Noteworthy News Articles on Mental Health Topics, March 16-21, 2008 In Praise of Melancholy. By Eric G. Wilson. 166 pp. Sarah Chrichton Books/Farrar, Straus & Giroux. $20. Review by Garrison Keillor, New York Times Book Review- 3/16/2008 It is a short but laborious book, and it begins: “Ours are ominous times. Each nervous glance portends some potential disaster. Paranoia most mornings shocks us to wakefulness, and we totter out under the ghostly sun. At night fear agitates the darkness.” It’s a hilarious opening, and you smell parody here as the author ticks off the ominous things that shock him awake in the morning — the holes in the ozone, the extinction of animal species, global warming, nuclear arms, the threat of human extinction — and then you come through a dark thicket and over a field of jagged rocks and you find his thesis: American obsession with happiness, typified by the widespread use of antidepressants, is eliminating melancholia, the wellspring of creativity, the source of so much great art and poetry and music. Kafka, Hart Crane, Jackson Pollock, Tennessee Williams, Mark Rothko, melancholics all, so why shouldn’t we accept our own bleakness and take long walks in the winter woods and look at the gnarled limbs of trees and struggle with the inscrutable and accept the beauty of permanent turmoil? It’s a good old-fashioned broadside against American optimism — the mass of men lead lives of shallow happiness, the superior man exults in his gloom. The author is a gloomy man who tried jogging, yoga, tai chi, Frank Capra movies, smiling, good grooming and eating salads, and finally decided to embrace his gloominess. This makes him an odd duck in America, a land of “crazed and compulsive hopefulness,” settled by seekers of utopia, a Promised Land that quickly became a shopping mall where “the typical American, the American bent on discovering happiness through securing stuff,” consumes Paxil and Prozac, Ambien and Botox, while seeking the instant gratification of the cellphone, the BlackBerry, the Internet, smiley faces, churches that are “happiness companies,” hugging and yearning for “up with no down.” Suburbia gets thumped hard, of course — “pretty things suggest a kind of emptiness,” everything “safe, clean, predictable,” like Wal-Mart, gated communities, prefab houses, freeways, convenience stores, Hallmark cards, franchise restaurants, the Lifetime channel (one is startled to come across the names of Norman Rockwell and Norman Vincent Peale and the Book-of-the-Month Club and Jell-O and Cool Whip — the man is swinging his softball bat at ghosts!), all the attempts to iron out life’s rough edges and to fend off melancholy, “the wakeful anguish of the soul,” as Keats put it, which is essential for mental health. It’s only right that the tide of inspirational books should yield to the occasional depressional one — for every humorist, a dishumorist, a man who runs his nails down the blackboard and makes everyone’s hair stand up, though we humorists would note that you have to work hard to get a laugh and that dishumor is tyrannical: you need only say out loud, “How can you people stand around here and enjoy yourselves while the world is falling apart?” and all conversation ends. The dishumorist brings a long face to the party and you are forced to ask, “What’s wrong?” And he whispers: “These are ominous times. I sense disaster. I wake up feeling paranoid. The sun was ghostly today. And now fear agitates the darkness.” O.K., pal. Thanks for sharing. “I often wonder if America would be better off, would be a richer and deeper nation, if it took seriously Jung’s version of Jesus,” Professor Wilson writes — one of those oft-wondered things you doubt get wondered that often — and we get some Jung, some Joni Mitchell, some John Lennon, Bruce Springsteen, some bits from old lectures on Coleridge, Keats, Blake, Crane and Melville, and of course Beethoven. Had psychiatry been practiced in the 18th century, we might have been deprived of the Eroica Symphony. Wilson is a true romantic. He loves beautiful ruins. He loves his chilly house with its crumbling bricks and rotting roof, its “sweet decadence.” He misses the old Times Square, “a seductive mixture of divas and drugs, gloriously dilapidated buildings and grim rings of illegal sex.” The new Times Square has “the drab predictability of a suburban mall.” “The greatest tragedy is to live without tragedy,” he writes. “To hug happiness is to hate life. To love peace is to loathe the self. The blues are clues to the sublime. The embrace of gloom stokes the heart.” Wilson clarifies his opposition to antidepressants later. He is not opposed to them in the case of severe depression, only in the case of mild to moderate depression. All right, thanks for that. The distinction between melancholia (good) and depression (bad), Wilson writes, is simple: depression is passive, melancholia is turbulent. Defending depression of any sort on the grounds that Beethoven suffered from it is awfully close to defending tuberculosis on the grounds that it sharpened John Keats’s vision or arguing that you shouldn’t clean up violent, drug-ridden neighborhoods because so many brilliant jazzmen came from there. And look at the long list of gin-soaked writers — practically the entire pantheon of the 20th century — so tell Hazelden to go soak its head. To argue for melancholia as a force for creativity prompts the question, Why isn’t this a better book, since the author is so miserable? And a Minnesotan reading Wilson, a North Carolinian, on the tonic effect of melancholy winter has to smile. Which brings me to the effusive thank-yous at the end of this book. Wilson thanks his “wonderful” agent, Bridget, for her encouragement; and his editor, Sarah, for her “brilliant” insights; and his kind friends and his patient parents and his inspiring wife. Why this Kodak moment at the end, the spritzing with Champagne, the presentation of bouquets? It’s so out of character for a guy who is awakened by paranoia to be thanking the folks who enabled him to write a not very good book. Maybe he should’ve worked more on his house. ON DEEP HISTORY AND THE BRAIN By Daniel Lord Smail. 271 pp. University of California Press. $21.95. Review by Alexander Star, New York Times Book Review- 3/16/2008 Why do horses snort? Sometimes, at the approach of a stranger or the appearance of a plane high above the pasture, a horse will widen its eyes, flare its nostrils and send a stuttering column of air out into the world. On other occasions, horses have been known to snort for no reason besides their own boredom. By suddenly creating a sound, the slack-minded horse elicits an automatic “startle response” — flooding its brain with chemicals, delivering a jolt of excitement and relieving, at least for a moment, the monotony of a long day in an empty field. The horse has in effect fooled its own nervous system — and benefited from the self-deceit. If horses can alter their own brain chemistries at will (and have good reasons to do so), what about human beings? In “On Deep History and the Brain,” Daniel Lord Smail suggests that human history can be understood as a long, unbroken sequence of snorts and sighs and other self-modifications of our mental states. We want to alter our own moods and feelings, and the rise of man from hunter-gatherer and farmer to office worker and video-game adept is the story of the ever proliferating devices — from coffee and tobacco to religious rites and romance novels — we’ve acquired to do so. Humans, Smail writes, have invented “a dizzying array of practices that stimulate the production and circulation of our own chemical messengers,” and those devices have become more plentiful with time. We make our own history, albeit with neurotransmitters not of our choosing. Ever since the invention of agriculture, Smail claims, we have seen “an ever