Noteworthy News Articles on Mental Health Topics, April 17-27, 2008



18.5% of Iraq, Afghanistan Veterans Have Mental Illness
Julian Barnes, Los Angeles Times- 4/17/2008

WASHINGTON -- Nearly one in five veterans of the Iraq and Afghanistan wars is currently suffering from depression or stress disorders, according to the latest and most comprehensive study of current and former military service members, released today. Less than half of those 300,000 veterans have received care for depression or post traumatic stress disorder (PTSD), according to the study, signaling significant problems with the U.S. mental healthcare system.The study shows that the stress disorders may be more prevalent and lasting than previously known. Although the Army has conducted annual evaluations of troops deployed in Iraq, the new study, conducted by the Rand Corp. and funded by the California Community Foundation, is the first to try and assess the mental health of the 1.65 million service members that have been deployed to Iraq or Afghanistan.
     Amid reports of increased mental health problems, the Army has been dramatically stepping up its screening of soldiers at the end of their tours. But the Rand study argues many soldiers and Marines are still slipping through the cracks in the bureaucratic system. The symptoms of depression and PTSD can appear months after an incident, and so mental problems that appear later may never be caught, the study said.
     Based on interviews with 1,965 current and former service members, the study asked how many had suffered from PTSD within the previous 30 days and suffered from depression within the previous two weeks. "We have tried to generate this estimate across the entire deployed population," said Terri Tanielian, one of the study's authors. "We are looking at the scope of the problem now among the population back in the United States." The study also shows that 19.5% of veterans had received a concussion or other traumatic brain injury during their combat tour, a number similar to Army estimates.
     Some service members may actively avoid a diagnosis of a mental health problem, fearing the negative consequences of being diagnosed with a stress disorder or depression, according to the study. These troops are worried that their career could be hurt or co-workers would have less confidence in them after a diagnosis. "When we asked folks what was limiting them from getting the help that they need, among the top barriers that were reported were really negative career repercussions," Tanielian said.
     The report recommends finding ways to allow service members to get mental healthcare "off the record" so that they would not have to disclose it to superior officers, unless it was those officers who referred the service member for help. Since some soldiers and Marines fear that seeking treatment will prevent them from being redeployed with their unit, the study authors also recommend not basing fitness-for-duty reports on whether a service member has sought mental healthcare.
     Those service members who want treatment face a dearth of healthcare providers with expertise in treating war-related mental disorders, the study found. The shortage leads to long wait times that discourage some people from getting help. Thousands more mental health professionals -- both in government hospitals and the civilian healthcare systems -- are needed to meet the need of troops and veterans, and new training is needed for current medical professionals, according to the report. "Since the dramatic increase in the need for services exists now, the required expansion in trained providers is already several years overdue," the report said.
     The study recommends finding ways to help Iraq and Afghanistan veterans get access to the civilian mental health providers. Mental healthcare also needs to be standardized and improved, and only a little more than half of the service members being treated for stress disorders and depressions received adequate care, according to the survey. "The prevalence of PTSD and major depression will likely remain high unless greater efforts are made to enhance systems of care for these individuals," the report said.
     Stress disorders and other combat-related mental ailments can lead to suicide, homelessness and physical health problems. But more mundane problems caused by stress disorders and depression can have long-term social consequences. "These conditions can impair relationships, disrupt marriages, aggravate the difficulties of parenting, and cause problems in children that may extend the consequences of combat trauma across generations," the study says.
     The failure to adequately treat depression and stress disorders can cost the United States up to $6.2 billion, said Lisa H. Jaycox, another of the study's authors. "While the existing therapies do not guarantee recovery in 100% of people," Jaycox said, "we make the case that investing in treatment early would prevent some of the negative consequences from unfolding and save money."
On the Net: Rand Corporation: http://www.rand.org
Army studies: http://www.armymedicine.army.mil



