Noteworthy News Articles on Mental Health Topics, March 1-4, 2008 Stepahnie Saul, New York Times- 3/1/2008 Faced with the looming loss of patent protection for its top-selling drug, the antidepressant Effexor XR, Wyeth received federal approval on Friday for a successor drug, Pristiq, which the company hopes will also become a blockbuster. With the Food and Drug Administration’s approval of Pristiq, Wyeth said the company planned a big sales effort to introduce the product to psychiatrists and primary care doctors. Wyeth needs a product that will replace some of the revenue expected to be lost to generic competitors of Effexor XR, whose patent protection expires in 2010. Sales of Effexor XR last year were $3.8 billion. Dr. Philip Ninan, a Wyeth vice president for neuroscience, said he thought that Pristiq, which is chemically similar to Effexor, would have similar benefits in treating major depression. But the company said the drug had distinct advantages over its existing product. Among them are that patients can start taking Pristiq at the therapeutic dose of 50 milligrams. Frequently, antidepressants must be started at a low dose, then ramped up to the therapeutic dose, to test whether patients can tolerate the drug and to determine the correct dose for the individual. Another advantage is that Pristiq does not have to be broken down by the liver, Dr. Ninan said, so it is not likely to interact with other medications metabolized by the liver. “I think what’s important to understand in the depression category is that many patients fail to respond to anything that’s available,” said Geno Germano, Wyeth’s president of pharmaceuticals for the United States. “What’s important is that physicians and patients need multiple options available.” But several analysts are skeptical of Pristiq, saying it has little advantage over other products on the market. And they raised questions about whether insurance companies would cover its cost in light of the availability of other drugs, including a less expensive generic version of Wyeth’s original version of Effexor that is already on the market. Wyeth applied for F.D.A. approval of Pristiq in 2005. But in January 2007, the agency asked for additional information, a process that delayed approval until now. Wyeth, based in Madison, N.J., has not yet announced how much Pristiq will cost. Effexor XR sells for about $120 for a 30-day supply, while the generic version of the original Effexor has been priced at less than half that recently on the Web site of one domestic chain pharmacy. Dr. Timothy Anderson, a pharmaceutical analyst for Sanford C. Bernstein & Company, said that data Wyeth presented at a recent meeting of the American College of Neuropsychopharmacology failed to distinguish Pristiq from other marketed antidepressants. “Payers are not likely to widely cover Pristiq in our view, and we forecast only low levels of sales,” Dr. Anderson wrote in a note to clients. He predicted the drug’s sales at $500 million by 2012, a relatively small figure in the antidepressant category. And Dr. Daniel Carlat, a psychiatrist in Newburyport, Mass., who publishes the Carlat Psychiatry Report, said the release of Pristiq appeared mainly to be an effort by the company to, in effect, extend its patent for Effexor XR. That is because Pristiq is a metabolite of Effexor — meaning it is the chemical compound that results after Effexor is swallowed and processed in the body. “Is there a compelling public health reason for Wyeth to be releasing another antidepressant into the market, with no clear advantages over others?” Dr. Carlat said. “Not that I can see.” Starving Themselves, Cocktail in Hand Sarah Kershaw, New York Times- 3/2/2008 All are dangerous variations on the eating disorders anorexia and bulimia, and have become buzzwords that are popping up on Web sites and blogs, on television and in newspaper articles. As celebrity magazines chronicle the glamorous and the suffering, therapists and a growing number of researchers are trying to treat and understand the conditions. The latest entry in the lexicon of food-related ills is drunkorexia, shorthand for a disturbing blend of behaviors: self-imposed starvation or bingeing and purging, combined with alcohol abuse. Drunkorexia is not an official medical term. But it hints at a troubling phenomenon in addiction and eating disorders. Among those who are described as drunkorexics are college-age binge drinkers, typically women, who starve all day to offset the calories in the alcohol they consume. The term is also associated with serious eating disorders, particularly bulimia, which often involve behavior like bingeing on food — and alcohol — and then purging. Anorexics, because they severely restrict their calorie intake, tend to avoid alcohol. But some drink to calm down before eating or to ease the anxiety of having indulged in a meal. Others consume alcohol as their only sustenance. Still others use drugs like cocaine and methamphetamine to suppress their appetites. “There are women who are afraid to put a grape in their mouth but have no problem drinking a beer,” said Douglas Bunnell, the director of outpatient clinical services for the Renfrew Center, based in Philadelphia. The center, like a small but growing number of eating-disorder and addiction-treatment facilities, most on the West Coast, offers a dual focus on substance abuse and eating disorders. Dr. Bunnell, the past president of the National Eating Disorders Association, said the obsession with being skinny and the social acceptance of drinking and using drugs — along with the sense, lately, that among celebrities, checking into rehab is almost a given, if not downright chic — are partly to blame. “Both disorders are behaviors that are glorified and reinforced,” Dr. Bunnell said. “Binge drinking is almost cool and hip, and losing