greater concentration of mood-altering mechanisms.” Some of these mechanisms Smail refers to as “teletropic”: they work primarily to affect the moods of others, stimulating a wash of neurochemicals at a distance. A baby cries and arouses its mother’s instinct to care; a priest intones a Mass and relieves parishioners of stress hormones. The modern era, however, belongs to what Smail calls “autotropic” devices, devices that alter our own moods. In modern Europe, coffee from the Arabian peninsula became a stimulant to “mind, body, conversation and creativity” for the rich and the mercantile. The cultivation of sugar on Caribbean slave plantations made cheap rum freely available, further inebriating the working classes. Individuals became ever more expert at changing their own chemistry, sometimes just for the pleasure of modulating one set of sensations into another. But ingesting substances was only the beginning. The same era saw the rise of novels and erotica, shopping and salons. Books are also autotropic devices, regulating attention and mood; indeed, in the 18th century, their impact was often likened to a fever, jeopardizing readers’ purchase on reality and their physical strength. In the age of Enlightenment, man overthrew kings and subjected himself to mild and intermittently pleasurable addictions. Of course, there was more to the Enlightenment than that. It’s not clear how a neurohistorian of the future would treat attitudes and beliefs alongside cravings and moods. Nor does Smail directly address the larger implications of what has been called “the psychoactive revolution.” What happens when we learn not just how to alter our moods but also to identify the chemical and electrical constituents of our experiences while we are having them? Is there a price to pay when we make the care of the brain a pre-eminent virtue? Three decades ago, in his influential study “Tastes of Paradise,” Wolfgang Schivelbusch argued that “the brain is the part of the human body of greatest concern to bourgeois civilization.” Coffee and tobacco, which spread through Europe in the 17th century, helped this reorientation, Schivelbusch said: “Coffee functioned positively, arousing and nourishing the brain. Tobacco functioned negatively, calming the rest of the body ... as was necessary for mental, i.e., sedentary, activity.” Smail focuses more attention on the “pursuit of psychotropy” than on its consequences. Still, an intelligent disquiet runs through these pages. As we “grow numb to the mechanisms that stimulate our moods and feelings on a daily basis,” we ceaselessly shift from one device to another. The prospects for human foresight and self-knowledge would seem dim. In the 1860s, Walter Pater wrote that “art comes to you proposing frankly to give nothing but the highest quality to your moments as they pass, and simply for those moments’ sake.” Has art become superfluous? Smail suggests we are all the choreographers of our own chemical dance, enjoying the “spikes” and “dips” as they follow one another, and simply for their own sake.
Lungs How Old? Susan Brink, Los Angeles Times- 3/17/2008 Smokers can't assume that their lungs are the same age as their other body parts. And when they know their lungs' age relative to their real age, they're more likely to kick the habit, according to a study in the March 6 British Medical Journal. Lung function -- meaning how well a person breathes -- naturally declines with age. But for some smokers, the decline is rapid. A three-decades-long smoker in her 50s, for example, could have the lungs of a 75-year old. Researchers in England wondered whether a lesson in individual lung age would help smokers quit. So they recruited 561 smokers aged 35 and older and gave them a simple breathing test. For half the group, they calculated lung age from the results. The other half received raw results without a calculation of lung age. The test was repeated a year later, along with a saliva test to verify reports of those who said they had quit smoking. Those who got the initial results in the form of their lung age were twice as likely to have quit a year later as those who just got the statistical medical result. This was true even for smokers whose lung ages came up normal. "We called this the win-win scenario," says lead author Dr. Gary Parkes, a general practitioner. "They were relieved to have a good result and decided to quit." Exercise Is Good for the Brain Shari Roan, Los Angeles Times- 3/17/2008 When he became a psychiatrist in the 1970s, John Ratey didn't expect to evolve into an exercise buff. But today, the Harvard University professor and expert in attention-deficit hyperactivity disorder calls exercise the single most important tool people have to optimize brain function. If you get your body in shape, he says, your mind will follow. Ratey describes the emerging research on exercise and the brain in a book, "Spark: The Revolutionary New Science of Exercise and the Brain," which was published in January by Little, Brown. His theory is straightforward: Humans evolved as physical creatures. When they're lulled into sedentary lives, their bodies -- and their brains -- get flabby from lack of physical exertion. Exercise, particularly aerobic exercise, can improve cognitive performance, soften the effects of stress, help fend off addiction-related cravings and tone down the negative consequences of women's hormonal changes, Ratey says. When it comes to psychiatric disorders, he calls exercise "one of the best treatments we have." Explain why you titled the book "Spark." We're talking about the brain and changing it. Exercise is adding the spark to the brain. It gives energy to the brain. We've heard that exercise increases neurotransmitters such as dopamine and serotonin. But what is brain-derived neurotrophic factor and why is it so important? It is a very key linchpin for me and for the neuroscience community. In the '90s, we learned in a big study [by UC Irvine neuroscientist Carl Cotman] that exercise is one of the factors that delayed the onset of cognitive decline. That surprised a lot of people and no one knew how to account for it. The assumption was that exercise didn't act on the brain. We also knew there was a thing called BDNF -- brain-derived neurotrophic factor [a protein that helps build and maintain the cell circuitry in the brain]. Another study [also by Cotman] showed exercise elevates BDNF. It truly is Miracle-Gro for the brain. Why does aerobic activity and complex motor activity, such as martial arts or dance, produce different effects in the brain? The more complicated the exercise, the more challenging it is. You're challenging the learning and focusing parts of your brain as well as doing the aerobics. It optimizes the brain to learn. Which is better to do? The ideal exercise plan would include both exercise that keeps you learning and [exercise that] keeps you moving -- and keeps the challenge up. Challenge is something that we should all be striving for. It's the key to a long and healthy life. Is walking helpful for the brain? Even moving a little bit, such as walking very slowly, causes some increase in heart rate, and it does help. But volume and intensity are different. If you're going to do one, limit the volume and increase the intensity. . . . Intensity is important for the benefits to the brain. Most of the studies showing the benefit of exercise on depression were of people doing brisk walking. That might be at 65% to 75% of maximum heart rate. But that really is the level where you're just beginning to get a benefit. Why is morning the best time to exercise? I think morning is such a good time because it helps you start the day off correctly. Your attention system is turned up and on. But you're still going to get quite a bit of benefit from exercising in the evening. You recommend exercise for depression, anxiety