Noteworthy News Articles on Mental Health Topics, March 5-7, 2008 Benedict Carey, New York Times- 3/5/2008 In marketing as in medicine, perception can be everything. A higher price can create the impression of higher value, just as a placebo pill can reduce pain. Now researchers have combined the two effects. A $2.50 placebo, they have found, works better one that costs 10 cents. The finding may explain the popularity of some high-cost drugs over cheaper alternatives, the authors conclude. It may also help account for patients’ reports that generic drugs are less effective than brand-name ones, though their active ingredients are identical. The research is being published on Wednesday in The Journal of the American Medical Association. The investigators had 82 men and women rate the pain caused by electric shocks applied to their wrist, before and after taking a pill. Half the participants had read that the pill, described as a newly approved prescription pain reliever, was regularly priced at $2.50 per dose. The other half read that it had been discounted to 10 cents. In fact, both were dummy pills. The pills had a strong placebo effect in both groups. But 85 percent of those using the expensive pills reported significant pain relief, compared with 61 percent on the cheaper pills. The investigators corrected for each person’s individual level of pain tolerance. “It’s a great finding,” said Guy H. Montgomery, an associate professor of cancer prevention at the Mount Sinai School of Medicine who was not involved in the research. “Their manipulation of price affected expectancies of drug benefit, and pain is the ultimate mind-body phenomenon.” Previous studies have shown that pill size and color also affect people’s perceptions of effectiveness. In one, people rated black and red capsules as “strongest” and white ones as “weakest.” Other information like the country where the drugs were manufactured can also affect perceptions. “It’s all about expectations,” said the lead researcher, Dan Ariely, a behavioral economist at Duke and the author of a new book, “Predictably Irrational: The Hidden Forces That Shape Our Decisions” (HarperCollins). His co-authors on the report were Rebecca Waber, Baba Shiv and Ziv Carmon. “When you’re expecting pain relief, you’re secreting your own opioids,” Dr. Ariely added. “And when you get it on discount, you doubt it, and your body doesn’t react as well.” Government Concedes Vaccine Injury Case Associated Press, 3/5/2008 Government health officials have conceded that childhood vaccines worsened a rare, underlying disorder that ultimately led to autism-like symptoms in a Georgia girl, and that she should be paid from a federal vaccine-injury fund. Medical and legal experts say the narrow wording and circumstances probably make the case an exception -- not a precedent for thousands of other pending claims. The government ''has not conceded that vaccines cause autism,'' said Linda Renzi, the lawyer representing federal officials, who have consistently maintained that childhood shots are safe. However, parents and advocates for autistic children see the case as a victory that may help certain others. Although the science on this is very limited, the girl's disorder may be more common in autistic children than in healthy ones. ''It's a beginning,'' said Kevin Conway, a Boston lawyer representing more than 1,200 families with vaccine injury claims. ''Each case is going to have to be proved on its individual merits. But it shows to me that the government has conceded that it's biologically plausible for a vaccine to cause these injuries. They've never done it before.'' A lawyer for the 9-year-old girl has scheduled a news conference in Atlanta on Thursday. Her parents have declined to comment in the meantime because the case is not final and the payment amount has not been set. Nearly 5,000 families are seeking compensation for autism or other developmental disabilities they blame on vaccines and a mercury-based preservative, thimerosal. It once was commonly used to prevent bacterial contamination but since 2001 has been used only in certain flu shots. Some cases contend that the cumulative effect of many shots given at once may have caused injuries. The cases are before a special ''vaccine court'' that doles out cash from a fund Congress set up to pay people injured by vaccines and to protect makers from damages as a way to help ensure an adequate vaccine supply. The burden of proof is lighter than in a traditional court, and is based on a preponderance of evidence. Since the fund started in 1988, it has paid roughly 950 claims -- none for autism. Studies repeatedly have discounted any link between thimerosal and