Noteworthy News Articles on Mental Health Topics, May 19-26, 2008



Not-Guilty Plea in Drownings
Raymond McCaffrey, Washington Post- 5/19/2008

The Rockville man accused of drowning his three young children in the bathtub of a Baltimore hotel room pleaded not guilty yesterday, with his attorney moving to invoke Maryland's version of the insanity defense.

In entering Castillo's plea, public defender Natasha Dartigue Moody also moved for an evaluation to determine whether her client was "not criminally responsible" for the killings -- a finding that could allow Castillo to avoid trial and be committed to a psychiatric facility. Castillo, who has a history of mental illness, confessed to the killings, according to charging documents.

Amy Castillo, a pediatrician who had fought in court to limit her children's contact with their father, was not at yesterday's arraignment but issued a statement saying: "This fight was about mental illness, human choice, spiritual forces that we don't understand, and an emergency situation that had a profound impact on three innocent children. What is important to me now is that Mark will no longer be able to hurt anyone else, and that my current or any future family will not have to live in fear."

Circuit Court Judge Timothy J. Doory set an Aug. 22 trial by jury date. The Baltimore state's attorney's office has not decided whether to pursue the death penalty or life without parole in the case, said Margaret T. Burns, a spokeswoman.

In court yesterday, his first public appearance since the children were found dead March 30, Castillo wore what appeared to be a hospital bracelet on one of his handcuffed wrists. Castillo, who has remained in a jail hospital since an April court hearing during which officials said he was a suicide risk, had a full beard. His eyes were watery as he was led from the courtroom, and he raised his head only to acknowledge a group of about a half-dozen individuals who appeared to be friends or family members. A member of the group declined to comment.

Castillo will now be evaluated by mental health experts with Court Medical Services, an independent judicial agency, an official said. Castillo probably will be interviewed one or more times by experts, who will also look at his mental health history, the official said.

Castillo has received diagnoses of depression and narcissistic personality disorder and has a history of suicidal behavior, according to court records and testimony. His wife once said he had told her that "the worst thing he could do to me would be to kill the children and not me," but psychologists determined that Castillo was not an immediate threat to his children, and judges upheld his right to visit them, according to records.

Castillo told investigators he killed the children 2 1/2 hours before he was required to return them to his wife under a visitation agreement worked out in court, authorities say. According to charging documents, Castillo said he swallowed 100 Motrin tablets and stabbed himself in the neck with a steak knife, then drifted into unconsciousness and woke up 19 hours later, realizing that his suicide attempt had failed, the documents say.

More than just a psychiatric history is needed for a defendant to be found criminally not responsible as a result of a mental disorder or retardation, an official said. Castillo's evaluators will focus on his mental state at the time of the crimes of which he is accused, the official said. It must be determined that Castillo lacks sufficient capacity to understand the criminality of his conduct or to conform his conduct to the requirements of law, the official said.

The Baltimore prosecutor's office has said that it will not fight such findings by the Baltimore Circuit Court Medical Service. If Castillo is found criminally not responsible for the killings, and the defense wishes him to be committed to a psychiatric facility such as the Clifford T. Perkins Hospital Center in Jessup, he must plead guilty to the charges, an official said. Otherwise, the defense will have to maintain his innocence during a trial, the official said.

The requirement that a guilty plea be entered by such cases is due to a Maryland law designed to make sure defendants committed to psychiatric hospitals had their criminal history taken into consideration before being released. In the past, defendants found not guilty by reason of insanity could be released from a psychiatric facility by proving that they are no longer a harm to themselves or others, the official said.

And the domestic violence screening question I’d asked months before — nestled between queries about smoking and seat belts — seemed to have been spectacularly ineffective, since she’d answered “no.”

When I had asked about violence at home, I had been following guidelines set by the surgeon general and many professional groups, including the American Medical Association. Those who support routine questioning say domestic violence is as or more common in women than many diseases for which doctors regularly check, including breast and colon cancer, and its health risks are well documented.

Despite these recommendations, screening for domestic abuse in seemingly healthy women is nowhere near as widespread among doctors as testing for breast cancer or high cholesterol.

Some physicians see domestic violence primarily as a criminal justice issue, and take umbrage at being expected to delve into a difficult, messy topic when they already have to screen for many other conditions and diagnose complicated diseases in the span of an ever-shorter visit.

In a recent nationwide study of nearly 5,000 women, only 7 percent said a health professional had ever asked them about domestic or family violence. When surveyed, doctors often respond that they don’t ask such questions because of a lack of time, training and easy access to services that help these patients.

Some have reported that they worry about offending patients and believe asking won’t make any difference.

“Just like anybody else, doctors avoid things they may have discomfort doing,” said Dr. Michael Rodriguez, a researcher and family practitioner at the University of California, Los Angeles. “There’s also an expectation on the part of some folks that once we identify abuse she should just walk away, and frustration when she doesn’t.”

Dr. Rodriguez and other experts say that urging an abused patient simply to leave may not be realistic or safe, for several reasons: The risk of being murdered is highest at the time one leaves, the woman may depend on her partner for food and shelter, and patients may not respond well to a doctor who dictates what to do.

