History > 2011 > USA > Health (III)

Florida Shutting ‘Pill Mill’ Clinics

August 31, 2011
The New York Times
By LIZETTE ALVAREZ

WEST PALM BEACH, Fla. — Florida has long been the nation’s center of the illegal sale of prescription drugs: Doctors here bought 89 percent of all the Oxycodone sold in the country last year. At its peak, so many out-of-staters flocked to Florida to buy drugs at more than 1,000 pain clinics that the state earned the nickname “Oxy Express.”

But with the help of tougher laws, officials have moved aggressively this year to shut down so-called pill mills and disrupt the pipeline that moves the drugs north. In the past year, more than 400 clinics were either shut down or closed their doors.

Prosecutors have indicted dozens of pill mill operators, and nearly 80 doctors have seen their licenses suspended for prescribing mass quantities of pills without clear medical need.

New laws are also cutting off distribution. As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year. The ban was phased in beginning last October, with a limit on the number of pills a doctor could dispense.

“We had no tough laws in place; now we do,” said Pam Bondi, Florida’s attorney general.

Law enforcement agencies are also keeping a closer eye on pharmacies. The number of applications to open new pharmacies in Florida has nearly doubled in the past two years, the result of doctors’ facing tougher rules. They now make up half of all the requests in the entire country, according to the latest Drug Enforcement Administration figures.

Now, among other things, background checks are required for owners and employees. Violators, whether they are pharmacists, doctors or clinic owners, face stiffer, swifter penalties if they prescribe or distribute legal narcotic drugs to people who do not need them or without following required steps.

One indication that law enforcement officials are choking the supply of prescription drugs sold illegally in Florida is that the price of Oxycodone on the streets here has nearly doubled from last year, to $15 per pill from $8, according to Capt. Eric Coleman, commander of the narcotics division of the Palm Beach County Sheriff’s Office. And on Commercial Boulevard, a major street in Broward County, the number of pain clinics has fallen in the past year from 29 to one.

Treatment centers are also seeing more addicts seeking help. “We have patients walking in the door that cannot afford prescription drugs any more,” said Dr. Barbara Krantz, the chief executive and medical director of Hanley Center, a large private treatment clinic in Palm Beach County.

Federal, state and local law enforcement officials have worked closely to increase the number of arrests and major indictments. They are dealing with pill mill operators as they would large criminal enterprises.

Last month federal prosecutors used racketeering laws to indict 32 people, including twin brothers who they say operated a sprawling pill mill operation. The brothers, who owned four pain clinics, also were charged with kidnapping, extortion and assault with a firearm under the indictment. Most of the prescriptions were written to patients who traveled to Florida from out of state, with Kentucky making up the largest share.

And in a rare move, a Florida doctor who worked at one of the pain clinics was charged with murder by Palm Beach County prosecutors after a patient died of an overdose in 2009, a few hours after the doctor prescribed him 210 pain pills.

One of the brothers who owned the clinic, Jeffrey George, pleaded guilty to second-degree murder this week. Prosecutors say the twins’ clinics were responsible for 56 overdose deaths.

The clinics were shut in 2010, but more than a year passed before the case was built, in part because Oxycodone is legal and the new laws were not in place.

Charging a doctor and a clinic owner with homicide “was a game changer,” said Sheriff Ric L. Bradshaw of Palm Beach County. “You are not going to get a slap on the wrist. You are looking at life in prison.”

Officials here acknowledge the drug problem is still alarming. Last year, seven people died in Florida each day from prescription drug overdoses, a nearly 8 percent increase from 2009. This is far more than the number who died from illegal drugs, and the figure is not expected to drop much this year. Oxycodone, which when abused has an effect similar to heroin, was the most lethal.

The illegal sale of prescription drugs, and Oxycodone in particular, boomed in Florida because of the absence of a widely used prescription drug monitoring system and lax state regulations. Until last year, even convicted felons could open pain clinics in Florida, Captain Coleman said.

There are still several hundred pain clinics in Florida, with many of them now migrating to central and northern Florida, where the crackdown until recently has been less intense. And nothing has prevented people from trying different doctors and pharmacies for prescriptions and pills.

This, too, will change. In October, the state will start a prescription drug monitoring system that will give pharmacies seven days to record the sale of controlled substances in a database.

That way, pharmacists will be able to pull up information on how often a patient is prescribed and sold these drugs. The tracking system, in theory, will prevent pharmacy-hopping for drugs. A majority of states already use a monitoring system, which government officials say has been crucial to shutting down the Oxycodone pipeline early on in states like Kentucky.

But in Florida, efforts to establish the database were slowed by legal challenges and lobbying over privacy rights. Gov. Rick Scott, a Republican, and State House Republican leaders opposed the creation of the database, saying it raised too many privacy concerns and was not the most effective way to curb the problem. The state did not finance the database. Instead, private donations are being used to start the program.