and addictions. But telling someone who is addicted or depressed to exercise sounds as if it's trivializing the problem, doesn't it? It might. I certainly would consult a physician first if you're depressed or if you need someone watching you. I'm not opposed to medicine at all. I think what is revolutionary is the new science that exercise may be the best second treatment you can use -- in conjunction with whatever treatment you're already doing. Exercise improves cognitive behavior therapy and it's a good partner to antidepressant and anti-anxiety medications. Why does exercise help people with ADHD so much? It is a very useful tool for ADHD. They may focus better and be less impulsive. People feel less like they have to move [making them less fidgety]. With exercise, you've changed things in the brain. How big an effect can regular aerobic exercise have on cognitive decline related to aging? The evidence on the benefits of exercise on cognitive decline really started the whole ball rolling. It has been studied so much. It certainly has a big impact, delaying cognitive decline by as much as seven to 10 years. It plays a huge role in maintaining and regaining cognitive function. So exercise is the best thing to do if you're worried about memory loss and cognitive decline during aging? No. 1 is exercise. No. 2 is learn and connect with other people. The ideal prescription is to do the exercise with someone. A social event has a positive effect with exercise and learning. If it lifts mood and increases energy and helps us think better, why do so many people hate exercise and quit? That is the biggest problem. Fifty percent of people who start exercise end up dropping it after six months or so. It does require planning, consideration and work. I tell people to make a commitment with a loved one, friend or neighbor. Often, that kind of social obligation can help get people started. That is probably the best way to begin. But it would be ideal if there were people to check on you and get you out of the house every day. Understanding its physical benefits hasn't gotten a lot of people to exercise. Will knowledge of the brain benefits carry more meaning -- and more motivation? That is exactly my point. If people were aware this was such good medicine in so many ways and gets you in a steady state mentally, more people would likely start and stick with an exercise regimen. But look at the studies that show exercise is as effective as antidepressants. It makes news for a day, and it's gone. It's like we've gotten into thinking we need a pill, not just for mood, for everything. Exercise is simple, but, oh boy, it really takes a commitment. That's why we need to tell people about the evidence that exercise benefits the brain and the body. Cocaine May Cause Heart Attack Symptoms Associated Press, 3/17/2008 DALLAS -- Younger ER patients with heart attack symptoms should be asked if they've recently used cocaine, which can cause similar chest pain, the American Heart Association warns doctors. For these patients, honesty can be a matter of life or death: Some heart attack treatments can be deadly to someone using cocaine. New guidelines published online Monday in the American Heart Association journal Circulation say that emergency room doctors need to be aware that symptoms of a heart attack in younger patients with no heart disease risk factors may be caused by cocaine use. Cocaine can cause chest pain, shortness of breath, anxiety, palpitations, dizziness, nausea and heavy sweating -- all symptoms of a heart attack. ''Not knowing what you are dealing with and giving the wrong therapies could mean death rather than benefit,'' said Dr. James Reiffel, professor of clinical medicine at Columbia University Medical Center/New York Presbyterian Hospital. The number of cocaine-related users visiting ERs rose 47 percent from 1995 to 2002, increasing from 135,711 to 199,198, according to the government's Substance Abuse and Mental Health Services Administration. (That's a tiny percentage of the more than 100 million patient visits to emergency rooms each year.) ''The symptoms that they get with the cocaine are very similar to a heart attack,'' said Dr. James McCord, who chaired the statement writing committee. Cocaine can cause a heart attack, but only about 1 percent to 6 percent of patients with cocaine associated chest pain actually have a heart attack, the statement says. Still, doctors say it's important for anyone with chest pain to get it checked out. Cocaine increases blood pressure and the heart rate, constricting arteries into the heart, said McCord, cardiology director of the chest pain unit for the Henry Ford Health System in Detroit. ''Your heart rate goes up because your heart needs more oxygen, then it shrinks the arteries to the heart,'' McCord said. The statement says that since most cocaine-associated chest pain isn't a heart attack, such patients should be monitored instead of being admitted to the hospital. They would have an electrocardiogram and other tests to rule out a heart attack. ''If you admit everyone to hospital with chest pain, you use valuable resources,'' said Reiffel. Two typical heart attack treatments can be dangerous to those using cocaine: -- Clot-busting drugs carry an extra risk of bleeding into the brain in patients whose blood pressure is high due to cocaine use. -- Betablockers that can lower blood pressure without constricting arteries in typical heart attack patients have the opposite effect in cocaine users, raising blood pressure and squeezing cocaine-narrowed arteries. Reiffel said doctors should explain why it's important to know if a patient is using cocaine. He said that admitting use of an illegal substance is confidential information that won't be reported to law enforcement. ''The caregiver is not here to judge.'' The statement also recommends that cocaine users who do have a coronary artery blockage get a bare metal stent instead of a drug-coated one since chronic drug users may not reliably take the medication needed to prevent new blockages. McCord said that the drug counseling available in observation units varies among hospitals, and that more could to improve the counseling cocaine-using patients get. ''I think an ideal scenario would be someone whose job is to talk to them about this -- explain the extent of the health problems, give them information about resources to help them quit cocaine,'' McCord said. On the Net: American Heart Association, www.americanheart.org OUR DAILY MEDS: How the Pharmaceutical Companies Transformed Themselves Into Slick Marketing Machines and Hooked the Nation on Prescription Drugs By Melody Petersen 432 pp. Sarah Crichton Books/Farrar Straus & Giroux. $26. Review by Janet Maslin, New York Times- 3/17/2008 By the time Melody Petersen gets around to interviewing Iowa’s state nosologist near the end of “Our Daily Meds,” the facts that she cites don’t even sound that grim. The nosologist’s job is to catalog Iowa’s deceased according to cause of death. He processes about 27,000 death certificates a year. And by his reckoning there were only five deaths caused by adverse reactions to prescription drugs in 2002. That low figure is jarringly out of whack with Ms. Petersen’s investigative reporting in an angrily illuminating book on drug-related corporate malfeasance and patient peril. “Could drugs be killing people but escaping all blame, leaving them to harm even more Americans until someone, finally, catches on?” Ms. Petersen asks. Given the information that her book uncovers, this a purely rhetorical question. Her study cites reckless and questionable behavior in all aspects of drug companies’ research and marketing ploys, even if much of this is familiar territory. It has been explored by earlier crusaders (notably Marcia Angell in “The Truth About the Drug Companies”) and in Ms. Petersen’s own