Noteworthy News Articles on Mental Health Topics, May 1-7, 2008 SAN FRANCISCO — The issue of whether veterans with mental health problems are neglected or whether their sheer numbers are overwhelming the system divided closing arguments on Wednesday in a class-action lawsuit in federal court here. Arturo J. Gonzalez, the lawyer arguing on behalf of the Veterans for Common Sense and the Veterans United for Truth, the two groups who brought the lawsuit against the Department of Veterans Affairs, said that the agency had failed to fully put into effect an action plan it developed four years ago. The fact that it takes more than 180 days to process a veteran’s claim for benefits represents a “pattern of neglect,” Mr. Gonzalez said, adding that anyone who enters an appeal has to wait four and a half years for a resolution. “I don’t know how any veteran can stand it and stick with it and get to the end of this process,” Mr. Gonzalez said. He also emphasized the high rate of suicide attempts, 1,000 a month, among the 5.6 million veterans that the V.A. treats, as a sign that mental health issues need far greater attention. Daniel Bensing, who made the closing arguments for the V.A., noted that 838,000 claims were filed last year, an increase of 25 percent, because of the jump in veterans from Iraq and Afghanistan and a surge from aging Vietnam veterans. While acknowledging the delays were lengthy, he said that the increase in claims for help was one of four factors causing problems. The others he cited were that the claims are highly complex, not least because the ties linking veterans’ military records to their medical problems have to be investigated; that the claims process is an open one that allows veterans to add information at any time; and budgetary limitations. While acknowledging suicide as a serious problem, Mr. Bensing also emphasized that change takes time given that the V.A. runs the largest health care system in the country. “It cannot all be done immediately like plaintiffs seem to think,” he said. The plaintiffs were not seeking monetary damages but want the judge, Samuel Conti, to intervene to force the V.A. to run more efficiently. The judge, who is expected to rule in June, said he would concentrate on what legal role the Federal District Court should play. Mr. Bensing said it should be up to Congress to change the system. Lawyers for the veterans fought to get testimony from Dr. Michael J. Kussman, the under secretary for health at the V.A. Asked on the stand whether he was playing down the traumatic stress issue, Dr. Kussman said, “It is unfair and inappropriate to stigmatize people with a mental health diagnosis when they are having what most people believe are normal reactions to an abnormal situation.” Gordon P. Erspamer, the lead lawyer for the plaintiffs, said the answer indicated that the V.A. had failed to recognize the problem. “That is 19th-century thinking about PTSD and mental health issues,” he said, referring to post-traumatic stress disorder, a combat trauma. Underlying the arguments were the long-debated questions swirling around the PTSD diagnosis itself, which experts said one trial will not settle. One view maintains that all veterans suffer some mental trauma, while others argue that the symptoms among veterans with PTSD are more sustained and definitely need treatment. Several experts also noted that the suicide statistics were not a reliable index as to whether the treatment program was viable because it is severe depression that usually leads to suicide and not post-traumatic stress disorder. PTSD can prompt depression, but it is not automatic. “Suicide can be a red herring in all this,” said Dr. Mardi Horowitz, professor of psychiatry at the University of California, San Francisco, who helped pioneer stress diagnosis for Vietnam veterans in 1980. “There are abnormal events and there are normal responses. The question is when it goes over an ambiguous line and becomes a diagnosable mental disorder.” Soldiers relieved to escape combat usually do not develop the problems right away; they develop later, which is why the role of the V.A. is considered so crucial. The policy change is part of a broader Pentagon effort to reduce the stigma that military service members and civilian defense workers face in seeking care for post-traumatic stress disorder and other psychological wounds of war. Gates said the security question -- which he referred to as the "infamous Question 21" -- has been an obstacle to care, and he urged service members to get help for mental health problems. "You can be tough and seek help for dealing with these problems," he told reporters. The change will apply not only to military and civilian employees of the Defense Department but also to all applicants for security clearances. The new policy revises the 21st question on the SF-86 Questionnaire for National Security Positions. The revised form allows applicants to respond "no" as to whether they have sought mental health care over the past seven years, if that care was not court-ordered and was "strictly related to adjustments from service in a military combat environment." Previously, military personnel and others applying for the clearance who had sought treatment for PTSD, anxiety, depression and other reactions to combat stress had to answer "yes" and provide details of who conducted the treatment. About 2.5 million of the 3.1 million defense personnel have security clearances. Only a small percentage of applicants were denied clearances for mental health problems, military officials said. They cited data for 2006 showing that only about 75 out of 800,000 applications were rejected for that reason. Last year, a report by the Army's inspector general found that soldiers were hesitant to seek treatment because they worried about losing their security clearances. "The perception was much more an issue than the reality of the situation," said Lt. Col. Patrick Ryder, a Pentagon spokesman. About 20 percent -- or 300,000 -- of service members returning from Iraq or Afghanistan report symptoms of PTSD or major depression, but only slightly more than half have sought treatment, a Rand Corp. study said last month. This survey and others have shown that a major reason service members do not get help is the fear it will harm their careers. The Rand survey found similar concerns about reporting mental health treatment on deployment and fitness evaluations, or simply reluctance in telling commanders about mental health appointments. Revising the security form is a step toward reducing stigmas but more are needed, Rand researcher Terri Tanielian said. "Seeking professional care for these mental health issues should not be perceived to jeopardize an individual's security clearance," said a memo signed by James R. Clapper Jr., the undersecretary for intelligence, and David S.C. Chu, the undersecretary for personnel and readiness, and released by the Pentagon yesterday. "On the contrary, failure to seek care actually increases the likelihood that psychological stress could escalate to a more serious mental condition, which could preclude an individual from performing sensitive duties," the