autism, but legal challenges continue. The issue even cropped up in the presidential campaign, with Republican John McCain asserting on Friday that ''there's strong evidence'' autism is connected to the preservative. The girl has a disorder involving her mitochondria, the energy factories of cells. The disorder -- which can be present at birth from an inherited gene or acquired later in life -- impairs cells' ability to use nutrients, and often causes problems in brain functioning. It can lead to delays in walking and talking. Federal officials say the law bars them from discussing the case or releasing documents without the family's permission. However, The Associated Press obtained a copy of the concession by U.S. Department of Health and Human Services officials. According to the document, five vaccines the girl received on one day in 2000 aggravated her mitochondrial condition, predisposing her to metabolic problems that manifested as worsening brain function ''with features of autism spectrum disorder.'' In the 1990s, the definition of autism was expanded to take in a group of milder, related conditions, which are known as autism spectrum disorders. The document does not address whether it was the thimerosal -- or something else entirely in the vaccines -- that was at fault. The compensation fund lists problems with brain function as a rare side effect of certain vaccines. Such problems are enough on their own to warrant compensation, even without autism-like symptoms, and the fund has made numerous payouts in such cases. The Health Resources and Services Administration, which is in charge of the fund, said: ''HRSA has maintained and continues to maintain the position that vaccines do not cause autism.'' A Portuguese study suggested that 7 percent of autistic children might also have the mitochondrial disorder, versus one in 5,000 people -- or 0.02 percent -- in the general population, said Dr. Marvin Natowicz, a Cleveland Clinic geneticist. ''Even if they're off by a factor of seven'' and only 1 percent are afflicted, ''it's still a striking statistic,'' he said. Others said they doubt the Georgia case will have much effect. ''No link between mitochondrial disorders and autism spectrum disorder has been made in mainstream medicine,'' said Dr. Michael Pichichero of the University of Rochester in Rochester, N.Y., who has consulted for the government on vaccines and has received speaking fees from vaccine makers. A decision is expected this spring on the first test case for a larger group of autism-vaccine claims, which are being heard in the U.S. Court of Federal Claims. Reported cases of autism have been rising in the U.S., even after thimerosal was removed from most childhood vaccines. However, some experts believe the rise is due to an expansion of the definition of autism and related conditions, and a desire to diagnose children so they qualify for special services and aid. On the Net: U.S. Court of Federal Claims: http://www.uscfc.uscourts.gov Vaccine injury fund: http://www.hrsa.gov/vaccinecompensation CDC autism page: http://www.cdc.gov/ncbddd/autism/index.htm American Academy of Pediatrics autism reports: http://www.aap.org/advocacy/releases/oct07autism.htm House Approves Mental Health Bill Associated Press, 3/5/2008 WASHINGTON -- The House voted Wednesday to require equal health insurance coverage for mental and physical illnesses when policies cover both. The 268-148 roll call was cheered by advocates who have been fighting more than a decade for what has come to be called mental health parity. Supporters said the measure would help end the stigma of mental illness and create greater access for people needing mental health and addiction treatment. Opponents warned it could drive up health care costs and force some employers to drop insurance coverage. The ''Paul Wellstone Mental Health and Addiction Equity Act of 2007'' was named for the late Minnesota Democratic senator who championed the issue for years and who was killed in a 2002 plane crash. ''It's a historic step,'' said the late senator's son, David, 42. ''It's a civil rights bill for people with mental illnesses and chemical addiction. It forces insurance companies to treat them as they treat others.'' Forty-seven Republicans joined 221 Democrats in voting for the bill. Three Democrats voted against it. The House vote sets the stage for talks with the Senate, which passed a narrower version of the bill last September with support from business and insurance groups. The White House said it favors the Senate bill because it addresses the need to treat mental illnesses with the same urgency as physical illnesses but wouldn't significantly raise health care costs. The House