“The prescription drug monitoring program is a way to turn the battleship in the bathtub,” said Michael Jackson, the executive vice president and chief executive of the Florida Pharmacy Association.

The fallout from the tougher laws may include an increase in pharmacy robberies, a problem that has been worse in Florida than any other state since 2007 (there were 65 armed robberies of pharmacies here last year).

Pharmacies are taking precautions like installing surveillance cameras, among other things. And the police, sheriffs and highway patrol are also keeping a close eye on drug cargo hijackings and thefts at manufacturer distribution points.

“We recognize what a horrible problem we have,” Ms. Bondi said. “We have, of course, many legitimate, good pain-management doctors. We are targeting the drug dealers wearing white coats.”

    Florida Shutting ‘Pill Mill’ Clinics, NYT, 31.8.2011,
    http://www.nytimes.com/2011/09/01/us/01drugs.html

The Shortage of Vital Drugs

August 25, 2011
The New York Times

A widespread shortage of prescription drugs is hampering the treatment of patients who have cancer, severe infections and other serious illnesses. While some Republican politicians have railed against the imaginary threat of rationing under health care reform, Congress has done nothing to alleviate the all-too-real rationing of lifesaving drugs caused by this crisis.

The Food and Drug Administration says that some 180 medically important drugs have been in short supply, many of which are older, cheaper generic drugs administered by injection that have to be kept sterile from contamination.

A survey of 820 hospitals in June by the American Hospital Association found that almost all of them had experienced a shortage of at least one drug in the previous six months and that nearly half had experienced shortages of 21 or more drugs. As a result, more than 80 percent of the hospitals delayed needed treatments, almost 70 percent gave patients a less effective drug, and almost 80 percent rationed or restricted access to drugs.

Although there is limited data on how many patients have been harmed, a survey of 1,800 health care practitioners last year by the Institute for Safe Medication Practices found that a third of the physicians and a fifth of the pharmacists knew of adverse patient outcomes because of shortages, including some deaths from microbes resistant to the backup drugs. Cancer patients receiving less effective drugs may well face increased risks in the future.

Nobody is sure just what is causing the shortages because drug manufacturers are not required to report any reasons to the F.D.A. But several factors are likely to be involved: contamination problems at some manufacturing plants, forcing unexpected production shutdowns; difficulties in getting pharmaceutical ingredients from suppliers, especially those abroad; reluctance to invest in production-line improvement for low-profit generics when high-priced brand-name drugs bring in far higher profits. Sweeping consolidation in the generic drug industry means that fewer companies are left in that market to make up for a shortage.

The shortages are forcing health care providers to buy more expensive products in the absence of cheap generics. Unscrupulous wholesalers have made matters worse by scooping up scarce drugs and offering them to hospitals at markups that often reach 20 times the normal price or more, according to a recent survey.

Beyond limited responses, like using the F.D.A.’s discretionary powers to expedite temporary imports of drugs that are sold overseas but not here, there are very few ways to ease the crisis. For the longer term, bipartisan bills in Congress would require drug makers to give the F.D.A. six months’ warning of problems that might disrupt supplies. For that to work, the penalties for noncompliance would need to be stiff.

Other proposals include a national stockpile of critically important drugs, incentives to encourage the manufacture of generic drugs, and broader powers and additional resources for the F.D.A. to head off looming shortages. Some, perhaps many, Congressional Republicans will inevitably oppose an expansion of the F.D.A.’s regulatory authority. This cannot and must not be a fight over ideology. For many Americans, it is a fight for their lives.

    The Shortage of Vital Drugs, NYT, 25.8.2011,
    http://www.nytimes.com/2011/08/26/opinion/the-shortage-of-vital-drugs.html

The Kids Are Not All Right

August 21, 2011
The New York Times
By JOEL BAKAN

Vancouver, British Columbia

WHEN I sit with my two teenagers, and they are a million miles away, absorbed by the titillating roil of online social life, the addictive pull of video games and virtual worlds, as they stare endlessly at video clips and digital pictures of themselves and their friends, it feels like something is wrong.

No doubt my parents felt similarly about the things I did as a kid, as did my grandparents about my parents’ childhood activities. But the issues confronting parents today can’t be dismissed as mere generational prejudices. There is reason to believe that childhood itself is now in crisis.

Throughout history, societies have struggled with how to deal with children and childhood. In the United States and elsewhere, a broad-based “child saving” movement emerged in the late 19th century to combat widespread child abuse in mines, mills and factories. By the early 20th century, the “century of the child,” as a prescient book published in 1909 called it, was in full throttle. Most modern states embraced the general idea that government had a duty to protect the health, education and welfare of children. Child labor was outlawed, as were the sale and marketing of tobacco, alcohol and pornography to children. Consumer protection laws were enacted to regulate product safety and advertising aimed at children.

