Noteworthy News Articles on Mental Health Topics, January 27-31, 2008



In More Cases, Combat Trauma Is Taking the Stand
Deborah Sontag & bLizette Alvarez- New York Times- 1/27/2008

When it came time to sentence James Allen Gregg for his conviction on murder charges, the judge in South Dakota took a moment to reflect on the defendant as an Iraq combat veteran who suffered from severe post-traumatic stress disorder.

“This is a terrible case, as all here have observed,” said Judge Charles B. Kornmann of United States District Court. “Obviously not all the casualties coming home from Iraq or Afghanistan come home in body bags.”

Judge Kornmann noted that Mr. Gregg, a fresh-faced young man who grew up on a cattle ranch, led “an exemplary life until that day, that terrible morning.” With no criminal record or psychiatric history, Mr. Gregg had started unraveling in Iraq, growing disillusioned with the war and volunteering for dangerous missions in the hope of getting killed, he testified.

Nonetheless, the judge found that Mr. Gregg’s combat trauma had not rendered him incapable of comprehending his actions when he shot an acquaintance in the back, fled the scene, and then pointed the gun at himself as a SWAT team approached — the helmeted officers “low crawling,” Mr. Gregg testified, and looking “like my own soldiers turning on me.”

When combat veterans like Mr. Gregg stand accused of killings and other offenses on their return from Iraq and Afghanistan, prosecutors, judges and juries are increasingly prodded to assess the role of combat trauma in their crimes and whether they deserve special treatment because of it.

That idea has met with considerable resistance from prosecutors and judges leery of creating any class of offenders with distinct privileges. In Mr. Gregg’s case, for instance, Judge Kornmann cautioned the jury that nobody got “a free pass to shoot somebody” because they “went to Iraq or Afghanistan or the moon.”

Still, more and more, with the troops’ mental health a rising concern, these defendants are succeeding in at least raising the issue of psychological war injuries. Aggressive defense lawyers, many in the military bar, are insisting that Iraq or Afghanistan be factored into the calculus of justice in these cases. They are arguing that war be seen as the backdrop for these crimes, most of which are committed by individuals without criminal records.

“I think they should always receive some kind of consideration for the fact that their mind has been broken by war,” said Lt. Col. Colby Vokey, Western regional defense counsel for the Marines.

Last year, California became the first state to pass legislation dealing with the small fraction of Iraq and Afghanistan veterans who end up entangled with the law. Updating a Vietnam-era statute, Gov. Arnold Schwarzenegger quietly signed a bill that permitted judges to divert troubled veterans into treatment programs.

“This is going to be on my tombstone, this bill,” said Pete Conaty, a Vietnam veteran who lobbied for it. “It has been a personal crusade of mine to make sure we don’t make the same mistake with Iraqi vets as we did with my generation.”

But the California law applies only to lesser crimes, as, in all likelihood, will any bills that it inspires, like one being debated in Minnesota.

Iraq and Afghanistan veterans facing homicide charges must defend themselves without the benefit of such laws. And in so doing, they often provoke intense moral and legal wrangling, turning local courthouses into unlikely forums for debate on the effects of the war.

Generally that debate takes place behind closed doors during plea negotiations. In cases that go to trial, however, the scene can be surreal, with Iraq commanding center stage as testimony about fingerprints and blood spatter alternates with questioning about mortar attacks in Baquba and civilian casualties in Baghdad.

Service members, sometimes wearing dress uniforms and spit-shined shoes, introduce their psychiatric evaluations into evidence and put their military colleagues on the stand to argue that the crime in question was completely out of character.

Tim Long, for instance, a company first sergeant with the South Dakota National Guard, testified about Mr. Gregg, whom he had nominated for a Bronze Star. “He’s a young farm boy, you know?” he said. “Competent young man. My friend.”

A Disorder Is Recognized
Born during the Vietnam War era, the combat version of what became known as the PTSD defense is being dusted off for a new generation of war veterans.

“I’m seeing it all the time now,” said David P. Sheldon, a civilian lawyer in Washington who represents military personnel. “And I will not be surprised to see this resonate as a consistent theme over the next few decades when people will be committing crimes after suffering repeated traumas in Iraq.”

It was in 1980, five years after the Vietnam War ended, that the psychiatric establishment first recognized post-traumatic stress disorder. Vietnam veterans quickly summoned it as a primary legal defense. In many cases, the veterans argued that they had been rendered temporarily insane as a result of flashbacks to the war while committing their crimes.

One of the first murder defendants to do so successfully was Charles G. Heads, who was found not guilty by reason of insanity for killing his brother-in-law a decade after he left Vietnam. Medical experts contended that Mr. Heads believed he was “cleaning out a hooch,” or hut, in Vietnam when he kicked in a door and shot his victim.

As time went on, the PTSD defense met increasing resistance just as the use of the insanity defense was limited by many states.

Taking a more cautious approach, the current generation of war-era defendants is most often using combat trauma not to escape culpability but to explain state of mind.

Were it not for their deployment to Iraq, they argue, they probably never would have committed the crime. Before Iraq, they claim, they were not paranoid, aggressive, jumpy or suicidal; they did not carry around loaded weapons, drink to excess, misread threats or explode in anger.

“In many of these cases, you have a nasty mix: a gun, intoxication and someone inaccurately assessing their environment and the consequences of their behavior,” said Thomas Grieger, a recently retired Navy forensic psychiatrist.

In general, the veterans raise their combat trauma during plea negotiations or in the sentencing phase of trials, hoping for reduced charges or a lesser sentence. Occasionally it works.

Anthony J. Klecker, a former marine, pleaded guilty to criminal vehicular homicide for a drunken crash that killed a high school cheerleader, Deanna Casey, in Minnesota in 2006. But his lawyer argued that Mr. Klecker, 29, who had already spent a year in jail, should be sentenced to six months of inpatient treatment instead of the 48 months in prison called for by sentencing guidelines.

“Tony would never, ever claim his war experiences, associated psychological injuries and alcoholism should excuse him from responsibility for Ms. Casey’s death,” his lawyer, Brockton D. Hunter, wrote the judge. But, he said, Mr. Klecker was a “psychological casualty of the war in Iraq who unsuccessfully sought treatment from an overstrained Veterans Administration.”

The state judge agreed to impose the alternative sentence, and Mr. Klecker was admitted to a dual program for substance abuse and PTSD at the Veterans Affairs hospital in St. Cloud, Minn.

But then things got complicated. After getting into a verbal fight with another veteran, Mr. Klecker lost his residency privileges. He was returned to jail; the prosecutor is seeking once more to send him to prison.

‘A Tale of Two Places’
“This is really a tale of two places,” James Gregg’s lawyer said during his opening statement in 2005 in the federal courthouse in Pierre, S.D.: the Crow Creek Indian Reservation where the killing took place and “a very, very faraway” place, “a place called Iraq.”

By framing the case this way from the start, the lawyer, Timothy J. Rensch, made it clear that Mr. Gregg’s explanation for the “murder in Indian country,” as the charge read, would be inextricably bound to his year as a National Guardsman in Iraq.

That approach rankled the prosecutor, who referred to it as “waving the flag,” although Mr. Rensch stated that he was not trying to use Iraq “as an excuse” since Mr. Gregg was arguing self-defense.

“But you need to understand about Iraq and what happened to Jim over there for you to be able to see things from his point of view, and understand his thinking, and especially understand, really, his desperation at the end,” Mr. Rensch said.

On the evening of July 3, 2004, Mr. Gregg, then 22, spent the night with friends in a roving pre-Independence Day celebration on the reservation where he grew up, part of a small non-Indian population. They drank at a Quonset hut bar called the Pit Stop, in a trailer community and finally at a mint farm where they built a bonfire, roasted marshmallows and made s’mores. According to the prosecutor, Mr. Gregg got upset because a young woman accompanying him gravitated to another man. This, the prosecutor said, led to Mr. Gregg spinning the wheels of his truck and spraying gravel on a car belonging to James Fallis, 26, a former high school football lineman who grew up performing American Indian dances on what is called the powwow circuit.

Some time later, a confrontation ensued. Mr. Gregg was severely beaten by Mr. Fallis and, primarily, by another man, suffering facial fractures. Later that night, with one eye swollen shut and a fat lip, he drove to Mr. Fallis’s neighborhood.

Mr. Fallis emerged from a trailer, removed his jacket, asked Mr. Gregg if he had come back for more and opened the door to Mr. Gregg’s pickup truck. Mr. Gregg then reached for the pistol that he carried with him after his return from Iraq. He pointed it at Mr. Fallis and warned him to back away.