memo said. At a Pentagon news conference, Adm. Michael G. Mullen, chairman of the Joint Chiefs of Staff, urged military leaders to set an example. "It's time for leaders of all stripes to step forward. . . . You can't expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won't do it," he said. After nearly seven years of war in Afghanistan and more than five in Iraq, it's past time "that we recognize the toll it's taking inside our minds, as well as outside our bodies, and to deal with that reality," he said. A Pentagon official at the news conference said the department expects that senior military leaders will come forward with their stories of receiving mental health care as part of a national campaign by the military to encourage service members to seek treatment. "We can change the policy, we can talk about how important it is. Ultimately, troops and families, they want to see leaders walking that talk," said Col. Loree Sutton, an aide to the assistant secretary of defense for health affairs. A positive work environment, the study also found, can help reduce secondary trauma and prevent job burnout from this secondary, or vicarious, trauma. "Listening to a person's traumatic experiences can be a difficult experience for a clinician," senior investigator Joseph Boscarino, of Geisinger Health System, said in a prepared statement. "Sometimes caregivers need emotional support of their own, and if they don't get it, they can become emotionally ill." His team's findings, expected to be published in the May issue of Research on Social Work Practice, are based on a study of the lives of 236 New York City social workers following the Sept. 11, 2001, terror attacks. The symptoms of secondary trauma are similar to those of post-traumatic stress disorder. They include nightmares or flashbacks, being easily startled, and avoiding situations similar to the original trauma. The study found that involvement in the World Trade Center recovery effort was the primary reason why social workers experienced secondary trauma. The Child Trauma Academy has more about secondary trauma. Drums Help Psychotherapist Deal With Parents' Deaths Melissa Healy, Los Angeles Times- 5/4/2008 Larry Graber, a Santa Monica psychotherapist whose parents died within six months of each other in 2000, has made his parents' deaths a very conscious point of departure for a journey of self-discovery and improvement. As second-generation Jewish immigrants, Graber's parents were frugal and had worked their way into the upper middle class by running pawn shops. Becoming a psychotherapist and living openly as a gay man, Graber had challenged many of their expectations. But he never stopped wanting to please them. He too worked hard and lived modestly, struggling to meet what he thought were their expectations of what he could accomplish. And when they became critically ill, Graber tended to them devotedly. For more than two years, he shuttled almost daily to nursing homes, hospitals and their home in Encino to oversee their care. Tending his parents at their most vulnerable, Graber said, allowed him to understand that they accepted him as he was and wanted only for him to be happy. Other positive changes came after their deaths, when Graber decided to take several months away from work to grieve and sort out his parents' affairs. Having played drums as a child, Graber wandered one day into the workshop of Remo recreational music center in North Hollywood. He struck up a conversation with the owner, who had a long-standing interest in the use of drums and rhythm instruments as a mode of comfort and healing. Graber went home to his parents' house that day with a djembe drum -- a style of rhythm instrument long used by medicine men in West Africa. He found the rhythms he beat both soothing and energizing, and in the months that followed, many more drums came home with him from Remo's workshop. Six months after he became an orphan, Graber was asked by a fellow therapist if he would bring his drums to a retreat for family caregivers of the elderly -- people doing what he had done for his parents. Leading stressed-out caregivers in a session of group drumming, Graber said he found new purpose in his life. His growing personal passion for rhythm became united with his long-standing professional commitment to psychotherapy. Now, Graber's "drum circles" are among the most highly rated activities at caregiver retreats run by the Los Angeles Caregiver Resource Center. Graber hopes to expand his practice of rhythm therapy and build on research that suggests it can lower blood pressure and improve immune function. "I definitely feel physical benefits from it," Graber said. "And it's wonderful to work with people who haven't been able to rest well." The drum circle "stimulates your thinking in a calm way, and afterward, you feel like you can rest." Freed of his parents' likely disapproval, Graber also says he has changed his approach to pursuing some of his passions. When he decided to buy a motorcycle, he decided not to compromise (the way his frugal parents would have done) by buying a cheaper copy of the one he really wanted. Instead, he splurged and bought the high-end one. "Now that my parents are dead, it's just one more indicator that there's no reason for me not to live the life I want," Graber said. "Because it doesn't go on forever. The people I have in my life, the things I do with my life, the things I do for myself . . . there's no reason to do things halfway." Adult Orphans: When Parents Die Melissa Healy, Los Angeles Times- 5/4/2008 Jeane Safer loved and revered her mother, and braced for impact as the seemingly indomitable woman's mind and heart began to fail seven years ago. But ready or not, the end came in December 2004. Esther Safer rallied long enough to exult to her daughter, "This is my day!" then died peacefully at 92. At 57 -- her father having died many years before -- Jeanne Safer became an orphan. As a psychotherapist in New York City for 30 years, Safer had heard countless patients talk about the effect their parents' deaths had on them. She anticipated the sadness, the heightened sense of her own mortality, the comfort taken in her mother's bequeathed treasures. But in the months and years that followed her mother's death, she began to confront in herself, and to recall from the accounts of many patients, something unexpected, a "shocking -- almost sacrilegious" truth: The death of your parents can be the best thing that ever happens to you. That provocative assertion became the opening line of "Death Benefits," an autobiography-cum-guidebook Safer has written about that most momentous of midlife passages -- becoming an adult orphan. The book, published by Basic Books, is due in bookstores this week. "The death of a parent -- any parent -- can set us free. It offers us our last, best chance to become our truest, deepest selves," Safer writes. "Nothing else in adult life has so much unrecognized potential to help us become more fulfilled human beings -- wiser, more mature, more open, less afraid." And maybe healthier too. Safer and other health professionals point to legions of adults in midlife whose