They also say the best way to ask about such abuse is in a private place, with no family members present, as part of the routine patient history. If the patient says she has been battered or threatened at home, experts recommend that the doctor offer empathy, tell her what’s happening is wrong, document her story in the medical record and provide her with information on places to go or refer her to someone who may be able to help, like a social worker.

Barbara Gerbert, director of the Center for Health Improvement and Prevention Studies at the University of California, San Francisco, said that while some women might deny domestic violence at first, the question itself could have a profound effect: many women remember that their doctor asked and eventually, even years later, reveal their secret. “Just by asking, you may be planting a seed for change,” she said.

Numerous studies indicate that doctors ask about domestic violence poorly, however, and don’t handle it well when they do get a yes answer.

Felicia M. Frezell, 34, an office manager in Omaha, told me recently that she visited her doctor’s office many times with her five children during the 15 years she lived with her ex-husband, who was convicted in 2005 of raping her. She said that even though she often had bruises, no one ever asked her why — until she asked her doctor to look at her swollen black eye and told him her husband had hit her.

“He just said, ‘You’d better get out of that situation’ and left it at that,” Ms. Frezell said, and added: “Looking back, I didn’t know the resources that were out there. The doctor’s office is a good place to go because it’s neutral and it’s confidential. It’s not like telling your husband you’re going to the police department.”

According to the Bureau of Justice Statistics, from 2001 to 2005 (the last year for which statistics are available) there was an annual average of nearly 511,000 violent assaults against women — and 105,000 against men — by a spouse or intimate partner, about half resulting in physical injury.

Despite such numbers, the United States Preventive Services Task Force concluded in 2004 that although clinicians should “be alert” for signs of violence, there was insufficient evidence to recommend for or against screening asymptomatic patients for domestic abuse — mainly because of a dearth of large-scale scientific studies looking at this question.

While many researchers say more money is needed to pay for such studies, some say the analogy to routine screening misses the point.

“Trying to equate it to a Pap smear is the wrong paradigm, and it’s just irrelevant,” said Dr. Christina Nicolaidis, a general internist and researcher at Oregon Health and Science University. “It’s not a test you can just check off.”

“The reasons to ask,” she continued, “are to educate a patient and to open the door so that the patient knows she can come to you. It’s part of developing a real relationship with your patient. Over time, you might be able to uncover the abuse and improve her safety, but you also might better understand why she’s having her symptoms and how to better approach her self-management of her illness.”

Abused women are at increased risk of chronic pain, depression, anxiety and alcohol and substance abuse, and they can have problems taking their medication correctly and getting to appointments. In one recent study, women who said they had been abused within the past year were more likely to have partners who interfered with their medical care.

Seven years ago, the Institute of Medicine, which advises the federal government, issued a major report on the training of health workers on family violence. The report concluded that such violence “was not a consistent priority” in health workers’ education and recommended that the Department of Health and Human Services establish education and research centers in family violence.

By unhappy coincidence, the report was unveiled at a news conference on Sept. 11, 2001, and has since “collected dust,” said one of the authors, Felicia Cohn, who now directs medical ethics at the University of California, Irvine.

“Certainly other issues took precedence at the time,” Dr. Cohn added, “but the continuing inattention is both inexcusable and embarrassing. This is a public health pandemic with immense health care implications.”

For my silver-haired patient — and other women I see at the clinic where I work — there have been no simple answers. I keep the telephone numbers for a local women’s shelter and the police department’s domestic violence unit in my lab coat pocket. And I keep asking the question, so my patients know there’s a place they can turn.

Erin N. Marcus is a general internist and associate medical director of the Institute for Women’s Health at the University of Miami Miller School of Medicine.

His sole weapon so far in battling his addiction, he says, has been willpower. But what scores of experts on nicotine addiction have come to learn is that willpower is rarely enough. Most diehard smokers need methods far stronger — and usually a combination of stop-smoking aids — to help quit in the first place and, more important, remain former smokers.

There are exceptions. I was amazed when my husband, who had smoked for 50 years, quit cold turkey in 1994 after one session with a hypnotist and a few sticks of nicotine gum.

Survey statistics from the Centers for Disease Control and Prevention show that 70 percent of smokers say they want to quit and that 40 percent try to quit each year. But 80 percent of smokers who try to quit on their own relapse within a month, the data show, and only 3 percent remain former smokers at six months.

Though long called a lifestyle choice or pernicious habit, smoking is now widely recognized as an addictive disease comparable to alcoholism or heroin addiction.

“Tobacco addiction is best considered a chronic disease, with most smokers requiring repeated interventions over time before achieving permanent abstinence,” Dr. Neal L. Benowitz of the University of California, San Francisco, said last month in The American Journal of Medicine.

Biological Basis of Addiction
Like other addicting substances, nicotine produces pleasurable effects that prompt smokers to keep up the habit and, ultimately, lose control over smoking, often even when dire consequences like a heart attack, cancer or emphysema result.

Among the addiction-maintaining effects of nicotine are arousal, relaxation, improved mood, reduced anxiety and stress, better concentration and faster reaction time. When deprived, smokers report withdrawal symptoms that include irritability, depression, restlessness, anxiety, difficulty concentrating, increased hunger, insomnia, a craving for tobacco, difficulty getting along with others and a feeling that life lacks pleasure.