Mr. Fallis moved toward the trunk of his car, and Mr. Gregg testified that he believed Mr. Fallis was going to get a weapon. He started shooting to stop him, he said, and then Mr. Fallis veered toward his house. Mr. Gregg fired nine times, and struck Mr. Fallis with five bullets.

Mr. Gregg drove quickly away, ending up in a pasture near his parents’ house. From there, he spoke on the phone to his best friend, Jacob Big Eagle, who told him that Mr. Fallis was dead.

According to Mr. Gregg’s testimony, he then put a magazine of more bullets in his gun, chambered a round and pointed it at his chest.

“Jim, why were you going to kill yourself?” his lawyer asked in court, seeking to rebut the prosecutor’s contention that guilt had driven him to suicidal despair.

“Because it felt like Iraq had come back,” Mr. Gregg said. “I felt hopeless. All that happened, no one would believe me. That I didn’t want this to happen. I never wanted to shoot him. Never wanted to hurt him. Never. Everything happened just so fast. I mean, it was almost instinct that I had to protect myself.”

Tense Courtroom Atmosphere
The atmosphere in the courtroom was tense throughout the trial, with American Indians on one side of the aisle and white ranchers on the other. Complicating matters, the participants in Mr. Gregg’s case traveled, in a sense, back and forth between the bluffs of the Missouri River and those of the Tigris as they grappled with the relevancy of his military experience.

Mr. Gregg joined the National Guard at 18. He was studying at a technical school, with the goal of becoming a diesel mechanic, when his combat engineering company, whose expertise resided in bridge building, was shipped to Iraq in the spring of 2003.

“He left for Iraq enthusiastic and energetic and eager to serve his country,” wrote one of four mental health professionals, including two government officials, who diagnosed PTSD in Mr. Gregg. He “returned impaired by PTSD complicated by his disillusionment with the military operation in Iraq.”

After building a bridge across the Tigris River, his National Guard company effectively became an infantry unit. Mr. Gregg estimated that he searched well over 10,000 vehicles and fired over 1,000 rounds.

Mr. Gregg found checkpoint duty unbearable, said Michael Furois, a Department of Veterans Affairs psychologist who treated him after his arrest. According to Mr. Furois’s testimony, Mr. Gregg disliked “standing guard at a gate when the Iraq civilians would bring in their dead or wounded and would be yelling and crying and blaming those at the gate for that occurring.”

After many months in Iraq, Mr. Gregg testified, he began to think about suicide, hoping that his “chance” at death would come if he volunteered for dangerous missions. His superior officer, Sergeant Long, testified that he selected him for a nighttime patrol team, instructing them never to hesitate when they perceived a threat because “if you hesitate, you’re dead.”

Cross-examining Sergeant Long, Mikal G. Hanson, an assistant United States attorney, asked him if he were implying that his instruction about hesitating had caused Mr. Gregg, on his return to the United States, to shoot “an unarmed civilian.” “I hope not,” Sergeant Long said.

When Mr. Gregg’s tour of duty ended in March 2004, he started drinking heavily to ease his stress and expressed the wish that he had died in Iraq. Mental health experts for the defense said, as one psychiatrist testified, that “PTSD was the driving force behind Mr. Gregg’s actions” when he shot his victim. Having suffered a severe beating, they said, he experienced an exaggerated “startle reaction” — a characteristic of PTSD — when Mr. Fallis reached for his car door, and responded instinctively.

Mr. Gregg’s trial lawyer put it theatrically: When Mr. Fallis rushed at Mr. Gregg, he said, Mr. Gregg switched into military mode. “What does he think?” the lawyer said. “Lethal threat, lethal threat, lethal threat, neutralize threat, boom, boom, boom, boom, boom, boom, boom, boom, boom, continues to shoot.”

The prosecutor, reflecting his skepticism about this explanation, asked Mr. Gregg if he had been a “walking time bomb” since Iraq. “You’re not telling this jury,” Mr. Hanson said, “that National Guard members like yourself that went through that experience are a threat to kill people?” Mr. Gregg: “I wouldn’t know.”

The prosecutor also referred to Mr. Gregg’s military experiences for his own purposes, asking whether military trainers tried to strengthen soldiers’ minds as well as bodies. “Not really,” Mr. Gregg said. “They actually break down your mind.” “Break down your mind,” Mr. Hanson said. “Explain that to the jury.” “They break down your mind, and then they try to build you back up,” Mr. Gregg said. “Into a killer?” the prosecutor asked. “Yes,” Mr. Gregg said.

The jury found Mr. Gregg guilty of second-degree but not first-degree murder. The judge later referred to this as having “dodged a bullet, so to speak.”

The Sentence: 21 Years
Judge Kornmann also said in court that he found the case troubling, calling the sentencing hearing “one of those days” when he wondered whether he should have declined the offer by Tom Daschle, the former Senate majority leader from South Dakota, to nominate him for a federal judgeship.

“I see these stickers that people have on their vehicles saying, ‘Support the troops,’ ” Judge Kornmann said. “I don’t see much support for the troops as years go on when these people come back injured and maimed.”

Nonetheless, the judge said that Mr. Gregg did not deserve any of the “downward departures” from sentencing guidelines that his lawyers had requested in consideration of his military service, his PTSD and his crime-free record. The mandatory minimum for a federal offense involving a gun is 10 years, and Mr. Gregg’s lawyers indicated that they hoped he would be sentenced to no more than 12. Judge Kornmann handed down a 21-year sentence.

Through a relative who works for the prominent law firm of WilmerHale, Mr. Gregg secured the company’s services; his case was taken pro bono. In late June, Mr. Gregg’s lawyers filed a habeas corpus petition, seeing to vacate his conviction on the basis of ineffective assistance of trial counsel. Mr. Rensch, they argue, did not demonstrate that Mr. Gregg’s state of mind was heavily influenced by being “vividly aware of specific, dramatic instances of past violent acts” by his victim.

While Mr. Gregg awaits the outcome, he is locked in a federal medical prison in Rochester, Minn., where he tried to kill himself on one occasion and has been placed on suicide watch episodically. If all efforts to free him fail, he is projected to be released on July 22, 2023, a few weeks shy of his 42nd birthday.

Adapted from an Israeli television series that turned into a national obsession, “In Treatment” is a surprisingly compelling show, given that most of the action occurs in a single room, and is built around Dr. Paul Weston’s ongoing interactions with a pouty anesthesiologist with attachment issues, a Navy pilot suffering from post-Iraq war stress, an aspiring Olympic gymnast given to troublingly incestuous urges and a married couple who enjoy each other sexually, yet turn into the Bickersons the second they’re out of bed.

It is also, as it happens, the latest instance of Hollywood’s century-old fascination with Freud and his descendants. Movies and television have both had a long and intimate relationship with a profession that has been alternately fetishized, sent up and rendered a cartoon. And that’s when it wasn’t being seen “through the distorting lenses of fear, defensive ridicule and the yearning for an ideal parent,” said Dr. Irving Schneider, a psychiatrist in Chevy Chase, Md., who has written extensively on depictions of psychotherapists in film.

These yearnings, if that is indeed what they are, have given us scores of pop cultural cuckoos, including the mind-destroying madman Dr. Caligari, Michael Caine’s homicidal transvestite psychiatrist in “Dressed to Kill” and, less famously though no less perversely, Art Garfunkel as a chain-smoking analyst caught up in a sadomasochistic affair in Nicolas Roeg’s “Bad Timing.”

Television and movies have presented shrinks as villains, as shamans, as pert, efficient problem solvers like Dr. Joyce Brothers and as supermommies in the mold of the late Penelope Russianoff, a therapist who played a therapist in Paul Mazursky’s 1978 “An Unmarried Woman.” And they have also provided proof there are few problems in life that cannot be remedied by a hug from Judd Hirsch.

Hollywood has always “loved shrinks,” said Krin Gabbard, a literature professor at the State University of New York at Stony Brook and an author of “Psychiatry and the Cinema.” This is not least because, as “The Sopranos” made clear, few theatrical devices speed plot exposition along quite as neatly as a therapeutic session.

“What Dr. Melfi was doing was what psychiatrists have always done” on film and television, Professor Gabbard said, referring to the character played by Lorraine Bracco. “It makes it a whole lot easier to get to know a character if they’re talking to a shrink.”

Or else it does not. Not many people are aware that the most often analyzed actress in cinema history is Ginger Rogers, and yet few would dispute that it would have taken a spelunker and not a therapist to plumb that particular performer’s inner depths. Therapy played for laughs, as it often was in Rogers’s movies, has its own loopy history, Professor Gabbard said.