parents' deaths inspired them to lose weight, tidy up poor health habits, get help for depression or anxiety, pursue new passions and shoulder responsibility for their physical and mental well-being. Dr. Howard Brody, a family physician for 30 years who now teaches ethics at the University of Texas Medical Campus in Galveston, remembers bracing for near-daily visits from one of his most needy, hypochondriacal patients after learning that the woman had lost both of her parents in the span of a month. What he got instead was a lesson in death benefits. "I was quite shocked when a new person, for all intents and purposes, walked into my office for her next visit," Brody reported. "This new person seemed much more confident and willing to take charge of her own life, and not to seek medical remedies for whatever ailed her." In her late 40s, this patient, who had long seemed incapable of taking steps to improve her life and health, had joined a church group, made new friends and appeared to be seized by a new sense of purpose. Though virtually universal, the adult experience of parental loss has been little studied. That is, in part, precisely because it is universal, and therefore perceived as a normal process, says Debra Umberson, one of the few who have conducted research on the phenomenon. Adult children, having seemingly established their independence, were long thought to absorb the expected blow and move on to tend to relationships with the living. Safer's book, however, comes amid an evolving view of this adult milestone. Increasingly, research psychologists and those in clinical practice see the loss of elderly parents as an event that not only touches off an emotional reaction that is real and long-lasting, it also is often the beginning of a continuing, though wholly different, relationship with the dead. At any stage of adulthood, losing one's parents can bring death benefits, Safer says. The adult intent on making the most of a parent's loss should be willing to examine her parents' emotional legacies carefully and consciously. Doing so, she argues, will better distinguish those parental legacies worth keeping -- the ones that contribute to health and well-being -- from those that no longer serve that end. The age of the adult matters less than his willingness to do that sorting "in a mindful way," she says. But in recent decades, profound demographic changes have made orphans in midlife the most common, and most receptive, beneficiaries of death benefits. As improved healthcare has pushed average life expectancies up into seven decades, parents have begun typically to live well into their children's adult lives. Today, one-third of American 50-year-olds have a father still living and two-thirds still have their mother. But by the time they turn 60, two-thirds of Americans will have become adult orphans. In short, midlife has become a time of loss -- and, Safer argues, of potential gain. As these increasingly older parents die, they are leaving children who have established mature identities but are on the cusp of new transitions. They can anticipate many more years -- in many cases decades -- of active life. But much of the hardest work of early adulthood is behind is them. Their own children may be leaving the home or having children of their own; their careers have often peaked or are in a state of flux; retirement looms and new horizons beckon; and as their bodies change and relationships shift, their self-images are primed for transformation. "Parent loss," Safer writes, "is the most potent catalyst for change in middle age." And because they have experienced so much of life by that point, these bereaved children can see their parents with more wisdom and greater understanding. "Finally," she writes, "we can empathize." Often, the death of parents brings an end to a period of intensive caregiving, freeing up time and emotional energy for an adult child to attend to his or her own needs. And with their parents gone, many adults keenly sense that they are "next in line" for decline, disability and demise. That often concentrates the mind on what's right, and wrong, in their lives -- what traits and behaviors have served them well and which would better be abandoned. With the prospect of several decades -- and whole chapters -- of life ahead, these adult orphans can and often do rechart the course of their lives, reassess their priorities and sometimes reject the parental expectations (whether of achievement or disappointment) that powerfully shaped the opening and middle chapters of their lives. Negative effects For many bereaved adults and those who study them, Safer's conviction that parents' deaths present a golden opportunity for healthful change flies in the face of much apparent evidence. "On average, it has adverse effect on adults -- all kinds of adults," says Umberson, a University of Texas at Austin sociologist who has conducted extensive research on family relationships and health. For three years, and often as many as seven, the adult children of parents who die are much more likely to increase their alcohol consumption significantly, take poorer care of themselves and become anxious or depressed, Umberson found in three comprehensive surveys of adults surviving a parent's death. Her findings are the basis for her 2003 book "Death of a Parent: Transition to a New Adult Identity." But Umberson, whose research was sponsored by the National Institute on Aging, also found a potential silver lining in a parent's death. Around the seven-year mark after their parental loss, "they do get better," Umberson says. Many of those she surveyed reported a marked improvement in health and healthful behavior. "A lot of people change very deliberately. And sometimes unconsciously, they change in ways that they think their parents would admire, or to become more like the person their parent would want them to be," Umberson says. "Sometimes people incorporate the good parts of their parents in ways that are very constructive for self-growth." But Safer and Umberson each argue that adult children would do better to be deliberate about cultivating death benefits, both before parents die and after their passing. Where possible, being intentional would mean confronting some difficult tasks, and truths, when a parent is still alive. "You can try to resolve things, and say the things you would want to say to parents before they die," Umberson says. Too many people, she says, shrink from doing so because they would prefer to shield themselves from the uncomfortable reality that their parents will die. "But it makes people feel really good when they've done that . . . . I've seen people who deeply regretted not having resolved things with one parent who died, and then not doing so with the parent who's still alive." Safer calls that process preparing for "the deathspace" -- "a place of seismic movement" that adult children wishing to reap death benefits must enter after the death of one parent or both. In it, she wrote, "truly terrible parents lose their power. . . . Children whose mothers or fathers were guilty of more routine crimes of the heart feel sympathetic and even come to identify