The Expanding Safety Net
Elizabeth Stone, New York Times- 4/20/2008

It was just before dawn, and the Salt Lake City campus of the University of Utah was deserted except for a silent squad of workers, four dozen strong. They carried 6,000 handwritten notes that had taken three weeks to prepare. By sunrise, the notes were scattered on tables, under chairs, in hallways — like seeds they hoped would take root. A few hours later, Bonnie Owens happened on one missive as she made her way through the student union. “I had this voyeuristic moment,” says Ms. Owens, a senior. “Though I could see the writing, I couldn’t read it, so I moved closer. The note said something like, ‘Sometimes, it’s all too much — maybe I should just get it over with.’ It was about suicide!” Others were also unnerved, wondering whom to call. One administrator told the counseling center’s director, Lauren Weitzman, that he had considered ordering a building lockdown. (This is the state, after all, where concealed weapons are permitted on public campuses.)
      But the notes were pure fiction, part of a campaign to reinforce the idea that emotional aches and pains are part of living and to increase awareness of the counseling center. It worked for Ms. Owens, who spotted the Web address, bigthingslittlethings.com, scribbled at the bottom of her note. “I thought, ‘Wait, what’s this?’ ” The counseling center is just a click away.
     Nationally, the suicide rate for college students has remained doggedly constant, though several campus murder-suicides last year have intensified efforts to find troubled students before the little things become too big. A year ago last Wednesday, Seung-Hui Cho killed 32 people and then himself at Virginia Polytechnic Institute, in Blacksburg; on Feb. 8, Latina Williams, a student at Louisiana Technical College in Baton Rouge, killed two and then herself. Six days later, Steven P. Kazmierczak, a graduate student at the University of Illinois, Urbana, took his own life after shooting five at Northern Illinois University, where he had graduated the previous spring.
     College counselors say they are seeing more students arrive on campus with serious mental health problems, and some campuses report twice as many in treatment as a decade ago. According to the Association for University and College Counseling Center Directors, 63 percent of colleges, including Virginia Tech, now have psychiatrists on staff at least part time, because so many students are on psychotropic medications. Overburdened counseling centers are adding clinicians: Virginia Tech hired three this year and will add three more in the fall.
     At the same time, some of the most troubled students are not seeking help. Recent surveys of counseling directors indicate that about four of five students who commit suicide are not in treatment at counseling centers. This was true of Mr. Cho. Ms. Williams’s college did not have a counseling facility. The Illinois universities have declined to say if Mr. Kazmierczak had come to their attention for mental health issues.
     Difficult as it is to identify students who might be suicidal, it’s even more complicated to find those who might be contemplating murder as well. An investigation into the events of April 16, 2007 (or, as it’s referred to at Virginia Tech, 4/16), blamed a failure by the university to “connect the dots,” as well as confusion over what could be shared about a student’s mental health under federal privacy law. Mr. Cho’s menacing prose had alarmed his professors, but their e-mail alerts to administrators received no response. Virginia Tech’s Care Team, long responsible for setting up plans for dealing with students at risk, now meets weekly instead of “as needed,” and a campus police representative and faculty members have been added to the group.
     But an incident in November underscores the complexities in identifying suicidal students — and keeping firearms out of their hands. This time, the e-mail warning — sent about Daniel Kim, a senior, by one of his online gaming buddies — prompted a response from the newly retooled Care Team. The friend said that Mr. Kim had bought a gun and was suicidal. A Blacksburg police officer, sent to Mr. Kim’s home, reported back that Mr. Kim was not a threat to himself, according to Larry Hincker, a university spokesman, and a background check found that no gun had been bought. “Given what we knew, we saw no need to go further,” says Mr. Hincker.
     In December, Mr. Kim got in his car, drove five miles to a deserted mall parking lot and shot himself in the head, using a gun bought after the background check. Gregory Eells, director of Cornell’s counseling service and president of the counseling center directors’ association, acknowledges: “There are so many contextual factors. In some cases, it’s obvious what to do, but most of the time, it’s a judgment call.”
     Since last April, the federal government has sought to resolve confusion over privacy laws, including proposing regulations last month clarifying when a student’s health information can be released and when parents can be called. Virginia Tech had the right to contact Daniel Kim’s parents. It chose not to. Another university might have.
     New York University and seven other campuses have been working in concert to identify students suffering from depression who are not getting help. Dr. Henry Chung, associate vice president for student health at N.Y.U., says males and members of minority groups, particularly Asians and Asian-Americans, are less likely to seek treatment because they see a stigma associated with therapy. And, he says, they are less likely to speak candidly about their feelings when asked. So Dr. Chung is making an end run around their reluctance by using the campus health center as a resource. “Ten to 15 percent of students will use a well-functioning counseling center,” he says, “but 50 to 80 percent will come to a well-functioning health center.”
     At the participating universities, every single student who visited the health center over 18 months, even for the sniffles, was screened for depression. Among the 40,000 evaluated, 800 were at least moderately depressed and reported not functioning well academically or socially. These students were given the option of either getting help at the counseling center or remaining with their primary care doctors at the health center. The burden was on the colleges to keep the students coming back, and not all were equally successful. Dr. Chung, a psychiatrist, says that 45 percent of the depressed students had improved by the end of eight weeks. In June, Dr. Chung will begin a similar project, this time with 30 colleges participating and a grant to improve follow-up.
