitals, primarily as a way of keeping out of prison. He drifted from job to job, drank heavily and used drugs, relying on disability checks to finance his marginal lifestyle. “All I had to do was be the guy who had the lobotomy,” he writes.

Mr. Dully eventually finds a woman who loves him, a love he returns to her, her son and the son they have together. Therein lies the answer to the biggest question of Mr. Dully’s life. The lobotomy, although terrible, was not the greatest injury done to him. His greatest misfortune, as his own testimony makes clear, was being raised by parents who could not give him love. The lobotomy, he writes, made him feel like a Frankenstein monster. But that’s not quite right. By the age of 12 he already felt that way. It’s this that makes “My Lobotomy” one of the saddest stories you’ll ever read.

Maybe, if you learn to practice “lucid dreaming,” a state in which a sleeping person becomes aware he or she is dreaming and may even be able to direct the action. Those who regularly experience the phenomenon say that like the physics-defying characters in “The Matrix,” they are able to generate or manipulate the fantastical events that unfold. They can fly without wings, play instruments they never learned, go bowling with T. S. Eliot — and, yes, indulge sexual fantasies.

It is likely some people have always had such dreams, said Jayne Gackenbach, a professor of psychology at Grant MacEwan College in Edmonton, Alberta, who conducts research into lucid dreaming. But the esoteric practice, which has been acknowledged in the West since at least 1867, seems on the verge of becoming much better known.

A film exploring its allure, “The Good Night,” written and directed by Jake Paltrow and starring his sister, Gwyneth, Penélope Cruz and Martin Freeman, is opening Oct. 5. Depressed by his waking life, the film’s main character is determined to master the art of lucid dreaming to escape to an inspiring, sensual unreality with a lacquer-lipped knockout. “What I find myself most attracted to are things that can actually occur,” Mr. Paltrow said in an interview. “There’s really nothing in this movie that couldn’t happen.”

For those wishing to become lucid dreamers, a nine-and-a-half-day instructional retreat, “Dreaming and Awakening: Lucid Dreaming, Consciousness and Dream Yoga,” is scheduled to begin Oct. 1 in Hawaii. Don’t want to pay the airfare? On Oct. 3, an online chat about lucid dreaming takes place, part of the PsiberDreaming conference of the International Association for the Study of Dreams. There are new and soon-to-be published books, like “Lucid Dreaming for Beginners: Simple Techniques for Creating Interactive Dreams” (Llewellyn Publications) and “Between the Gates: Lucid Dreaming, Astral Projection and the Body of Light in Western Esotericism” (Weiser Books).

“It has gone from this very obscure type of dream to being discussed at the various dream and consciousness conferences,” Dr. Gackenbach said.

But it is not only dream experts discussing the topic. Two filmmakers described their lucid dreaming earlier this year. Michel Gondry, who directed “Eternal Sunshine of the Spotless Mind,” described for The Guardian lucid dreams in which “I generally end up having sex with the first girl I can find.” Guillermo del Toro, the director of “Pan’s Labyrinth,” mentioned his lucid dreaming on the National Public Radio program “Fresh Air.” “Pan’s Labyrinth” brings to life a twiggy mythological creature (a faun) he encountered in lucid dreams as a boy; the film won an Oscar this year for its surrealistic makeup.

Other films, including “Waking Life” and “Vanilla Sky,” have woven lucid dreaming into their plots. So have television series like “Alias,” “Star Trek” and “Ed” (Daryl Hall and John Oates make an appearance in Ed’s dream). Novelists including Stephen King, William Boyd and Graham Joyce have written about lucid dreaming, and the Verve, a British rock band, sang about it in “Catching the Butterfly.” “Lucid dream” is the name of pop and jazz CDs, small businesses, modern artworks, even a sex toy.