Think of Dr. Von Hallor, the Viennese psychiatrist in “Mr. Deeds Goes to Town,” his accent and diagnostic skills as thick as schlag. Think of Peter Sellers’s sex-crazed Dr. Fritz Fassbender in the 1965 film “What’s New, Pussycat?” gazing into the soul of Peter O’Toole from behind Beatle bangs. Think of the psychiatrist in “Airplane II: the Sequel,” who, when asked to give his impression of a defendant deadpanned: “I don’t do impressions. My training is in psychiatry.”

It was Dr. Schneider who, after studying more than 200 movies, arrived at a “typology” of therapists on film and the three essential archetypes he called Dr. Dippy, Dr. Evil and Dr. Wonderful. The amiable quack Dr. Dippy had a literal basis in cinematic history, appearing in the first American film representation of so-called “mind doctors” as the title character in “Dr. Dippy’s Sanitarium,” a 1906 film based on a popular comic strip.

“As long as there have been mental health professionals, asylum keepers or alienists, they’ve been caricatured,” Professor Gabbard said, adding that portrayals of Dr. Dippy are sometimes more generous to mental health practitioners than to the people they ostensibly help. “Dr. Dippy is really more of a parody of mental patients — the sleepwalker in the flowing white dress, with a candle out front, that Dr. Dippy tries to control.”

Once a movie staple, the nefarious psychotherapist embodied by Leo G. Carroll in Alfred Hitchcock’s “Spellbound” and Anthony Hopkins as Hannibal Lecter (whose cannibalism was easy to read as a wink at the psychoanalytic theory of “oral incorporation”) has lately become scarce.

Probably this is because these days a baddie like Dr. Caligari, the original “good example of a bad shrink” as Dr. Schneider called him, would be stopped by his own supervising therapist before he could plant murderous thoughts in Conrad Veidt’s mind.

Dianne Wiest plays Gabriel Byrne’s former supervisor in “In Treatment,” and, more than any other relationship in the series, theirs provides the show with the heft of verisimilitude. Like its Israeli model, “Be’ Tipul” — whose creators include Hagai Levi, the son of therapists, and Ori Sivan, who has described himself as a “therapy true believer” — “In Treatment” assiduously sidesteps the “Analyze This!” clichés. That it scrupulously observes therapeutic boundaries most films make a point of flouting (that hug from Judd Hirsch) in some ways renders the series both more mundane and more thrilling to the viewer, more “real.”

“The problem with most movie depictions of therapy is that they are not just cartoons, but melodramas, and melodrama is the enemy” of a process that can be dynamically glacial and untheatrical by its very nature, said Dr. Adrienne Harris, a Manhattan psychotherapist. “In so many feature film depictions, there are boundary violations, melodramatic crises and denouements, and that is not really how therapy works.”

“What seems intriguing about this new show,” Dr. Harris said, “is that it will focus on listening respectfully and managing the complicated feelings that get stirred up. Therapy is much more like a meditative process than it is like a drama.”

This is another way of saying that the success of “Be’ Tipul” and — HBO executives anticipate — “In Treatment” depends upon tapping into fascinations and compulsions hard to analyze or even explain.

“You know, the National Institute of Mental Health once decided to film an entire analysis,” Dr. Schneider said, describing how sessions were for several years recorded through a one-way mirror, using cameras with reels that ran a full hour. “It was a stupid project,” he said. “The analyst got disenchanted and wanted to stop, but had to keep going, and when they finished hardly anyone wanted to watch. I hope the HBO thing doesn’t turn out like that.”

In my work as a specialist in cancer, blood diseases and AIDS, hardly a week goes by when patients do not bring up the above interventions, as well as Buddhist meditation, qigong, acupuncture, megavitamins and macrobiotic diets. In “The Cure Within,” her splendid history of mind-body medicine, Anne Harrington tries to explain why we draw connections between emotions and illness, and helps trace how today’s myriad alternative and complementary treatments came to be. A professor and chairman of the history of science department at Harvard, Harrington has produced a book that desperately needed to be written. Some 60 million Americans use these therapies in the effort to combat serious diseases like cancer and AIDS, as well as the normal physiology of aging. In the United States, office visits to providers of complementary and alternative medicine now outnumber visits to primary care physicians. The costs of such care approach $40 billion dollars a year. Books, talk shows and Web sites present riveting testimonials of clinical benefits from Eastern breathing techniques, dietary supplements, positive thinking and prayer.

Doctors like myself are schooled in the cause and effect of changes in DNA, cells and tissues. We apply this biology to identify what is wrong with a patient, then recommend a medication, procedure or behavioral change that will ameliorate the physical problem. “Quite often, this physicalist way of thinking about illness works,” Harrington writes. “Patients take the antibiotic and recover from their infection, learn to inject themselves with insulin and normalize their blood sugar levels, have surgery and learn that their cancer has gone into remission or take the antidepressant and find they can get out of bed again in the morning.”

Sometimes, of course, standard treatments don’t work or simply don’t exist. And sometimes tests fail to uncover any physical cause for a patient’s suffering at all. But such failures, Harrington argues, explain only part of the widespread dissatisfaction with mainstream medicine. Of equal or greater import, she writes, is medicine’s failure to address the “existential” aspect of illness, to answer the questions “Why me? Why now? What next?” Doctors usually frame their answers to such questions in language that forgoes any meaning for the individual. Whether cancer will return is a matter of statistical likelihoods derived from the study of large groups of patients — or, in lay terms, “bad luck.” There is no meaning in randomness, and for the patient no sense of control. Perhaps someday genomic research will help predict the particular behavior of each individual’s cancer, but for now doctors cannot say with any precision who will relapse or why.

As patients, we may be modern in many ways, but we find such uncertainty hard to accept. Throughout history, Harrington rightly argues, people have strained to make “personal sense” of illness and suffering. Western cultures, like all cultures, have traditionally provided people “a stockpile of religious, moral and social stories to help them answer the great ‘why’ questions of their suffering, and to connect their experiences to some larger understanding of their identities and destinies.” But today, she writes, the story offered by mainstream medicine “is as impersonal as they come.”

In fluid prose and with the precision of a detective story, Harrington offers a taxonomy of the main narratives that we draw on to try to make sense of disease, whether they emphasize our ability to heal ourselves or more magical interventions. The root of most of our mind-body narratives is the Bible and other religious writings that describe the struggle against “possession” by demonic forces. While Jewish mystics offered incantations and other rituals to expel dybbuks, the Gospels associate the powers of exorcism with belief in Jesus. Harrington cites the Gospel of Mark, in which Jesus casts out a spirit that has caused convulsions, foaming at the mouth and gnashing of teeth — an accurate clinical description of epilepsy: “If you can believe, all things are possible to him who believes. ... Deaf and dumb spirit, I command you, come out of him and enter him no more!” Belief in demonic possession and its exorcism by priests, common to cultures the world over, remained part of Catholic theology, essentially unaltered, until 1999.

Harrington uses the term “power of suggestion” to describe the skeptical narrative that science ultimately developed to explain cases in which an authority figure, whether a priest uttering incantations or a doctor administering a placebo, cures afflictions that may have no organic cause. Much of what today strikes us as quackery in fact originated in attempts to apply scientific ideas to healing the body. For example, the 18th-century Austrian physician Franz Mesmer, inspired by Newton’s ideas, moved mineral magnets around the bodies of his patients in order to manipulate supposed invisible fluids that, like the oceans, responded to planetary gravitation. The patients reported powerful sensations of energy coursing through their flesh and experienced involuntary movements to the point of violent convulsions; many were cured or much improved. Next, Mesmer found he could trigger the same effects simply waving his hands over the patient. He assumed that he himself was the source of healing force, which he called “animal magnetism.”

Mesmer was succeeded by Jean-Martin Charcot in France, and later Sigmund Freud in Vienna, each of whom sought to identify the nonphysical causes of their patients’ symptoms and tried to devise cures outside of chemical pills and surgical procedures. These efforts, Harrington observes, ushered in another narrative of healing, one she calls “the body that speaks.” Charcot and Freud called the underlying condition “hysteria,” and used hypnosis and the “talking cure” to relieve their distraught, usually female patients of those fits of blindness, coughing and paralysis that supposedly reflected buried traumatic memories or taboo childhood fantasies. Doctors treating traumatized male soldiers during World War I called it “shell shock.”

The clergy tried to recapture lost ground in the healing realm, whether in the form of Christian Science or the “power of positive thinking” promoted by the decidedly mainstream pastor Norman Vincent Peale of the Marble Collegiate Church in New York City. Scientists, of course, were not so quick to yield, probing ever deeper into the question of the mind’s effect on the body. For example, the Harvard physiologist Walter B. Cannon discovered that emotions could ramify through the body in unexpected ways beyond “hysteria.” In studies of digestion done in the 1930s, he discovered that animals experiencing distress or rage showed inhibited peristalsis, the ordered muscular contractions that move food through the gut. Tests showed elevated levels of adrenaline in the animals’ blood, which Cannon determined was involved with biochemical self-regulatory processes connected to the “fight or flight” reaction crucial to survival in the wild.