By the middle of the century, childhood was a robustly protected legal category. In 1959, the United Nations issued its Declaration of the Rights of the Child. Children were now legal persons; the “best interests of the child” became a touchstone for legal reform.

But the 20th century also witnessed another momentous shift, one that would ultimately threaten the welfare of children: the rise of the for-profit corporation. Lawyers, policy makers and business lobbied successfully for various rights and entitlements traditionally connected, legally, with personhood. New laws recognized corporations as legal — albeit artificial — “persons,” granting them many of the same legal rights and privileges as human beings. In an eerie parallel with the child-protective efforts, “the best interests of the corporation” was soon introduced as a legal precept.

A clash between these two newly created legal entities — children and corporations — was, perhaps, inevitable. Century-of-the-child reformers sought to resolve conflicts in favor of children. But over the last 30 years there has been a dramatic reversal: corporate interests now prevail. Deregulation, privatization, weak enforcement of existing regulations and legal and political resistance to new regulations have eroded our ability, as a society, to protect children.

Childhood obesity mounts as junk food purveyors bombard children with advertising, even at school. A recent Kaiser Family Foundation study reports that children spend more hours engaging with various electronic media — TV, games, videos and other online entertainments — than they spend in school. Much of what children watch involves violent, sexual imagery, and yet children’s media remain largely unregulated. Attempts to curb excesses — like California’s ban on the sale or rental of violent video games to minors — have been struck down by courts as free speech violations.

Another area of concern: we medicate increasing numbers of children with potentially harmful psychotropic drugs, a trend fueled in part by questionable and under-regulated pharmaceutical industry practices. In the early 2000s, for example, drug companies withheld data suggesting that such drugs were more dangerous and less effective for children and teenagers than parents had been led to believe. The law now requires “black box” warnings on those drugs’ labels, but regulators have done little more to protect children from sometimes unneeded and dangerous drug treatments.

Children today are also exposed to increasing quantities of toxic chemicals. We know that children, because their biological systems are still developing, are uniquely vulnerable to the dangers posed by many common chemical compounds. We also know that corporations often use such chemicals as key ingredients in children’s products, saturating their environments. Yet these chemicals remain in circulation, as current federal laws demand unreasonably high proof of harm before curbing a chemical’s use.

The challenge before us is to reignite the guiding ethos and practices of the century of the child. As Nelson Mandela has said, “there can be no keener revelation of a society’s soul than the way in which it treats its children.” By that measure, our current failure to provide stronger protection of children in the face of corporate-caused harm reveals a sickness in our societal soul. The good news is that we can — and should — work as citizens, through democratic channels and institutions, to bring about change.

Joel Bakan, a law professor at the University of British Columbia, is the author of “Childhood Under Siege: How Big Business Targets Children.”

    The Kids Are Not All Right, NYT, 21.8.2011,
    http://www.nytimes.com/2011/08/22/opinion/corporate-interests-threaten-childrens-welfare.html

Preaching a Healthy Diet in the Deep-Fried Delta

August 21, 2011
The New York Times
By CAMPBELL ROBERTSON

HERNANDO, Miss. — Not much seems out of place in the Mississippi Delta, where everything appears to be as it always has been, only more so as the years go by. But here in the fellowship hall of a little Baptist church on a country road is an astonishing sight: a plate of fresh fruit.

“You get used to it,” said Arelia Robertson, who has been attending the church for almost eight decades.

Despite a dirge of grim health statistics, an epidemic of diabetes and heart disease and campaigns by heath agencies and organizations, the Delta diet, a heavenly smorgasbord of things fried, salted and boiled with pork, has persisted.

It has persisted because it tastes good, but also because it has been passed down through generations and sustained through such cultural mainstays as the church fellowship dinner. But if the church helped get everybody into this mess, it may be the church that helps get everybody out.

For over a decade from his pulpit here at Oak Hill Baptist in North Mississippi, the Rev. Michael O. Minor has waged war against obesity and bad health. In the Delta this may seem akin to waging war against humidity, but Mr. Minor has the air of the salesman he once was, and the animated persistence to match.

Years into his war, he is beginning to claim victories.

The National Baptist Convention, which represents some seven million people in nearly 10,000 churches, is ramping up a far-reaching health campaign devised by Mr. Minor, which aims to have a “health ambassador” in every member church by September 2012. The goals of the program, the most ambitious of its kind, will be demanding but concrete, said the Rev. George W. Waddles Sr., the president of the convention’s Congress of Christian Education.

The signs of change in the Delta may be most noticeable because they are the most hard-fought.

A sign in the kitchen of First Baptist Church in Clarksdale declares it a “No Fry Zone.” Bel Mount Missionary Baptist Church in the sleepy hamlet of Marks just had its first Taste Test Sunday, where the women of the church put out a spread of healthier foods, like sugar-free apple pie, to convince members that healthy cuisine does not have to taste like old tires.