journalism. She spent four years as a reporter covering the drug industry for The New York Times. The newer and scarier material in “Our Daily Meds” concerns the increasingly serious consequences of Americans’ dependency on prescription drugs. Disagreeing with Iowa’s nosologist, Ms. Petersen says the lethal consequences of overprescribed or misprescribed drugs are too readily accepted as “natural” death. She cites the unwillingness of pathologists to question the wisdom with which doctors dispense medications. The reluctance of hospitals to perform autopsies, she says, has impeded medical research into what these interactions can do. “Our Daily Meds” begins by illustrating the established drug-company practices that have led to this sorry juncture. There is the rigging of studies, so that to be deemed “effective” a drug need only perform better than a sugar pill. There are the promotional strategies that evade the need for F.D.A. warnings by, say, planting logos for the sexual enhancement drug Viagra and the antidepressant Wellbutrin on Nascar vehicles. There is the co-option of doctors and university researchers by aggressive, payola-dispensing drug company representatives. Ms. Petersen, who has done much of her digging with the help of obscure but gratifying corporate documents, even finds feedback from doctors about the bribe-style amenities offered by drug company junkets. (“Hotel too cold inside,” one said, in an evaluation of a June 1998 drug company program, adding, “Resort places preferred.” From a different doctor, miffed at the lack of a chauffeur at another event: “Hired car would have been much preferable.” But she moves to weightier matters in assessing the directions in which heavy drug dependence is leading Americans. First of all there are the business strategies that have created illnesses out of what used to be facts of life, labeled them as syndromes, and have hooked customers into long-term use of medication to cure them. (Detrol, the obnoxiously advertised cure for what its manufacturer calls “overactive bladder,” is a case in point, especially since it can cause hallucinations that resemble symptoms of Alzheimer’s disease.) Second, there are the economics of creating chronic consumers for marginally necessary drugs. Irate as she is that in a period (1980-2003) when Americans doubled what they spent on cars they increased their spending on prescription drugs by 17 times, Ms. Petersen steps back to consider the long-term consequences of this shift in consumption. She notes that the first generation of children raised in front of ubiquitous, sunny drug-company advertisements (which became legal in 1997) has acquired the notions that prescription pills fix everything, and that they are less dangerous than street drugs. Then, looking to the elderly, she points out that increasing numbers of drugs are accumulating in these patients, with little regard for the consequences. “As older patients move through time, often from physician to physician,” one doctor tells her, “they are at increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer upon layer of coral.” And when the side effects of sleeping pills or antidepressants mean more elderly people fall down, the solution is not likely to be the scaling back of such prescriptions. “Instead,” she writes, “the companies have used the statistics on falls to create a new blockbuster pharmaceutical market for drugs they claim will reduce the chances of breaking a bone.” The market for just two of these drugs, Fosamax and Actonel, is expected to be worth $10 billion by 2011. Ms. Petersen compiles this data in anecdotal style, even though they would have hit harder in more crystallized, succinct form. But although she rambles and repeats herself at times, this material remains tough, cogent and disturbing enough to have a serious impact. So do her recommendations at the end of this chilling investigation. Among them: Look at the pens and tissue boxes in your doctor’s office. If they feature drug ads, then a drug company representative has been courting your doctor, trying to influence the ways in which that doctor issues prescriptions. Don’t trust paid celebrity drug endorsements. Be aware that your symptoms may be caused not by illness but by medication, especially when more than one medication is involved. Ms. Petersen urges more study of these interactions, particularly on the part of police officers who can assess drunk drivers but not overmedicated ones. “Our Daily Meds” also advocates more supervision of doctors’ research articles, many of which are ghostwritten by drug company spokesmen. It calls for drug watchdog agencies that are not overseen by the government, since government officials can so easily be lobbied. Most drastically, she advocates prison time for executives implicated in pharmaceutical crimes. But those crimes are part of a time-honored tradition. As a federal investigator put it in 1937, after a barely tested elixir killed as many as 30 percent of the people who took it: “Apparently they just throw drugs together and if they don’t explode they are placed on sale.” Teenage Suicides Bewilder an Island, and the Experts Benedict Carey, New York Times- 3/18/2008 NANTUCKET, Mass. — If the three deaths were connected, no one on the island could say exactly how. The first, a 15-year-old, killed himself at his home near the high school in February 2007. The second, a 17-year-old ‘A’ student and an athlete, committed suicide last October. The third, a 16-year-old found dead at home in January, may have been an accidental death, not a suicide. None had been good friends. Yet they were all islanders, talented and well-liked students in a high school of 400 that had not had a suicide for more than 40 years. The small year-round community on Nantucket Island, deeply shaken, turned to outside experts for help. Then the specialists began to descend. Some visited classrooms, wanting to talk students through their grief. Another emphasized the importance of telling young people that suicide was wrong, and an awful way to solve problems. Still another promoted relaxation techniques and warned that suicidal behavior could be contagious. “These experts, they trickled in after the first death,” said Olivia Hull, 18, a writer and an editor at the school newspaper, Veritas. “Then there were more after the others. It was all very confusing.” As the island quickly learned, there is no consensus on how best to respond to a cluster of teenage suicides — or even how to tell a cluster from a statistical fluke. Other researchers warn that some interventions may do more harm than good. “It’s possible that some aspects of a well-intended response could inadvertently increase the risk of subsequent suicidal behavior,” Matthew Nock, an associate professor of psychology at Harvard, said. “So you want to respond, but should do so with knowledge of the potential risks.” Dr. Nock and other psychologists do not dispute that teenage suicides can occur in clusters — on average in at least five communities a year in this country, studies suggest. Researchers estimate that up to 5 percent of teenage suicides occur close to other ones, a higher rate than found in adults. Some clusters appear to involve a deadly, incomprehensible fad. In the last year, 17 young people are thought to have killed themselves in Bridgend, a city of 130,000 in Wales. Others may just be coincidence, and in places with sequential teenage suicides, investigators have looked in vain for similarities or common reasons. “There’s really no such thing as a suicide town,” said Dr. Madelyn Gould, a psychiatry professor at Columbia’s College of Physicians and Surgeons. “That’s the bottom line.” Nantucket, ablaze with flowers and wealthy visitors in summer, goes quiet in winter, the middle-class community of 10,000 turning more inward. Teenagers here have the usual