with them. Flawed parents are discovered to have hidden virtues and idealized ones to have serious flaws." In short, the basis for an honest, adult relationship with one's parents -- at last -- is often established in the deathspace, Safer says. But because "all further communication with them is unilateral," she notes, adult children gain an upper hand in that relationship: They can chastise or forgive their parents, reinvent them, accept some of their lifelong advice and disregard the rest. In the process, they can mature and learn to stand on their own, she says. Reviewing legacies Safer's effort to reap "Death Benefits" started with a painstaking review of her mother's personal history and her legacies -- good and bad. In their 57 years together, Esther Safer had taught or given her daughter fierce persistence in the pursuit of goals, a love of writing and music, and a penchant for decorating with red. But she also cast her daughter in a compulsory support and cheerleading role. And this midcentury, middle-American mother became helpless at any sign of physical infirmity in her only daughter. The result was a daughter determined enough to have earned a doctorate in psychology, built a successful psychotherapy practice in New York City, written four well-regarded books and made herself and her husband a New York City sanctuary that is lovingly layered with exotic and distinctive treasures. But beneath her seeming confidence lay a vulnerability she could not explain until recognizing it as a legacy from her mother: Jeanne Safer had an enduring and inconsolable anxiety about being or becoming physically weakened or ill. While Safer's husband gamely battled cancer, Jeanne would become undone by a common cold or a sudden headache. For years, Safer's irrational distress flummoxed her. "My reaction to certain kinds of adversity made me feel weak and helpless and fraudulent; a psychoanalyst incapable of penetrating the most wounded part of her own psyche is like an out-of-shape personal trainer," Safer wrote in "Death Benefits." As Safer conducted this personal inventory after her mother's death, she found that some of her mother's emotional inheritances were worth keeping. Others, Safer wrote, had not served her well. And once she recognized their source and understood their effect, Jeanne Safer decided they should be abandoned. Like a parent's ratty, old easy chair, the psychological fallout of Esther Safer's inability to console her daughter in sickness would simply have to be left behind. On the same curb, Jeanne Safer vowed she would try to leave her mother's penchant for perfectionism and her inability to forgive friends or family who let her down -- both tendencies Jeanne saw in herself. Accept flawed love, Safer told herself, and remember that family and true friends accept you, flaws and all. Finally, as she looked hard at her mother's life, Safer saw something else she wanted to leave behind: a fear of abandonment that had dogged her mother from childhood into adult life. This, Jeanne came to understand, was why her own visits home as an adult were so often spoiled by her mother's ire and accusations: All Esther Safer could do during these much-anticipated homecomings was to focus on the prospect of her daughter leaving. Esther Safer focused on the likelihood of abandonment to protect herself from disappointment when it happened; for Jeanne Safer, that kind of catastrophic thinking prompted assumptions of life-threatening illness when she caught a bug or pulled a muscle. Once she recognized the source of "that hopeless dread" that so often threatened to engulf her, Safer says its power over her began to fade. Only her mother's death could open the door to such insights, Safer says. And only such insights, she adds, can open the door to changes in the way she thought about herself, acted on her feelings and behaved toward those around her. "Death makes all the difference; it broadens your perspective," Safer writes. "I had tried to see [Esther Safer] before, but until then, the effort of simply coping with her and the feelings she evoked got in the way. . . . Now I could see us together from a therapeutic distance -- beyond blame, beyond the frantic need to get through or justify myself, beyond disappointment, beyond rage -- beyond fear." A new kind of mourning Safer's book reflects a view of bereavement that has evolved significantly in recent years. Until the 1990s, mental health professionals continued to take their cues from Sigmund Freud. In "Mourning and Melancholia," published in 1917, the father of psychoanalytic theory conceptualized healthy mourning as a process by which the bereaved effectively detaches himself from the dead. When that "decathexis" is accomplished, the bereaved can shift the emotional energy invested in that relationship with the deceased into bonds with the living. The relationship with the departed is effectively frozen in place, preserved without further development or further drain on the survivor's emotional energies. By the mid-1990s, however, a new approach to grief began to take hold in psychotherapy circles. Prompted by clinical observations and research evidence, mental health professionals began to see grief as a process in which the bereaved maintains an ongoing -- and evolving -- relationship with the departed. Conversations continue. But in addition to holding up her end of the exchange, the survivor gets to choose what advice the departed gives and what opinions the departed holds. In this process, the bereaved regains power over a relationship that may, in real life, have been ambivalent, overwhelming, unsatisfying or unstable. She may derive strength from that ongoing relationship, alter it to suit her needs or, if necessary, strip it of power over her life. "We don't really ever detach from them," said psychologist Dov Shmotkin of the Tel Aviv University. A study by Shmotkin, published in 1999, underscored this point. Shmotkin surveyed several hundred Israeli adults -- ages 17 to 77 -- about the intensity and quality of their bonds to their parents. When he compared adult children whose parents were dead with those whose parents were still alive, he found something that surprised him: The death of parents did not diminish the intensity of their children's reported bonds to them. Children whose parents were dead were just as likely as those with living parents to describe their relationship as close. The bond survived. When Shmotkin looked at the reported quality of adult children's relationships with their parents, he found evidence that that bond evolves beyond death as well. Those whose parents were dead rated their bond with those parents as more positive on average than did those whose parents were still alive. Though adult children with living parents were more ambivalent in how they felt about their parents, those whose parents had died were likely to see the relationship in rosier terms. "It is idealization, which is keeping the best and throwing away the worst" about the relationship with parents, Shmotkin said. By casting that bond in a positive light, Shmotkin surmised, adult children prop up their self-images. The children of "such good, perfect, wonderful parents," he surmised, would have to feel like good and worthy people -- and good parents to their own children, as well, he said. Four years after her death, Esther Safer has become a source of pride, of encouragement and of ongoing advice to her daughter. In life, Esther Shafer's insistence on her daughter's constant attention and admiration -- as well as her unbending pronouncements on good taste -- were a decidedly mixed blessing. With her death benefits firmly in hand, Jeanne Safer's admiration for her mother is unambivalent. And those pronouncements on style -- muted by death and selectively observed by her daughter -- are accepted with unalloyed love and gratitude. "Esther wouldn't have it any other way," her daughter says.