Carved out of the fields behind Seek Well Baptist Church in the tiny town of Lula is a new community garden. The pastor, the Rev. Kevin Wiley, is even thinking about becoming a vegetarian, a sort of person he says he has never met in the Delta.

Many pastors tell the same story: They started worrying about their own health, but were motivated to push their congregations by the campaign that began in Mr. Minor’s church.

“I’m not going to say it has to be done by the church,” Mr. Wiley said. “But it has to be done by people within the community. How long is an outsider going to stay in Lula, Mississippi?”

Certainly, others have been trying to help.

Mississippi finds itself on the wrong end of just about every list of health indicators. It is first among states in percentage of children who are obese, according to the Kaiser Family Foundation. It is first in rates of heart disease, second in the number of adults with diabetes, second in adult obesity, near last in the percentage of adults who participate in physical activity, near last in fruit and vegetable consumption and dead last in life expectancy.

On almost all these scales, the Delta is the worst part of Mississippi. The state has fought this by putting healthier meals in schools, working with mayors to create parks and farmers’ markets and paying for public awareness campaigns.

But the solution is not just a matter of telling people to live healthier, said Victor D. Sutton, director of preventive health for the Mississippi State Department of Health. The Delta is one of the poorest areas of the country, and its problems are deep and varied. The church is part of that whole equation.

“It’s not going to be the answer,” he said, “but it’s going to be one of the answers.”

Mr. Minor was born in the Delta but left for Harvard and a stint selling cars in Boston. He returned to Memphis and in the middle 1990s became the pastor at Oak Hill outside Hernando, about an hour south of Memphis.

If Mr. Minor had never left, he probably would never have noticed it. But he saw it immediately when he returned.

“There were a lot of people not only in this church, but in churches that we fellowship with, that were ...” he searched for the right phrase, “of good size.”

When he began preaching his health gospel right from the start, he was met not by outright resistance — that would have been rude — but by a polite disregard. This is the way people have always cooked here, church members said, and they ignored him.

He argued that while the food may be the same, people’s lifestyles had changed, and few put forth the physical effort that life in the Delta once required. Preparing pork chops used to involve raising and slaughtering a pig; now it requires little more than a trip to the grocery store. But he eventually realized he would have to adjust his strategy.

Around 2000, he began enlisting his ushers and those from other churches to go after hesitant pastors with a baldly practical line of argument.

“Your sick members can’t tithe,” he said with a laugh.

At Oak Hill now, as in several other churches around the Delta, fried foods are banned. Greens are boiled with turkey necks instead of ham hocks. Sweet tea and soft drinks have given way to bottled water. A track was built around the church for organized walks, which members say are pretty well attended.

Traditional Delta cuisine might not even be where the real fight is. The old fare has already been giving way to the new, just as at Taco Bell and Wendy’s. The restaurant Mr. Minor singled out as “the bane of our existence” was a Chinese buffet.

“I think the most resistance will be with your youth who say McDonald’s is so tempting,” said Johnnie Carter, who is helping lead the health push at Bel Mount, driven to get involved after she had a heart attack at the age of 41. But, she added, “you’ll have your older folks who say, ‘I’ve been eating this way all my life.’ It’s around the board.”

As Taste Test Sunday was wrapping up at Bel Mount, those who had just left Silent Grove Missionary Baptist across town were heading toward a traditional Delta buffet place called the Dining Room. Silent Grove has not joined in Mr. Minor’s fight — after all, the Dining Room is run by the pastor’s son.

“Once you taste it, you’re hooked,” said James Figg, a 69-year-old driving instructor, polishing off a tasty-looking pile of greens, fried chicken, macaroni and cheese and peach cobbler. Still, even he said he was making only one trip through the buffet line in these days of hospitalizations and funerals.

“When you get up to get seconds, you think about burying Brother So-and-So last week,” Mr. Figg said, looking wistfully at his near-empty plate. “And you leave it at that.”

    Preaching a Healthy Diet in the Deep-Fried Delta, NYT, 21.8.2011,
    http://www.nytimes.com/2011/08/22/us/22delta.html

Nuns, a ‘Dying Breed,’

Fade From Leadership Roles at Catholic Hospitals

August 20, 2011
The New York Times
By KEVIN SACK

ST. LOUIS — When Sister Mary Jean Ryan entered the convent as a young nurse in 1960, virtually every department of every Catholic hospital was run by a nun, from pediatrics to dietary to billing. After her retirement on July 31 as the chief executive of one of the country’s largest networks of Catholic hospitals, only 11 nuns remained among her company’s more than 22,000 employees, and none were administrators.

For SSM Health Care, a $4.2 billion enterprise that evolved from the work of five German nuns who arrived here in 1872, Sister Mary Jean’s departure after 25 years as the company’s first chief executive marks a poignant passing. The gradual transition from religious to lay leadership, which has been changing the face of Catholic health care for decades, is now nearly complete.