bill was sponsored by Reps. Patrick Kennedy, D-R.I., who has battled depression, alcoholism and drug abuse, and Jim Ramstad, R-Minn., a recovering alcoholic who is Kennedy's Alcoholics Anonymous sponsor. ''It's about opening up the doors and ending the shadow of discrimination against the mentally ill,'' said Kennedy. Former first lady Rosalynn Carter, a longtime mental health advocate, said the bill would help erase the stigma of mental illness that prevents many people from seeking treatment. The Senate bill was sponsored by Kennedy's father, Massachusetts Democrat Edward Kennedy, along with GOP Sens. Pete Domenici of New Mexico and Mike Enzi of Wyoming. The younger Kennedy will negotiate with his father on a compromise measure. ''We've discussed strategies and ways we can try to move this,'' the congressman said. The House measure specifies that if a plan provides mental health benefits, it must cover mental illnesses and addiction disorders listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, which is used by mental health professionals. The Senate bill gives insurers more leeway on the types of mental disorders they would have to cover. Rep. Phil Gingrey, R-Ga., complained the House bill would mandate coverage for such conditions as jet lag and sexual dysfunction that are listed in the psychiatric association's manual. ''Can you imagine any employer being willing to cover things like that?'' said Gingrey, a doctor. Opponents said because the House bill requires much broader coverage than the Senate bill, it would prevent some businesses from providing any mental health coverage at all. ''The House bill will put us in the awkward position of either covering everything in the professional manual -- or covering nothing at all,'' said Neil Trautwein, the National Retail Federation's health care lobbyist. The federation, a trade association for the retail industry, favors the Senate version. The Senate bill was a compromise reached after negotiations with businesses, the insurance industry and mental health advocates. Business and insurance groups had fought previous versions, arguing the proposals would drive up insurance costs. On the Net: Information on the bills, H.R. 1424 and S. 558, can be found at http://thomas.loc.gov Ex-Mayor of Atlanta Enrolled in Prison Drug Program After Denial of a Problem Shaila Dewan, New York Times- 3/5/2008 ATLANTA — The federal Bureau of Prisons allowed Bill Campbell, the former mayor of Atlanta now serving time for tax evasion, to shorten his sentence by enrolling in a drug treatment program just a few months after he told a federal judge that he had no substance abuse problems. Mr. Campbell, originally sentenced to serve 30 months in prison and get out in February 2009, has completed the program and since December has been in a halfway house where he has a job and is eligible to go home on weekends, prison officials said. Completion of the residential treatment program allows up to a year to be deducted from an inmate’s sentence, and permits early transfer to a halfway house. Mr. Campbell’s projected release date is in June, more than seven months short of his original sentence. About half of the reduction is because of good behavior in prison; the rest is because of his participation in the rehabilitation program. But after Mr. Campbell’s conviction in 2006, his own lawyers argued in a sentencing memorandum that he should serve no prison time because of his clean record. “Mr. Campbell is a well-educated man, with no health or substance abuse problems,” his lawyers wrote in the memorandum to the judge before sentencing. He had no need of what they called the prison system’s “thinly spread” resources, they wrote. There is a waiting list for the drug treatment program. Prison officials said inmates must offer documentation of prior substance abuse to enter the treatment program, but for privacy reasons they said they could not disclose whether Mr. Campbell submitted such proof. The lawyers’ sentencing memorandum that cited Mr. Campbell’s sobriety, along with other court papers, was not reviewed when determining his eligibility for treatment, said Felicia Ponce, a spokeswoman for the bureau. “We wouldn’t look at any evidence,” Ms. Ponce said. “We would look at the presentencing investigation report.” The presentencing investigation report is written by a probation officer and is not a public document. But major discrepancies between that report and the defense sentencing memorandum are highly unusual, legal experts said. The investigation report summarizes the defendant’s role in the crime, community ties, physical condition, substance abuse history and other details. Both prosecutors and defense