But Cannon also saw implications for human beings. “In the modern era,” Harrington writes of his research, “life had become so fast paced, so uncertain and consequently so anxiety-provoking that many people went through their days as if they were cats faced with dogs perpetually barking at them.”

Hans Selye, a Czech physician and biochemist at the University of Montreal, took these ideas further, introducing the term “stress” (borrowed from metallurgy) to describe the way trauma caused overactivity of the adrenal gland, and with it a disruption of bodily equilibrium. In the most extreme case, Selye argued, stress could wear down the body’s adaptation mechanisms, resulting in death. His narrative fit well into the cultural discourse of the cold-war era, where, Harrington writes, many saw themselves as “broken by modern life.” Selye’s ideas, in her view, were “especially appealing to people who knew they felt worried or unwell, but were perhaps no longer quite persuaded by the doctrine of bad nerves that had helped their parents and grandparents make sense of their experiences of malaise.”

Selye’s work prompted further research on the impact of family dynamics, interpersonal relationships and community ties on health. Most of this work initially focused on the heart and hypertension, prominent in the public mind following President Eisenhower’s cardiac crisis. Later, scrutiny was extended to the emotional dimensions of the other great specter of the time, cancer. If stress lay at the root of so many modern maladies, Harrington writes, then “healing ties” might be the prophylactic, if not the cure, for cancer as well.

In 1989, David Spiegel, a psychiatrist at Stanford, published a widely reported study of 86 women with advanced breast cancer, all receiving conventional medical therapies. Some were randomly assigned to weekly support groups, where they spoke openly about their fears and hopes and were taught self-hypnosis to manage pain and stress, while others were simply given routine care. Spiegel reported that the women in group therapy lived twice as long, 36.6 months, as those in the control group, who lived 18.9 months. (As point of comparison, Herceptin — the most promising new drug for women with advanced breast cancer — extends patients’ lives by a median of five months compared with those who receive chemotherapy without it.) Spiegel’s research seemed to support the assertions of Bernie Siegel, a surgeon at Yale, who in his best-selling “Love, Medicine, and Miracles” (1986) claimed that emotional turmoil was a cause of breast cancer and that dramatic remissions could occur if patients simply gave up their emotional repression, without chemotherapy or radiation.

In one of the most poignant moments in her book, Harrington visits a group of women in a follow-up study designed to replicate Spiegel’s stunning data. Spiegel has not released the results of this subsequent research, although the study was due to end more than seven years ago. Some have speculated that the initial results were a fluke. “Spiegel remains unwilling to say that support therapy does not extend the life of women with cancer,” Harrington writes. “He and his team believe there is still some kind of biological story to be told about the power of healing ties in the case of cancer, even if it might not be quite the story with which they started.” (Clinical trials of Siegel’s approach to breast cancer, she notes, failed to show greater survival rates.)

During her visit, Harrington asks the women whether they thought Spiegel’s group therapy was helping them live longer. “A silent snort went around the table,” she writes. “No, they said, they did not believe the premise of the study — not really. Why not? I asked. Their answer was clear: the evidence was not there for them; they had seen too many people in their group die.” But then one woman surprises Harrington, and the reader, by saying she doesn’t care about Spiegel’s hypothesis. “I don’t think it matters to me at all,” she says. “That’s not why I joined the group.” Why, then, did she stick with it? To learn “how to live better with cancer and how to die better from cancer, something that they could learn nowhere else in their culture.”

In her final chapter, Harrington offers close observations of the interactions between the Harvard cardiologist Herbert Benson (and later the neuroscientist Richard Davidson of the University of Wisconsin) and the Dalai Lama and his Tibetan monks. She admits longing for scientific support for what is, in essence, an “Orientalist” conception, that the “Other” holds wisdom and therapeutic treasures beyond those imaginable to us in the West. Some of Harrington’s wish is fulfilled in the biology of the placebo response. Recent studies show that belief, even in inert treatments, can have profound benefits in relieving pain, likely via release of endorphins and other mediators in the brain. But despite several decades of concerted research in the field of psychoneuroimmunology, to my scrutiny no robust effects of meditation or other relaxation techniques that could combat illnesses like cancer or AIDS have been identified.

Harrington concludes with the questions that her students at Harvard regularly ask: Which mind-body narratives are “true”? Are all the stories we tell ourselves about illness equally valuable? Harrington has already answered these queries in part in the voice of the woman with breast cancer in the Stanford study. Yet, she has still been “haunted” over the years by unusual events, like the case of a man whose tumors seemed to melt “like snowballs on a hot stove” in response to a “worthlesss” cancer treatment that he nonetheless believed in. The physicist Freeman Dyson once noted that, to a scientist, an event like the spontaneous remission of a tumor is viewed as occurring at the asymptote of probability, one in several million, but through the eyes of a believer it becomes not mathematics but a miracle. Harrington shows us that, whatever science reveals about the cause and course of disease, we will continue to tell ourselves stories, and try to use our own metaphors to find meaning in randomness.



Pediatricians Group Wants Show Canceled
Associated Press, 1/28/2008

CHICAGO -- The nation's largest pediatricians' group on Monday said ABC should cancel the first episode of a new series because it perpetuates the myth that vaccines can cause autism.

ABC's new drama, ''Eli Stone,'' debuts on Thursday. It features British actor Jonny Lee Miller as a prophet-like lawyer who in the opening episode argues in court that a flu vaccine made a child autistic. When it is revealed in court that an executive at the fictional vaccine maker didn't allow his own child to get the shot, jurors side with the family, giving them a huge award.

The show's co-creators say they're not anti-vaccine and would be upset if parents chose not to immunize their children after seeing the show.

But, said Dr. Renee R. Jenkins, president of the influential American Academy of Pediatrics, ''A television show that perpetuates the myth that vaccines cause autism is the height of reckless irresponsibility on the part of ABC and its parent company, The Walt Disney Co.''

''If parents watch this program and choose to deny their children immunizations, ABC will share in the responsibility for the suffering and deaths that occur as a result. The consequences of a decline in immunization rates could be devastating to the health of our nation's children,'' Jenkins said in a statement.

Autism is a complex disorder featuring repetitive behaviors and poor social interaction and communication skills. Scientists generally believe that genetics plays a role in causing the disorder; a theory that a mercury-based preservative once widely used in childhood vaccines is to blame has been repeatedly discounted in scientific studies.

The academy released the text of a letter Jenkins wrote on Friday, addressed to Anne Sweeney, president of Disney-ABC Television Group. In the letter, Jenkins writes that many viewers ''trust the health information presented on fictional television shows, which influences their decisions about health care. ''

Jenkins noted that erroneous reports in the United Kingdom linking the measles vaccine to autism prompted a decline in vaccination and the worst outbreak of measles in two decades.

Greg Berlanti, a co-creator of the show, said the episode is fictional but designed ''to participate in what is a national conversation'' about a controversial subject. He said the boy who plays the autistic child has autism, but that the show's producers have no connection with advocates involved in the autism debate.

''We would be deeply upset'' if parents opted against vaccination because of the episode, Berlanti said.

Marc Guggenheim, who helped create the show, said the first episode shows how a fictional company covered up a study that raised questions about its product, and that the message is really about ''the downside of the corporatization of America.''

On the Net:
Academy: http://www.aap.org
ABC: http://www.abc.com

On the Couch on a Hollywood Soundstage
Margy Rochlin, New York Times- 1/28/2008

Aside from its being a half-hour long, you wouldn’t think HBO’s new therapy-session series, “In Treatment,” had anything in common with the channel’s hit comedy about wild boys in Hollywood, “Entourage.” They do, however, share an executive producer, Stephen Levinson, who said he thinks that there is an intersection between them: Each presents a glimpse into a world that feels eerily accurate.

“You get a sense of reality from both of them,” Mr. Levinson said. “I think they both give you that fly-on-the-wall experience, which is what I’m really drawn to.”

Much of the motor that drives “In Treatment” is its aura of stark authenticity. From Monday to Thursday most of the drama takes place on a single set: the shabbily-appointed home office of Dr. Paul Weston (Gabriel Byrne), a psychotherapist with a contemplative nod, a creaking leather therapist’s chair, a sagging orange couch and a roster of patients, each of whom divulge their anxieties and dark secrets in compelling bits, as if offering up weekly pieces to an emotional puzzle. The only time we see Dr. Weston on foreign turf is on Friday, when he visits his own therapist, Gina (Dianne Wiest) and tries to sort out his own tangled feelings.