In 1968, nuns or priests served as chief executives of 770 of the country’s 796 Catholic hospitals, according to the Catholic Health Association. Today, they preside over 8 of 636 hospitals. With Sister Mary Jean’s departure, only 8 of 59 Catholic health care systems are directed by religious executives.

SSM, which is now led by William P. Thompson, a Catholic layman and longtime company executive, had been the largest Catholic health system still managed by a nun. Formed in 1986, the St. Louis firm consolidated the management of 15 Catholic hospitals and two nursing homes in Missouri, Illinois, Oklahoma and Wisconsin.

As with other healing orders that have ceded control, the Franciscan Sisters of Mary prepared for their inevitable detachment from SSM with more planning than sentiment.

“We can’t be maudlin about this,” said Sister Mary Jean, 73, who still presides over the company’s board. “I mean, yes, we are a dying breed. We are disappearing from the face of the earth and all of that. That being said, perhaps this is a moment for people to acknowledge the contribution that has been made by women religious throughout our history in the United States.”

The leadership shift has stirred angst in many Catholic hospitals about whether the values imparted by the nuns, concerning the treatment of both patients and employees, can withstand bottom-line forces without their day-to-day vigilance. Although their influence is often described as intangible, the nuns kept their hospitals focused on serving the needy and brought a spiritual reassurance that healing would prevail over profit, authorities on Catholic health care say.

In the case of SSM, that has meant turning away business arrangements with doctors who decline to accept Medicaid. It has meant discounting treatment for the poor and offering charity care to the uninsured, just as the order’s founders did. The St. Louis nuns’ earliest ledgers denoted patients unable to pay as “Our dear Lord’s.”

The near extinction of nuns from American hospitals stems largely from the drastic decline of religious orders that accompanied the women’s movement, the sexual revolution, ethnic assimilation and the Second Vatican Council’s opening of the church to lay leadership.

Even as the country’s Roman Catholic population surged by nearly 50 percent over the last half-century, the number of nuns dropped precipitously, to 56,000 today from 180,000 in 1965, according to the Center for Applied Research in the Apostolate at Georgetown University. In 2009, 91 percent of all nuns were at least 60 years old.

Sister Mary Jean’s order has dwindled to about 100 from a peak of more than 500. Most moved out of their convent last year and into a retirement and nursing home. There has not been an initiate for 25 years, and several years ago the sisters reluctantly stopped looking.

“It was painful,” Sister Mary Jean said in an interview in her modest apartment, “but I think it was also courageous to say we’re just not going to recruit any more. Let’s just live out the rest of our lives to the fullest that we possibly can and thank God for what we’ve been able to do. And when the time comes, as they say, the last person turn the lights out.”

Along with parochial education, health care has long been a central mission of nuns in this country, a natural outgrowth of the Catholic insistence on the sacredness of life. Since 1727, when the Ursuline sisters landed in New Orleans, they have built 12 of the country’s 40 largest health care systems. In 2009, Catholic hospitals accounted for one of every six admissions in the United States, according to the Catholic Health Association.

Other than crucifixes on the walls and marble Madonnas in the lobby, Catholic hospitals do not look particularly different from secular ones. But their administrators say that what makes them distinct is a values-driven approach, reflected at SSM in a mission statement that pledges to use exceptional care to “reveal the healing presence of God.”

Catholic health systems have been criticized, along with other nonprofit hospitals, as not dedicating enough resources to the community’s benefit. But surveys also show that, on average, they provide higher-quality performance than other hospitals and are more likely to offer specialty services that are not profit centers.

Sister Mary Jean, who was dispatched by her order to earn a master’s degree in hospital administration, has managed her realm with iron-willed competence and unblinking compassion, SSM executives said.

She is both stern and good-humored enough that the company’s vice president for communications, Suzy Farren, felt comfortable writing a farewell tribute that depicted her as “at times, gruff and demanding and stubborn.” Michael R. Panicola, the company’s vice president for ethics, remembered thinking during his job interview that he was facing “the female version of Mickey,” the crusty trainer in “Rocky” played by Burgess Meredith.

Those who underestimated the nuns as managers “made a mistake,” Sister Mary Jean said, volunteering that many hospital executives with multimillion-dollar salaries were “arrogant” and “overpaid.” Having taken a vow of poverty, Sister Mary Jean worked for free, although SSM paid the Franciscan Sisters of Mary an annual fee — $1.96 million in 2009, according to tax forms — as compensation for their labor.

Operating revenues at SSM (the initials honor the Sisters of St. Mary, a predecessor order) more than quintupled during Sister Mary Jean’s tenure, to $3 billion in 2010. The company produced net income that year of $247.9 million and provided $115.4 million in uncompensated care.

A decade ago, Sister Mary Jean led SSM through a relentless campaign to improve performance that was recognized with the first Malcolm Baldrige National Quality Award given to a health care company.