     According to Dr. Chung, men were still underrepresented among the 800. “We haven’t done a very good job to get males to utilize health care of any sort,” he says. But ethnic and racial minorities were slightly overrepresented. That was good news to Dr. Chung, because those students’ problems would otherwise have gone undetected. With minority and immigrant students now accounting for 30 percent of all students, Dr. Chung’s concerns are increasingly shared by other colleges.
     National data does not distinguish among minority groups, but a study by Cornell of its own students found that 63 percent of those who attempted suicide from 2003 to 2005 were foreign-born, and half were Asian or Asian-American. Asian women were five times more likely to attempt suicide than white women.
     At Cornell, if troubled students won’t come to treatment, then treatment will meet them halfway: the university has strategically placed 10 drop-in centers so students it wants to reach can’t miss them. One is near the office for International Students and the Latino Studies Program. In 2006-7, 58 percent of those who dropped in to talk were members of minorities, while the counseling center’s share is only 34 percent, says Matt Boone, the coordinator of the program, called Let’s Talk. The treatment that Cornell makes available beyond the counseling center is not psychotherapy but troubleshooting, in all aspects of a student’s life. “Stress in someone’s life can become a trigger for depression,” Mr. Boone explains. “If we identify the stress — financial aid, visa problems, problems with a professor, poor grades — then we can nip it in the bud.”
      If students don’t drop into the first safety net, there is a second, called Community Consultation and Intervention. Its two clinicians devote their days to advising professors, resident advisers and anyone else who alerts them to a student in trouble. The two help 300 or so students a year, most of whom they never meet; they solve their practical problems behind the scenes. This could mean intervening when a student has a “dysfunctional” relationship with a graduate professor with a big say in the student’s future, or when a foreign student is having trouble adapting to a new culture, or when a student is unable to get housing.
     Anecdotally, at least, the program has succeeded, says Sharon Mier, one of the clinicians. Not too long ago, she says, she was called about a student whose graduation was in peril because his father was ill and unable to pay the final semester’s tuition. The student had begun selling his possessions to pay his bill, but on the day the final payment was due, the sale of a major item fell through. “We were able to work with a number of people to help him develop a plan to make payments over time,” she says. “When we gave him the news that we had a solution, he broke down and told us that he had planned to kill himself later in the day.”
     While campuses have expanded their efforts to discover students who might hurt themselves, they are simultaneously on the alert for students like Mr. Cho and Mr. Kazmierczak. These students are psychologically distinct from the simply suicidal and are harder to identify, says Dr. Peter M. Marzuk, a professor of psychiatry at Cornell Medical College whose research interest is mass murderers who commit suicide. “They are not impulsive,” he says. “They are aggrieved brooders, possibly with a history of violence or paranoia, and they plan their attack. Most of all, what distinguishes these people is they want to be in control. Killing others makes them feel in control, and the final act of killing themselves before they can be apprehended is also a way of being in control.” He adds: “I want to stress that this group is very, very rare, but it is also the case that there is no way of predicting who will be a murder-suicide, because so many people with this brooding, aggrieved profile do not.”
     Paradoxically, the University of Illinois, where Mr. Kazmierczak had begun his studies in September, has long been recognized for its suicide prevention program. Since the program began, in 1984, the university’s suicide rate has been cut in half. Now it is refining its approach to discover students who have the potential to commit violence. “In the year since Virginia Tech, the university has intensified efforts to find students who display what we call excessive ‘in chargeness,’ ” says Paul Joffe, a psychologist and director of the program. “That might be someone who is too vehement in pursuing a romantic partner who declines contact,” or someone who makes a threat of violence that leaves “a reasonable person in fear of his safety.”
     Mr. Joffe will not discuss details but says this: “When we identify a student with such a difficulty, we see if we can address that behavior. If the student can live with the limits we set, fine. If the student persists in the behavior, we get doubly concerned.” Sanctions, including suspension, are policy here, an approach that meets with approval from the university’s lawyers. George Washington University lost a lawsuit in 2006 for suspending a student because he had sought treatment for depression. Increasingly, though, suicidal students are required to take medical leaves of absence until they can document that they’re better, says Dr. Eells of Cornell.
     Illinois is also grappling with how to respond to a student whose creative works suggest violence. Previously, a piece of violent fiction passed on to the counseling center by a teacher would be followed up only if it included a named target, says Mr. Joffe. This policy changed when it became apparent that they would never have had the chance to evaluate Mr. Cho. “His writing was homicidal, but it was often fantasy, divorced from his present-day community,” Mr. Joffe says. Now a student who writes anything focused on killing should be called in.
     Asking a counseling center to examine a creative writing assignment for its pathology was never part of the role most college counselors envisioned when they got into the field. As Richard J. Ferraro, assistant vice president for student affairs at Virginia Tech, says, “The original mission of the counseling centers had been to support the academic mission,” helping those stumbling academically as they dealt with the usual problems of growing up. Today, that’s no longer enough. “Increasingly,” he says, “counseling centers on college campuses will need to deal with long-term and grave cases as well.”