Still, many people have never heard of it. Established sleep researchers say lucid dreaming is occasionally reported by subjects, though it is difficult to validate scientifically. “Yes, lucid dreaming exists,” said Dr. Rodney Radtke, the medical director of the Sleep Disorders Center at Duke University. “Yes, people certainly can, within their dream, realize ‘this is just a dream’ and continue to participate.”

“Do I believe that someone could potentially alter or interact with their dreams in such a way that they could change the dream? Yes,” he said. “Do I think that you could essentially design a dream — ‘Oh, I want to go to Honolulu and have this big hunk hit on me’? It’s a bit of a stretch. But I can’t say it can’t happen.” He added: “Only in New York or California do they worry about this stuff.”

Stephen LaBerge, a psychophysiologist and the founder of the Lucidity Institute (lucidity.com), conducts lucid dream research and teaches people to do it.

“It’s kind of fun to do the impossible,” Dr. LaBerge said. “Fly. Dream sex. That’s what everybody likes to do. There’s also the possibility of creative problem-solving, overcoming nightmares and anxieties, learning more about yourself.”

A student at Stanford University, where Dr. LaBerge conducted much of his research, wrote in The Stanford Daily: “In one of my earliest experiences with lucidity, I announced to an auditorium full of people that I was their god (wasn’t I?). When they did not respond deferentially, I used telekinesis to send one of them flying across the room.”

It can be particularly appealing to those who have nightmares, as it allows them to realize while still asleep that they are just dreaming.

Interest in these potential real-world benefits and the otherworldly freedoms of lucid dreaming — as well as the questions it provokes about the precarious nature of reality — has spurred the invention and evolution of seemingly wacky dream aids. There are masks with lights and sounds; Orwellian devices that announce THIS IS A DREAM! in the middle of the night; and pills.

At the Hawaii gathering next month, attendees will be able to check out Dr. LaBerge’s NovaDreamer, a mask meant to light up during REM sleep and cue the person entangled in the sheets that he or she is dreaming. It is based on the notion that people can make a plan while awake and then execute it in their dreams. A light or sound is meant to remind them of their goal of lucid dreaming without actually waking them up. Participants may also take part in experiments with an herbal version of a drug that impacts acetylcholine, a neurotransmitting compound that affects memory.

As bizarre as these things may sound, there is a scientific rationale for cueing users during REM sleep. “REM-sleep dreams are much more visual,” said Matthew P. Walker, the director of the Sleep and Neuroimaging Laboratory at the University of California, Berkeley, and a former assistant professor of psychology at the Harvard Medical School. “They have a strong narrative that runs through them. They’re hallucinogenic.”

There are several reasons for this, including that the lateral prefrontal cortex, the part of the brain involved in logical reasoning and working memory, becomes more inactive during REM sleep, while other areas of the brain, like the visual and emotional centers, rev up.

Scientists, however, are still trying to discover the difference between the dreaming brain and the lucid-dreaming brain. The leading candidate, Dr. Walker said, is the lateral prefrontal cortex. He thinks that during REM sleep, the activity level of this logic-oriented part of the brain begins to rise back to waking levels, and when it does, an invisible switch is flipped and the sleeper gains lucidity. “In the next five years, I think somebody will demonstrate that,” he said.

Lucid-dream researchers say there are myriad mental exercises a person can do during waking hours to try to become cognizant while dreaming. One technique involves performing various reality checks many times a day — such as looking at the numbers on a watch, looking away, and then looking at them again to make sure that night has not suddenly become day. The theory is that if a person does this regularly while awake, he or she will likely repeat it while dreaming and will recognize inconsistencies — if, say, the watch is melting in a Dali-esque way. Then the sleeper will think: “This looks surreal. I must be dreaming.”

In “The Good Night,” the would-be lucid dreamer performs a series of reality checks: he flips a light switch on and off (light in dreams is not usually nuanced); looks in a mirror (reflections in dreams are often obscured); and stares at his hands (in dreams one’s hands may be elongated or have fewer fingers).