“In Treatment” features almost as few camera angles as it does backdrops. What it does offer is something you don’t see much on television, which is a cast concentrating on bringing life to long, complicated monologues while remaining seated.

“That was actually the concern: ‘How do we make this interesting? How do you make a two-page speech about what you were like when you were a kid compelling?’ ” said Embeth Davidtz, who plays Amy, half of a couple who consult with Dr. Weston about their detonating marriage. “Those things would make our hair stand on end. It was really intense.”

“In Treatment” is based on “Be’ Tipul” (“In Therapy”), a television series that had its debut in Israel in 2005. It found its way to the United States after coming to the attention of Noa Tishby, an Israeli-born actress who was visiting Tel Aviv from Los Angeles for a niece’s bat mitzvah. “The first season had just finished airing, and the country was in complete addiction mode,” Ms. Tishby said. So in the span of 48 hours she discovered the show, attended her niece’s ceremony, tracked down the show’s creator and frequent director, Hagai Levi, and obtained permission to take it back to her manager, Mr. Levinson.

“The bottom line is, people are people are people,” said Ms. Tishby, an unknown in Hollywood who considers her “In Treatment” co-executive producer credit her biggest career break in America. “It was clear the minute I saw it that it was about human nature,” she said.

To sell the series, Mr. Levinson simply lent Ms. Tishby’s disc of the first week of “Be’ Tipul” to Carolyn Strauss, president of HBO entertainment. Ms. Strauss said, “All we had to do was look at the Israeli shows and go, ‘Wow, two people sitting in a room talking can be a terrific show.’ ” She also understood that HBO was being offered not just a serious drama, but also an intriguingly new kind of program arrangement.

The “In Treatment” ad campaign promises: “One doctor. Five sessions. Five nights a week.” But the way the series is structured, viewers can tune in according to their interest level. Those who find only Tuesday’s patient interesting, for example, might only watch that night. Meanwhile completists who prefer mini-marathons to nightly viewing can catch a week’s worth of episodes in a block on HBO2 on Saturday and Sunday nights.

Since commissioning “In Treatment,” HBO has purchased the format of another Israeli series, a sort of Romeo and Juliet story called “A Touch Away.” “I don’t know what’s in the drinking water there,” Ms. Strauss said. “But for as tiny as that country is, they make some interesting television shows.”

Unlike a show from another country that is carefully sanded and polished to suit American tastes, “In Treatment” is essentially the same Israeli show but with English-speaking actors. Worried that the new cast — which also includes Blair Underwood, Josh Charles, Melissa George and Mia Wasikowska — would be influenced by their predecessors, Mr. Levinson and the executive producer Rodrigo Garcia encouraged them not to watch the original and discover in advance how their stories unfold.

“We all had a sort of vague outline,” Ms. Davidtz said. “But then Rodrigo would say: ‘Gosh, Embeth. Later you’re going to find out she was fat as a child.’ And I’d be like: ‘Oh, Lord! Well, that informs certain things here.’ ”

To imagine how “In Treatment” was assembled, it’s almost easier to think of a series of one-act plays or even a nine-week-long highbrow soap opera. For five months actors would show up at Stage 25 on the Paramount Pictures lot in Hollywood and on a two-day-per-episode shooting schedule recite pages and pages of confessional dialogue. Then they’d rest for five days, then start the cycle again.

Except, of course, for Mr. Byrne, who is featured in almost every scene in the 43-episode run and engendered in Ms. Davidtz a certain sympathy.

“Poor guy,” she said. “I’d go away on holiday and come back, and he’d still be sitting in that chair, nodding.” But at the same time Mr. Byrne functioned as the closest thing “In Treatment” had to a social hub.

“I got to be very close with Josh and Gabriel, but otherwise we were all sort of separated,” said Ms. Davidtz, recalling the only time she even saw Ms. Wiest backstage. “I said, ‘Hello, Dianne.’ And she said, ‘Hello’ and kept going down the stairs. I think she thought I was a crew member.”

Four Days, a Therapist; Fifth Day, a Patient
Allesandra Stanley, New York Times- 1/28/2008

Some things sound simply awful: a family reunion holiday cruise, an all-you-can-eat haggis buffet, a television series set entirely in a psychotherapist’s office.

And that is the premise of “In Treatment,” a series that begins Monday on HBO. For nine weeks, five nights a week, viewers are invited to sit in on the therapy sessions of Paul Weston (Gabriel Byrne). He treats four patients (five, actually, since one session is with a married couple), and then on the fifth day he discusses his demons with his own therapist, Gina (Dianne Wiest). Electroshock therapy might seem more welcome.

“In Treatment,” however, is hypnotic, mostly because it withholds information as intelligently as it reveals it. Each night a new half-hour episode follows a different patient’s session. In every session the patients’ words are veined with allusions and elusions, clues to problems or patterns that are invisible to them but absorbing for the viewer.

Freud famously described psychoanalysis as archaeology, the unearthing of meaning layered deep beneath an “expanse of ruins.” In television and movies it’s closer to a detective story.

Suspicion shifts from suspect to suspect in a police procedural; on shrink shows there is one suspect, and suspicion shifts from symptom to symptom — “Law & Disorder.” These investigators could use some analysis of their own. Paul, the craggy, caring healer, has serious family problems, while his mentor, Gina, wise and warm as cocoa and cinnamon toast, is not as benevolent as she seems.

This is not HBO’s first attempt to explore psychotherapy of course. The founding principle — and opening joke — of “The Sopranos” involved a mobster who consults a therapist. Lately, however, HBO seems to have developed something of a compulsion.

In September it offered “Tell Me You Love Me,” about a sex therapist and three couples in her care. The series blended graphic sex scenes with a plodding, sorrowful look at marriage and its discontents. But there was never much doubt about the underlying cause of all that marital tension: marriage.

Showtime has left deep tracks on the psychic landscape with its series “Huff,” which ran from 2004 to 2006 and starred Hank Azaria as a successful therapist who starts to fall apart after a patient’s suicide. (The therapist with an issue has become almost a television cliché, a white-coat version of the whore with the heart of gold. In 2006 ABC tried out “Help Me Help You,” a short-lived sitcom that starred Ted Danson as a therapist who, on his own time, is on the brink of a crackup.)

Sometimes, however, a series is just a series. “In Treatment” is not a sign of network post-traumatic stress disorder but of HBO’s inner resilience. This show is smart and rigorous, with a concentration that bores deep without growing dull. Particularly after the lackluster performance of “Tell Me You Love Me,” it is commendable that HBO chose a show that is entirely wrapped around the practice of psychotherapy; the camera rarely leaves Paul’s office, and when it does, it is to record his sessions in Gina’s office.

“In Treatment” is not entirely a plunge into the unknown, however. The show is HBO’s version of “Be’ Tipul,” one of Israel’s most successful and most talked about dramas ever. The American adaptation hews close to the original, with minor adjustments: a patient is a combat veteran of the Iraq war, not the Israeli-Palestinian conflict.

It also helps that Paul’s patients have an interesting patchwork of neuroses. Laura (Melissa George) is a young, very pretty hospital worker with a fierce erotic attachment to her therapist. Alex (Blair Underwood) is an ace Navy pilot who had a heart attack after a disastrous bombing mission in Iraq. Sophie (Mia Wasikowska) is a 16-year-old schoolgirl and a gifted gymnast who may have suicidal impulses as well as an unhealthy relationship with her coach. Jake and Amy (Josh Charles and Embeth Davidtz) are a couple straining over whether to have a second child.

All of them are intelligent, cagey and hard to classify, let alone treat. And as the problems pile up, Paul’s confidence begins to sag.

The half-hour episodes are addictive, and few viewers are likely to be satisfied with just one session at a time. Bending to the age of the Internet, DVR and DVD, HBO is making it easy for viewers to indulge. All the previous episodes about a given character will be shown again on that character’s night, and Sundays will have marathons of the previous week’s episodes.

Therapy five days a week may seem like more than even the most exacting psychoanalyst could expect, yet it’s still not enough. “In Treatment” provides an irresistible peek at the psychopathology of everyday life — on someone else’s tab.