For years, medical schools and residency training programs studiously avoided the topic of emotions. Doctors learned the nuts and bolts of cancer and other serious diseases. Yet when it came time to reveal grim diagnoses, they were largely on their own.

These days, all medical schools have some type of education in topics like the physician-patient relationship and breaking bad news. But knowing how to respond to a personal wave of stress or sadness remains a major challenge. Is crying O.K.? How about hugging a patient who starts to cry?

One physician who cautions against excess emotions is Dr. Hiram S. Cody III, acting chief of the breast cancer service at Memorial Sloan-Kettering Cancer Center. Although Dr. Cody emphasizes the need for doctors “to understand, to sympathize, to empathize and to reassure,” he says his job “is not to be emotional and/or cry with my patients.”

There are two reasons for this stance, Dr. Cody tells young physicians on rounds: It is not therapeutic for the patient, and it will cause “emotional burnout” in the doctor. These beliefs are shared by many other physicians, but some new data suggest that crying in a medical setting is common among young doctors. At a recent meeting of the Society of General Internal Medicine, Dr. Anthony D. Sung of Harvard Medical School and colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once. As might be expected, more than twice as many women cried as men.

In some instances on the wards, the emotions just flow. For example, in the 1988 PBS documentary “Can We Make a Better Doctor?” a Harvard medical student, Jane Liebschutz, sees her patient unexpectedly die during a cardiac bypass operation. She suddenly bursts into tears and wanders away from her colleagues until the chief surgeon, who has witnessed what happened, assures her that her response was natural.

Other physicians may choose to place themselves in emotional situations. Dr. May Hua, an anesthesiology resident at Columbia University Medical Center, recently told me that during her internship, her supervising resident, Dr. Benita Burke, skipped lunch to spend extra time with her cancer patients. They dubbed this time “mental health rounds,” during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace. “I think patients adored Benita,” Dr. Hua said, “both as their doctor and as their friend.”

But even as she admired her colleague, Dr. Hua realized that such public emotion was not for her. “I knew this was something I couldn’t do, because I needed to have a level of detachment to these people.” I understood exactly what Dr. Hua meant. Whether because of my personality or my being a man, I, too, have never cried in front of a patient.

Dr. Burke says she believes that her crying stems from being “very involved” in her cases, which leads her to “take everything to heart.” In the case of the lung cancer patient, Dr. Burke had been the first physician to inform her that further aggressive treatment was unlikely to help. In other words, the patient was dying.

Dr. Burke said she realized that this level of involvement was uncommon but believed that she could not be any other kind of doctor. “I’ve always been a very emotional person at baseline,” she said.

Dr. Sung’s study concludes with a call for senior doctors to acknowledge and discuss openly the apparent high rates of crying among medical trainees. Yet while health professionals — not only physicians but also nurses and social workers — may debate among themselves the propriety of emotional displays, what probably matters most is what patients think. Just as different doctors respond differently to sad situations, so do patients and their families. While some might appreciate physical contact or tears, others find such displays to be too “touchy-feely.”

Cancer patients may encounter such situations more than most. One breast cancer survivor, Sharon Rapoport, of Roanoke, Va., said she greatly admired physicians like Dr. Cody, who may appear reserved but communicate their concern through their actions. But Ms. Rapoport also said she had an extra appreciation for doctors who felt comfortable with outward displays of emotion. “If that means tears,” she said, “bring them on.”

Dr. Barron H. Lerner teaches medicine and public health at Columbia University Medical Center.

In a slurred voice, heavy from weeping, the veteran, named Robert, told her that he was homeless and wanted to “just lay down in the river and never get up.” Ms. Nosewicz, a social worker, listened. Then in a voice firm and comforting like a big sister, she said: “We don’t want you to either. Today we’re not thinking about the alcohol or the housing, Robert. Today it’s about keeping you safe.” She gave an assistant Robert’s phone number to find his address and alert local police to stand by. The chain of care resembled a relay race, with one runner trying not let go of the baton until the next runner had it in hand.