Keeping a dream journal is also said to promote better recall and to train people to identify signs that indicate they are dreaming — chatting with the deceased, floating cars, talking skeletons. Again, the idea is that when people are sleeping, they will recognize these things as signs they are dreaming and they will become lucid.

Waking up half an hour earlier than usual, staying awake for 30 to 60 minutes and then going back to sleep may also induce lucid dreams, Dr. LaBerge has found. Dr. LaBerge honed his own lucid-dreaming abilities by writing his dreams down immediately after waking and telling himself he intended to remember and recognize his dreams.

Psychologists who study lucid dreaming do not know why some people need more help triggering full lucidity than others, though they agree that adept lucid dreamers are excellent at remembering dreams. Dr. Gackenbach said they tend to have strong visualization and spatial skills. They can look at a machine and envision how the parts work inside, she said, or sew a dress from scratch and know exactly what the finished frock will look like. Many practice meditation.

Of course some professionals, particularly psychoanalysts, think orchestrating one’s dreams is not a critical goal.

“We distinguish between the manifest content of the dream — the dream as you remember it — and the latent content of it,” said Dr. Edward Nersessian, a clinical professor of psychiatry at Weill Cornell Medical College and a training and supervising psychoanalyst at the New York Psychoanalytic Society and Institute. “Whatever you manage or do not manage to do with the manifest content isn’t really that relevant. That’s like a screen behind which lies all sorts of answers which you have to go digging for.”

When then asked if lucid dreaming was a dangerous enterprise, he chuckled gently and said: “If people who do it think it calms their anxiety, I’m all for it.”

Darkness Invisible
Daphne Merkin, New York Times Magazine- 9/17/2007

Here is the question lurking behind the recent news of Owen Wilson’s suicide bid: In a culture that encourages outing everything from incest to pedophilia, is depression the last stigma, the one remaining subject that dares not gossip its name? Does a disclosure about depression, especially from someone who seems to have it all, violate an unspoken code of silence — or, at the least, make us radically uncomfortable with its suggestion of a blithe public face masking a troubled inner life?

Most of us have experienced the everyday, transient blues — the emotions nibbling around the edges of depression (whether they manifest themselves as a sense of malaise, dejection or comic-tinged despair) that can be brought on by a shift in the weather or an unfortunate event. They may be chronic yet benign, the sort of moroseness that causes the narrator of Camus’s “Stranger” to stand around listlessly puffing on a cigarette. Sadness is probably more endemic to the human subtext than sanguine spirits, which is why funereal songs like Billie Holiday’s “Gloomy Sunday” strike a universal chord and why Freud conjectured that “ordinary unhappiness” (as opposed to what he called “hysterical misery”) was the best the talking cure could hope to achieve.

The romance of melancholy — a style of self-presentation marked by an appealing air of ennui — has been with us since Hamlet. It is perhaps best expressed in the opening of Chekhov’s “Seagull,” when Masha, asked why she always wears black, replies, “I am in mourning for my life.” But a poetic conception that tethers creativity to a despondent temperament is also misleading, discounting as it does how unproductively crippling the malady can be.

Depression — the real hard stuff — is not chic, and it doesn’t sell tickets. It is a clinical illness urgently requiring treatment, usually hit-or-miss medication that tinkers with serotonin or dopamine levels. I am referring to the sort of condition that subverts lives, making it difficult to talk to people and impossible to leave the house. At its worst, it can spiral into the sort of suicidal ideation that requires hospitalization, or into suicide.

From a young age, I have intermittently found myself in this painful, barren zone. Each time it occurs, I am struck by how paralyzing and isolating the experience is; it remains essentially impenetrable to people who can’t (or don’t care to) distinguish it from a random bad day. For all that it is acknowledged to be a disease afflicting millions — we are as much a Prozac Nation as a Fast Food Nation — depression remains culturally quarantined. The revelation that Wilson may be afflicted with a physiological vulnerability to the downward pull — to the sort of self-annihilating impulse best described in William Styron’s “Darkness Visible” — simultaneously fascinates us and causes us to avert our gaze.