But her legacy also extends to preaching about the dignity of patients, paying blue-collar workers above scale, making her hospitals smoke-free, banning the use of foam cups and plastic water bottles, and insisting on gender-neutral and nonviolent language. There are no “bullet points” in SSM presentations, and photographs are “enlarged,” never “blown up.”

Even Sister Mary Jean can struggle to define precisely what the nuns brought to their hospitals. “There is this thing called presence,” she said, explaining that she was trained to see Jesus in the face of every patient, “and I think that’s the piece that is lost.”

Mr. Thompson, Sister Mary Jean’s handpicked successor, said he planned to hold fast to her commitment to patients, the environment and nonviolence. But he also acknowledged that he would be “trying to drive more efficiencies in the system.”

“I would hope,” he said, “that those two things never come into conflict, at least no more than they ever have in the past.”

    Nuns, a ‘Dying Breed,’ Fade From Leadership Roles at Catholic Hospitals, NYT, 20.8.2011,
    http://www.nytimes.com/2011/08/21/us/21nuns.html

Bernadine P. Healy,

a Pioneer at National Institutes of Health, Dies at 67

August 8, 2011
The New York Times
By ROBERT D. McFADDEN

Dr. Bernadine P. Healy, the first woman to lead the National Institutes of Health and the first physician to lead the American Red Cross until she was forced out in a storm of criticism over flawed responses to the Sept. 11 terrorist attacks, died on Saturday at her home in Gates Mills, Ohio. She was 67.

The cause was recurring brain cancer, which she had battled for 13 years, her husband, Dr. Floyd D. Loop, said.

In a hybrid career in the largely male domains of medicine and government, Dr. Healy — a cardiologist and feminist — was a professor at Johns Hopkins University, dean of the Ohio State University medical school, a White House science adviser and president of the American Heart Association. She wrote scientific papers and magazine columns, and once ran for the United States Senate.

But she was best known as a tough, innovative administrator who, as director of the National Institutes of Health from 1991 to 1993, championed studies that overturned false assumptions about women’s health. And as president of the American Red Cross from 1999 to 2001, she struggled to coordinate its complex, often contradictory missions of humanitarian disaster relief and the businesslike maintenance of blood supplies.

Dr. Healy’s résumé was a compendium of academic and professional achievements that in its cold detail omitted a central fact: her relentless attack on the misperception that heart attacks were men’s problems. Heart disease was by far the leading killer of American women, who accounted for nearly 40 percent of its victims. Women’s groups had long sought a greater focus on women’s coronary health, cancers and the role of hormonal changes and therapy.

Dr. Healy, who had pushed similar concerns within cardiology, went to Washington and made the issue her own.

“The problem is to convince both the lay and medical sectors that coronary heart disease is also a women’s disease, not a man’s disease in disguise,” Dr. Healy wrote in The New England Journal of Medicine in 1991. At the institutes of health, the country’s largest medical research organization, Dr. Healy, a Republican appointed by President George Bush, inherited a sprawling agency of 15,000 people. It had gone without a director for two years and was beset by bureaucratic infighting, political interference and declining morale.

“I am willing to go out on a limb, shake the tree and even take a few bruises,” she told reporters. “I’m not particularly concerned about being popular.”

Dr. Healy cracked the whip on bureaucrats, recruited new talent, expanded the Human Genome Project and reversed policies that, like the medical establishment, had focused largely on men’s health and virtually excluded women from clinical trials. She mandated the inclusion of women in trials wherever appropriate.

She began the Women’s Health Initiative, a $625 million study of the causes, prevention and treatment of cardiovascular diseases, osteoporosis and cancer in middle-aged and older women. Long after her tenure, the initiative continued yielding important findings. In 2002, it found that prolonged estrogen-progestin hormone replacement therapy in postmenopausal women increased risks of breast cancer, stroke and heart attacks.

“Dr. Healy’s stubborn insistence that the N.I.H. concern itself with women’s health was not broadly supported at the time,” Anne M. Dranginis, an associate professor of biological sciences at St. John’s University, wrote in a 2002 Op-Ed article in The New York Times. “Had Dr. Healy not championed research on women’s health, how much longer would healthy women have been encouraged to take hormone drugs?”

Dr. Healy stepped down when President Bill Clinton named a new N.I.H. director in 1993.

Six years later, Dr. Healy faced even more daunting challenges at the Red Cross. While it was widely seen as an icon of humanitarian work, the organization was an unwieldy behemoth with 1,000 chapters, 1.2 million volunteers, 3,000 staff members and a $3 billion budget. It was also a house divided, with nonprofit disaster-relief on one side and, on the other, a blood business run like a corporation.

Recovering from a brain tumor as she took over, Dr. Healy found what she called “turf battles, gossip and very little teamwork.”

Her reform efforts stumbled in the face of resistant autonomous chapters, a staff that chafed under her hard-driving style, cases of embezzlement and lax controls, which led to record fines for infected blood products. She made the safety of blood supplies a priority.