The veterans hot line is part of a specialized effort by the Department of Veterans Affairs to reduce suicide by enabling counselors, for the first time, to instantly check a veteran’s medical records and then combine emergency response with local follow-up services. It comes after years of criticism that the department has been neglecting tens of thousands of wounded service men and women who have returned from war zones in Iraq and Afghanistan.

On Monday, a class action suit brought by veterans groups opened in San Francisco charging a “systemwide breakdown,” citing long delays in receiving disability benefits and flaws in the way discharged soldiers at risk for suicide had been treated. Kerri J. Childress, a department spokeswoman, said Monday that there were an average of 18 suicides a day among America’s 25 million veterans and that more than a fifth were committed by men and women being treated by Veterans Affairs.

Up and running since August, the hot line tries to respond to at least some of those in crisis. Over eight months, it has received more than 37,200 calls and made more than 720 rescues — sending out, from a narrow office here in upstate New York, emergency responders all over the country to find someone on a bridge, with a gun in his hand, with a stomach full of pills.

Paul Sullivan, the director of Veterans for Common Sense, one of the groups involved in the lawsuit, said of the department: “I’m pleased they’re responding. However, much more needs to be done so vets aren’t turned away from health care and don’t have to wait for benefits.”

Mr. Sullivan says suicidal patients have not been able to get care promptly; he cited the case of Jonathan Schulze, who was turned away twice from a Veterans Affairs hospital before he killed himself in January 2007. “More than 600,000 veterans are waiting, on average, more than six months for disability benefits,” said Mr. Sullivan, who worked at the department monitoring benefits.

Experts agree that veterans are more likely, perhaps twice as much, to commit suicide as people who have never served in the military. Meanwhile, a study released last week by the RAND Corporation estimates that roughly one in five veterans of Iraq and Afghanistan has symptoms of post-traumatic stress disorder, which heightens the risk of suicide.

Yet whatever larger failings may exist, the staff of social workers, addiction specialists and nurses who keep the hot line running — 24 hours a day, seven days a week — can count at least some victories by the end of each shift.

Unique about this hot line, said Janet Kemp, the national suicide prevention coordinator with the department, is that now the counselors have medical information at their fingertips, which they use to connect vets with counseling near their homes. The model evolved from a new research program on suicide prevention paid for by the department.

“For years people thought that asking questions about suicide put the thought in people’s mind, but now we know that’s not true,” said Dr. Kemp, who travels throughout the country training V.A. staff.

The department is spending about $3 million to start and operate the hot line during its first year, said a spokesman, Daniel Ryan, and another $2.9 million on a mental health research center at the sprawling red-brick V.A. Medical Center in Canandaigua. Referring to the hot line’s relay model, Kerry Knox, the director of the new research center, said, “You don’t want them to fall through the cracks.”

With Robert, for example — whose last name was not provided for confidentiality — Ms. Nosewicz gradually nudged him to agree to be taken to a hospital and to give his name and Social Security number so she could check his file and put him in contact with the department’s suicide prevention coordinator in his area.

Meanwhile, Denise Slocum, a health assistant, relayed questions from the local police dispatcher. “The police are asking if you’re near an elementary school,” asked Ms. Nosewicz, who then nodded her head at Ms. Slocum. “No, no, no — no handcuffs,” Ms. Nosewicz reassured Robert. “You’re going to go to the hospital.” “Do you have a tissue to blow your nose? Then use your sleeve.” “When they come in, you put them on the phone with me, and I’ll tell them to treat you with respect.”

Twenty minutes later, Ms. Slocum called the police again to confirm that Robert had been taken to a hospital. Ms. Nosewicz alerted the prevention coordinator. One is at each of the department’s 156 health centers. Robert’s name was added to a board near the doorway so that the staff could follow up to ensure a local counselor actually met with him.

Of course, sometimes a crack is unavoidable. “He’s going to do it. He’s really going to do it,” said Terri Rose, a counselor who was working the noon-to-midnight shift. She was wiping her red-rimmed eyes. A caller from Texas, who said he was 65 and a helicopter gunner in Vietnam, said he had a suicide pact with his friend, but the friend had gone off and killed himself. Now he, too, was ready to die, saying he had even found a coffin for $150, said Ms. Rose, who is an Air Force veteran herself. The veteran hung up and had stopped answering her calls.

Sometimes veterans have a lot of trouble asking for help, said Jacalyn O’Loughlin, a counselor. “They keep saying, ‘I’m sorry, I’m sorry, I’m sorry,’ ” Ms. O’Loughlin said. “Especially marines. They feel they’re weak if they reach out.”

Mr. Ryan said about half the calls to the hot line — 1-800-273-TALK (8255) — were from veterans, split fairly evenly between Vietnam and Iraq. Family members and friends also frequently call. About 30 percent of the veterans are women.