Hitting It Off, Thanks to Algorithms of Love
John Tierney, New York Times- 1/29/3008

PASADENA, Calif. — The two students in Southern California had just been introduced during an experiment to test their “interpersonal chemistry.” The man, a graduate student, dutifully asked the undergraduate woman what her major was. “Spanish and sociology,” she said. “Interesting,” he said. ‘‘I was a sociology major. What are you going to do with that?” “You are just full of questions.” “It’s true.” “My passion has always been Spanish, the language, the culture. I love traveling and knowing new cultures and places.”
      Bogart and Bacall it was not. But Gian Gonzaga, a social psychologist, could see possibilities for this couple as he watched their recorded chat on a television screen. They were nodding and smiling in unison, and the woman stroked her hair and briefly licked her lips — positive signs of chemistry that would be duly recorded in this experiment at the new eHarmony Labs here. By comparing these results with the couple’s answers to hundreds of other questions, the researchers hoped to draw closer to a new and extremely lucrative grail — making the right match.
     Once upon a time, finding a mate was considered too important to be entrusted to people under the influence of raging hormones. Their parents, sometimes assisted by astrologers and matchmakers, supervised courtship until customs changed in the West because of what was called the Romeo and Juliet revolution. Grown-ups, leave the kids alone. But now some social scientists have rediscovered the appeal of adult supervision — provided the adults have doctorates and vast caches of psychometric data. Online matchmaking has become a boom industry as rival scientists test their algorithms for finding love.
     The leading yenta is eHarmony, which pioneered the don’t-try-this-yourself approach eight years ago by refusing to let its online customers browse for their own dates. It requires them to answer a 258-question personality test and then picks potential partners. The company estimates, based on a national Harris survey it commissioned, that its matchmaking was responsible for about 2 percent of the marriages in America last year, nearly 120 weddings a day.
     Another company, Perfectmatch.com, is using an algorithm designed by Pepper Schwartz, a sociologist at the University of Washington at Seattle. Match.com, which became the largest online dating service by letting people find their own partners, set up a new matchmaking service, Chemistry.com, using an algorithm created by Helen E. Fisher, an anthropologist at Rutgers who has studied the neural chemistry of people in love.
     As the matchmakers compete for customers — and denigrate each other’s methodology — the battle has intrigued academic researchers who study the mating game. On the one hand, they are skeptical, because the algorithms and the results have not been published for peer review. But they also realize that these online companies give scientists a remarkable opportunity to gather enormous amounts of data and test their theories in the field. EHarmony says more than 19 million people have filled out its questionnaire.
     Its algorithm was developed a decade ago by Galen Buckwalter, a psychologist who had previously been a research professor at the University of Southern California. Drawing on previous evidence that personality similarities predict happiness in a relationship, he administered hundreds of personality questions to 5,000 married couples and correlated the answers with the couples’ marital happiness, as measured by an existing instrument called the dyadic adjustment scale. The result was an algorithm that is supposed to match people on 29 “core traits,” like social style or emotional temperament, and “vital attributes” like relationship skills. (For details: nytimes.com/tierneylab.) “We’re not looking for clones, but our models emphasize similarities in personality and in values,” Dr. Buckwalter said. “It’s fairly common that differences can initially be appealing, but they’re not so cute after two years. If you have someone who’s Type A and real hard charging, put them with someone else like that. It’s just much easier for people to relate if they don’t have to negotiate all these differences.”
     Does this method actually work? In theory, thanks to its millions of customers and their fees (up to $60 a month), eHarmony has the data and resources to conduct cutting-edge research. It has an advisory board of prominent social scientists and a new laboratory with researchers lured from academia like Dr. Gonzaga, who previously worked at a marriage-research lab at U.C.L.A.
     So far, except for a presentation at a psychologists’ conference, the company has not produced much scientific evidence that its system works. It has started a longitudinal study comparing eHarmony couples with a control group, and Dr. Buckwalter says it is committed to publishing peer-reviewed research, but not the details of its algorithm. That secrecy may be a smart business move, but it makes eHarmony a target for scientific critics, not to mention its rivals.
     In the battle of the matchmakers, Chemistry.com has been running commercials faulting eHarmony for refusing to match gay couples (eHarmony says it can’t because its algorithm is based on data from heterosexuals), and eHarmony asked the Better Business Bureau to stop Chemistry.com from claiming its algorithm had been scientifically validated. The bureau concurred that there was not enough evidence, and Chemistry.com agreed to stop advertising that Dr. Fisher’s method was based on “the latest science of attraction.”
     Dr. Fisher now says the ruling against her last year made sense because her algorithm at that time was still a work in progress as she correlated sociological and psychological measures, as well as indicators linked to chemical systems in the brain. But now, she said, she has the evidence from Chemistry.com users to validate the method, and she plans to publish it along with the details of the algorithm. “I believe in transparency,” she said, taking a dig at eHarmony. “I want to share my data so that I will get peer review.”
     Until outside scientists have a good look at the numbers, no one can know how effective any of these algorithms are, but one thing is already clear. People aren’t so good at picking their own mates online. Researchers who studied online dating found that the customers typically ended up going out with fewer than 1 percent of the people whose profiles they studied, and that those dates often ended up being huge letdowns. The people make up impossible shopping lists for what they want in a partner, says Eli Finkel, a psychologist who studies dating at Northwestern University’s Relationships Lab. “They think they know what they want,” Dr. Finkel said. “But meeting somebody who possesses the characteristics they claim are so important is much less inspiring than they would have predicted.” The new matchmakers may or may not have the right formula. But their computers at least know better than to give you what you want.

In many cases, post-traumatic stress and depression may be driving the symptoms, doctors reported Wednesday. And that's good news because those are treatable.

The study by U.S. military doctors was praised by outside experts who found the conclusions convincing.

Returning soldiers have struggled with memory loss, irritability, trouble sleeping and other problems. Many have suffered mild blast-related concussions, but there is no easy way to separate which symptoms are due to physical damage and which are from mental problems caused by the traumatic stress of war. Imaging of the brain is being tested, but hasn't yet proven to be helpful.

The new study, based on a survey of 2,525 soldiers, found that brain injury made traumatic stress more likely. The study tied only one symptom _ headaches _ specifically to brain injury.

"We found that the symptoms and health concerns that we expected to be due to the concussion actually proved to be more strongly related to PTSD," or post-traumatic stress disorder, and depression, said Dr. Charles Hoge, a colonel and psychiatry chief at Walter Reed Army Institute of Research who led the study. "There isn't a clear delineation between a psychological and a physical problem."

Other doctors were optimistic about treatment efforts. "It gives us hope, because we've got good treatments for PTSD," said Barbara Rothbaum, a psychologist who heads a trauma recovery program at Emory University in Atlanta. "If we can relieve the PTSD and depression, I'm hoping we'll see alleviation of a lot of these physical symptoms."

Hoge reported on the survey Wednesday at a military health conference in Washington. Results also were published in Thursday's New England Journal of Medicine.

The journal's editor-in-chief, Dr. Jeffrey Drazen, said editors initially were skeptical of the findings, which depart from the gloom-and-doom picture some have painted for soldiers with brain injuries.

However, the solid research methods and the "strong and robust" data linking stress and concussion symptoms persuaded them, said Drazen, who is a scientific adviser to the Veterans Administration.

The case of Eric O'Brien, a 33-year-old Army staff sergeant from Iowa's Quad Cities, suggests the researchers may be right.

After an explosion in Baghdad in 2006, O'Brien was treated at Vanderbilt University's brain injury rehabilitation program and at Fort Campbell, Ky., for post-traumatic stress. Now he is preparing to redeploy, this time to Afghanistan.

"I retested on a lot of the tests and they showed a pretty decent increase," he said of his mental function tests. As for stress, "I don't know if it's something you just learn to deal with or if it just gets a little bit better over time," he said. "It's not as bad as it was."

The vast majority of brain injuries, or concussions, are mild, but the military previously estimated that one-fifth cause symptoms lasting a year or more.

The new study tried to pin down the potential long-term effects of mild brain injury, through an anonymous survey of two Army combat brigades _ one active and one Reserve _ in 2006, several months after they returned home from Iraq.

Fifteen percent of soldiers reported a mild brain injury _ having been knocked unconscious or left confused or "seeing stars" after a blast. They were more likely than other soldiers to report health problems, missing work, and symptoms such as trouble concentrating.

The worst symptoms were in soldiers who lost consciousness. About 44 percent of them met the criteria for post-traumatic stress, compared with 16 percent of soldiers with non-head injuries, and only 9 percent of those with no injuries.

"The same incident might have triggered both processes," Rothbaum said, noting that after World War I, "they thought that shell shock was a neurological disorder and it turned out to have a lot of overlap with the psychological disorder."

However, Dr. Greg O'Shanick, a psychiatrist and medical director for the advocacy group Brain Injury Association of America, said it would be over-simplifying to think that treating PTSD alone would be enough.

"It's like having fleas and ticks," he said. Getting rid of one may not make you stop itching, "and if you've got one, it makes it harder to handle the other."

Concussions may compound stress by damaging brain areas that tamp down responses to fear, Richard Bryant, a psychologist at the University of New South Wales in Sydney, Australia, writes in an editorial in the journal.