weight and being thin is a cultural imperative for young women in America. Mixing both is not surprising, and it has reached a tipping point in terms of public awareness.” Psychologists say that eating disorders, like other addictions, are often rooted in the need to numb emotional pain with substances or the rush provided by bingeing and purging. The disorders are often driven by childhood trauma like sexual abuse, neglect and other sources of mental anguish. Manorexia is the male version of anorexia. Orthorexia is an obsession with what is perceived as healthy food — eliminating fats and preservatives, for example. But people with this condition can dangerously deprive themselves of needed nutrients. Diabulimia refers to diabetics who avoid taking insulin, which can cause weight gain, in order to control their weight. Despite the name, the disorder does not typically involve purging. Binge Eating Disorder refers to obsessive overeating, especially of foods high in salt and sugar, that does not involve excessive exercise or purging to compensate for the high caloric intake. Judy Van De Veen, 36, who lives in Gillette, N.J., became anorexic at 24. She said she starved herself, meting out small bites of low-calorie food for two months. Then she began bingeing and purging, throwing up entire boxes of cereal, whole pizzas and fast food from drive-throughs that sometimes cost her $80 a day. She went into treatment, both inpatient and outpatient, for her eating disorder for several years in the late 1990s, with mixed results. In 2001, still struggling with bulimia, she took up drinking. If she ate while drinking, she said, she would purge, but then consume more alcohol to make up for the loss, because she wanted to remain drunk. Many bulimics who drink use alcohol to vomit, experts on eating disorders say, because liquid is easier to purge. They also tend to vomit because they often drink on empty stomachs. “In the beginning of my eating disorder I wouldn’t touch alcohol because it is so high in calories,” said Ms. Van De Veen, who later found herself regularly hospitalized for dehydration. “But I have the disease of more: I just want more no matter what it is.” Two years into her drinking problem, she joined a 12-step program. She spent the next two years in and out of six residential rehab programs, spending about $25,000 of her own money because she didn’t have health insurance. But none of the programs were equipped to address eating disorders, so she binged and purged and her eating disorder raged. Ms. Van De Veen said she has been sober for three years, but is still struggling with bulimia. She now has a 14-month-old daughter, Cheyenne, and she said that her pregnancy and support groups had helped her make progress on her eating disorder. “I had an excuse to eat,” she said of being pregnant. “I didn’t care and I loved it.” But she said the temptation to binge and purge is haunting her again. Trish, 27, who has had an eating disorder for the last 10 years, recently checked into Renfrew, her fifth stint in a treatment center or hospital. Like Ms. Van De Veen, Trish, who agreed to be interviewed on the condition that only her first name be used to protect her privacy, struggled with anorexia first and then found alcohol. Before she was admitted to Renfrew, she said she was blacking out from lack of food and suffering from excruciating stomach pain. Trish, a nurse who lives in Ohio and works with cardiac patients, said she would starve herself through her 8- or 12-hour shifts, staring at the clock and fixating on when she could have her first drink. Drinking, she said, relaxed her when she had to eat in front of other people, a huge source of stress.“The alcohol is probably what kept any weight on me,” she said in an interview late last month at the Renfrew Center, which she entered on New Year’s Eve for eight weeks of treatment. “Drinking helped me be less anxious,” she said. “It helped me be more of Trish. The two go together: If I drink more, I’m more into my eating disorder and vice versa.” Studies show that binge drinking and alcohol abuse are on the rise among women, who are also more prone than men to eating disorders. About 25 to 33 percent of bulimics also struggle with alcohol or drugs, according to a study published last year in the journal Biological Psychiatry. Between 20 and 25 percent of anorexics have substance abuse problems, the study found. A growing number of researchers are examining the psychological and neurological links between eating disorders and substance abuse: Does eating a chocolate bar, or bingeing and purging, stimulate the same pleasure centers in the brain as drugs or alcohol? Suzette M. Evans, a professor of clinical neuroscience at Columbia, recently began a study of the connection between bulimia and substance abuse, a field she said has been neglected. “People are finally beginning to realize that food can function in the same way as drugs and alcohol,” Dr. Evans said. As more patients seek treatment for both eating disorders and substance abuse, a complicated set of mixed messages can arise. The response to addiction is abstinence; but quitting food is not an option. “We’re trying to get our patients to find effective behaviors and life skills,” said Dr. Kevin Wandler, the vice president for medical services at Remuda Ranch, which addresses both eating disorders and addiction at its facilities in Arizona and Virginia. “Eating normally would be an effective behavior, but it’s easier to give up alcohol and drugs because you never need it again,” Dr. Wandler said. “If your drug is food, that’s a challenge.” Trish left Renfrew on Feb. 22, after her second time in treatment there. She was determined, she said, to break her obsessions with weight, food and alcohol. Before she checked in, “I didn’t even have the energy to laugh,” she