These effects have a biological basis. Nicotine easily crosses the blood-brain barrier, where it binds to nicotine-specific receptors in the brain. This results in the release of a host of neurotransmitters, primarily dopamine, that “signals a pleasurable experience and is critical to the reinforcing effects of nicotine and other drugs of abuse,” Dr. Benowitz explained.

Repeated exposure to nicotine increases the receptors and induces tolerance to and dependence on nicotine. Smokers typically take in the amount of nicotine needed to bind to the receptors. When the drug is withdrawn, in a night’s sleep, for example, or in an effort to quit, the falloff in nicotine rewards becomes a barrier to lasting abstinence. Changes also occur in brain function as measured on an electroencephalogram, especially in the so-called reward center of the brain.

In addition to the biological effects of nicotine, conditioned behaviors reinforce its continued use. Smokers quickly learn to associate nicotine intake with certain moods, situations or environmental circumstances, both pleasant and unpleasant. As Mr. Shaw of Brooklyn has found, those circumstances become powerful cues for the urge to smoke.

Dr. Benowitz also noted that other aspects of smoking like lighting up, manipulating the cigarette, the taste or smell of smoke and the feel of smoke in the throat also become linked to the pleasurable effects of smoking.

Sources for Treatment
Since smoking addiction involves physiological, behavioral and psychological factors, all three need to be addressed, often repeatedly, to help smokers quit for good.

As Dr. Stephen I. Rennard of the University of Nebraska Medical Center in Omaha wrote in the journal, addressing fellow clinicians, “It is no longer adequate simply to recommend smoking cessation.”

As with other chronic diseases like diabetes and heart disease, Dr. Rennard said, both pharmacological and behavioral therapy are needed to control it. He added that because smoking is often a relapsing disorder, clinicians “must be prepared to readdress the problem of smoking on a regular basis and to re-treat patients who backslide.”

Many products on the market can reduce or eliminate the symptoms of nicotine withdrawal, which so often lead to failed attempts to quit. Nicotine replacement therapy is regarded as safe, even in high doses and even for heart patients, and it carries none of the risks of smoking, which exposes people to higher levels of nicotine and 4,000 toxins. Products are available as skin patches, gums, lozenges, inhalers and nasal spray.

Individuals can choose whichever method is most comfortable and convenient, as well as using a combination of a short-acting product like nicotine gum or nasal spray with a longer-acting one like the nicotine patch. According to Dr. Michael B. Steinberg of the University of Medicine and Dentistry of New Jersey in New Brunswick, nicotine replacement can be safely used for as long as a former smoker finds it necessary.

Lack of insurance coverage is a major barrier to effective use of nicotine replacements. Writing in The Annals of Internal Medicine in April, Dr. Steinberg and colleagues urged that the cost be covered by medical insurance, especially because it would be much cheaper than treating a smoking-induced disease. They noted that “tobacco dependence kills more people than many classic medical diseases” and far more than any other forms of addiction.

Two other drugs approved for treating smokers who want to quit are a sustained-release form of the antidepressant bupropion, which helps to curb weight gain among former smokers, and a relatively new drug, varenicline. It is the first non-nicotine product created specifically to enhance smoking cessation by partly filling up nicotine receptors to prevent the reinforcing effects of smoking.

To help would-be quitters resist emotional and behavioral cues to smoke, there are individual and group counseling programs, as well as smoking cessation phone lines, Web sites and chat rooms and state-financed support services. Call (800) QU-I-T-N-O-W to connect with a local quit line.

Smoking cessation experts at the Mayo Clinic recommend these Web sites: www.becomeanex.org, www.quitnet.com and, to locate state services, www.naquitline.org.

In addition, some would-be quitters like my husband have been helped by hypnosis or acupuncture, though well-thought-out studies have yet to validate these methods fully, Dr. Benowitz said in an interview.

Remember, too, that even if you fail to quit once, twice or even three or more times, try again. There are more tools available than ever to assure the success of everyone who wants to become a former smoker.



Decline of a Baghdad Psychiatric Hospital
Erica Goode, New York Times- 5/20/2008

BAGHDAD — In a different time, in another country, where violence and terror did not stalk the streets, Dr. Amir Hussain could practice psychiatry the way he once hoped to.

He can see it in his mind: the clean, tastefully decorated hospital wards, the well-stocked pharmacies, the gleaming laboratory equipment, the thickly carpeted consulting rooms, the halfway houses and outreach teams that help chronically ill patients re-establish their lives outside the hospital.

He has witnessed such things firsthand. In 2005, he left Iraq to spend five months in England, learning specialized care for the elderly and watching psychiatrists at work.

But Dr. Hussain, who entered his profession at a time when Iraqi doctors were among the most sophisticated and highly trained in the Middle East, is caught in a time warp in a war-torn land where knowledge and sophistication have been largely overwhelmed by third-world decay, and ancient equipment has plunged some treatments into a “One Flew Over the Cuckoo’s Nest” barbarism, despite the best intentions.

He cares for patients whose illnesses are often set off or worsened by the mayhem around them, who crowd into his tiny office at Ibn Rushid psychiatric hospital in central Baghdad, accompanied by their mothers and aunts, wives and brothers.

The litany of death and misery they recite no longer shocks him.

“We are used to hearing it, and I think our emotions are frozen,” he says.

Besides, his own experiences are not that different. Like many other Iraqis, he suffers from some symptoms of traumatic stress: insomnia, anxiety, a tendency to start at loud noises.