Wilson, a 38-year-old light-as-air actor and sometime screenwriter, was a golden-haired member of the Frat Pack, the last person you would associate with a long, concealed history of this disease. He suggests that more familiar construction: a bachelor who ran in a fast crowd, used hard drugs and flipped when his romance with another movie star went sour. According to this scenario, Wilson slit his wrist because he spotted a candid of his ex, Kate Hudson, smooching a new man in a grocery store — as if life obligingly played itself out as a series of press-ready storyboards: Girl dumps boy. Girl moves on to new boy. Ex-boy tries to kill himself. Shoot and print. He becomes just another funny man harboring an inner sad sack — a “Tears of a Clown” syndrome — alongside Robin Williams and Richard Pryor.

However you parse Wilson’s desperate act, it is clear that in an instant-fix, cure-all culture — one in which we habitually reduce fraught real-life dramas into smart-alecky quips on late-night talk shows — we want instant-fix, cure-all answers. Addiction and recovery sagas are by now more boring than heartrending, but they go down smoothly and are media-pleasing. These versions of psychological mayhem sidestep the complex interior drama of self-destruction — Lindsay Lohan’s father visits her in rehab! — and thereby allow us off the hook. How much thought can you give to yet another celebrity who checks in and out of a $1,600-a-day rehab center as if it were Canyon Ranch?

Put it this way: It’s one thing for Wilson to draw upon his familiarity with “the black dog” (as Winston Churchill called it) in order to co-write “The Royal Tenenbaums,” a darkly funny movie about an unhappy family of grown-up child prodigies that includes a lovelorn sibling (played by Wilson’s own brother, Luke) who tries to kill himself. That’s entertainment, diverting in a poignant way. But it’s another thing to be the guy with everything who tries to take his own life. That’s threatening, suggesting a failure of will that might prove contagious — or worse, capsize box-office investment.

People who want to end it all have lost the necessary illusions that make life bearable; the sources of their pain are impossible to pinpoint but all the same infect the air they breathe. The defining tragedy of severe depression is that it comes without an objective correlative like a white plaster cast. This makes it easy to mistake those who suffer from this disorder for people who, with a little coaxing — a dinner with friends or a distracting movie like “Wedding Crashers” (starring, Lord help us, Owen Wilson) — might bounce back the following day.

Perhaps this is what makes depression dangerous to scrutinize too closely. If we don’t keep it at arm’s length, it might implicate us in a way that the coked-up antics of the Rehab Gang fail to. Which is why it is all the more important that when it ravages those who seem as if they should be riding high, it isn’t spun merely as a side effect of addiction or heartbreak. It is an illness that deserves to be given its due, uneasy as it may make us.

Researchers examined a multiethnic group of 41,574 postmenopausal women, following them for an average of eight years and using questionnaires about diet and drinking habits. In that time, the team found 324 cases of endometrial cancer, the type that forms in the tissue that lines the uterus. According to the National Cancer Institute, the United States has 40,000 new cases of endometrial cancer a year and 7,400 deaths.

After controlling for variables including body mass index, age, hormone therapy and whether they had been pregnant, the researchers found that women who had less than two drinks a day had no increased risk of endometrial cancer. But those who had more than two drinks a day had slightly more than twice the risk. It made no difference whether the women drank beer, wine or hard liquor.

The exact mechanism is unknown, but alcohol raises estrogen levels, and it is well established that prolonged exposure to estrogen increases mutations and DNA replication errors, predecessors of cancerous growths.

“Relatively few studies have examined the relationship between endometrial cancer and drinking,” said Veronica Wendy Setiawan, the lead researcher and an assistant professor of research at the Keck School of Medicine of the University of Southern California. “If this is a true association, that’s one more lifestyle change women can make.”

The study appeared online Aug. 31 and will be published in a future print issue of The International Journal of Cancer.