lawyers review a draft of the report before it is submitted to the judge. If there is no mention of a drug or alcohol problem in the presentencing report, inmates who want treatment must submit documentation of an abuse history from a doctor, treatment facility, psychologist or other “legitimate verifiable outside source,” Ms. Ponce said. Mr. Campbell is no stranger to questionable documentation. At his trial, prosecutors presented evidence that many of his living expenses were paid with cash, rather than his salary. Later they released a letter provided by the defense, purporting to have been written to Mr. Campbell by his mother before her death and claiming that she had provided the cash. The letter veered from legalese (“I, June Kay Campbell, have given my son thousands of dollars in cash gifts”) to sentiment (“It was done just between the two of us and I wanted you to have it, although you did not ever want it and always helped others”). Gabe Pascarella, an Atlanta businessman who testified at the trial, said he was surprised to hear that Mr. Campbell, a close associate for two decades, had undergone substance abuse treatment. “I was never, ever aware of any substance abuse problem he had with alcohol or anything else,” Mr. Pascarella said. What’s in a Chair? Penelope Green, New York Times- 3/6/2008 Ann Loftin could write a textbook on the nuances of modern psychotherapeutic methods — and the personality types of their practitioners — based on the home office décor of the therapists who have treated her. There was the strict Freudian whose couch was covered in plastic and who barely spoke, though every once in a while a phrase like “mother’s milk” might have slipped out. Another’s office featured phallic African statuary and pictures of a young wife, who was herself always audible somewhere in the background. A licensed clinical social worker had lots of comfy, overstuffed furniture and encouraged patients to sit anywhere (sessions ended in long hugs that suggested much countertransference). Her last analyst, with whom she spent a fruitful decade, did not see patients in his home, but in an office building, and his room there held nothing more than two nondescript leather chairs, a bookcase lined with medical texts and a table holding a box of tissues. “I’ve seen the good, the bad and the ugly,” said Ms. Loftin, a 53-year-old freelance writer from Lakeville, Conn., with 20 years of therapy behind her. Like many patients, Ms. Loftin learned long ago that a therapist’s office — particularly a home office — and the stuff that’s in it can be freighted with more revelations than Sunday morning in a Baptist church. Therapists have been working out of their homes ever since psychoanalysis was invented, but recently the meaning and message of that setting have come under particular scrutiny. As viewers of the HBO series “In Treatment” will attest, a home office can be a very problematic space. In an early episode of the series, starring Gabriel Byrne as a therapist named Paul Weston, Laura, a repellently narcissistic patient with a bad case of erotic transference (that’s shrink talk for having a crush on your doctor), nearly claws down the door that separates Weston’s office from his house in an attempt to get to a bathroom (the bathroom in his office is broken). Agitation on both sides ensues. For the writers of “In Treatment,” Weston’s office becomes a metaphor for how the boundaries are breaking down between his work and his personal life. But even in the real world, therapists are increasingly aware that their office space can have a profound impact on their patients. Last year, an article in Psychoanalytic Psychology, a journal of the American Psychological Association, created a ruckus by questioning the ethical considerations surrounding therapists’ home offices. Its author, Karen J. Maroda, an analyst and the former ethics chair of the division of psychoanalysis of the American Psychological Association, wrote that the sights and smells of the doctor’s home were “keyholes” into his or her life that could be overly stimulating or overwhelming. “Oedipal material, for instance, should arise when a patient is ready to face it,” she wrote, “not when he or she bumps into the analyst’s spouse in the driveway.” Dr. Maroda remembered her own experience as a young analyst and patient being seen in her therapist’s tony home, replete with family members and an ample household staff. “I didn’t realize the negative effect on me as a patient until years later when I had more objectivity,” she said last week. “The session was on Saturday mornings and so I’d see her son, the glaring teenager, who was obviously resenting her time away from him. I felt