Seventy-two workers have been fired in the past three years over allegations of abuse, while hundreds of others have been fired for other violations, including sleeping on the job and overmedicating patients, according to personnel records obtained by The Dallas Morning News. The violence against patients included choke holds, headlocks and threats against patients at the state's 10 psychiatric hospitals, the newspaper reported. There are about 18,000 patients and about 7,400 employees in the state psychiatric hospital system. Officials with the Department of State Health Services, the agency that runs the psychiatric hospitals, said they take all allegations of mistreatment seriously. But they said that abuse and neglect are ''absolutely not'' pervasive -- and that verified cases are actually dropping. Psychiatric hospitals are stressful environments, said agency spokesman Doug McBride. He acknowledged there are times when employees ''do not handle a situation appropriately.'' State officials say that the rules for reporting abuse and neglect are stringent and that confirmed cases of physical and sexual abuse are reported to police. In the past year, Texas juvenile prisons, group homes for the disabled and state schools for people with mental disabilities came under fire for reports of widespread physical and sexual abuse. The Texas Youth Commission has undergone a complete restructuring. Like other systems for vulnerable Texans, the state psychiatric hospitals are chronically starved for cash, advocates of more state funding say, and services at the local level can't keep up. ''You get what you pay for,'' said Rep. Garnet Coleman, D-Houston, who has bipolar disorder. ''When you financially dumb something down, you make services cheap, something's got to give. Unfortunately, it usually ends up being a mentally ill or disabled Texan.'' Texas ranks 48th in the country in per capita funding for people with mental illness.
Does it mean U.S. kids are being over-treated? Or that U.K. children are being under-treated? Experts say that's almost beside the point, because use is rising on both sides of the Atlantic. And with scant long-term safety data, it's likely the drugs are being over-prescribed for both U.S. and U.K. children, research suggests. Among the most commonly used drugs were those to treat hyperactivity. In the U.K. study, there were 595 anti-psychotic prescriptions for children in 1992, or a rate of fewer than four children per 10,000 using the drugs. By 2005, 2,917 prescriptions were written, or a rate of seven children per 10,000 -- a near-doubling, said lead author Fariz Rani, a researcher at the University of London's pharmacy school. The study is being released Monday in the May edition of the journal Pediatrics. By contrast, an earlier U.S. study found that nearly 45 American children out of 10,000 used the drugs in 2001 versus more than 23 per 10,000 in 1996. There are big differences that could help explain the vastly higher U.S. rate. A recent report in The Lancet suggested that the U.K.'s universal health care system limits prescribing practices there. The report also said direct-to-consumer ads are more common in the United States. These ads raise consumer awareness and demand for medication. While drug company ties with doctors are common in both the U.S. and U.K., Vanderbilt University researcher Wayne Ray said U.K. physicians generally are more conservative about prescribing psychiatric drugs. Ray co-authored the U.S. study, published in 2004. The new U.K. study, involving 1992-2005 health records of more than 16,000 children, is the first large examination of these drugs in U.K. children. It found the increase was mostly in medicines that haven't been officially approved for kids. They were most commonly prescribed for behavior and conduct disorders, which include attention deficit disorder. Side effects including weight gain, nervous-system problems and heart trouble have been reported in children using these drugs and there's little long-term evidence about whether they're safe for them, the study authors said. ''This highlights the need for long-term safety investigations and ongoing clinical monitoring,'' they said, ''particularly if the prescribing rate of these medicines continues to rise.'' One of the most commonly used anti-psychotics in the U.K. study was Risperdal, a schizophrenia drug that is sometimes used to treat irritability and aggression in autism. Its side effects include drowsiness and weight gain. Thioridazine, sometimes used to treat hyperactivity in attention deficit disorder, was frequently used early on. Its use decreased after 2000 when a U.K. safety committee warned of heart-related side effects, the authors said. Reasons for the increases are uncertain but may be similar to those in the United States, such as an increase in autism cases and drug industry influence. In both countries, the issue isn't simply how many children are getting these drugs, said Dr. David Fassler, a University of Vermont psychiatry professor. ''The more important question is whether or not the right kids are getting the most appropriate and effective treatment possible,'' he said. Fassler wasn't involved in the study. Dr. William Cooper, a Vanderbilt pediatrician, said the study shows the drugs are being used ''without full understanding about the risks.'' ''I find it really interesting that we're now seeing increases in other countries besides the U.S., which suggests that the magnitude of this issue is global,'' said Cooper, also an author of the 2004 U.S. study. On the Net: American Academy of Pediatrics: www.aap.org While the survey, which is not peer-reviewed, is likely to draw criticism from some academics, the project offers a window into the attitudes of men who buy sex in Chicago. The results, to be made public Wednesday, show men are often deeply conflicted about their behavior, said Rachel Durchslag, director of the Chicago Alliance Against Sexual Exploitation, which conducted the survey in Chicago with the Evanston-based Justice Project Against Sexual Harm. Though most of the men interviewed said they believe there is nothing wrong with prostitution, a large majority, 83 percent, view buying sex as a form of addiction, according to the study. Most men said they believed women entered prostitution freely, but they acknowledge that the sex trade is devastating to the women involved. A