In addition to questions about their own beliefs, the 100 psychiatrists and 1,044 other specialists who responded to the survey were asked about their attitudes toward religion in clinical practice. For example, the survey asked doctors whether they thought it proper to ask about patients’ religious beliefs and whether they had ever prayed with a patient.

Although psychiatrists were just as likely as other physicians to report that religious beliefs influenced their practice — about half said it did — just 29 percent of psychiatrists, compared with 47 percent of other doctors, said they attended religious services more than once a month. When asked whether they described themselves as religious or spiritual, 42 percent of psychiatrists and 53 percent of other doctors said they did. About a third of psychiatrists, but almost half of other physicians, said they “look to God for strength, support, and guidance.” Psychiatrists were significantly less likely to be Protestant or Catholic and more likely to be Jewish or have no religious affiliation.

Most doctors would refer a patient to a psychiatrist for emotional problems. Protestants were about half as likely as those with no religious affiliation to do so, preferring clergy or other religious counselors.

“Religion and psychiatry are two different ways of responding, and two different ways of bringing healing,” said Dr. Farr A. Curlin, the lead author of the paper, published in the September issue of Psychiatric Services and an assistant professor of medicine at the University of Chicago. “In some clinical situations, they will always be rivals.”

Her niece arrived at the house they shared in Baton Rouge, La., to find police already there. Golsan had killed herself with a gunshot to the head.

''Every single day it makes me feel like I wish I could have done something,'' Jane Golsan Ray said, recalling her aunt's death eight years ago. ''I wish I could turn back the clock and prevent it. It doesn't get any better, it hurts every day.''

The elderly are the highest risk population in the country for suicide. But few suicide-prevention programs target them -- a result, advocates say, of scarce funding and lack of concern for older Americans.

And mental heath experts say the number of elderly suicides is likely to climb as baby boomers enter their twilight years.

The overall U.S. suicide rate is 11 per 100,000 people. But for those 65 and older, that figure rises to 14 per 100,000, according to the Centers for Disease Control and Prevention, which based its findings on 2004 data, the most recent available.

Older adults are less likely to seek help and are more lethal in their suicide attempts. So experts say special care is needed to reach out.

Dale Smith, 67, said he might not be alive if not for a suicide-prevention program in Spokane, Wash.

Two years ago, he attended a meeting at his retirement complex where everyone filled out a screening form for depression, a key risk factor for suicide.

Based on his answers, a caseworker and psychiatrist later visited Smith at his home, where they discussed what turned out to be a lifetime of depression. They developed a plan of medication and therapy that Smith says probably saved his life.

''I'm not unique. I think there's a lot of individuals out there who do suffer from depression and they have no clue,'' he said. ''They just know they're not happy. They are tired, they want to pull the covers over their heads and not look at the world, and they don't know what it is.''

But many older Americans have fewer options for treatment than younger people.

''It's a not-so-subtle social-political assignment of resources,'' said Donna Cohen, a professor in the Department of Aging and Mental Health at the University of South Florida.

Ten states passed laws last year intended to curb suicide among children and young adults. But only two -- New Jersey and New Mexico -- passed laws addressing suicide among the elderly, according to Suicide Prevention Action Network USA, a national advocacy group based in Washington, D.C.

Depression is underdetected at all ages, mental health groups say. But much more funding is available for treating younger people, including $82 million in federal money approved in 2004.

The situation prompted Sen. Harry Reid of Nevada, who lost his father to suicide, to propose funding more suicide-prevention programs for the elderly and changing a Medicare coverage rule that forces seniors to pay more for outpatient mental health services than other medical care.

Some advocates and mental health workers say they also have to battle a prevailing notion that depression is a normal part of aging.

''It is not natural and should be treated at all times,'' said Dr. Paula Clayton, a psychiatrist and medical director for the American Foundation for Suicide Prevention.

Janice Hodge of Sandy, Ore. said she didn't realize until after her 91-year old father, Anthony Liberto, died that he had been depressed.