“The traffic jams, this is a stress, then all of a sudden something explodes,” he said.

He tries when he can to listen to relaxing music. The trips to the countryside he once enjoyed are no longer an option. The roads are too perilous.

Nevertheless, he does his best to help his patients. Some he treats with the limited number of psychiatric drugs at his disposal. For others, patients who are suicidal or catatonic or do not respond to drugs, he prescribes electroconvulsive therapy, administered with a 25-year-old machine that, he says, has “technical problems.”

The patients are sometimes given Valium before the treatments. But because there is no anesthesiologist on staff, the shocks are delivered without anesthesia, as they were decades ago in the United States.

Dr. Hussain is acutely aware that what he has to offer is far from ideal — that the way the hospital gives electroshock therapy is “inhuman and dangerous,” that patients do not receive the panoply of special programs and therapies routinely available in other countries.

“I feel frustrated,” Dr. Hussain said. “I feel sad. I see the correct things but I cannot do them because there are barriers and limitations. We do not have the equipment, we do not have the treatable medication.”

Despite that, he says, patients often improve.

Only 4 of 11 psychiatrists remain at Ibn Rushid; the rest have moved north to Kurdistan, where the risk of kidnapping or assassination is lower, or have fled the country.

The psychiatric hospital, one of two in Iraq, provides short-term treatment and was once considered a jewel of the country’s medical system, renowned for its modern care. Patients from as far away as Syria and Jordan came for treatment, and the hospital’s 75 beds were always full. Specialists from Western countries visited to teach the latest forms of treatment.

But Ibn Rushid’s fortunes have fallen with those of the broken city around it, a decline that began under Saddam Hussein and that has grown steeper each year since 2003. The paint on the walls is cracking. Tattered lace curtains cover the windows in the hallways.

In the morning, Dr. Hussain sees patients in the hospital’s outpatient clinic: a woman who became psychotic shortly after the Americans entered Baghdad in 2003, convinced that she would be hit by a bullet fired from the television set; an 18-year-old who watched a cellphone video of a close friend being tortured and killed and later became so violent that his family tied him down with a rope.

The psychiatrist listens, lifts his glasses to read a medical chart, probes for more information.

His cellphone — equipped with a photo of Oprah Winfrey — rings constantly. Staff members push through the thicket of patients, asking him to sign forms and authorize treatments.

He assesses each case in a few minutes, writes a prescription or orders a test, and moves on. Khalida Ibrahim, a social worker at the hospital, said that treating patients with physical injuries might be difficult, but trying to help depressed patients who have lost children, husbands, sometimes whole families, is emotionally exhausting.

“Sometimes we are talking to them and trying to comfort them, but inside our hearts we feel pain because we also face the same problems,” she said. “We also have lost people, but we must pretend to be another person, to hide our real feelings and our real suffering.”

Given what the patients face in their daily lives — car bombs, killings, fighting between militia members and Iraqi and American forces — relapses are frequent. There is no time for people to recover, Dr. Hussain said, and once they do, “there is a new stress, grief after grief, losses after losses, violence after violence.”

On a recent morning, a 15-year-old girl brought her mother, who she said was “addicted to whiskey,” to the hospital’s women’s ward, a suite of sparsely furnished rooms on the second floor. Mother and daughter sat on plastic chairs in the nurse’s small office.

“I am here for treatment because I want to die all the time,” the mother, Hana al-Dolaimi, said. “I wish to commit suicide.”

Ms. Dolaimi said she had a long history of psychiatric problems, and her condition had improved, but “because of the violence and political developments, I collapsed.”

Her husband left one day to visit his sister in another town and never came back. She heard that he had been killed, but she could not go to the morgue to identify the body.

“I have high blood pressure and it terrified me to go,” she said.

Ten days later, three gunmen went to her house in Baghdad, demanding money and asking if she was Shiite or Sunni.

“I said, ‘What have I done to you? I am just like your mother,’ ” Ms. Dolaimi said.

Now, she added, “Everything makes me sad. My houses are gone. My husband is gone. Everything sweet in this life is gone.”

Any patient admitted to the hospital must be accompanied by a family member, who stays close at all times and helps keep the patient calm.

Psychiatric illness carries a high stigma in Iraq, said Ms. Ibrahim, the social worker, and many patients who come to Ibn Rushid have been beaten by husbands or parents who think they are simply acting badly. In the past, Dr. Hussain said, psychiatrists used to visit patients at their homes, “but nowadays, we are afraid to go.”

A few weeks ago, a mortar shell landed a few yards from the hospital. One day, Dr. Hussain found himself the only psychiatrist on duty. Fighting in the city had prevented the others from coming to work. Another morning, he arrived to find the wards all but empty — the patients, frightened by the clashes, had gone home.

Al Rashad hospital, a 1,000-patient facility for chronic psychiatric cases on the outskirts of Sadr City, was caught in the recent fighting between Mahdi Army militia members and American and Iraqi forces.

So far, no gunmen have invaded Ibn Rushid, though “we expect it at any moment,” Dr. Hussain said.

After two female suicide bombers blew themselves up at pet markets in central Baghdad in February, killing at least 90 people, and American officials said the women were mentally ill, American and Iraqi soldiers came to the hospital, Dr. Hussain said. They showed him a woman’s photograph and told him her name.