guilty. I felt angry. They were wealthy; I was just starting out. The first session, the door was opened by a maid. For someone who didn’t come from money it was very intimidating.” At the same time, it was a deeply nurturing experience, she said, adding this caution: “Just because it feels good in the moment doesn’t mean that it’s ultimately therapeutic.” What she hadn’t bargained on, continued Dr. Maroda, was how angry the response would be to her article, expressed in follow-up pieces published in the journal, as well as affronted comments to its editor and to her. “I had someone say that I was conducting a witch hunt,” she said. Clearly, Dr. Maroda had touched the analytic community right where it lived. At home. Two Sundays ago, Lewis Aron, director of New York University’s postdoctoral program in psychotherapy and psychoanalysis, organized a salon for his peers. The topic? “In Treatment.” Two hundred analysts showed up. “It went like this,” said Dr. Aron. “Someone would stand up and say, ‘Hi, my name is Judy X and I’m addicted to ‘In Treatment,’ and then everybody would say, ‘Hi, Judy!’ ” For two hours, the analysts discussed the various mistakes Weston makes regarding boundary issues, and one analyst broached the idea that the placement of his office in his home was the cause of his many transgressions. “Someone brought up Maroda’s article,” said Dr. Aron. “He didn’t agree with her. I don’t either. I think there is always a dialectic tension between the personal and the professional and we lose a lot by making the setting too clinical. There is something engaging in seeing the therapist has a real life, and is a real person.” Few therapists today would contend that it’s possible or even desirable to present oneself as a true blank slate, with an office and treatment style utterly free from personal influence. And so the conversation now centers on degrees of influence and revelation: is a family photograph too much? What about the family dog? Consider the experience of Betsy Israel, a Manhattan author, as a case of rather too much revelation. When she was in her 20’s, Ms. Israel, now 49, was treated by an elderly female analyst who was “so strict, so doctrinaire it was like being analyzed by Anna Freud,” she said. “I had a brilliant transference: she was my mother, and for two years we were trying to get through talking about sex and denial.” One day, Ms. Israel was waiting for her session in the long hall that led to the office, which was in a cavernous apartment on the Upper West Side. She began to focus on the faded, 50s-era nude watercolors that lined the hall and realized with horror that the subject of those nudes was her doctor. “She was a very proper lady in tweeds, not a naked person at all, if you know what I mean,” said Ms. Israel with an audible shudder. “I never brought it up. I felt like that was a failure on my part, but it also began the process of turning away” from treatment, she said, which perhaps was not such a bad thing. Ms. Israel speculated that the nudes’ placement was intentional, possibly to “raise the stakes” for certain patients. But what the child psychologist who treated Ms. Israel’s young daughter after 9/11 intended by laying out a book of Robert Mapplethorpe nudes in the waiting room was beyond her reasoning. “I couldn’t make sense of it,” she said. The presence of a pet in a therapist’s office can be similarly confounding. Tom Cashin, a vice president at Jed Johnson Associates, was too embarrassed and shy, he said, to address the “four eyes” of his therapist and the therapist’s German shepherd. And Shannon Birk remembers choosing a therapist from a list provided by her H.M.O. seven years ago, when she was “smack dab in a major depression.” The doctor’s office contained a dog bed, housebreaking training pads and a small dog. One day, Ms. Birk found herself in the waiting room well past the appointed session time. When the door finally swung open, there was the dog, outfitted in a Halloween devil costume. “The doctor had the little red-horned headband and scissors in her hand,” Ms. Birk remembered, “while she explained the headpiece was too big. Apparently she had been attempting to alter it while she kept me waiting.” During another session, recalled Ms. Birk, the doctor paused to give the dog a biscuit for performing a trick. So what do therapists think about when they decorate an office? Ann Maloney, an interior designer turned psychiatrist, works on the ground floor of the Manhattan brownstone where she also lives (the entrances are separate). She knows a thing or two about the semiotics of objects and the meanings that lurk behind décor. Working as a designer in her 20’s, “I realized that when my