clubs and sports. They have parties around bonfires on the beach, and most of all, they have one another, friends, rivals and acquaintances they have known since preschool, for better and worse. The deaths, so close together, hit the island like an earthquake. Teachers were devastated. School officials called an assembly after each one, announcing that a student had “died unexpectedly.” After the third death, the school day unraveled. Students gathered in the halls in shock, some crying. Most were allowed to go home. “Parents, especially, have been very concerned, wondering why this is happening and what they can do to protect their own children,” said Dr. Timothy Lepore, the island’s surgeon and medical examiner, who has lived there for 25 years and has been on the school board for most of that time. The first outside experts to arrive were counselors from the State Mental Health Department, who spoke to the faculty and to students in class. The state sent one counselor to help after the first death. After the third, the agency rotated in about six, said Peter Evers, southeast area director at the agency. The counselors helped settle the faculty’s emotions, School Superintendent Robert Pellicone and others said. Their effects on the students were harder to gauge. In one classroom session, a grief counselor kept referring by the first name to a friend of hers who had the same name as the Nantucket girl who had just died, causing some students to burst into tears each time. “It was very strange,” Ms. Hull said. The state also contracted a trauma specialist from the Boston area, Robert D. Macy, to coordinate the community response. On Jan. 18, Dr. Macy, who has organized responses to teenage suicides in other towns, appeared on local television and said, “We’ve had a number of children kill themselves in a short period of time, and that’s called contagion.” In fact, there is no hard and fast equation to distinguish related events from statistical aberrations, said Thomas Joiner, a psychology professor at Florida State University. Nor is there any good definition of behavioral contagion, he added. It may be simply that a classmate’s death by suicide makes the act itself seem suddenly more acceptable or accessible, a dark fantasy made real. Or it may be that struggling teenagers feel an urge to imitate another’s behavior, especially if the details of it are widely known through news media reports and if the death was dignified by well-meaning memorials and tributes like those that flooded Nantucket High School after all three deaths. A scholarship fund was even established in the name of one student who died. Most likely, Dr. Joiner said, teenagers who are depressed or self-critical tend to find one another and hang out in similar circles, and the death of one of them is itself a trauma that can set off self-destructive actions by the others. It was unclear whether these factors were in play on Nantucket. But in an interview, Dr. Macy said he was taking no chances. In early February at what was called a training session, he told a group of more than 70 teachers, parents and community leaders that they had to be prepared in case of another tragedy. He told them up front that the deaths were not their fault. In three days of sessions, he led deep-breathing exercises, demonstrated how to become more focused by balancing a peacock feather on the palm or finger, and taught a method to interview people who have been through a crisis called psychological first aid. “From the traumatologist’s perspective, these are survivors of the deaths, and you’re there to give them choices,” Dr. Macy said. He said people could help others through a crisis only if they were calm themselves. “You want people to come down after they’ve been revved up, and one of the first things they can do is to experience exhaling more fully than they inhale, to get rid of CO2,” he said. “That and other things like their balancing a feather can help people stay grounded.” Several islanders who attended the demonstration said it was helpful in uniting residents who wanted to help. Others said they were not sure that the school needed another 75 crisis intervention experts to descend in case something else occurred. A few days later, another expert, this one invited by the school district, took another tack in addressing a group of parents. The district’s expert, Maria Trozzi, director of the Good Grief program at Children’s Hospital Boston, strongly urged the audience not to think of the island as being under siege by an infectious problem. “This is not a virus that’s going to suddenly strike in this room, and there’s nothing we can do about it,” Dr. Trozzi told a group of 60 people, mostly mothers and couples, in the high school auditorium. A father of three raised his hand and asked the question that was on everyone’s mind. “So what exactly do we tell our children about this?” Tell them it was wrong, she said. Do not romanticize the act, glorify it with lasting memorials or dignify it with easy excuses like, “He hated his father,” or, “He got rejected from Harvard,” Dr. Trozzi advised. Most of all, she said, make it very clear to your children that those who took their lives were not very good problem solvers — to put it mildly. “Ask them,” she suggested, “ ‘Who do you think you can talk to if you have a problem?’ ” On those points, at least, the many suicide experts who have visited Nantucket in recent months all agreed. “The people who have come to advise us all have had very good intentions and ideas,” said Selectman Mike Kopko, who has helped coordinate the response. “Now it’s time for us to vet all the suggestions we’ve been getting and decide what’s best for those of us who live here.” And none too soon, for some. In a recent letter to The Boston Globe, Katie McInerney, a senior at Nantucket High, warned against assuming that island teenagers were somehow more fragile than any others. “Yes, it is cold and secluded out here, but we are pretty creative in finding ways to deal with this that don’t include feeling hopeless and falling into depression.” Ms. Hull, the student editor, said she and her friends had had about enough expert advice for now and were ready to move on. “They didn’t even know us,” she said. “Now, it’s like — out. Done. You’re voted off the island.” She added, “You can say that here, because it is one.” Gene May Help Explain PTSD Associated Press, 3/18/2008 CHICAGO -- Groundbreaking research suggests genes help explain why some people can recover from a traumatic event while others suffer post-traumatic stress disorder. Though preliminary, the study provides insight into a condition expected to strike increasing numbers of military veterans returning from combat in Iraq and Afghanistan, one health expert said. Researchers found that specific variations in a stress-related gene appeared to be influenced by trauma at a young age -- in this case child abuse. That interaction strongly increased the chances for adult survivors of abuse to develop signs of PTSD. Among adult survivors of severe child abuse, those with the specific gene variations scored more than twice as high (31) on a scale of post-traumatic stress, compared with those without the variations (13). The worse the abuse, the stronger the risk in people with those gene variations. The study of 900 adults is among the first to show that genes can be influenced by outside, nongenetic factors to trigger signs of PTSD. It is the largest of just two reports to show molecular evidence of a genetic influence on PTSD. ''We have known for over a decade, from twin studies, that genetic factors play a role in vulnerability to developing PTSD, but have had little success in identifying specific genetic variants that increase risk of the disorder,'' said Karestan Koenen, a Harvard psychologist doing similar research. She was not involved in