"PTSD and depression may be the primary problem," he writes. "Soldiers should not be led to believe that they have a brain injury that will result in permanent change."

The military recently started screening all returning troops for concussions. Any soldiers who saw intense combat should be similarly checked for stress disorder, said Anthony Stringer, director of Emory University's neuropsychology rehabilitation program.

The new study can be viewed as positive "if the results are used to make sure that soldiers have the care they need when they return," he said.

On the Net:
New England Journal: http://www.nejm.org
Army Medicine: http://www.armymedicine.army.mil
Defense and Brain Injury Center: http://www.dvbic.org/
Centers for Disease Control: http://www.cdc.gov/ncipc/factsheets/tbi.htm
National Institutes of Health: http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm

Soldier Suicides at Record Level
Dana Priest, Washington Post- 1/31/2008

Lt. Elizabeth Whiteside, a psychiatric outpatient at Walter Reed Army Medical Center who was waiting for the Army to decide whether to court-martial her for endangering another soldier and turning a gun on herself last year in Iraq, attempted to kill herself Monday evening. In so doing, the 25-year-old Army reservist joined a record number of soldiers who have committed or tried to commit suicide after serving in Iraq or Afghanistan.

"I'm very disappointed with the Army," Whiteside wrote in a note before swallowing dozens of antidepressants and other pills. "Hopefully this will help other soldiers." She was taken to the emergency room early Tuesday. Whiteside, who is now in stable physical condition, learned yesterday that the charges against her had been dismissed.

Whiteside's personal tragedy is part of an alarming phenomenon in the Army's ranks: Suicides among active-duty soldiers in 2007 reached their highest level since the Army began keeping such records in 1980, according to a draft internal study obtained by The Washington Post. Last year, 121 soldiers took their own lives, nearly 20 percent more than in 2006.

At the same time, the number of attempted suicides or self-inflicted injuries in the Army has jumped sixfold since the Iraq war began. Last year, about 2,100 soldiers injured themselves or attempted suicide, compared with about 350 in 2002, according to the U.S. Army Medical Command Suicide Prevention Action Plan.

The Army was unprepared for the high number of suicides and cases of post-traumatic stress disorder among its troops, as the wars in Iraq and Afghanistan have continued far longer than anticipated. Many Army posts still do not offer enough individual counseling and some soldiers suffering psychological problems complain that they are stigmatized by commanders. Over the past year, four high-level commissions have recommended reforms and Congress has given the military hundreds of millions of dollars to improve its mental health care, but critics charge that significant progress has not been made.

The conflicts in Iraq and Afghanistan have placed severe stress on the Army, caused in part by repeated and lengthened deployments. Historically, suicide rates tend to decrease when soldiers are in conflicts overseas, but that trend has reversed in recent years. From a suicide rate of 9.8 per 100,000 active-duty soldiers in 2001 -- the lowest rate on record -- the Army reached an all-time high of 17.5 suicides per 100,000 active-duty soldiers in 2006.

Last year, twice as many soldier suicides occurred in the United States than in Iraq and Afghanistan.

Col. Elspeth Cameron Ritchie, the Army's top psychiatrist and author of the study, said that suicides and attempted suicides "are continuing to rise despite a lot of things we're doing now and have been doing." Ritchie added: "We need to improve training and education. We need to improve our capacity to provide behavioral health care."

Ritchie's team conducted more than 200 interviews in the United States and overseas, and found that the common factors in suicides and attempted suicides include failed personal relationships; legal, financial or occupational problems; and the frequency and length of overseas deployments. She said the Army must do a better job of making sure that soldiers in distress receive mental health services. "We need to know what to do when we're concerned about one of our fellows."

The study, which the Army's top personnel chief ordered six months ago, acknowledges that the Army still does not know how to adequately assess, monitor and treat soldiers with psychological problems. In fact, it says that "the current Army Suicide Prevention Program was not originally designed for a combat/deployment environment."

Staff Sgt. Gladys Santos, an Army medic who attempted suicide after three tours in Iraq, said the Army urgently needs to hire more psychiatrists and psychologists who have an understanding of war. "They gave me an 800 number to call if I needed help," she said. "When I come to feeling overwhelmed, I don't care about the 800 number. I want a one-on-one talk with a trained psychiatrist who's either been to war or understands war."

Santos, who is being treated at Walter Reed, said the only effective therapy she has received there in the past year have been the one-on-one sessions with her psychiatrist, not the group sessions in which soldiers are told "Don't hit your wife, don't hit your kids," or the other groups where they play bingo or learn how to properly set a table.

Over the past year, the Army has reinvigorated its efforts to understand mental health issues and has instituted new assessment surveys and new online videos and questionnaires to help soldiers recognize problems and become more resilient, Ritchie said. It has also hired more mental health providers. The plan calls for attaching more chaplains to deployed units and assigning "battle buddies" to improve peer support and monitoring.

Increasing suicides raise "real questions about whether you can have an Army this size with multiple deployments," said David Rudd, a former Army psychologist and chairman of the psychology department at Texas Tech University.

On Monday night, as President Bush delivered his State of the Union address and asked Congress to "improve the system of care for our wounded warriors and help them build lives of hope and promise and dignity," Whiteside was dozing off from the effects of her drug overdose. Her case highlights the Army's continuing struggles to remove the stigma surrounding mental illness and to make it easier for soldiers and officers to seek psychological help.

Whiteside, the subject of a Post article in December, was a high-achieving University of Virginia graduate, and she earned top scores from her Army raters. But as a medic in charge of a small prison team in Iraq, she was repeatedly harassed by one of her commanders, which disturbed her greatly, according to an Army investigation.

On Jan. 1, 2007, weary from helping to quell riots in the prison after the execution of Saddam Hussein, Whiteside had a mental breakdown, according to an Army sanity board investigation. She pointed a gun at a superior, fired two shots into the ceiling and then turned the weapon on herself, piercing several organs. She has been at Walter Reed ever since.

Whiteside's two immediate commanders brought charges against her, but Maj. Gen. Eric B. Schoomaker, the only physician in her chain of command and then the commander of Walter Reed, recommended that the charges be dropped, citing her "demonstrably severe depression" and "7 years of credible and honorable service."

The case hinged in part on whether her mental illness prompted her actions, as Walter Reed psychiatrists testified last month, or whether it was "an excuse" for her actions, as her company commander wrote when he proffered the original charges in April. Those charges included assault on a superior commissioned officer, aggravated assault, kidnapping, reckless endangerment, wrongful discharge of a firearm, communication of a threat and two attempts of intentional self-injury without intent to avoid service.

An Army hearing officer cited "Army values" and the need to do "what is right, legally and morally" when he recommended last month that Whiteside not face court-martial or other administration punishment, but that she be discharged and receive the medical benefits "she will desperately need for the remainder of her life." Whiteside decided to speak publicly about her case only after a soldier she had befriended at the hospital's psychiatric ward hanged herself after she was discharged without benefits.

But the U.S. Army Military District of Washington, which has ultimate legal jurisdiction over the case, declined for weeks to tell Whiteside whether others in her chain of command have concurred or differed with the hearing officer, said Matthew MacLean, Whiteside's civilian attorney and a former military lawyer.

MacLean and Whiteside's father, Thomas Whiteside, said the uncertainty took its toll on the young officer's mental state. "I've never seen anything like this. It's just so far off the page," said Thomas Whiteside, his voice cracking with emotion. "I told her, 'If you check out of here, you're not going to be able to help other soldiers.' "

Whiteside recently had begun to take prerequisite classes for a nursing degree, and her mental stability seemed to be improving, her father said. Then late last week, she told him she was having trouble sleeping, with a possible court-martial weighing on her. On Monday night, she asked her father to take her back to her room at Walter Reed so she could study.

She swallowed her pills there. A soldier and his wife, who live next door, came to her room and, after a while, noticed that she was becoming groggy, Thomas Whiteside said. When they returned later and she would not open the door, they called hospital authorities.

Yesterday, after having spent two nights in the intensive care unit, he said, his daughter was transferred to the psychiatric ward.

Whiteside left two notes, one titled "Business," in which her top concern was the fate of her dog. "Appointment for the Vetenarian is in my blue book. Additional paperwork on Chewy is in the closet at the apartment in a folder." On her second note, she penned a postscript: "Sorry to do this to my family + friends. I love you."

As many as 121 soldiers committed suicide in 2007, an increase of some 20 percent over 2006, according to preliminary figures released Thursday.

The number who tried to commit suicide or injured themselves for some other reason jumped six-fold in the last several years -- from 350 in 2002 to about 2,100 incidents last year. Officials said an unknown portion of that increase was likely due to use of a new electronic tracking system that is more thorough in capturing health data than the previous system.