He recognized the woman — he had treated her — and he gave a copy of her chart to the soldiers. But two weeks later, he said, the patient, who suffered from schizophrenia, walked into the hospital, alive, and apparently innocent.

Now, the Health Ministry, which oversees the public hospital system, has ruled that no patient can be seen without a current photo and identification card, lest the patients be suspected of working with the insurgents, Dr. Hussain said.

He is always trying to move forward. At night, he scours the Web on his home computer — the hospital does not have an Internet connection — for information on the latest psychiatric theories, the latest treatments. He runs a journal club for the psychiatric residents to discuss the latest research, and he hopes to start a program for elderly patients.

Dr. Hussain said the hospital had asked the Health Ministry to help out with the shortages of medication, equipment and staff, but so far nothing had changed.

A plan by the American government to send teams of Iraqi psychiatrists, psychologists and social workers, including Dr. Hussain, to the United States for training has stirred great excitement.

But the program, originally scheduled for last fall, has been delayed repeatedly, and the participants were recently notified of another postponement.

Dr. Hussain envisioned things differently when he chose to become a psychiatrist in the 1980s, fascinated by the psychiatric symptoms of soldiers returning from the distant battlefields of the Iraq-Iran war.

But now a different war has settled over his country, and his patients, though not soldiers, are all, in a way, the casualties.

He could leave Iraq, but he has no intention of doing so, he said. He loves his work. “Nobody forced me to be a psychiatrist,” Dr. Hussain said.



Pondering a Common Word With One Dreaded Meaning
Neil Genzlinger, New York Times- 5/21/2008

Some words are asked to do too much. “Love” is what you feel for ice cream and your life partner. “God” is a multipurpose interjection or the creator of the universe. In “Depression: Out of the Shadows,” a stark documentary on Wednesday on PBS, Andrew Solomon, who won a National Book Award for his book about depression, makes his own nomination for this grouping.

“It’s a poverty of the English language,” he says, “that we only have that one word, depression, that’s used to describe how a little kid feels when it rains on the day of his baseball game, and it’s also used to describe why people spend their lives in mental hospitals and end up killing themselves.”

The word may be tossed around casually, but through the stories of an assortment of people like Mr. Solomon (the author of “The Noonday Demon: An Atlas of Depression”), who have battled the condition or lost loved ones to it, this program makes clear just how devastating clinical depression is.

“Suicide is almost twice as common as homicide in the United States,” Thomas R. Insel, director of the National Institute of Mental Health, says bluntly. “We have roughly 30,000 suicides a year. And 90 percent of those are associated with mental illness, most commonly depression.”

Those to whom depression is just a vaguely defined condition may be surprised by the variety of manifestations seen here: postpartum depression, bipolar disease, late-onset depression, the mild but persistent depression known as dysthymia. And, commendably, the filmmakers don’t focus just on the affluent whites who are the easiest subjects to line up for programs like this; one segment looks at the particular problems depression presents for the urban poor, and especially blacks.

“Many of us would rather tell somebody that we have a relative in jail or on drugs before we will ever utter ‘mental illness,’ ” says Terrie M. Williams, a black public relations executive who has battled depression.

Programs like this always dangle promising medical advances as a counter to the jarring personal stories, and “Out of the Shadows” is no exception. But there’s a surprise. One of the more effective treatments in some instances is the seemingly primitive electroshock therapy. It is a tool, we’re told, that remains underused, and you can guess why: those memorable scenes from the film “One Flew Over the Cuckoo’s Nest.”

DEPRESSION: Out of the Shadows
Produced by Twin Cities Public Television (TPT) and WGBH Boston. Produced, written and directed by Larkin McPhee. For WGBH: Laurie Donnelly, executive producer; Anne Adams, senior producer. For TPT: Phyllis Geller, executive producer.

This lack of ability to concentrate costs the average adult sufferer 22.1 days of ''role performance,'' per year, including 8.7 extra days absent, according to researchers led by Dr. Ron de Graaf of the Netherlands Institute of Mental Health and Addiction.

It might be cost-effective for employers to screen workers for ADHD and provide treatment, the researchers suggest. ''There were many more people than most of us who have done these studies had expected,'' that were affected by adult ADHD, said Dr. Ronald C. Kessler of Harvard University, a co-author of the report. ''People don't come for treatment for this ... it's kind of one of those hidden things,'' he said in a telephone interview. ''It's an enormous impairment,'' Kessler said, citing absences, accidents and low performance on the job.

Kessler said he had worked with workers suffering depression and found that treatment costing $1,000 could help prevent $4,000 in lost productivity. ''It sure looks like the effect would be as big, if not bigger, for ADHD,'' he said. ''We're looking around for an employer or two who might be willing to give this a try.''

Linda S. Anderson, president of the Adult Attention Deficit Disorder Association, said workplace assistance and treatment can be vital, Most people think of ADHD as a children's problem, but when it continues into adulthood people have a problem coping with the workplace and need assistance, said Anderson, who was not part of the research team.

The new study may underestimate the adult rate of ADHD, she said, noting that many victims may not have jobs. Those who do often struggle to keep up, but there are treatments available, she said.