clients were arguing about the drapes,” she said, “it was never really about the drapes.” Dr. Maloney continued, “My bent is, the most important thing about your space is that you’re comfortable enough to do your work well, and that it reflect you,” she said. “I don’t mean your inner dark secrets, but something about you as a person. It’s a market, and patients are savvy. Your home and your office are reflections of you. Why would you want to see someone who doesn’t appear to have their act together?” Though as Christian McLaughlin, a movie producer explained, grotty décor can be therapeutic. “I always had this vision of therapists’ offices as fairly posh and leathery, with degrees on the walls from Ivy League institutions,” said Mr. McLaughlin, 38. In other words, aspirational. But then Mr. McLaughlin, who moved to Los Angeles from New York eight years ago to produce “Legally Blonde,” found himself in therapy for the first time, in a dump of an office in the Valley next to a casting agency. “The large couch on which I’d sit every week was covered with cheap stuffed animals caked in dried tears and snot,” he recalled. “I never started a therapy session in which I wasn’t physically repulsed by the surroundings, like an animal fearing for its life. Therapy was already so wildly uncomfortable to me, and since the setting was, too, it just all went hand in hand and I had to embrace it.” Florence Fellman, a movie set decorator, said that when she creates a set for a psychiatrist character, she uses “clichéd objects” so the audience can read the scene immediately, like American Indian baskets and African art and “all kinds of familiar ethnic art that says, ‘I’m accepting of all cultures and customs so anything you say here won’t shock me.’ ” When her son was a teenager, “and needed help coping,” she said, he was referred to a psychiatrist whose office looked like one of Ms. Fellman’s sets come to life. “I tried to suppress my instinct that his advice would be as clichéd as his office.” Four $400 sessions later, her instinct turned out to be right. The set of “In Treatment” displays none of these clichés. In fact, Weston’s overstuffed office, with its huge boat models, parchment-shaded lamps and books, reads most like the living room of a Harvard academic with a trust fund, or maybe a Kennedy relative. Suzuki Ingerslev, the show’s production designer, dressed it thus not in service to any ideal she carried about a therapist’s office but “to create interest behind the character’s heads. If we had blank walls in there, people would die watching it,” she said. “It’s like an antique shop,” said Robert Langs, a Manhattan psychoanalyst. “And the bathroom inside it! I think the whole show is chaos, and he’s trying to drive his patients crazy.” Tchotchkes and plumbing aside, for Dr. Langs, who described himself as a revisionist Freudian with a sparsely furnished office in an office building, “there is only one archetypal unconscious view of a home office. And that is that the home office is totally inappropriate and destructive to the patient. And what about the impact on the therapist’s own family?” David Tolchinsky, a 45-year-old screenwriter and chair of the Radio, Television and Film department at Northwestern University, has thought a lot about that question. He grew up with an analyst father who saw patients in the family living room. This was closed off by two double doors, and no family member could walk around during sessions or enter or leave the house when patients were doing so. Mr. Tolchinsky admitted it was an oppressive environment, but it was also a boon, he said. One of his screenplays in development, “Reflections on a Teenage Antichrist,” is about a heavy metal loving teenager who slowly begins to believe his psychiatrist father may in fact be the devil. “A lot of the scenes take place in his house, with the teen hero listening at the double doors of his father’s office. O.K., so I don’t think my father was the devil, but he did give me a great gift as a writer, which is the image of those closed double doors.”
On the Net:
New Generation Gap as Older Addicts Seek Help Jane Gross, New York Times- 3/6/2008 WEST PALM BEACH, Fla. — All is peaceful and orderly on the older adult unit at Hanley Center, where substance abusers over the age of 55 are spared the noisy swagger of addicts half their age across the campus. In their separate oasis, alcoholics and prescription drug abusers of a certain age do not curse at one another, raise their voices in anger or blast music at midnight. They don’t brag about their macho pasts or stage drama-queen breakups on the communal pay phone. They show up on time for therapy groups. “We have different health issues, different emotional issues, different grief issues,” said Patrick Gallagher, 66, who was treated here for a dual addiction to pain medication and alcohol. “We need more peace and quiet and a different pace.” Across the country, substance abuse centers are reaching out to older addicts whose numbers are growing and who have historically been ignored. There are now residential and outpatient clinics dedicated to those over 50, special counselors just for them at clinics that serve all ages, and screenings at centers for older Americans and physicians’ offices to identify older people unaware of their risk. Addiction specialists and organizations for the elderly anticipate a tidal wave of baby boomers needing help for addictions, often for different substances and with different attitudes toward treatment than the generation that came before them. Federal data shows the shifting demographics: In 2005, 184,400 Americans who were admitted to drug treatment programs — roughly 10 percent of the total — were over 50, up from 143,000, or 8 percent of the total, in 2001. The same report, by the Substance Abuse and Mental Health Services Administration, foresees 4.4 million older substance abusers by 2020, compared with 1.7 million in 2001 — numbers that are “likely to swamp the current system,” said Deborah Trunzo, who coordinates research for the agency. At Hanley Center, Carol Colleran, a 71-year-old counselor, pioneered age-segregated residential treatment, challenging one-size-fits-all programs that mix people of all ages. Odyssey House in East Harlem, with its low-income clientele, has followed Hanley’s lead. Older adults are harder to lure into treatment, officials say, because of a generational aversion to airing one’s laundry in public. But once there, they are often highly motivated and more likely to complete a program. “We are reticent and don’t readily share our feelings in a group,” Mr. Gallagher said. “That’s not something we’ve grown up with.” But living with people of a similar background, he said, had given him a “comfort level and a sense of belonging” conducive to success. Treatment providers are seeing signs that the 50-and-over group is not, in fact, monolithic. Rather, it is divided between the “old old” and the “young old,” the Silent Generation and the Me Generation. Neither feels much kinship with the Lindsay Lohan set. But neither do they necessarily feel much kinship with each other, and counselors are bracing for a collision of cultures. According to the federal report, 83 percent of older addicts were 50 to 59, and the trailing edge of the baby boom, age 50 to 54, is the fastest-growing older group: They were 6 percent of all admissions in 2005, from 3 percent a decade earlier. “It’s already changing,” said Tom Early, a counselor on Hanley’s older-adult unit, where the patients, all alcoholics or prescription drug abusers, are 55 to 78. “We can see it. We can feel it.” Alcohol remains the dominant problem for both groups, although that is changing quickly. Among patients over 65, 76 percent abuse alcohol; many have allowed social drinking to get out of hand after the isolation of retirement or loss of a spouse. In the 50-to-54 age group, by contrast, 55 percent cite alcohol, followed by opiates, cocaine, marijuana and methamphetamines. Prescription drug abuse is climbing in both groups, led by anti-anxiety drugs like Xanax and pain-killers like Oxycontin. Ms. Colleran said prescription drug abuse among the “old old” was usually accidental. They have faith that anything a doctor prescribes must be safe, she said. In the younger group, these medications are knowingly abused, experts said, by buying them online or borrowing from friends. As the age group skews younger, Ms. Colleran said: “They say, ‘I’m not like anyone else.’ They challenge everything.” These characteristics, she added, make treatment tricky and require new techniques, like cognitive behavior therapy and lectures on anger management by the noted male-consciousness-raiser Iron John (a k a Robert Bly). Anger and stubbornness are more prevalent among those in their 50s. At Senior Hope, an outpatient clinic for older adults in Albany, 55-year-old Ken Einbinder described fantasies of violence that seemed to dismay or embarrass group members in their 70s. Only John Quinn, 54, nodded knowingly. He was struggling after a recent relapse and had been prescribed an antidepressant. Mr. Quinn tossed out the pills without telling anyone because, he told the group, they caused erectile dysfunction. Dr. William Rockwood, founder of Senior Hope, said older clients, even if they complained of the same side effect, would have complied with medical advice. On Hanley’s