The increases come despite a host of efforts to improve the mental health of a force that has been stressed by lengthy and repeated deployments to the longer-than-expected war in Iraq, and the most deadly year yet in the now six-year-old conflict in Afghanistan.

''We have been perturbed by the rise despite all of our efforts,'' said Col. Elspeth Ritchie, psychiatry consultant to the Army surgeon general.

Those efforts include more training and education programs, the hiring of more mental health professionals and the addition of screening programs launched after a succession of studies found the military's peacetime health care system overwhelmed by troops coming home from the two foreign wars.

''We know we've been doing a lot of training and education,'' Ritchie told a Pentagon press conference. ''Clearly we need to be doing more.''

The preliminary figures on 2007 show that among active duty soldiers and National Guard and Reserve troops that have been activated there were 89 confirmed suicides and 32 deaths that are suspected suicides but still under investigation.

Less than a third of those who committed suicide -- about 34 -- happened during deployments in Iraq. That compared with 27 in Iraq the previous year. Four were confirmed in Afghanistan compared with three there in 2006.

The total of 121, if all are confirmed, would be more than double the 52 reported in 2001, before the Sept. 11 attacks prompted the Bush administration to launch its counter-terror war. The toll was 87 by 2005 and 102 in 2006.

Officials said the rate of suicides per 100,000 active duty soldiers has not yet been calculated for 2007. The 2006 toll of 102 translated to a rate of 17.5 per 100,000, the highest since the Army started counting in 1980, officials said. The rate has fluctuated over those years, with the low being 9.1 per 100,000 in 2001.

That toll and rate for 2006 is a revision from figures released in August. Officials earlier had reported that 99 soldiers had killed themselves in 2006 and two cases were pending -- as opposed to the 102 now all confirmed. It's common for investigations to take time and for officials to study results at length before releasing them publicly.

Ritchie said Thursday, as she did last year, that officials are finding that failed personal relationships are the main motive for the suicides, followed by legal and financial problems as well as job-related difficulties.

Long and repeated tours of duty away from home contribute significantly in that they weigh heavily on family relations and compound the other problems, officials said.

''People don't tend to suicide as a direct result of combat,'' Ritchie said. ''But the frequent deployments strain relationships. And strained relations and divorce are definitely related to increased suicide.''

With the Army stretched thin by years of fighting the two wars, the Pentagon last year extended normal tours of duty from 12 months to 15 months and has sent some troops back to the wars several times. The Army has been hoping to reduce tour lengths this summer. But the prospect could depend heavily on what Gen. David Petraeus, the top U.S. commander in Iraq, recommends when he gives his assessment of security in Iraq and troop needs to Congress in April.

U.S. Sen. Patty Murray, D-Wash., a leading critic of the treatment given returning Iraq and Afghanistan veterans, called the new figures ''heart-wrenching.''

''Until they come to grips with how long and frequent deployments are straining soldiers and shattering lives we will continue to see this frightening trend,'' she said.

''And as the White House signals that there won't be any further troop cuts beyond July, there is dwindling hope that things will turn around soon,'' she said.

Because of improved security in Iraq in recent months, the administration has started to draw down extra troops sent last year. But Bush and commanders have been indicating reluctance to continue cuts beyond July out of fear the fragile security gains could be lost.

On the Net: Defense Department: www.defenselink.mil

Lilly Considers $1 Billion Fine to Settle Case
Alex Berenson, New York Times- 1/31/2008

and federal prosecutors are discussing a settlement of a civil and criminal investigation into the company’s marketing of the antipsychotic drug Zyprexa that could result in Lilly’s paying more than $1 billion to federal and state governments.

If a deal is reached, the fine would be the largest ever paid by a drug company for breaking the federal laws that govern how drug makers can promote their medicines.

Several people involved in the investigation confirmed the settlement discussions, which began last year and took on new urgency this month. The people insisted on anonymity because they have not been authorized to talk about the negotiations.

Zyprexa has serious side effects and is approved only to treat people with schizophrenia and severe bipolar disorder. But documents from Eli Lilly show that from 2000 to 2003 the company encouraged doctors to prescribe Zyprexa to people with age-related dementia, as well as people with mild bipolar disorder who had previously had a diagnosis of depression.

Although doctors can prescribe drugs for any use once they are on the market, it is illegal for drug makers to promote their medicines for any uses not formally approved by the Food and Drug Administration.

Lilly may also plead guilty to a misdemeanor criminal charge as part of the agreement, the people involved with the investigation said. But the company would be allowed to keep selling Zyprexa to Medicare and Medicaid, the government programs that are the biggest customers of the drug.

Zyprexa is Lilly’s most profitable product and among the world’s best-selling medicines, with 2007 sales of $4.8 billion, about half in the United States.

Lilly would neither confirm nor deny the settlement talks.

“We have been and are continuing to cooperate in state and federal investigations related to Zyprexa, including providing a broad range of documents and information,” Lilly said in a statement Wednesday afternoon. “As part of that cooperation we regularly have discussions with the government. However, we have no intention of sharing those discussions with the news media and it would be speculative and irresponsible for anyone to do so.”

Lilly also said that it had always followed state and federal laws when promoting Zyprexa.

The Lilly fine would be distributed among federal and state governments, which spend about $1.5 billion on Zyprexa each year through Medicare and Medicaid.

The fine would be in addition to $1.2 billion that Lilly has already paid to settle 30,000 lawsuits from people who claim that Zyprexa caused them to develop diabetes or other diseases. Zyprexa can cause severe weight gain in many patients and has been linked to diabetes by the American Diabetes Association.

Prescriptions for Zyprexa have skidded since 2003 over concerns about those side effects. But the drug continues to be widely used, especially among severely mentally ill patients. Many psychiatrists say that it works better than other medicines at calming patients who are psychotic and hallucinating. About four million Zyprexa prescriptions were written in the United States last year.

Federal prosecutors in Philadelphia are leading the settlement talks for the government, in consultation with the Justice Department in Washington. State attorneys general’s offices are also involved. Lawyers at Pepper Hamilton, a firm based in Philadelphia, and Sidley Austin, a firm based in Chicago, are negotiating for Lilly.

Nina Gussack, a lawyer at Pepper Hamilton who is representing Lilly, said she could not comment on the case. Joseph Trautwein, an assistant United States attorney for the Eastern District of Pennsylvania, also declined to comment.

While a settlement has not been concluded and the negotiations could collapse, both sides want to reach an agreement, according to the people involved in the investigation.

Besides the escalating pressure of the federal criminal inquiry, Lilly faces a civil trial scheduled for March in Anchorage, in a lawsuit brought by the state of Alaska to recover money the state has spent on Zyprexa prescriptions. A loss in that lawsuit would damage Lilly’s bargaining position in the Philadelphia talks.

While expensive for Lilly, the settlement would end a four-year federal investigation and remove a cloud over Zyprexa. While Zyprexa prescriptions are falling, its dollar volume of sales is rising because Lilly has raised Zyprexa’s price about 40 percent since 2003.

Federal prosecutors have been investigating Lilly for its marketing of Zyprexa since 2004, and state attorneys general have been doing so since 2005. The people involved in the investigations said the inquiries gained momentum after December 2006, when The New York Times published articles describing Lilly’s years-long efforts to play down Zyprexa’s side effects and to promote the drug for conditions other than schizophrenia and severe bipolar disorder — a practice called off-label marketing.

Internal Lilly marketing documents and e-mail messages showed that Lilly wanted to persuade doctors to prescribe Zyprexa for patients with age-related dementia or relatively mild bipolar disorder.

In one document, an unidentified Lilly marketing executive wrote that primary care doctors “do treat dementia” but leave schizophrenia and bipolar disorder to psychiatrists. As a result, sales representatives should discuss dementia with primary care doctors, according to the document, which appears to be part of a larger marketing presentation but is not marked more specifically. Later, the same document says that some primary care doctors “might prescribe outside of label.”

In late 2000, Lilly began a marketing campaign called Viva Zyprexa and told sales representatives to suggest that doctors prescribe Zyprexa to older patients with symptoms of dementia.

The documents were under federal court seal when The Times published the articles, and Judge Jack B. Weinstein of United States District Court in Brooklyn rebuked The Times for publishing them.

The settlement negotiations in Philadelphia began several months ago, according to the people involved in the investigation.

Last fall, the two sides were close to a deal in which Lilly would have paid less than $1 billion to settle the case, which at the time consisted only of a civil complaint.

Then Justice Department lawyers in Washington pressed for a grand jury investigation to examine whether Lilly should be charged criminally for its promotional activities, according to the people involved in the negotiations. A few days ago, facing the possibility of both civil and criminal charges, Lilly opened new discussions with the prosecutors in Philadelphia.