said. But as she prepared to go home, she had more hope than she has had in years. “I will not live my life like this,” she said. “I’ve learned this time not to be ashamed. I want to love myself and I want to forgive myself.” Disintegration of a Mother’s Life Was Long Hidden in Plain Sight Paul Vitello, New York Times- 3/2/2008 NEW CASSEL, N.Y. — She was sometimes seen good-naturedly juggling her children while pushing a stroller laden with groceries. At other times she seemed lost in thought, pushing the same stroller, empty, through the streets while the children remained home alone. Leatrice Brewer, 27, was a troubled woman known to her family and neighbors as an uneven mother whose manner with her children seemed to toggle between extreme possessiveness and blithe neglect. Yet like many things hidden in plain sight, the disintegration of her life — and the drowning of her three children, who the police say died at Ms. Brewer’s hands — was an end that no one saw coming, and everyone saw coming. Relatives and friends poring through the remembered details of Ms. Brewer’s life portrayed her as someone who had struggled with the painful legacy of abandonment in childhood by her mentally ill mother; who drove herself to live an independent life, frequently working two jobs; who could lavish love and attention on her children despite bouts of depression, drug dependence and mental illness of her own; and who seemed in the end to have abandoned her haunted sense of duty as a mother and transferred it in large measure to the shoulders of her precocious 6-year-old daughter. Last Sunday, Ms. Brewer dialed 911 to report that she had drowned the children one by one in the bathtub in their small, neatly kept apartment here. Ms. Brewer said she first had subdued the oldest, 6-year-old Jewell Ward, by stabbing her repeatedly with a knife. Ms. Brewer then threw herself from the second-floor bedroom window. On Tuesday, while handcuffed to her bed at Nassau University Medical Center, Ms. Brewer was arraigned on three counts of murder and pleaded not guilty. She was under treatment there for a back injury suffered in her fall, which the police said appeared to have been a suicide attempt. A lawyer representing Ms. Brewer, Michelle Armstrong, said on Saturday that it had not been decided whether Ms. Brewer would undergo a psychiatric evaluation of her fitness to stand trial. “It’s not only a tragedy that it’s happened to these children,” Ms. Armstrong said, “but what happened to their mother as well.” Last week, relatives blamed the Nassau County child welfare agency for the catastrophe, saying it should have intervened more aggressively. But family members and the authorities seemed to share a sense of disbelief at how familiar they had been with Ms. Brewer’s troubles, and yet how unimaginable the danger to her children was all along. “Everybody knew she left the kids home sometimes,” said Anthony Brooks, a cousin of Jewell’s father, Ricky Ward. “But never would you think that something like this would happen.” In retrospect, scenes both happy and troubling took on deeply darker shades of meaning: The way Jewell was so adept at changing diapers and washing the baby bottles for her half-brother, 18-month-old Innocent Demesyeux, and was so proud when she was called her brothers’ “little mommy.” The way the middle child, 5-year-old Michael Demesyeux, would cling to visitors and ask with a smile to be taken home by them. The many times Ms. Brewer bought egg salad sandwiches at the nearby bodega for her children and a 40-ounce bottle of beer for herself, telling the owner she was in a hurry because the children were home unattended. The many times the police were called to her apartment by the children’s fathers, who claimed she had exploded in anger and assaulted them when they tried to see their children. In a tight-knit community where a dozen churches and scores of family members were within walking distance, where individual social workers and case workers were known on the street by sight, the social safety net in all its guises seemed to have been as much at a loss as Ms. Brewer herself was in those solitary walks with the empty stroller. “People can snap,” said Satina Fenner, 26, who said she had known Ms. Brewer since grammar school in New Cassel. In some ways, critics said last week, the bonds between a community and one of its own can also snap. Leatrice Brewer was the elder child of Pearly Mae Mickens, who was remembered in this working-class Long Island community of black and immigrant residents as struggling throughout her 46-year life with drug addiction and mental illness. During one of their mother’s absences — relatives were unsure whether she was in jail or hospitalized — Leatrice and her brother, Robert, went to live with their grandmother Maebell Mickens. When their mother was released, she lived in their grandmother’s house off and on, but never again established a household with her children. Daquann Redd, 20, a cousin of Leatrice and Robert, remembers Leatrice as a teenager, “determined to succeed at something,” and somewhat scarred by “how messed up her mom’s life was.” For a couple of years, Leatrice was Daquann’s regular baby sitter, meeting him at the bus stop after school and looking after him until his mother, Sylvia Croker, Leatrice’s aunt, got home from work. She was a taskmaster, said Mr. Redd. “She was like, ‘Don’t play so much basketball. Do your homework. Read books,’ ” he said. “She wanted to be a nurse. I looked up to her because she had goals.” Ms. Brewer is pictured in the 1999 Westbury High School yearbook as a senior, smiling and wearing a festive formal dress. There are no extracurricular activities listed under her name, but relatives remember that for a couple of years she had an after-school job with the maintenance department at the high