A couple of months ago, Ms. O’Loughlin said, a distraught woman called from Oregon who was driving to the woods and then threatened to “walk and walk and walk and never come back.” Ms. O’Loughlin rang the tiny silver bell on her desk to signal the health technician. The health tech checked the area code and phoned the closest Veterans Affairs health center.

“And lo and behold, that suicide prevention coordinator knew her just by her first name,” Ms. O’Loughlin said. The tech called the police and the coordinator called the woman’s husband, getting the car’s make and model. Ms. O’Loughlin kept her on the line; when she hung up, Ms. O’Loughlin called her back. “This went on for hours,” she said. “I could hear her getting out of the car. I could hear the rustling from the leaves.”

Meanwhile, the police and her husband were driving up and down roads. They spotted the car, dashed through the trees and found her. She had a bottle of pills in her hand but had not yet swallowed them.

Sometimes, the victories are smaller but no less satisfying. That morning, Ms. Nosewicz spoke to a veteran whose house was destroyed by Hurricane Katrina; he had been relocated to a different state. “He called crying because he can’t find a job, saying ‘my teeth are so rotten and my mouth stinks,’ ” Ms. Nosewicz said.

Dental referrals are not exactly part of the job description, but Ms. Nosewicz tried dental schools in his area until she found a school to do the work. “He was crying on the phone,” she recalled, “and said, ‘Thanks so much. Thanks so much.’ ” All in all not a bad day’s work, Ms. Nosewicz said, as she got ready to leave. “Three rescues, four consults and one set of teeth.”

Akaka, the committee's chairman, said in a letter to the VA that Katz's "personal conduct and professional judgment" had been called into question by his response to veteran suicides. Veterans, and the VA itself, "would be best served by his immediate resignation," Akaka said.

A number of Democratic senators said they were appalled at e-mails showing Katz and other VA officials apparently trying to conceal the number of suicides by veterans. An e-mail message from Katz disclosed this week as part of a lawsuit that went to trial in San Francisco starts with "Shh!" and claims 12,000 veterans a year attempt suicide while under department treatment. "Is this something we should (carefully) address ourselves in some sort of release before someone stumbles on it?" the e-mail asks. A VA spokesman declined to comment Tuesday. Another e-mail said an average of 18 war veterans kill themselves each day and five of them are under VA care when they commit suicide.

"It is completely outrageous that the federal agency charged with helping veterans would instead cover up the hard truth, that more and more Americans coming home after bravely fighting for their country are suffering from mental illnesses and in the most tragic circumstances, committing suicide," said Sen. Tom Harkin, D-Iowa. "Anyone at the VA who is involved in this cover-up should be removed immediately."

Harkin, Murray and Sen. Russ Feingold, D-Wis., introduced legislation Tuesday calling on the VA to track how many veterans commit suicide each year. Currently, VA facilities record the number of suicides and attempted suicides in VA facilities _ but do not record how many veterans overall take their own lives. The agency, however, is reluctant to disclose specific numbers, veterans advocates complain.

The new bill would require the VA to report to Congress within 180 days the number of veterans who have died by suicide since Jan. 1, 1997, and continue reports annually. Harkin's office said statistics provided earlier this year by the VA showed that 790 veterans under VA care attempted suicide in 2007. That figure is contradicted by the e-mail revealed this week.

Two veterans groups last year filed the class-action lawsuit against a sprawling VA system that handled a record 838,000 claims last year. A government lawyer on Monday urged a judge to dismiss the lawsuit, saying the agency runs a "world class" medical care system.



Elderly Drinkers May Be Putting Themselves at Risk
Deborah Shelton, Chicago Tribune- 4/22/2008

The 71-year-old former community college teacher was struggling in her retirement. She missed her job. Divorced and living alone, with her children far away, she felt increasingly isolated and lonely. As boredom and depression sunk in, she turned more and more to alcohol for solace. But her drinking presented a whole new set of problems. The retired Chicago teacher stopped eating and lost weight, and she fell several times, injuring herself.

With the nation's population graying, health professionals have grown increasingly concerned about the number of people 65 and older who drink unhealthy amounts of alcohol. A recent study published in the Journal of the American Geriatrics Society reported that 9 percent of elderly Medicare beneficiaries—16 percent of the men and 4 percent of the women—engaged in unhealthy drinking. Researchers said those numbers could be conservative because they are based on self-reporting.