But she upset many by auditing local chapters’ finances, overriding veteran administrators’ decisions and strongly supporting Israel’s Red Shield of David in its effort to join the international Red Cross and Red Crescent societies without having to accept a cross or crescent as its emblem. When the effort failed, she withheld dues from the international body in protest.

Missteps after the Sept. 11 terrorist attacks precipitated her downfall. Red Cross disaster-relief units responded poorly, especially at the Pentagon crash site, critics said. Later, her handling of blood donations for 9/11 victims came under fire. Collections far exceeded amounts needed. Some blood was kept for other users, but much of it expired and had to be discarded.

She was excoriated in Congress and by chapter leaders and donors over her Liberty Fund, established to aid victims of the terrorist attacks. It collected $564 million but kept $264 million for other uses, including aid in future attacks. She said it had never been intended just for Sept. 11 victims, but her critics insisted that the money had been raised under false pretenses. In response to the protests, the Red Cross redirected all the money to Sept. 11 relief.

Critics called Dr. Healy autocratic and said she had jeopardized the good will of a revered charity. Allies defended her as smartly decisive, even if she sometimes ignored political realities. She resigned under pressure, although one Red Cross director acknowledged, “We hired a change agent for a culture resistant to change.”

Bernadine Patricia Healy was born in New York City on Aug. 2, 1944, one of four daughters of Michael and Violet McGrath Healy. Her parents ran a small perfume factory in Long Island City, Queens, where she grew up.

She graduated from Hunter High School in Manhattan in 1962, got through Vassar College in three years and graduated from Harvard Medical School in 1970. After postdoctoral work, she became a full professor at Johns Hopkins in 1982 and directed its cardiac care unit from 1976 to 1984.

Her first marriage, to Dr. George Bulkley, a surgeon she had met in medical school, ended in divorce in 1981. They had a daughter, Bartlett Bulkley. In 1985, Dr. Healy married Dr. Loop, a cardiac surgeon. They had a daughter, Marie McGrath Loop. Dr. Loop and her two daughters survive her.

Dr. Healy was President Ronald Reagan’s deputy science adviser in 1984 and 1985, president of the American Heart Association in 1988 and 1989, and from 1985 to 1991 practiced cardiology and directed research at the Cleveland Clinic Foundation, which was operated by Dr. Loop.

She lost a Senate primary in Ohio in 1994, was a professor and dean at Ohio State from 1995 to 1999 and an adviser on bioterrorism to President George W. Bush.

This article has been revised to reflect the following correction:

Correction: August 9, 2011

An earlier version incorrectly identified Dr. Healy's husband, Dr. Floyd D. Loop.
He is a cardiac surgeon, not a cardiologist.

    Bernadine P. Healy, a Pioneer at National Institutes of Health, Dies at 67, NYT, 8.8.2011,
    http://www.nytimes.com/2011/08/09/us/09healy.html

Teenager’s Path and a Killing Put Spotlight on Mental Care

August 2, 2011
The New York Times
By DEBORAH SONTAG

LOWELL, Mass. — Pericles Clergeau, a tall, sturdy teenager with a troubled past, did not much like it when Kevin Allard, a radiant, sometimes manic youth, arrived at Adolescent Unit 2 at the Westborough state psychiatric hospital early last year.

“He was like the alpha male of the place, and I was the competition,” Mr. Allard said. “It was his turf, and I was mowing the lawn.”

On Feb. 3, 2010, the two 18-year-olds faced off in a basketball game called Taps, where one player can send the other’s score plummeting to zero by tapping in a rebound. The game was close and tense, and the verbal sparring kept escalating, too. Mr. Clergeau was near 21 points when a swish by Mr. Allard derailed him.

Catching his breath, Mr. Allard felt Mr. Clergeau — about six inches taller — very close behind. In seconds, Mr. Allard said, Mr. Clergeau’s arm was wrapped around his throat and he was dangling in a choke hold. He tried to wriggle free but passed out. Mr. Clergeau dropped him on the tarmac, and Mr. Allard came to with a deep laceration on his forehead, dripping blood, according to several accounts.

The next day, Dr. Bruce Meltzer, the unit’s medical director and psychiatrist, told a state mental health department investigator that “he fears the perp could commit murder and that it could happen at any time,” according to an internal document.

That concern got buried in an internal investigation. Mr. Clergeau was neither prosecuted nor placed for long in a more secure situation. And almost exactly a year later, on Jan. 29, 2011, Mr. Clergeau, homeless and adrift, was arrested in the killing of an employee at the shelter in Lowell where he had been staying. When the police arrived, Mr. Clergeau was standing behind the reception desk clutching a bloodstained knife. “I did it, I did it,” he said as he was being handcuffed, according to the police report.