the new study. The results suggest that there are critical periods in childhood when the brain is vulnerable ''to outside influences that can shape the developing stress-response system,'' said Emory University researcher and study co-author Dr. Kerry Ressler. The study appears in Wednesday's Journal of the American Medical Association. Several study authors, including Ressler, reported having financial ties to makers of psychiatric drugs. Ressler noted that there are probably many other gene variants that contribute to risks for PTSD, and others may be more strongly linked to the disorder than the ones the researchers focused on. Still, he and outside experts said the study is important and that similar advances could lead to tests that will help identify who's most at risk. Treatments including psychotherapy and psychiatric drugs could be targeted to those people, Ressler said. About a quarter of a million Americans will develop PTSD at some point in their lives after being victimized or witnessing violence or other traumatic events. Rates are much higher in war veterans and people living in high-crime areas. Symptoms can develop long after the event and usually include recurrent terrifying recollections of the trauma. Sufferers often have debilitating anxiety, irritability, insomnia and other signs of stress. Dr. Thomas Insel, director of the National Institute of Mental Health, said the study is particularly valuable for the light it sheds on military veterans, who are known to be vulnerable to PTSD. He said the results help explain differences in how two people see the same roadside bomb blast. One simply experiences it as ''a bad day but goes back and is able to function.'' The other later develops paralyzing stress symptoms. ''This could be quite a wave that will hit us over the months and years ahead,'' Insel said. His agency paid for the study. Study participants were mostly low-income black adults, aged 40 on average, who sought non-psychiatric health care at a public hospital in Atlanta. They were asked about experiences in childhood and as adults and gave saliva samples that underwent genetic testing. Almost 30 percent of participants reported having been sexually or physically abused as children. Most also had experienced trauma as adults, including rape, attacks with weapons and other violence. Researchers focused on symptoms of PTSD rather than an actual diagnosis, and found that about 25 percent had stress symptoms severe enough to meet criteria for the disorder, Ressler said. Childhood abuse and adult trauma each increased risks for PTSD symptoms in adulthood. But the most severe symptoms occurred in the 30 percent of child abuse survivors who had variations in the stress gene. Researchers were not able to determine if the symptoms were reactions to the child abuse or to the more recent trauma -- or both, said co-author Rebekah Bradley, also of Emory University. The study is an important contribution to a growing body of research showing how severe abuse early in life can have profound, lasting effects, said Duke University psychiatry expert John Fairbank, co-director of the National Center for Child Traumatic Stress. He was not involved in the research. On the Net: JAMA: http://jama.ama-assn.org PTSD: http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd For Dementia, Fewer Antipsychothic Drugs May Be Stronger Medicine Warren Wolfe, Chicago Tribune- 3/18/2008 MINNEAPOLIS - It's hard to believe when you meet 94-year-old Meta Miller today. But then her daughter Carol Johnson begins describing just how bad it got as she struggled to manage her mom's dementia at home before Thanksgiving 2006. "She would roam the house all night with her cane, talking to imaginary people, knocking things down, yelling at me, accusing me of horrible things -- my own mom," Johnson recalled with tears. "And it just got worse when she went to the first nursing home. That's when she started screaming." Coping with combative, irrational and sometimes violent behavior of people with dementia is among the most difficult situations for nursing homes and families. Thousands of nursing homes nationwide are doing what a hospice program and then a nursing home did for Miller: using powerful antipsychotic drugs to quiet disruptive people with dementia -- at times a step that's easier and cheaper than taking staff time to fix the problem. That practice is alarming Medicaid officials. Last year they ordered Minnesota nursing home inspectors to crack down on the inappropriate use of these drugs. So dangerous are the drugs that the U.S. Food and Drug Administration requires some to carry a "black box warning" that they heighten risk of death for older patients, a warning that the agency might extend to all antipsychotic drugs. They also increase the risk of confusion and falling. The drugs often are prescribed whether the resident is psychotic or not. Antipsychotic drugs have become the No. 1 drug paid for by Medicaid, which regulates and pays for most nursing home care. They are prescribed for about 30 percent of all nursing home residents. Sometimes the drug treatment helps, said Dr. Robert Sonntag, a specialist on aging who works in 16 nursing homes, including Beverly LivingCenter-Hopkins, where he is medical director and Meta Miller's physician. "But sometimes, as with Mrs. Miller, it makes people worse -- either more agitated or drugged into a stupor, much more likely to fall and break a hip," Sonntag said. Unless the resident is combative because of a mental illness such as paranoia, there's almost always a better way to control disruptive behavior in someone with dementia than with drugs, said John Brose, a Minneapolis psychologist who consults at more than 100 nursing homes, including Hopkins. "Usually, that person is trying to communicate something -- I'm too cold, too hot, constipated, frightened, tired, thirsty," he said. "Figure that out, then deal with the real problem." With Miller -- no longer in hospice care -- it now appears her combativeness and agitation may have been caused primarily by modest dementia, pain in her swollen legs from congestive heart failure, severe deafness and constipation. More typical of Sonntag's patients is Helen Ross, 100, with advanced dementia, who had knocked down and hurt two aides and resisted help with care. The doctor took her off a range of drugs, including an antidepressant that had worsened her appetite and confusion. "Without the drugs, she's much more calm, much more stable," said her son, Gerald Ross. "At this stage, that's all we can ask for." In Meta Miller's case, her journey began with Miller living alone in her home of 52 years. She was leaving the stove on, forgetting to eat and entertaining invisible visitors, some sporting prom dresses. That's when her daughter took Miller into her home. Miller's doctor approved hospice care because she appeared to be dying. "It was bad from the start because Mom was always in charge of everything, but now was pretty confused," Johnson remembered. "Then the hospice program started giving her Haldol to calm her, and it got worse. She was vicious." Later, with Miller now on a new-generation antipsychotic called Seroquel that also didn't help, she was moved to the Hopkins home and met Sonntag. "Most people in nursing homes are overmedicated -- heck, most older people are overmedicated -- and not just on antipsychotics," he said. Sonntag began weaning her from Seroquel and other drugs, and Miller blossomed. "She's kind of the queen bee of the dementia unit," said nurse Joan Sang, co-director of Miller's unit. Johnson, for her part, heaped praise on the nursing home and Sonntag. "She's a changed woman. We didn't know enough to question the drugs they were giving Mom before," she said. "We learned the hard way." A BRIEF HISTORY OF ANXIETY--Yours and Mine By Patricia Pearson 198 pages. Bloomsbury. $23.95. Review by William Grimes, New York Times- 3/19/2008 For a brief but intense period in 2006, Patricia Pearson logged on daily to Flu Wiki. This is a Web site (fluwikie.com) devoted to the concerns — the very deep concerns — of people convinced that a worldwide outbreak of influenza is imminent, and that it will make the ravages of the Black Death seem like a mildly unpleasant interlude. “Here could be found a great milling together of fiercely articulate and freaked-out people from around the world, posting to discussion topics like ‘What Will We Do With the Bodies?’ Ms. Pearson writes in “A Brief History of Anxiety.” Visitors to the site offered suggestions on how to turn back the infected, zombie-like hordes who, in a desperate search for food, will try to invade the fortified homes of the healthy. Ms. Pearson, the author of the highly amusing “Area Woman Blows Gasket,” sees the humor in Flu Wiki, but she too worries about pandemics. A lot. She also obsesses about sudden liver failure, possibly cancerous moles, flying insects, the supervolcano underneath Yosemite National Park and the possibility that her car will blow up. All of this seems potentially hilarious, but the humor quickly freezes as Ms. Pearson describes a lifetime of absurd but crippling fears. Like 40 million Americans, Ms. Pearson suffers from anxiety, which she pithily calls “fear in search of a cause.” Her own case fascinates her, and quite rightly. It presents her with the opportunity to examine modern civilization and its discontents, as well as her own miseries, which she does, thoughtfully and incisively. Her subject is elusive. Unnamed until Freud coined the term “anxiety neurosis,” the uninvited stranger lurks at the margins of history. When King David, in the Bible, says that “fearfulness and trembling are come upon me,” is he suffering an anxiety attack? Ms. Pearson cites an 18th-century English treatise blaming city living for “a class and set of distempers, with atrocious and frightful symptoms, scarce known to our Ancestors,” that is, “nervous disorders” afflicting a third of the population. Could this be it? Everywhere and nowhere, anxiety, Ms. Pearson writes, is “unbearably vivid yet insanely abstract.” In many cases it is the fear of fear itself, a free-floating, nebulous entity that, like a mutant virus, feeds on any available host. Reason is powerless against it. Ms. Pearson argues, in fact, that rationalism, intended to banish superstition and fear, has instead removed one of the most effective weapons against anxiety, namely religious faith and ritual. Even worse, the worship of reason and science, by encouraging the notion that human beings can control their environment, has created a terrible fault line in the modern psyche, although not all societies suffer equally. Mexicans have lots to worry about but don’t. The World Mental Health Survey, conducted in 2002, found that only 6.6 percent of Mexicans had ever experienced a major episode of anxiety or depression. Meanwhile, to their north, 28.8 percent of the American population has been afflicted with anxiety, the highest level in the world. Mexicans who move to the United States adapt, becoming more anxious. In searching for the roots of her affliction, Ms. Pearson finds a common thread connecting her traumas and her phobias, the fear of losing control, of being unable to cope. As a child, caught up in the India-Pakistan war in 1971, she cowered in her family’s house in New Delhi, waiting for bombs to fall. She was terrified of the dark. At 23, she suffered a nervous breakdown after her boyfriend casually informed her, on a visit to her family’s summer house in Canada, that he was seeing another woman. A diagnosis of “generalized anxiety disorder” ensued. Ms. Pearson never finds satisfactory answers to her self-interrogations, but the professionals do not do much better. The angriest pages in her book are devoted to the psychiatrists who put her on a regimen of anti-anxiety medications, which dulled the static in her brain but left her “in an emotional half-light,” secure but disengaged. “I’d watch movies without being stirred by them, listen to music without real interest,” she writes. “In truth, I began to feel faintly sociopathic.” She became addicted to Effexor, and late in the book drops the small bombshell that, as she writes, she has been off an antidepressant called Lexapro for only six weeks. Ms. Pearson married and had children. She has a successful writing career. But the woman she describes can barely hold her life together. One night she dreams that she is lying on a cushioned bench admiring the Grand Canyon. Suddenly she realizes that the bench is attached at one end to a cliff face but is otherwise suspended in midair. “If I moved even an inch in any direction, I would fall for miles,” she writes. “The choking panic that I felt was extraordinary. I felt a perfect — a Platonic — sense of terror.” That, in a nutshell, is her situation, one that she addresses through therapy, pull-up-your-socks willpower and a blend of religion and the insights of writers like the cultural geographer Yi-Fu Tuan. It all seems touch and go — but give her major points for wit and flair. The author biography on the dust jacket reads: “She lives in Toronto with her husband, her two children and her dread.” A Good Marriage Equals Good Blood Pressure Associated Press, 3/20/2008 NEW YORK -- A happy marriage is good for your blood pressure, but a stressed one can be worse than being single, a preliminary study suggests. That second finding is a surprise because prior studies have shown that married people tend to be healthier than singles, said researcher Julianne Holt-Lunstad. It would take further study to sort out what the results mean for long-term health, said Holt-Lunstad, an assistant psychology professor at Brigham Young University. Her study was reported online Thursday by the Annals of Behavioral Medicine. The study involved 204 married people and 99 single adults. Most were white, and it's not clear whether the same results would apply to other ethnic groups, Holt-Lunstad said. Study volunteers wore devices that recorded their blood pressure at random times over 24 hours. Married participants also filled out questionnaires about their marriage. Analysis found that the more marital satisfaction and adjustment spouses reported, the lower their average blood pressure was over the 24 hours and during the daytime. But spouses who scored low in marital satisfaction had higher average blood pressure than single people did. During the daytime, their average was about five points higher, entering a range that's considered a warning sign. (That result is for the top number in a blood pressure reading). ''I think this (study) is worth some attention,'' said Karen Matthews, a professor of psychiatry, psychology and epidemiology at the University of Pittsburgh. She studies heart disease and high blood pressure but didn't participate in the new work. Few studies of the risk for high blood pressure have looked at marital quality rather than just marital status, she said. It makes sense that marital quality is more important than just being married when it comes to affecting blood pressure, said Dr. Brian Baker, an associate professor of psychiatry at the University of Toronto. Public Health Risk Seen as Parents Reject Vaccines Jennifer Steinhauer, New York Times- 3/21/2008 The parents who objected to their children being inoculated are among a small but growing number of vaccine skeptics in California and other states who take advantage of exemptions to laws requiring vaccinations for school-age children. The exemptions have been growing since the early 1990s at a rate that many epidemiologists, public health officials and physicians find disturbing. Children who are not vaccinated are unnecessarily susceptible to serious illnesses, they