He was struggling to care for his 85-year-old wife, who suffered from Parkinson's disease. He did not work and he could no longer play golf, his favorite pastime. Friends and family still visited, but they say he spent much of his time lying on the couch and growing frustrated with suggestions that he place his wife of 62 years in a nursing home.

Eventually, he shot his wife and killed himself, leaving a note that read: ''Sorry we had to leave this way, forgive me. Love, your Dad.''

Experts say there need to be services tailored to the elderly because they handle depression differently than younger patients.

In Spokane, the program that helped Smith, called Elder Services, trains people who come in contact with the elderly -- from bank tellers to postal carriers -- to notice signs of trouble, such as mail piling up or bills going unpaid. Those people can then notify social workers.

In San Francisco, Patrick Arbore founded the Friendship Line in San Francisco in 1973 after seeing the lack of understanding some suicide hot line workers displayed for older people.

The line, which lets people call just to talk or get support, now handles more than 3,000 calls a month. About one-quarter of the callers have suicidal thoughts, a staffer said. But most just want a compassionate listener.

''It's about reminding people that they are still a part of their community,'' Arbore said. ''Those connections bind us to life.''

On the Web-
National Institute for Mental Health on elderly suicide: http://www.nimh.nih.gov/publicat/elderlydepsuicide

Centers for Disease Control suicide information: http://www.cdc.gov/ncipc/dvp/suicide/

The bill, which passed by unanimous consent, moves advocates one step closer in their years-long quest for a concept known as mental health parity.

''The passage tonight of the Mental Health Parity bill underscores our commitment to treat all patients facing all diseases with the dignity and respect they deserve,'' said Sen. Edward Kennedy, D-Mass. ''This new legislation will bring dramatic new help to millions of Americans who today are denied needed mental health care and treatment.''

Passage came on the same day that supporters inundated House Speaker Nancy Pelosi's office, urging a vote on mental health parity legislation in the House.

The call-in was organized by Wellstone Action, a group founded to carry out the work of the late Sen. Paul Wellstone, D-Minn., who had championed the legislation for years. The House version is called the ''Paul Wellstone Mental Health and Addiction Equity Act.''

Wellstone Action is urging a House vote by the middle of next month. The bill has 270 co-sponsors, more than half of the House membership.

Pelosi spokesman Brendan Daly said that the speaker supports the legislation and would like it to come to a vote on the floor soon. He said a mid-October vote was a realistic target.

The bill is sponsored by Kennedy's son, Rep. Patrick Kennedy, a Rhode Island Democrat who has battled depression, alcoholism and drug abuse, and Rep. Jim Ramstad, a Minnesota Republican who is a recovering alcoholic. Ramstad just announced he would not seek re-election and said he hoped to see the bill pass as his legacy.

Wellstone's son, David Wellstone, who is co-chairman of the Wellstone Action board, said he had no doubt that Pelosi supported the bill.

''But it's always helpful to have the speaker pushing hard,'' he said. ''This is just a little backup. We need the momentum. With a crowded calendar, it's hard to get your stuff going.''

In 1996, Paul Wellstone and Sen. Pete Domenici, R-N.M., won passage of a law banning plans that offer mental health coverage from setting lower annual and lifetime spending limits for mental treatments than for physical ailments.

Both the House and Senate bills would build on that by adding things like co-payments, deductibles and treatment limitations, a longtime goal of Wellstone's. He died in a plane crash in 2002.

The Senate bill was sponsored by Edward Kennedy along with Domenici and Mike Enzi, R-Wyo.

Originally, that bill called for pre-emption of state parity laws in treatment limitations and financial requirements, causing a rift between supporters of the House and Senate bills. The Senate bill dropped that provision, but David Wellstone argued the House bill was still superior because it specifically says that state laws will not be pre-empted.

The House version also specifies that if a plan provides mental health benefits, then it must cover conditions provided by the health plan with the highest average enrollment of federal employees. The Senate legislation does not include that language.