large percentage of the men, 57 percent, suspect the women they pay were abused as children, and nearly a third said they viewed women's relationships with pimps as harmful. About 40 percent of men said they are usually intoxicated when they buy sex. According to one man who was quoted anonymously in the report, "For a small second after I buy sex, I feel happy, and then it's over. It's so fleeting. There's frustration beforehand, and depression afterward [because] it's so quick. Those feelings are always there. They're associated with buying sex." Nonetheless, most men said they viewed their interaction with prostitutes as a business contract in which payment entitles them to treat the women any way they like. Women surrender the right to say no to anything once they accept a customer's money, many said. "Prostitutes are a product, like cereal," said one man. "You go to the grocery, pick the brand you want and pay for it. It's business." The survey was designed by anti-prostitution activist Melissa Farley, who is controversial because academics have accused her of tilting previous research to support a political agenda. The Chicago study is part of an international project that includes surveys in Scotland, India and Cambodia. Critics of the Scotland survey called Farley's methods unscientific. Durchslag is aware of the criticism of Farley but said she feels confident in the relevance of the Chicago survey. Although Farley created the survey questions, she was not involved in reporting the results, Durchslag said. "We have always said this was an exploratory study, and I feel very confident with the way the questions were asked." Durchslag said she was stunned by the large response from men, and their willingness to talk to strangers about such a taboo subject. The men who answered questions represented a variety of backgrounds. A majority were college-educated, and more than half were either married or in a committed relationship, according to the study. Her team of researchers anticipated feeling angry at their subjects, which happened frequently as some of the men talked freely about their attitudes toward women as sex objects, she said. In one case, a man gave answers that basically acknowledged he had committed rape, she said. But there were also many interviews in which they felt empathy for the men and their confusion about their own sexuality. "A lot of us felt really sad for a lot of these men," she said. "It's more complicated. We were all surprised by the number of men who said, 'I've never had a chance to talk about this.' " Still, the goal of the research is to push for harsher criminal punishment for men who buy sex from prostitutes, she said. Nearly 90 percent of the men said that they would stop if they felt there was a likely chance they would be caught and prosecuted. Men expressing conflicted feelings and frustration "is the good news," said Farley, who is based in San Francisco. "That they are conflicted. They do have deeply mixed feelings when someone takes the time to really inquire."
The guidelines mention other options, too, and highly recommend combining counseling and medication. But doctors are encouraged to talk to all smokers who want to quit about trying medication. Consumer advocates cautioned that the safety picture on Chantix is incomplete because it's a relatively new drug, on the market just since 2006. ''It is somewhat better than other therapies; on the other hand, it appears to have more risk,'' said Dr. Sidney Wolfe of the watchdog group Public Citizen. ''That part of the risk-benefit equation is missing, and it's changing rapidly.'' Another issue with the quit-smoking guidelines, released this week by the U.S. Public Health Service, is the lead author's past connections with Pfizer. Dr. Michael Fiore, an expert on smoking and health issues, was a consultant to the maker of Chantix. But he said he cut those ties in 2005. Fiore's views are shaped by his past ties to the drug industry, and those ties still pose a conflict, at least one consumer advocate said. John Polito, a smoking cessation educator who runs the WhyQuit.com site advocating quitting ''cold turkey,'' called the revised guidelines ''a sales pitch'' for the drug industry. The task force overlooked research showing that quitting cold turkey works, Polito said, and studies showing Chantix is superior don't reflect how it's used ''in the real world.'' ''People are quitting smoking to save their lives,'' Polito said. If Chantix's risks outweigh its benefits, ''then it's insane for people to risk their lives'' by using it, he said. The guidelines are based on an extensive review of scientific evidence, were reviewed by 90 independent experts and were endorsed by 60 public health entities, Fiore said, adding that his past financial ties to the drug industry had no influence. ''Independent reviewers of it came to the conclusion that this is a document that reflects the science, and that's what we were charged to do,'' Fiore said. The guideline authors analyzed 83 studies and found that Chantix helped 33 percent stay off tobacco for six months after quitting, compared with a nearly 14 percent abstinence rate for dummy pills. The guidelines recommend combining counseling and medication as the most effective way to kick the tobacco habit, stating ''both counseling and medication should be provided to patients trying to quit smoking.'' Medications have not been shown to be effective in certain groups, the guidelines say. Those groups include pregnant women, smokeless tobacco users, light smokers and adolescents. The guidelines say doctors should consider asking about their patients' psychiatric history before prescribing Chantix. Doctors also should monitor patients for changes in mood and behavior while on the drug. Lois Biener, a researcher of tobacco use and control efforts at the University of Massachusetts in Boston, said most people who quit do so without smoking-cessation drugs. There's little evidence that these drugs are superior in the long run to quitting without help, and while a few studies have shown some benefit, it's ''way less than what is claimed'' by medication advocates, Biener said. Three of 24 panelists who wrote the guidelines reported ''significant financial interests'' in the pharmaceutical industry, including speaking fees and stock ownership. Joann Klimkiewcz, Hartford Courant- 5/7/2008 The online dating site eHarmony.com has finally managed to get those singles hitched, claiming its scientific system is responsible for 118 marriages a day. Now the company has made it its business to make sure they stay that way. The site has expanded into couples counseling in the past two years with eHarmony Marriage, an online therapy service for people who are married or in committed relationships. There's no traditional talk therapy involved. Instead, couples answer an extensive questionnaire and receive a computerized assessment of their relationship's strengths and weaknesses. Based on that information, the service prescribes a series of self-directed exercises and interactive videos that target their trouble areas — communication, intimacy and conflict resolution, for