say, but also present a danger to children who have had their shots — the measles vaccine, for instance, is only 95 percent effective — and to those children too young to receive certain vaccines. Measles, almost wholly eradicated in the United States through vaccines, can cause pneumonia and brain swelling, which in rare cases can lead to death. The measles outbreak here alarmed public health officials, sickened babies and sent one child to the hospital. Every state allows medical exemptions, and most permit exemptions based on religious practices. But an increasing number of the vaccine skeptics belong to a different group — those who object to the inoculations because of their personal beliefs, often related to an unproven notion that vaccines are linked to autism and other disorders. Twenty states, including California, Ohio and Texas, allow some kind of personal exemption, according to a tally by the Johns Hopkins University. “I refuse to sacrifice my children for the greater good,” said Sybil Carlson, whose 6-year-old son goes to school with several of the children hit by the measles outbreak here. The boy is immunized against some diseases but not measles, Ms. Carlson said, while his 3-year-old brother has had just one shot, protecting him against meningitis. “When I began to read about vaccines and how they work,” she said, “I saw medical studies, not given to use by the mainstream media, connecting them with neurological disorders, asthma and immunology.” Ms. Carlson said she understood what was at stake. “I cannot deny that my child can put someone else at risk,” she said. In 1991, less than 1 percent of children in the states with personal-belief exemptions went without vaccines based on the exemption; by 2004, the most recent year for which data are available, the percentage had increased to 2.54 percent, said Saad B. Omer, an assistant scientist at the Johns Hopkins Bloomberg School of Public Health. While nationwide over 90 percent of children old enough to receive vaccines get them, the number of exemptions worries many health officials and experts. They say that vaccines have saved countless lives, and that personal-belief exemptions are potentially dangerous and bad public policy because they are not based on sound science. “If you have clusters of exemptions, you increase the risk of exposing everyone in the community,” said Dr. Omer, who has extensively studied disease outbreaks and vaccines. It is the absence, or close to it, of some illnesses in the United States that keep some parents from opting for the shots. Worldwide, 242,000 children a year die from measles, but it used to be near one million. The deaths have dropped because of vaccination, a 68 percent decrease from 2000 to 2006. “The very success of immunizations has turned out to be an Achilles’ heel,” said Dr. Mark Sawyer, a pediatrician and infectious disease specialist at Rady Children’s Hospital in San Diego. “Most of these parents have never seen measles, and don’t realize it could be a bad disease so they turn their concerns to unfounded risks. They do not perceive risk of the disease but perceive risk of the vaccine.” Dr. Sawyer and the vast majority of pediatricians believe strongly that vaccinations are the cornerstone of sound public health. Many doctors view the so-called exempters as parasites, of a sort, benefiting from the otherwise inoculated majority. Most children get immunized to measles from a combined measles, mumps and rubella vaccine, a live virus. While the picture of an unvaccinated child was once that of the offspring of poor and uneducated parents, “exempters” are often well educated and financially stable, and hold a host of like-minded child-rearing beliefs. Vaccine skeptics provide differing explanations for their belief that vaccines may cause various illnesses and disorders, including autism. Recent news that a federal vaccine court agreed to pay the family of an autistic child in Georgia who had an underlying mitochondrial disorder has led some skeptics to speculate that vaccines may worsen such conditions. Again, researchers say there is no evidence to support this thesis. Alexandra Stewart, director of the Epidemiology of U.S. Immunization Law project at George Washington University, said many of these parents are influenced by misinformation obtained from Web sites that oppose vaccination. “The autism debate has convinced these parents to refuse vaccines to the detriment of their own children as well as the community,” Ms. Stewart said. While many parents meet deep resistance and even hostility from pediatricians when they choose to delay, space or reject vaccines, they are often able to find doctors who support their choice. “I do think vaccines help with the public health and helping prevent the occasional fatality,” said Dr. Bob Sears, the son of the well-known child-care author by the same name, who practices pediatrics in San Clemente. Roughly 20 percent of his patients do not vaccinate, Dr. Sears said, and another 20 percent partially vaccinate. “I don’t think it is such a critical public health issue that we should force parents into it,” Dr. Sears said. “I don’t lecture the parents or try to change their mind; if they flat out tell me they understand the risks I feel that I should be very respectful of their decision.” Some parents of unvaccinated children go to great lengths to expose their children to childhood diseases to help them build natural immunities. In the wake of last month’s outbreak, Linda Palmer considered sending her son to a measles party to contract the virus. Several years ago, the boy, now 12, contracted chicken pox when Ms. Palmer had him attend a gathering of children with that virus. “It is a very common thing in the natural-health oriented world,” Ms. Palmer said of the parties. She ultimately decided against the measles party for fear of having her son ostracized if he became ill. In the late 1960s and 1970s, measles outbreaks in Alaska and California triggered strong enforcement of vaccine mandates by states, and exemption laws followed. While the laws vary from state to state, most allow children to attend school if their parents agree to keep them home during any outbreak of illnesses prevented by vaccines. The easier it is to get an exemption — some states require barely any paperwork — the more people opt for them, according to Dr. Omer’s research, supported by other vaccine experts. There are differences within states, too. There tend to be geographic clusters of “exempters” in certain counties or even neighborhoods or schools. According to a 2006 article in The Journal of The American Medical Association, exemption rates of 15 percent to 18 percent have been found in Ashland, Ore., and Vashon, Wash. In California, where the statewide rate is about 1.5 percent, some counties were as high as 10 percent to 19 percent of kindergartners. In the San Diego measles outbreak, four of the cases, including the first one, came from a single charter school, and 17 children stayed home during the outbreak to avoid contracting the illness. There is substantial evidence that communities with pools of unvaccinated clusters risk infecting a broad community that includes people who have been inoculated. For instance, in a 2006 mumps outbreak in Iowa that infected 219 people, the majority of those sickened had been vaccinated. In a 2005 measles outbreak in Indiana, there were 34 cases, including six people who had been vaccinated. In California, six pertussis outbreaks infected 24 people in 2007; only 2 of 24 were documented as having been appropriately immunized. A surveillance program in the mid ’90s in Canada of infants and preschoolers found that cases of Hib fell to between 8 and 10 cases a year from 550 a year after a vaccine program was begun, and roughly half of those cases were among children whose vaccine failed. |