school. She is absent from the 1996 and 1998 yearbooks, and she wears a scowl in 1997, the year police records show she was twice fined $150 for disorderly conduct. Over the next few years she held several jobs, including work as a filing clerk for a Hicksville law firm and a sales assistant at a Kohl’s department store. Sometimes she worked at fast-food restaurants to supplement her income, other times as a housekeeper. Often, said Teoni Maddox, a longtime friend, she held two jobs at once. “Leatrice was moody, and she could be a little ‘off’ — one day friendly, the next day like she never knew you,” Ms. Maddox said. “But I always thought it was because she was always so busy.” Then in 2002, Ms. Brewer met and had her first baby with Ricky Ward, a man who grew up in the neighborhood, not far from the white bungalow with a red roof where Ms. Brewer was raised by her grandmother. Relatives said that their relationship did not last and that after giving birth to Jewell, Ms. Brewer suffered a period of depression. “ ‘I don’t know what to do,’ ” her cousin, Mr. Redd, recalls her saying. “ ‘I wasn’t ready for this.’ ” Police records confirm that it was a tough year. Though details about the cases were unavailable, she was charged with third-degree assault and second-degree criminal contempt, and sentenced to three years’ probation. In 2003, Ms. Brewer’s mother, with whom she had remained close despite their many separations, died of cancer. In her final years, Pearly Mae Mickens was a familiar figure to the police officers who patrolled Prospect Avenue, the main thoroughfare of New Cassel, sometimes panhandling, and sometimes asking officers to take her to the hospital because she was hearing voices. That year, Ms. Brewer and a Queens man, Innocent Demesyeux, began a relationship, which produced a second child, Michael. The couple lived together off and on. In between times, Ms. Brewer and her two children resided at her grandmother’s house — an arrangement that fell apart around 2006, after Ms. Brewer became pregnant by Mr. Demesyeux a second time, and her grandmother asked her to leave. County child welfare caseworkers helped Ms. Brewer find the apartment at 819 Prospect Avenue, where her children would die. Mary Curtis, the deputy county executive for health and human services, said that Ms. Brewer also received rental assistance, food stamps, a stipend from the federal Women, Infants and Children program, and temporary help with day care. Whatever help she got, family members say, the move to 819 Prospect marked the beginning of a downward spiral during which Ms. Brewer was alternately frantic with mothering and supporting her children and absent from them. Ms. Brewer went back to work, and with the help of a baby sitter, continued to work after the birth of Innocent in the summer of 2006. Family members, including her grandmother, pleaded with Ms. Brewer to let the children live with them instead of being cared for by a stranger. “There was a big argument in the family,” said Mr. Redd, the cousin. “But she wanted to prove to us that she could make it. Being that her mom had all that stuff in her life, she wanted to show that she was different.” Nassau County records show that from 2003 until last week, caseworkers from Child Protective Services investigated nine complaints against Ms. Brewer brought by neighbors or members of her own family who alleged that she was neglecting her children, leaving them home unattended, or failing to send them to school. The charges were deemed unfounded in six instances and verified in three, after which Ms. Brewer had to attend a class to improve her skills as a parent. But her custody of the children was never in jeopardy, Dr. Curtis said. “When we spoke to the kids, they were not bruised, they looked well cared for, the house was clean,” Dr. Curtis said. “There did not seem to be a threat to the children.” Asked if caseworkers were qualified to recognize mental instability, she said they probably were not, but added, "Being mentally ill is not automatically grounds for removing children from their mother." The fathers of Ms. Brewer’s children thought differently.Both Mr. Ward and Mr. Demesyeux went to Nassau County Family Court to seek custody, claiming Ms. Brewer was mentally ill and neglectful and may have been abusing drugs. The police were frequently summoned to the apartment after one father or the other tried to visit and violence erupted with Ms. Brewer, who was 6 feet tall and weighed about 200 pounds. Orders of protection were issued to all parties, but no criminal charges were filed. Among the factors contributing to the failure of government to protect Ms. Brewer’s three children, officials said last week, were privacy regulations. Police, mental health, child protection and Family Court officials all had case files on the family, Dr. Curtis said, yet none was in communication with workers in the other agencies — a problem officials said they would try to remedy. Ms. Brewer stopped working sometime in the last year. By some accounts, she was fired from her last job. Her behavior became more strange. Visitors to the apartment often found the children alone. “You would ring the bell and the little girl would say, ‘No, my mommy’s not home, come back later,’ ” Calvin Cannon, a friend from the neighborhood, said. Neighbors also noticed that Jewell was handling more and more of her brothers’ care. “She would change the baby’s diapers, wipe Michael’s nose, take care of the house, make sure they didn’t play near the stove, all that kind of stuff,” said Ms. Maddox, Ms. Brewer’s friend. At Christmas, Ms. Brewer permitted Jewell to spend the evening with her father, Mr. Ward, at a relative’s home in Westbury. The relative, Mr. Brooks, Mr. Ward’s cousin, said Ms. Brewer telephoned the house several times an hour to check on