The majority of the lost performance was associated with reductions in quantity and quality of work rather than actual absenteeism, the researchers said.

Many employers assume occasional absences are part of the cost of doing business, but the paper noted that, ''typically they expect their workers to be working when they are on the job.''

To find that most of the ADHD-related loss occurs on days when the worker is present is both striking and disturbing from an employer perspective, the authors said.

Researchers interviewed 7,075 workers aged 18 to 44 in 10 countries, concluding that an average of 3.5 percent had ADHD. Their findings are published in Tuesday's online edition of the journal Occupational and Environmental Medicine.

In 2006, a study led by Kessler estimated that 4.4 percent of adults aged 18 to 44 in the United States experience ADHD symptoms and some disability.

The new research estimated the U.S. rate at 4.5 percent among workers, costing an average of 28.3 days performance. The highest rate was for France, 6.3 percent, but the lost time was lower at 20.1 days.

Other countries studied and ADHD rates among adults, and estimated days lost per affected worker, were Lebanon, 0.9 percent, 19.4 days; Spain, 1.3 percent, 1.1 days; Colombia, 1.9 percent, 29.4 days; Mexico, 2.4 percent, 6.1 days; Italy, 3.4 percent, 22.2 days; Germany, 3.5 percent, 13.6 days; Belgium, 3.7 percent, 16.5 days; Netherlands, 4.9 percent, performance improved.

The researchers were unable to explain why the ADHD affected workers in the Netherlands had improved performance rather than the declines seen in every other country studied. ''We periodically find one of those blips, we just don't know why,'' Kessler said.

In a separate study issued earlier this month, researchers led by Kessler reported that major mental disorders cost the U.S. at least $193 billion annually in lost earnings alone. That study was published in the American Journal of Psychiatry.

The new international study was supported by the World Health Organization, U.S. National Institute of Mental Health, John D. and Catharine T. MacArthur Foundation, the Pfizer Foundation, U.S. Public Health Service, Fogarty International Center, Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical Inc., GlaxoSmithKline and Bristol-Myers Squibb Company.

On the Net:
Occupational and Environmental Medicine: http://oem.bmj.com/
Adult Attention Deficit Disorder Association: http://www.add.org



Scientists Test Brain Pacemakers for Depression
Associated Press, 5/26/2008

WASHINGTON -- It's a new frontier for psychiatric illness: Brain pacemakers that promise to act as antidepressants by changing how patients' nerve circuitry fires. Scientists already know the power of these devices to block the tremors of Parkinson's disease and related illnesses; more than 40,000 such patients worldwide have the implants.

But psychiatric illnesses are much more complex and the new experiments with so-called deep brain stimulation, or DBS, are in their infancy. Only a few dozen patients with severe depression or obsessive-compulsive disorder so far have been treated in closely monitored studies.

Still, the early results are promising. Dramatic video shows one patient visibly brightening as doctors turn on her brain pacemaker and she says in surprise: ''I'm starting to smile.'' And new reports this month show that some worst-case patients -- whose depression wasn't relieved by medication, psychotherapy, even controversial shock treatment -- are finding lasting relief.

Six of 17 severely depressed patients were in remission a year after undergoing DBS and four more markedly improved, and more than half of 26 obsessive-compulsive patients showed substantial improvement over three years, say studies from a team at the Cleveland Clinic, Brown University, and Belgium's University of Leuven.

''Not all patients get better, but when patients respond, it's significant,'' says Dr. Helen Mayberg of Emory University, who has implanted about 50 depression patients. Her first remains in remission after five years; she estimates that four of every six show enough improvement to be classified ''responders.'' ''We're rewiring the brain in many ways,'' says Dr. Ali Rezai, chief of the Cleveland Clinic's Center for Neurologic Restoration.

There's a need for innovative therapies. Up to 20 percent of depression patients and 10 percent of those with obsessive-compulsive disorder are treatment-resistent -- several million people in the U.S. alone.

The rationale behind DBS is credible, says Dr. Wayne Goodman of the National Institute for Mental Health: Surgery sometimes helps worst-case patients by destroying misfiring patches of brain tissue. The electrodes are placed into similar spots, but don't destroy tissue -- the electrical signals can be adjusted and turned off.

But it's not yet ready for prime-time, Goodman cautions. He worries that because the electrodes already are widely available, centers without proper training will start offering the $40,000 implant surgeries to psychiatric patients before science proves if they're really valuable. ''It is an invasive, experimental procedure,'' he warns, with risks including bleeding in the brain and infections. He calls DBS ''the last resort for stringently selected patients.''

Earlier this month, federal health officials and the Cleveland Clinic brought together the field's leading researchers to highlight progress so far and debate if it's time for much larger studies -- even whether DBS might be tweaked to help people with traumatic brain injuries, such as Iraq war veterans.

''There's not enough awareness of what the potential is of this kind of stimulation,'' says meeting co-chair Dr. Margaret Giannini, who heads the government's Office on Disability.

In deep brain stimulation for Parkinson's, a wire is implanted within a walnut-sized area known as the thalamus, a hub of sensory information. That electrode is connected by a cable running through the neck to a pulse generated under the collarbone. Tiny electrical zaps disable overactive nerve cells, blocking tremors.