example. Offered in 20-minute weekly sessions over three months, the site touts among its benefits at-home convenience and a $149 price tag that would otherwise buy them one, maybe two sessions with a traditional therapist. "It was a logical extension of our matchmaking product," says Galen Buckwalter, chief scientist at eHarmony. "The intent was to have [a resource] that could be available to everyone ... that could help them make their marriage as good as possible." The company claims the service has so far been a success, drawing between 300 to 500 new registrations daily. Its preliminary in-house study shows that 19 percent of couples considered "at risk" for serious marriage problems were no longer considered such after completing the three-month program. The concept of online therapy has its critics, who say individuals shouldn't be left alone to hash out their problems in front of a computer screen. Computerized therapy, they say, can't match the effectiveness of in-person sessions led by trained psychologists who can root out the underlying causes of marital strife, spot important non-verbal cues and see the visual clues to more serious problems, such as domestic abuse. eHarmony acknowledges that its service can't be a replacement for the real thing; it's intended as a practical tool to get couples talking about their relationship in a way they might not otherwise. Sometimes it's used in concert with traditional therapy, and sometimes it leads couples to discover they need deeper work, says Les Parrot, a clinical psychologist who, with his wife, Leslie, a marriage and family therapist, helped develop the program with a team at eHarmony. "There's still a stigma of this idea of going to marriage counseling for some people. And typically it's the men who don't want to go to a therapist's office and are more likely to go online," says Parrott, who, with his wife, founded the Center for Relationship Development at Seattle Pacific University. Together they operate RealRelationships.com. "We don't say this is a substitute. We value what therapy can do. This can do things therapy can't do, and therapy can do things this can't do." No Guidelines While eHarmony Marriage might be one of the higher-profile online therapy services on the market, it's not the only one. Since the Internet developed a pulse, websites have been cramming it with promises to treat depression, anxiety and host of other behavior problems through virtual therapy. And it's all happening without regulation. A team of clinical practitioners and patient advocates developed a set of professional guidelines in 2000 called the eHealth Code of Ethics. But those are simply suggested standards, and don't have the teeth of a formal statement by an established medical association. Marlene Maheu, a licensed psychologist in California who has studied the evolution of online therapy, doesn't see it as a significantly growing Internet market. She says many therapists wade into the online waters only to pull back, realizing how rife Internet therapy is with deception, ethical concerns and obstacles to delivering sound treatment. Clients might misrepresent their gender, age and cultural backgrounds — accurate information needed for successful therapy. Those with serious mental illness can't be left to grapple with the emotions that come up in a session without a medical professional present. Fact is, she says, face-to-face assessment always trumps anything done online. "People don't jump at the chance to tell you their character flaws. It takes all the skills I have as a clinician of 30 years to get the truth out of people who are sitting right in front of me, and it's by cocking my head and looking at them and saying, 'Really? Really? ,'" says Maheu, author of the 2005 book, "The Mental Health Professional and the New Technologies: A Handbook for Practice Today." She puts it more bluntly: "If you had a child who was suicidal, would you go online ... or would you call your pediatrician and drag your At eHarmony Marriage, Buckwalter says the service might not be for everyone. But the results of couples who have participated so far are encouraging, he says. kid in their to get treatment?" "I think the same level of evaluation should go into picking the online therapy as goes into choosing in-person therapy," he says. "It's always a process of vetting the organization or the person you're working with. That doesn't change because it's online." Scram, for Secure Continuous Remote Alcohol Monitor, records the wearer’s alcohol intake by measuring air and perspiration emissions from the skin every hour. It detects blood alcohol levels as low as 0.02 percent, which corresponds to one drink or less an hour, and can even tell when the alcohol was consumed. Once a day, John has to be near a modem so it can transmit data from the last 24 hours to a monitoring agency and his probation officer. Last year, American courts ordered Scram devices on thousands of defendants released on bond and awaiting trial for alcohol-related offenses, those sentenced to probation, and under-age drinkers. They pay a monitoring agency an average of $12 a day for the device, as well as installation and service fees. Criminal justice professionals report high compliance rates, at least while these people remain in the court system. Last summer, the actress Lindsay Lohan wore one. Yet the device is not perfect. For one thing, it can lead to unexpected and embarrassing situations. When John was chosen by a favorite instructor to work on a fashion show at the airport, he worried how to inform her before his device was discovered by airport security. I urged him to be honest, and fortunately the teacher proved entirely supportive. She suggested letting the others in their group pass through security first and, a little later, explaining the situation to the inspectors. “It worked like a charm,” John told me the next week. Defense lawyers say that despite widespread use, independent, peer-reviewed scientific data is lacking on the device’s reliability and the technology it uses to measure alcohol levels. False positive readings are also a risk. Among other things, baked goods like raisin bread and sourdough English muffins can cause the body to produce its own alcohol. And like any computer-based device, the Scram can malfunction. John can testify that the notification is swift. One afternoon, he received a call from his probation officer about a tamper alarm recorded from 5 to 6 o’clock that morning. John convinced the officer that he was neither drinking nor scamming and provided evidence of reporting to work sober at 8 a.m. Because his device had never registered alcohol consumption in all the time he had worn it, the officer gave him a second chance. The next morning, the same thing happened. A stressful conference followed. “I’ve got to admit,” John recalled, “it was looking pretty bad.” Fortunately, the probation officer was in an experimental mood. The culprit was a five-month buildup of sweat and dirt on the sensors. There have been no false alarms since the device was thoroughly cleaned. John is beginning to understand the severity of his alcohol addiction