Jewell and to find out when she would be returning home. “She just called and called and called,” said Mr. Brooks, 21. Two days before the children were killed, Mr. Demesyeux complained to Child Protective Services that while he was visiting her home, Ms. Brewer was behaving bizarrely and threatening to harm her children. A caseworker was sent to investigate that day but found no one home. A second caseworker, dispatched that night, was also unable to get into the apartment. A night supervisor scheduled another visit for Sunday, instead of ordering a follow-up visit for Saturday; he was suspended without pay pending a department investigation. Two days after the children were killed, Maebell Mickens, Ms. Brewer’s grandmother, visited her in the detention wing of the medical center, where she was being held under guard. Ms. Mickens later said, according to an article in Newsday, that her granddaughter alternately denied and acknowledged what she had done to the children. She quoted Ms. Brewer, the child of Pearly Mae Mickens, as telling her, “The voices took control, and I had to do it.”
Connecticut's Nursing Homes Overusing Antipsychotics
But federal data do suggest that Connecticut is more aggressive than other states in citing nursing homes for administering unnecessary antipsychotic drugs and other medications. In the latest surveys, state health inspectors cited 21.7 percent of Connecticut's 244 licensed homes for administering "unnecessary drugs" to residents, a rate higher than the regional average of 14.7 percent and the national average of 18 percent. Although unnecessary drugs can include all kinds of medication, the citation frequently is issued for improper use of psychoactive drugs. Cass, the health department program manager, said that Connecticut has been "very astute" in identifying unnecessary drug violations, in part because the state uses a more in-depth inspection process than many other states. In each nursing home, inspectors closely review the medication records of a sampling of residents to ensure that there are appropriate diagnoses, she said. In addition, the health department flags homes with high rates of prescribing antipsychotics and conducts "more focused reviews" of those facilities. Inspection data show that the state has issued more than 110 citations to nursing homes since October 2005 for administering unnecessary drugs. Eleven homes have been cited twice for that violation, with the second citation coming within a year of the first. Among the homes cited twice was Wethersfield Health Care Center, which was included on a recent federal list of 54 of the most poorly performing nursing homes nationwide. Eight homes owned by Haven Healthcare have been cited for unnecessary drugs in the past two years, federal records show. Haven's chain of 15 Connecticut homes filed for bankruptcy in November after The Courant's stories detailed the chain's repeated patient-care deficiencies, lower-than-average staffing and serious financial problems. The improper use of psychotropic drugs at one Haven home in Torrington led the health department to issue a consent order against the home in December 2006 that mandated closer monitoring of residents receiving antipsychotics. State health inspectors had cited the home for seven cases in which it failed to justify the use of antipsychotic, antidepressant or sedative medications, or to monitor residents for side effects. In one of those cases, a resident receiving five such medications, without an appropriate diagnosis, was found to be in such declining health that hospice was called — until a physician was alerted and ordered a reduction in the drugs. The resident's mental state then rebounded: "The agitation and anxiety are gone, the resident is much more alert [and] vital signs are stable," the state health inspection report says. More recently, in November 2007, state health inspectors imposed a consent order and two years' probation on Haven's home in New Haven for myriad violations, among them failing to justify and monitor the use of antipsychotic medications prescribed to two residents. The New Haven home also was cited for low staffing levels. Nationally, the rate of prescribing psychoactive drugs in nursing homes has been rising in recent years, with a 2005 study showing that antipsychotic use in 2000-01 had reached the highest level in more than a decade. That study, headed by a University of Massachusetts Medical School researcher, found that about one-third of nursing home residents receiving antipsychotics had "inappropriate indications" for the drugs. In 2005, the taxpayer-funded Medicaid program — the main payer for drugs prescribed in nursing homes — spent more than $5 billion on antipsychotics such as Risperdal and Seroquel, which retail for several dollars per pill. Since the FDA warnings, some doctors increasingly have turned to antidepressants to treat the agitation and psychotic symptoms associated with dementia. Morgan said that depression can be an underlying cause of agitation, and he noted that antidepressants don't carry the adverse side effects — or expense — of antipsychotics. Morgan said that although most Connecticut nursing homes have a large proportion of residents with dementia-related symptoms — 50 percent to 70 percent, in his estimation — many homes "don't think of themselves as dementia-care facilities, in terms of having special expertise" or extensive training for staff. That needs to change, he said. "We have to begin to shift the model of dementia care away from skilled-nursing facilities, so that we also focus on behavioral interventions [and] recreational and interpersonal activities," Morgan said. "Staffing certainly has to be looked at, but so does the training of that staff." New Tools Help In Early Identification of Addiction William Hathaway, Hartford Courant- 