older-adult unit, there is disdain for street drugs, which “very few of us have used,” Mr. Gallagher said. On the patio where residents take cigarette breaks , a half dozen said the harmony of the group would be compromised by the addition of crack, heroin or even marijuana abusers. One 61-year-old alcoholic said that “if the numbers flipped so there were more of them than me, I’d be out of here.” He added that he had stopped attending Alcoholic Anonymous meetings, and relapsed, because of an influx of young drug addicts. The antipathy toward street drugs is a function of socio-economic class, said Frederic Blow, who studies elderly substance abuse at the Addiction Research Center at the University of Michigan. For Hanley’s clients, who pay $24,500 for a 28-day rehab, “it’s not part of their culture.” Indeed, no such distinction is made at the unit for older adults at Odyssey House, where clients are mostly poor, addicted to heroin or crack, and remanded by the courts for 12 to 18 months of subsidized care. But across social class, many older substance abusers said, they no longer consider themselves invincible. A 66-year-old chief of staff at a veterans’ hospital, recently treated at Hanley, said he had no patience with men in their 20s and 30s who “aren’t finished drinking and drugging and think their war stories are a badge of honor.” The doctor, since retired, pointed to “all we have to lose — the social binding” that accumulates with age. In his case, that included a 40-year marriage and children and grandchildren who refused to see him until he was sober. “I just wanted to stop drinking and get on with my life,” he said. At Odyssey House, Charles White, 57, said of the younger clients: “They think they have another run in them. And as far as the ladies go, they have no respect.” Mr. White was dignified in a dark suit and tie and chivalrous as he held a chair for Doris Ellison, 55, another longtime heroin addict, also dressed in her Sunday best. “It was a different era,” Ms. Ellison said. “We had a lot of guidance growing up. They don’t have that at home. Their parents — and that includes some of us — are out there drugging. But now, for however many years we have left, we can try and do the right thing.” For Ms. Ellison, that includes setting an example for 26-year-old Milagros Bonilla, who lives on a separate floor and attends separate therapy groups but got to know the older woman on long bus rides to high school equivalency classes. Ms. Bonilla said people her age were “kind of loud and obnoxious” and often less disciplined than their elders. She credits Ms. Ellison with inspiring her to get clean, stick to her studies and remain hopeful that she will regain custody of three daughters in foster care. “She’s more motivating to me than anyone my age, because she makes me feel anything is possible,” Ms. Bonilla, whose own mother is dead, said of Ms. Ellison. Officials at these age-segregated programs promote the success of their clients. But, Dr. Blow said, completion rates are poor statistical measures of long-term sobriety. Nevertheless, he is persuaded, based on years of observation, that age-specific treatment “makes total sense.” At Senior Hope in Albany, Dan Fitzsimmons, 79, an executive for a major utility, and Tom Hyde, 76, who owned a sheet music business, became good friends. Both let their drinking get out of hand in retirement, when they had too much time on their hands and a shrinking circle of companions. Both relapsed once and helped each other get back on the wagon. Now, they are determined to leave a proper legacy for their grandchildren. Mr. Fitzsimmons needs only to think back to his own adolescence, when he was assigned the task of finding his grandfather in neighborhood bars. All these years later, Mr. Fitzsimmons said, he carries the indelible memory of “an old gray-haired guy out on another toot.” “I’m not going to let that happen to me,” he said. “It’s not the way I want to be remembered.” House Approves Bill on Mental Health Parity Robert Pear, New York Times- 3/6/2008 WASHINGTON — After more than a decade of struggle, the House on Wednesday passed a bill requiring most group health plans to provide more generous coverage for treatment of mental illnesses, comparable to what they provide for physical illnesses. The vote was 268 to 148, with 47 Republicans joining 221 Democrats in support of the measure. The Senate has passed a similar bill requiring equivalence, or parity, in coverage of mental and physical ailments. Federal law now allows insurers to discriminate, and most do so, by setting higher co-payments or stricter limits on mental health benefits.
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