Scientists don't have nearly as much understanding of what goes awry to cause depression or other psychiatric illnesses -- but they do know the thalamus isn't the right spot for those patients. They're focusing instead on two regions with names only a neurologist could love -- the ventral capsule/ventral striatum and so-called Brodmann Area 25. Ignore the names; the point is that these are regions where brain circuitry involved in mood and anxiety intersect.

It's not yet clear who should have DBS in which spot, or if there are still other target areas. Much of the research to date has been funded by electrode manufacturers, with some paid for by the government -- and consists of measuring patients' disability before and after DBS, not more rigorous studies that randomly assign patients to treatment.

Still, Diane Hire of Cleveland, the patient whose first smile was recorded, illustrates the hope. The 12-year Navy veteran was medically discharged for depression and spent a decade on disability, unable to function. ''I basically felt like a dead person walking. I had no feelings, no emotions,'' she told the scientists' meeting.

Her DBS was switched on in January 2007, and ''my whole world changed,'' says Hire, 54. She's not back to work yet: ''It is a real challenge to learn how to live as a healthy person again,'' she adds, saying she doesn't handle stress or multitasking well. But, ''I wake up every day looking forward to what's ahead.''

Records show roughly 40,000 troops have been diagnosed with the illness, also known as PTSD, since 2003. Officials believe that many more are likely keeping their illness a secret. ''I don't think right now we ... have good numbers,'' Army Surgeon General Eric Schoomaker said Tuesday.

Defense officials had not previously disclosed the number of PTSD cases from Iraq and Afghanistan. Army statistics showed there were nearly 14,000 newly diagnosed cases across the services in 2007 compared with more than 9,500 new cases the previous year and 1,632 in 2003.

Schoomaker attributed the big rise over the years partly to the fact that officials started an electronic record system in 2004 that captures more information, and to the fact that as time goes on the people keeping records are more knowledgeable about the illness. He also blamed increased exposure of troops to combat.

Factors increasing troop exposure to combat in 2007 included President Bush's troop buildup and the fact that 2007 was the most violent year in both conflicts. More troops also were serving their second, third or fourth tours of duty -- a factor mental health experts say dramatically increases stress. And in order to supply enough forces for the buildup, officials also extended tour lengths to 15 months from 12, another factor that caused extra emotional strain.

Officials have been encouraging troops to get help even if it means they go to civilian therapists and don't report it to the military. ''We're trying very hard to encourage soldiers and families to seek care and to not have them feel in any way, shape or form that we're looking over their shoulder or that we're invading their privacy,'' Schoomaker told a group of defense writers. Noting that stigma is a problem in American civilian society, not just the military, he said, ''I think that's the preferred way to do it.''

The accounting of diagnosed cases released Tuesday shows those hardest hit last year were Marines and Army personnel, the two ground forces bearing the brunt of combat in Iraq and Afghanistan.

The Army reported more than 10,000 new cases last year, compared with more than 6,800 new cases the previous year. More than 28,000 soldiers altogether were diagnosed with the disorder over the last five years, the data showed. The Marine Corps had more than 2,100 new cases in 2007, compared with 1,366 in 2006. More than 5,000 Marines have been diagnosed with PTSD since 2003, the data showed. Navy officials who would have data on Marine health issues did not return a phone call seeking to confirm the numbers released by Schoomaker's office.

Schoomaker said he believes PTSD is widely misunderstood by the press and the public -- and that what is often just normal post-traumatic anxiety and stress is mistaken for full-blown PTSD. Experts say many troops have symptoms of stress, such as nightmares and flashbacks, and can get better with early treatment.

The Pentagon had previously only given a percentage of troops believed affected by depression, anxiety, stress and so on -- saying up to 20 percent return home with symptoms of mental health problems. A recent private study estimated that could mean up to 300,000 of those who've served have symptoms.

The Veterans Affairs Department said recently it has seen some 120,000 Iraq and Afghanistan veterans who have received at least a preliminary mental health diagnosis, with PTSD being the most common diagnosis at nearly 60,000.

An undisclosed number of troops also go to private care providers who are part of the huge military health care system. Schoomaker noted that National Guard and Reserve troops often go home to communities where there is not a veterans facility nearby. ''We're working very hard with the VA and with the National Guard and Reserves to get a better feel for, a grasp on, how big this is,'' Schoomaker said, adding that over time officials will be able to collect data and get ''a better feel for, handle on, the numbers.''

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

While his physical injuries from China's May 12 earthquake are healing, mental trauma has made the 13-year-old withdraw into mostly silence.

Li Fuhong, a psychology professor who voluntarily drove nearly 200 miles to the disaster zone, speaks softly to Liu. He coaxes the boy to tell him what happened when he escaped the ruins of his school in the city of Mianzhu and makes him repeat these words: ''The bad events are over. The future will be better. I need to be strong.''

The teenager is lucky to be getting help. Across central China's disaster zone, many other such victims with mental trauma are going untreated because health services are already strained.

Hospitals and clinics were destroyed along with so much else across Sichuan province in the quake, leaving acute shortages of staff and facilities. In the immediate aftermath, medical services have focused on treating crushed and broken bones, amputated limbs and on preventing disease outbreaks.

Experts warn that mental trauma could be a hidden toll for many survivors.