3/3/2008 Ray B., now in his 30s, lives in suburban Hartford. In accordance with the principles of Alcoholics Anonymous, he prefers not to be identified. This is the story he does tell: Ray began smoking pot and sneaking drinks from his parents by the time he was 9, and by 14 he was a daily drinker and drug user. His father was a drunk, and two of his siblings were addicts. By the time he reached his early 30s, Ray had been arrested a dozen times, was dealing drugs and was living in a van in California with his wife and two children. He gave as much thought to picking up a drink or a drug as he would to breathing. "It's like going to a shopping center and you throw a bag of Doritos into the cart," he said. Ray's history is not unusual, but new tools are offering new answers to the question of why someone like him becomes an addict. Combining a new understanding of the genetic origins of substance abuse with brain scans that can track neurological changes, researchers can do something they've not been able to do before: spot potential alcoholics and addicts before it's too late. And as their understanding of addiction increases, so does the urgency researchers feel about preventing drug abuse at the youngest possible age. "We are turning adversity into opportunity," said B.J. Casey, director of the Sackler Institute for Developmental Psychobiology at Weill Medical College of Cornell University. "It has nothing to do with stigma. 'Just say no' is just not working." Risk Factors Central to this new approach is a growing understanding of how many people are born with at least one foot planted on addiction's slope — and that the earlier they begin abusing drugs or alcohol the more momentum they gain along their path to misery. Ray B., for example, has a host of the risk factors that clinicians, parents and counselors should be looking for, researchers say. He's the child of an alcoholic, making the risk of becoming an addict four times more likely. Even if the children of alcoholics are raised by non-alcoholics, their risk is still higher. Ray also started drinking before the age of 13, which ups the risk by a factor of eight. By contrast, children of alcoholics who don't start drinking until they are 21 or older have only a slightly greater lifetime risk of addiction. Add stress and you have a recipe for big and intractable lifelong problems. In addition to a better understanding of just how much these issues influence behavior, researchers are using imaging technology to understand what's happening inside the brains of youngsters at risk of abusing substances. Brain Differences Studying colored images of brain activity in youths, researchers have viewed differences in brain function between those at risk of addiction and their peers. In addition to differences in how pleasure, or its anticipation, is processed in the brain's reward centers, the frontal cortex — the area of the brain that helps control impulses and governs rational behavior — is slow to develop in those at risk of addiction. That area of the brain develops last in all teenagers — a subject that has received a good deal of attention over the past several years. But in those prone to drug abuse, the ability to govern rational behavior is a particularly late bloomer. These adolescents tend to engage in all sorts of risky behavior, whether sexual adventures, gambling, driving fast — or substance abuse. Imaging studies, moreover, show that when these children drink or do drugs, it can further impair these key brain areas. And later, after extended use, drinking or using drugs becomes habitual — as automatic as Ray B.'s grabbing a bag of chips at the supermarket. "There is a feedback loop," said Dr. John Krystal, professor of psychiatry at Yale University and head of alcohol research center at VA Connecticut Health Care System in West Haven. "Once they drink, their ability to assess long-term benefits of putting down the drink never develops. The impaired judgment can become ingrained." "In the heat of the moment, they don't have control," Casey agreed. Not only do these youths fail to perceive dangers of drinking and doing drugs, they tend not to be able to value positive goals such as work or school that require sustained effort. "They have a problem in sustaining motivational sense," Krystal said. "They work for a period of time, but if it is too long and frustrating, they lose track of the work they are trying to do." Instead, they crave only the immediate reward of the drug or drink. When you add stress, it becomes even more unlikely an adolescent can assess negative consequences of his or her behavior. Essentially, stress jams a wedge between rational centers of the brain and the more impulsive "fight or flight" response. Because of their genes, they are more sensitive to the pleasurable allure of drugs and alcohol and even more prone to the risky behavior, a hallmark of the teen years anyway. And areas of the brain that can moderate their behavior develop late or not at all if damaged at an early age by drugs and alcohol. These young addicts in training "face a triple whammy," Casey said. Identify And Intervene That's why, experts say, parents and schools need to work to identify the Ray B.'s of the world early in life. The new understanding of just how vulnerable certain children are underscores the need for early identification and intervention. If there is a family history of alcoholism and drug abuse, if a child faces many stresses in his or her life, and if the child is found experimenting with drugs at an early age, then adults need to act quickly to try to stop the behavior before the descent into addiction gains too much momentum. "Simply put, you don't want people drinking before they are able to assess the impact of their drinking," Krystal said. However, predisposition is not fate and