Establishing the profile
Unhealthy drinking was defined in the study as consuming more than 30 drinks a month or drinking more than three drinks on any single day in a typical month. Elderly people with higher incomes and educational levels, and those who were smokers, white, unmarried or perceived themselves as healthy were more likely to be unhealthy drinkers, according to the study. Funded by the National Institute on Alcohol Abuse and Alcoholism, the study evaluated data on 12,413 Medicare beneficiaries age 65 and older.

According to the guidelines of the national institute and the American Geriatrics Society, risky drinking for someone 65 or older involves consuming more than seven drinks weekly or more than three drinks on a single day. Other guidelines have suggested that single-occasion drinking should be limited to no more than two drinks. Guidelines advise women to drink lower amounts than men.

Age alters sensitivity
Because older adults are more sensitive to alcohol and less able to metabolize it, the recommended limits are lower for older adults than for younger people. "It's important for health-care providers and others who work with this population to be aware of this issue so they can screen for it and talk to people about the maximum amount of drinking that is healthy," said study co-author Dr. Elizabeth Merrick, a senior scientist at Brandeis University's Heller School for Social Policy and Management. Stigma remains an issue, and many older adults are reluctant to seek treatment on their own, some health professionals said. Berger recounted the story of the retired Chicago teacher but did not disclose the woman's name to protect her privacy. No seniors contacted for this story agreed to be interviewed.

Merrick emphasized that not every older adult who drinks more than the recommended amounts is an alcoholic. "But people who drink over the guidelines could potentially be putting themselves at risk of many adverse events, even if they don't have an alcohol disorder per se," she said. It is important for older adults to talk to their physicians about the risks and benefits of drinking, taking into account their specific health status and current medications, she said. "For some people, any alcohol can be a problem," Merrick said. "For others, drinking up to these recommended limits could be fine."

Unhealthy drinkers span the spectrum—from those who have been drinking excessively for years to those who only recently picked up the habit, said Jill Berger, a licensed clinical social worker in the division of geriatrics at Northwestern Medical Faculty Foundation.

Harder to detect
But it can be harder to identify problem drinkers when they are older. Typical signs of a serious problem seen in younger people, such as poor work performance, getting in fights or not getting along with loved ones at home, are not always applicable to older people, who are less likely to get involved in physical altercations and may be retired and living alone.

Alcohol can exacerbate dementia and mask other health problems, Berger said. Older drinkers also may become more depressed, lose their appetite or forget to eat. Because of the possibility of dangerous drug interactions, drinking can be particularly hazardous for older adults who take prescription medication. "They tend to have problems with balance—falling more because they are intoxicated," she said. "They might stay in bed for long periods. In some cases, they become bed-bound and are no longer able to get up and move around like they used to. Once they get to that point, they may need physical therapy."

Older adults sometimes try to live independently longer—and perhaps unsafely—in housing that doesn't suit their needs because they don't want to give up drinking, said Anna Walters, program director at the Chicago chapter of Little Brothers—Friends of the Elderly, a national network of volunteer-based organizations. Nursing homes typically prohibit alcohol.

Need for treatment
And the lack of outpatient programs geared toward the needs of older adults can make it difficult to get them into treatment, Walters said. Inpatient medical detox programs are sometimes necessary for long-term drinkers. Nutritional and psychological issues need to be addressed as well. Walters said drinkers who don't want to stop are referred to community agencies that provide in-home support services, such as a cook or housekeeper, to maximize their safety at home.

As a starting point, family members worried about an older parent or relative should share their concerns with that person's health-care provider, Berger said. The retired teacher from Chicago was lucky, she said. A visit to her primary-care doctor uncovered her drinking problem and she got help. Today she is doing well.



Risks of Depression Dims Hopes for Anti-Addiction Drug
Associated Press, 4/23/2008

CHICAGO -- Two years ago, scientists had high hopes for new pills that would help people quit smoking, lose weight and maybe kick other tough addictions like alcohol and cocaine.

The pills worked in a novel way, by blocking pleasure centers in the brain that provide the feel-good response from smoking or eating. Now it seems the drugs may block pleasure too well, possibly raising the risk of depression and suicide.

Margaret Bastian of suburban Rochester, N.Y., was among patients who reported problems with Chantix, a highly touted quit-smoking pill from Pfizer Inc. that has been linked to dozens of reports of suicides and hundreds of suicidal behaviors.

''I started to get severely depressed and just going down into that hole ... the one you can't crawl out of,'' said Bastian, whose doctor took her off Chantix after she swallowed too many sleeping pills and other medicines one night.

Side effects also plague two other drugs:
-- Rimonabant, an obesity pill sold as Acomplia in Europe, was tied to higher rates of depression and a suicide in a study last month. The maker, Sanofi-Aventis SA, still hopes to win its approval in the United States.
-- Taranabant, a similar pill in late-stage testing, led to higher rates of depression and other side effects in a study last month. Its maker, Merck & Co., stopped testing it at middle and high doses.