The government says the quake may have killed more than 80,000 people, leaving many more to deal with the deaths of loved ones. Millions have had their homes shattered and their lives thrown into turmoil. No government estimate of people needing psychological help has been released, although the state-run Legal Daily newspaper quoted an expert as saying they could number as high as 600,000.

Teams of psychologists, psychiatrists and volunteer counselors like Li Fuhong have gone to the hardest-hit areas, where mental health professionals have been swamped.

''China has been struggling to help thousands of people distressed and traumatized in the unprecedented earthquake that ravaged many parts of Sichuan,'' the official Xinhua News Agency said last week. ''Many volunteers and experts have rushed to quake zones but psychologists are still in great demand.''

In the past, there has been a social stigma attached to mental illness in China. Increasingly fast-paced -- and stressful -- lifestyles stemming from two decades of economic success have forced a greater awareness of the problem.

Xinhua reported last year that there were 16 million mental patients in the country but services at the grass roots level were still lacking, and public awareness was minimal. Health officials have said that by of the end of 2006, there were only 1,124 mental institutions, with 146,000 beds and 19,000 psychiatrists or assistant psychiatrists.

Hospitals left standing by the quake have been overrun with serious injuries. The government has rushed more than 10,000 doctors or nurses to the area and a dozen field hospitals have been erected, Health Ministry spokesman Sun Jiahai said Tuesday in Beijing.

Signs of mental and emotional strain are widespread.

Relatives, weeping inconsolably, fall to the ground in front of plastic-wrapped bodies of sons and daughters killed in a school collapse in Hanwang. In the town of Beichuan, so badly damaged that it has been abandoned, villagers stare blankly in shock at what used to be their homes. Some talk with gratitude about having escaped with their lives -- only to dissolve into tears.

Metin Basoglu, head of trauma studies at London's Institute of Psychiatry at King's College and the director of the Istanbul Center for Behavior Research and Therapy in Turkey, said 80 percent of the survivors could be expected to suffer short-term effects of post-traumatic stress disorder, a condition that can develop after a person is exposed to a terrifying event in which physical harm has either occurred or was threatened.

Half will have longer-term problems, which include obsession with the trauma, nightmares, flashbacks, emotional numbing, loss of interest in life, irritability, memory problems and hyper-vigilance -- a state of constant alertness.

''Fear is the most serious problem,'' Basoglu said. ''Many people will find that their fear of earthquakes interferes with their everyday activities,'' including sleeping, bathing -- even walking into a building.

In the Deyang City No. 1 People's Hospital, the scene was chaotic last week as doctors and nurses rushed from one injured person to the next as they lay on beds cramming hallways and in tents on the hospital grounds. Away from the hubbub, Li -- the counselor from Southwest University in Chongqing -- talked quietly with the teenager, Liu.

Liu's mother, Zhao Xiaoxia, said the normally outgoing teen barely ate in the days after the disaster, and could not fall sleep unless she was holding his hand.

But the therapy by Li seems to be working.

''Now,'' Zhao said with a broad smile, ''he wants fried chicken.''

In another sign that health care professionals will not reach everybody in need right away, the Ministry of Health has issued a handout of guidelines on how to help survivors, rescue workers and volunteers who have experienced the carnage. Blue flyers circulated by Sichuan health authorities offer concern and compassion from the ruling Communist Party.

''When we're facing a disaster, the first thing we want to do is to continue living,'' it said. ''That's the only way we can fight the disaster.''

To make up for the shortage of counselors, doctors are encouraging survivors to look after each other, trying to create support systems in quake-shattered communities.

In Shifang, a town surrounded by rice fields where two chemical plants collapsed and buried more than 600 people, a steady stream of people visited three tables lined with medicines and staffed by doctors from the Taiwan-based Buddhist Compassion Relief Tzu-Chi Foundation.

''It's different from America here. Social and familial support is strong and it makes people feel better, safer,'' said Chien Sou Hsin of the foundation. ''It's a special thing.''

China is officially atheist, and there were no signs apparent that people were taking solace in religious counseling.

Basoglu, the trauma expert, and his colleagues have developed a method for dealing with large numbers of survivors from disasters -- work that grew from his experience after two quakes killed 19,000 people in Turkey in 1999. The method encourages victims to confront their fears and the simple message can be delivered through pamphlets, television or radio.

''Once they overcome their fear, all other PTSD and depression symptoms disappear,'' he said.

For some, recovery seems far away.

The nights have been the hardest for retired soldier Luo Tiangui. He flails violently in his hospital bed, eyes unblinking and shouting incoherently. ''I am a bad person,'' he says, over and over.

Luo, 57, was buried in his house but survived with a broken thigh and fractured ribs. His mental state is more fragile.

Lying shirtless and sweating, Luo stared at the ceiling, murmuring ''It's on fire, it's on fire'' -- one of the many hallucinations his family says he's been suffering.

Doctors said Luo has suffered a great fright, and he's being given drugs to help him sleep. They have told his family they should share happy moments with him in the hope that it helps.

At his bedside, Luo's wife, Wei Yunqun, and 21-year-old daughter, Luo Cui, stroke his hands, which did not stop trembling. The TV above his bed is kept off so he isn't bombarded with news from the quake.

''It's too hard to bear,'' said Wei, 54, her eyes filling with tears as she looked at her husband, a former construction worker and furniture-maker.

''There was never anything wrong with his mind,'' Cui said.