and how it threatens his life and well-being. Over the past five months, I believe, he has remained sober and made significant progress. But I have also treated enough substance abusers to be suitably impressed by the consuming grip of the disease. Active alcoholics do not often tell me the truth about their abuse. They lie, in essence, to protect the continued use of their most cherished commodity. One could argue that Scram and the threat of jail bought those five months of sobriety and treatment for John. As a physician, I remain uncomfortable aiding and abetting coercive methods like Scram. But this concern is overshadowed by a far greater one surrounding his long-term health. Soon John will “graduate” from his court-supervised treatment. His real test of recovery begins the day his Scram device is removed from his ankle. Howard Markel is a professor of pediatrics, psychiatry and the history of medicine at the University of Michigan. The Growing Wave of Teenage Self-Injury Jane Brody, New York Times- 5/7/2008 “I feel relieved and less anxious after I cut. The emotional pain slowly slips away into the physical pain.” “It’s a way to have control over my body because I can’t control anything else in my life.” “It expresses emotional pain or feelings that I’m unable to put into words.” “I usually feel like I have a black hole in the pit of my stomach. At least if I feel pain it’s better than nothing.” These are some of the reasons young people have given for why they deliberately and repeatedly injure their own bodies, a disturbing and hard-to-treat phenomenon that experts say is increasing among adolescents, college students and young adults. Experts urge parents, teachers, friends and doctors to be more alert to signs of this behavior and not accept without question often spurious explanations for injuries, like “I cut myself on the countertop,” “I fell down the stairs” or “My cat scratched me.” The sooner the behavior is detected and treated, the experts maintain, the more quickly it is likely to end without leaving lasting physical scars. There are no exact numbers for this largely hidden problem, but anonymous surveys among college students suggest that 17 percent of them have self-injured, and experts estimate that self-injury is practiced by 15 percent of the general adolescent population. Experts say self-injury is often an emotional response, not a suicidal one, though suicide among self-injurers is a concern. The Canadian Mental Health Association describes it this way: “Usually they are not trying to end all feeling; they are trying to feel better. They feel pain on the outside, not the inside.” Janis Whitlock, a psychologist who has interviewed about 40 people with histories of self-injury and is participating in an eight-college study of it, says the Internet is spreading the word about self-injury, prompting many to try it who might not otherwise have known about it. “There is a rising trend for teens to discuss cutting on the Internet and form cutting clubs at school,” the Canadian association has stated. Celebrities, too, have contributed to its higher profile. Among those who have confessed to being self-injurers are the late Princess Diana, Johnny Depp, Angelina Jolie, Nicole Richie, Richie Edwards, Courtney Love and the lead singer on the Garbage band album “Bleed Like Me.” Common self-injuries include carving or cutting the skin, scratching, burning, ripping or pulling skin or hair, pinching, biting, swallowing sublethal doses of toxic substances, head banging, needle sticking and breaking bones. The usual targets are the arms, legs and torso, areas within easy reach and easily hidden by clothing. Self-injury can become addictive. Experts theorize that it may be reinforced by the release in the brain of opioidlike endorphins that result in a natural high and emotional relief. Dr. Whitlock, director of the Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults, said in an interview that self-injury mainly seemed to function to “self-regulate feelings and help people cope with overwhelming negative emotions they have no other way to dispel.” Self-injury makes some people feel part of a group. Teenagers who self-injure often report that there is no adult they could talk to who accepts them for who they are. “A 13-year-old can go on the Internet and instantly find community and get hitched to this behavior,” Dr. Whitlock said. “When they don’t want to self-injure anymore, it means they have to leave a community.” Self-injury can be manipulative, an effort to make others care or feel guilty or to drive them away. More often, though, it is secretive. Self-injurers may try to hide wounds under long pants and long sleeves even in hot weather, and may avoid activities like swimming. Who Is Vulnerable? Although female self-injurers are more likely to be seen by a professional, in-depth studies indicate that the behavior is practiced equally by young men and women. No racial or socioeconomic group has been found to be more vulnerable, although self-injury is slightly less common among Asians and Asian-Americans, Dr. Whitlock said. Interviews with self-injurers have found background factors that may prompt and perpetuate the behavior. A history of childhood sexual, and especially emotional, abuse has been reported by half or more of self-injurers. Some seek relief from the resulting emotional pain. Others self-inflict pain to punish themselves for what they perceive as their role in inviting the abuse. Low self-esteem is common among self-injurers. Childhood neglect, social isolation and unstable living conditions have also been cited as risk factors. In about 25 percent of self-injurers, there is a history of eating disorders, as well as an overlap with risky drinking and unsafe sex. The families of self-injurers commonly suppress unpleasant emotions. Children grow up not knowing how to express and deal with anger and sadness, instead turning emotional pain on themselves. Depression, for example, is often described as anger turned inward. Although 60 percent of self-injurers have never had suicidal thoughts, self-injury can be a harbinger of suicidal behavior. It can also accidentally result in suicide. “Those who self-injure should be evaluated for suicidal potential,” Dr. Whitlock said. There is some evidence that self-injury is more common among those with family histories of suicide. And some self-injurers suffer from chronic yet treatable emotional problems like depression, anxiety, post-traumatic stress disorder or obsessive-compulsive disorder. Self-injury can be set off by certain events like being rejected by someone important, feeling wronged or being blamed for something over which the person had no control. Treatment The therapy also helps them see themselves not as victims, but as powerful agents, Dr. Whitlock said. In addition, self-injurers can learn more wholesome ways to relieve stress like practicing meditation or yoga, engaging in vigorous physical activity or reaching out to a friend. Some self-injurers have noted that they can sometimes avoid the behavior, Dr. Whitlock said, simply by doing something else for several minutes when the urge arises. |