every adolescent is different, Casey stressed. "The last thing I want to do is stereotype people," Casey said. "Any psychotherapy should be individualized treatment based on their history and genetic factors." And even after decades of addiction, the hijacking of neurological pathways, the sheer perpetual habit of substance abuse, recovery sometimes happens. After a decade of misery, Ray B. followed the example of his father and a brother, and sought treatment for alcoholism. Three years ago, he began to go to AA meetings. He recently obtained his high school diploma and is even thinking of junior college. "Three years ago, I never thought I would be here," he said. Brutal Killing of Psychologist Has Therapists on Edge Erika Hayasaki, Los Angeles Times- 3/4/2008 NEW YORK -- Since a psychologist was hacked to death in her Upper East Side office last month allegedly by a mentally unstable man wielding a meat cleaver, therapists across this city have been reevaluating safety practices as they confront risks inherent in their profession. "Anybody who goes into this business knows there is a possibility that something could happen," said Debra E. Pearl, a New York City therapist for more than 30 years, who sees patients in her doorman-secured office building. She will make exceptions, doing consultations at her home if it is an emergency and as long as she knows the client well. But Pearl said she knew there were uncontrollable risks: "People can flip." In this city, evening therapy sessions are almost as common as hitting the gym or happy hour. As details emerge about the gruesome killing of Kathryn Faughey, 56, a psychologist slain the night of Feb. 12, the dangerous reality of the job has caused concern among some mental health professionals, as well as their patients. Most therapists try to work with clients for years, getting to know them through weekly sessions, said Ravil Raj Sharms, a Manhattan-based psychologist. Over time, he said, it becomes easier to read and treat their mood swings. "But it is different if you worked with a person years ago and they came back with some kind of vendetta against you," he added. "You can't gauge that at all." Police said Faughey was killed when David Tarloff, 39, who had a history of schizophrenia and was not taking his prescribed medications, entered her office looking for her colleague, psychiatrist Kent Shinbach. Tarloff was arrested two days after Faughey's death. Investigators said they matched his palm prints with those at her bloodstained office. Authorities said Tarloff told them he wanted to rob Shinbach, who shared office space with Faughey, to get back at him for helping commit him to a mental hospital 17 years ago. Police said Tarloff ran into Faughey instead, hacking her in the head and chest. When Shinbach heard Faughey's screams and rushed to help, police said, Tarloff attacked him too. After two psychiatric experts examined Tarloff, a judge declared him mentally competent to stand trial in Faughey's death. Tarloff faces charges of first-degree murder and the possibility of serving a life sentence with no parole. He is also charged with attempted murder, first-degree assault and attempted robbery in the attack on Shinbach. "This is a very unusual situation and it has shaken a lot of people up," said Richard H. Wexler, president of the New York State Psychological Assn., which has been offering free therapy and support groups for friends or family of Faughey, as well as for professionals who need to talk about her death. "Remember that every psychologist is a human being first." There are more than 9,000 licensed psychologists in New York state, and Wexler's association has more than 3,000 members. He said the organization had launched an emergency task force to deal with safety issues after the recent attack, one of a handful of therapist killings across the nation in recent years. In 2006, a schizophrenia specialist was beaten to death by a 19-year-old patient during an emergency session in Bethesda, Md. In August, a Nebraska psychiatrist died after a patient attacked him as he arrived at a medical center. On Feb. 6, a therapist was allegedly stabbed to death in North Andover, Mass., by a client during a house call. Many New York therapists say being cautious is part of their daily practice. They know it can be a dangerous job, but it is a risk they take because of their commitment to the people they want to help. "The rewards of being able to help those in need far outweighs the concerns," said Wexler, who added that the average income for a psychologist was about $60,000 a year. "They do this for the love of the profession." Some therapists see patients in office buildings or as part of larger practices while others invite clients into their homes for private practice. They see clients facing a range of issues; most do not have a history of violence. But in recent weeks, some have considered installing panic buttons in their private offices to alert authorities if they find themselves in danger. Others say they are carefully screening new patients and trusting their instincts as to whether someone could pose a threat. Sharms, who works in private practice, favors the idea of setting up a panic-button system, which he said large-scale practices often established. He said female colleagues had talked of sitting near doors during patient meetings in the event a threatening situation should arise. Sharms said he was confident that he could read his patients' personalities to assess whether they were becoming volatile, and while training to become a therapist he learned martial arts moves in case he ever needed to defend himself. Pearl said she was always careful, and although she did not feel threatened by the 30 to 35 patients she saw each week, she was mindful of risks. She remembered counseling a man who was