The makers of the new drugs insist they are safe, although perhaps not for everyone, such as people with a history of depression. Having to restrict the drugs' use would be a big setback because it would deprive the very people who need help the most, since addictions and depression often go hand-in-hand, doctors say.

A bigger fear is that the whole approach may be in trouble. Researchers say blocking pleasure, especially the way the obesity drugs do, might take the fun out of many things, not just the harmful substances and behaviors these drugs target.

It may be possible to improve the drugs so they act more precisely. Chantix targets a different pathway -- nicotine pleasure switches -- and in a different way than the obesity drugs, which aim at the same pathway that gives pot smokers the munchies. That is one reason many doctors are optimistic that any risks about Chantix will prove manageable.

But doctors are no longer talking about so-called ''super pills'' for a host of addictions. ''It certainly diminishes my enthusiasm'' to see these side effects, said Mark Egli, co-leader of medicine development at the National Institute on Alcohol Abuse and Alcoholism.

The buzz started four years ago, when studies showed rimonabant helped people shed weight and keep it off longer than previous pills had. It also was being tested for smoking cessation. The Associated Press and other media reported extensively on prospects for a pill that might tackle two big problems at once.

Rimonabant won approval in Europe. But advisers to the U.S. Food and Drug Administration opposed it because of depression risks that became clearer with further study. Sanofi withdrew its U.S. application and said it hoped to resubmit after more research.

But in a new study last month, 43 percent of people taking rimonabant developed psychiatric issues versus 28 percent of those on dummy pills. One rimonabant patient committed suicide and one in the placebo group tried to. Unlike previous studies, this one did not exclude people who had depression in the past. ''I felt it was important to do an 'all-comers' study'' to see how real-world patients might fare, said Cleveland Clinic's Dr. Steven Nissen, who led the work.

Sanofi now tells doctors to avoid giving the drug to people with a history of depression, said a company vice president, Dr. Douglas Greene. ''We are at the cutting edge of being able to manage this risk,'' he said.

Meanwhile, Merck had bad news from a study of its obesity drug, taranabant, which showed an increased risk of depression and other side effects among people taking medium and high doses. ''We're doing a lot to define this risk-benefit,'' including adding another year to all studies under way and going forward only with the lowest dose, said a Merck vice president, Dr. John Amatruda.

Others were less optimistic. ''The door is closing'' on this approach, said Dr. James Stein, a University of Wisconsin-Madison cardiologist. If another study he is helping lead does not show benefit for rimonabant, ''this drug's already slim chances of approval will be even more jeopardized,'' he said.

The situation is murkier with Chantix, which went on sale in the U.S. in 2006 and is sold as Champix in other countries. The drug binds to the same spots in the brain that nicotine does when people smoke, causing release of a ''feel-good'' chemical, dopamine. Taking it is supposed to keep any inhaled nicotine from giving the same buzz.

In February, the FDA said a link between Chantix and psychiatric problems appears ''increasingly likely.'' Pfizer added warnings to the drug's label and said that although a link had not been proved, it could not be ruled out.

But a Pfizer vice president, Dr. Ponni Subbiah, said nicotine withdrawal and even quitting smoking can cause mood swings and depression. It is hard to know ''what is causing what,'' she said. ''We know that smokers are at higher risk of suicide than non-smokers, and heavy smokers are at higher risk than lighter smokers.''

Some doctors agreed. ''Psychologically, just giving up this 'friend' that they've had many years in their life can be depressing,'' said Dr. Geoffrey Williams, co-director of the Greater Rochester Area Tobacco Cessation Center and a paid speaker for Pfizer.

Jeanne Morrison, 63, of suburban of Louisville, Ky., looked forward to giving up cigarettes when she and a friend went on Chantix. The friend did well, but Morrison lasted only 10 days on it.

''I got so depressed, I didn't want to go anywhere. I didn't want to do anything, and I'm a very high-energy person. It was a depression like I've never experienced in my life,'' she said. She also had ''major, major nightmares. These would wake me up, and I would be absolutely shaking and sweating.''

Several doctors said such reactions are rare, and that most patients do well on Chantix. Morrison's doctor, psychiatrist Dr. Jesse Wright at the University of Louisville, said Chantix helped one of his schizophrenic patients, ''who smoked like a smokestack,'' without worsening his psychological symptoms.

''The risk-benefit ratio is still very much on the side of use of the medication,'' Williams said. ''The alternative, smoking, is extremely highly risky.''