telling her a story about a time in his life in which he had become violent. "As he was telling me, he started getting more and more agitated," Pearl said. "He stood up. I was in a small office, and what I said wasn't therapeutic. I said, 'You're scaring me.' " Her response startled the patient, Pearl recalled, and he relaxed. She will never forget the fear she felt in that moment, but said she did not let the possibility of danger consume her thoughts. "There are all kinds of things to be afraid of in life," she said, adding she chooses not to be. "I don't want to live my life that way." When People Drink Themselves Silly, and Why Benedict Carey, New York Times- 3/4/2008 The urge to binge mindlessly, though it can strike at any time, seems to stir in the collective unconscious during the last weeks of winter. Maybe it’s the television images from places like Fort Lauderdale and Cabo San Lucas, of communications majors’ face planting outside bars or on beaches. Or perhaps it’s a simple a case of seasonal affective disorder in reverse. Not SAD at all, but anticipation of warmth and eagerness for a little disorder. Either way, researchers have had a hard time understanding binge behavior. Until recently, their definition of binge drinking — five drinks or more in 24 hours — was so loose that it invited debate and ridicule from some scholars. And investigators who ventured into the field, into the spray of warm backwash and press of wet T-shirts, often returned with findings like this one from a 2006 study: “Spring break trips are a risk factor for escalated alcohol use.” Or this, from a 1998 analysis: “The men’s reported levels of alcohol consumption, binge drinking and intoxication were significantly higher than the women’s.” In fact, the dynamics of bingeing may have more to do with personal and cultural expectations than with the number of upside-down margaritas consumed. In their classic 1969 book, “Drunken Comportment,” recently out in paperback, the social scientists Craig MacAndrew and Robert B. Edgerton wrote that the disconnect between the conventional wisdom on drunken behavior and the available evidence “is even now so scandalous as to exceed the limits of reasonable toleration.” They detailed the vast differences in the way people from diverse cultures behave after excessive alcohol. In contrast to nearby tribes, for example, the Yuruna Indians in the Xingu region of Brazil would become exceptionally reserved when rendered sideways by large helpings of moonshine. The Camba of eastern Bolivia would drink excessively twice a month. Sitting in a circle, they would toast one another, more lavishly with each pop. In a Japanese island village, Takashima, people knew a drinking occasion had gone completely off the dials if villagers began to sing or, wilder still, to dance. Aggression, sexual or otherwise, was unheard of during these sessions. Western cultures are more likely to excuse binge drinking as a needed mental vacation. “An awful lot of cultures have institutionalized bingeing as a kind of time out like Mardi Gras or New Year’s Eve, a culturally recognized period where a certain amount of acting out is acceptable,” said Dwight Heath, emeritus professor of anthropology at Brown. Not to say that would-be bingers, when ordering that first tray of Irish car bombs for the table, think about discharging a cultural tradition. They have their own reasons. And those, too, shape subsequent drunken behavior. In a series of studies in the 1970s and ’80s, psychologists at the University of Washington put more than 300 students into a study room outfitted like a bar with mirrors, music and a stretch of polished pine. The researchers served alcoholic drinks, most often icy vodka tonics, to some of the students and nonalcoholic ones, usually icy tonic water, to others. The drinks looked and tasted the same, and the students typically drank five in an hour or two. The studies found that people who thought they were drinking alcohol behaved exactly as aggressively, or as affectionately, or as merrily as they expected to when drunk. “No significant difference between those who got alcohol and those who didn’t,” Alan Marlatt, the senior author, said. “Their behavior was totally determined by their expectations of how they would behave.” In a repeat of the session performed for a coming documentary, one participant insisted that she could not have been drinking because alcohol always made her flush. “We told her that, yes, in fact she was drinking it,” Dr. Marlatt said. “She immediately flushed.” Somewhere between personal preferences and social custom, moreover, the peer group asserts itself. In a recent study, public health researchers in New Zealand conducted extensive interviews with teenage girls in one of two cliques at a high school. Both groups associated drinking with uninhibited behavior — and that is what they exhibited. But one group considered being uninhibited to include making out, and the other considered it to include far more. In their discussion, Dr. MacAndrew and Dr. Edgerton acknowledged that Western societies, and certainly the United States, send multiple signals on bingeing. At times, the signals cross, as when movies show spring-break binging as sunburned, sexy fun, while health pronouncements make it look like an orgy of near-criminal behavior. At other times, cultural expectations and personal preferences reinforce each other. The hope that a wild session might “reveal new things about myself” or “allow me to act completely out of character” is widely echoed in literature, pop culture and drinking lore. If the research is a guide, those hopes should be self-fulfilling at some level. Unless, that is, the binge goes beyond any reasonable definition of excess. Then the amount of tequila consumed matters very much — and poison is poison in any culture. |