The killing happened nine days after a 25-year-old mental health worker named Stephanie Moulton was slain at a group home in Revere. Ms. Moulton’s case spurred a statewide debate on whether budget cuts had eroded the public mental health system and endangered the safety of its workers. Indeed, in late June, a mental health safety task force issued a blistering report proclaiming the system to be in a crisis that, among other problems, created worrisome risks of violent tragedy.

The death of the shelter worker, Jose R. Roldan, 34, did not get as much attention as Ms. Moulton’s. But an examination of Mr. Clergeau’s case, based on interviews, confidential documents and court records, suggests that it involved an even more overt failure by the state both to help a deeply disturbed and dangerous individual and to keep the public safe.

Mr. Roldan’s killing was, in a way, a death foretold. Whether it was preventable cannot be known.

But Mr. Clergeau’s destructive and self-destructive path crisscrossed Massachusetts, taking him in and out of the custody of three state agencies as well as multiple treatment centers, hospitals, police departments and courts.

Over time, Mr. Clergeau established a clear pattern of lashing out violently. In turn, the government developed a pattern, too, of shuttling him from place to place until it released him to the streets and he ended up on the doorstep of a homeless shelter with little security, few resources and no knowledge of his history.

Other institutions that had treated Mr. Clergeau previously did not know his full history, either.

“No one seemingly put together a composite,” his court-appointed lawyer, Michael Collora, said. “Each incident was viewed in isolation.”

Those who had encountered Mr. Clergeau during his violent odyssey were saddened but not surprised by his first-degree murder charge. (He has pleaded not guilty.)

“I was only surprised it didn’t happen sooner,” said Christopher Casaubon, a mental health technician who suffered a shattered eye socket at Mr. Clergeau’s hand.

 

A Troubled Path

Speaking in the leafy courtyard of a public housing complex in Cambridge, Mr. Clergeau’s father said, “I knew something like that would be happening one day.”

The father, Joslin Clergeau, said Pericles started exhibiting emotional and behavioral problems at 4 or 5, not long after they emigrated from western Haiti.

“When Pericles was mad, he would bang his head on the walls,” said Mr. Clergeau, a taxi driver. “If you see his arm, you see the line of scars from when he’d bite, bite, bite himself.”

Mr. Clergeau said Pericles was first hospitalized at 7 or 8 after “he beat a boy with a chair when the boy called him gay.” He said Pericles celebrated his first communion on a psychiatric ward at Cambridge Hospital.

He also said — and Mr. Collora echoed — that no single psychiatric diagnosis was ever fixed to Pericles. Doctors speculated that Pericles had been traumatized by witnessing violence in Haiti, his father said. He did not think that was true. Even so, Pericles’s behavior came to mirror that of a small but intractable population of youths who, often based on trauma in their lives, are filled with rage that turns into violence.

Unable to pay for treatment, Mr. Clergeau said, he eventually granted custody of Pericles to the Department of Children and Families, which sent him to foster homes and residential schools.

At some point — Mr. Clergeau was fuzzy about when — Pericles accused him of child abuse. An investigation was done and, the father said, the accusation was not substantiated.

That could not be confirmed. The young man’s state agency files are closed, as is his juvenile criminal record. (The state’s Executive Office of Health and Human Services did not respond to questions for its child welfare and mental health departments.)

At 17, though, Pericles Clergeau became an adult in the eyes of the Massachusetts criminal justice system, and from then on his bumpy path can be more clearly traced.

 

Into the System

The year between Mr. Clergeau’s 17th and 18th birthdays was tumultuous. He was moved five times by a system that did not seem to know what to do with his increasing aggression.

Teenagers who violently challenge authority often disrupt a therapeutic environment and endanger the staff. Even though child welfare experts consider stability of placement to be beneficial and instability detrimental, these youths are the most likely to be bounced from program to program.

In early 2009, Mr. Clergeau, kicked out of his previous program because of an assault, turned 17 at a juvenile detention center. From there, he was transferred to the Hillcrest Center, a 14-acre campus in the Berkshires that specializes in youths with extreme psychiatric, emotional and behavioral disorders.

He tried to run away a few times, but his first major encounter with the police there occurred in May, when he flew into a despairing rage, destroying furniture, hitting an employee with a rock and trying to hang himself.

The following month, the police were summoned again. Arriving at the main building, Officer William C. Colvin observed broken glass and other debris littering the entrance. Inside, he saw a 6-foot-2-inch male student — Mr. Clergeau — face down on the floor with one staff member holding each of his legs and two more employees lying across his back.

Earlier that day, Mr. Clergeau had “gone AWOL,” and when finally located on the property, he was hostile, screaming and wielding a four-foot-long wooden sign post, the police report said.

Swinging the stick, he had run back into the school, smashing a large glass clock and a photocopier. He charged a solid wooden door, cracking it in half and tearing it from its hinges. When the principal and others tackled him, he tore at the principal’s face with the jagged post, causing what Officer Colvin described as “a long bruiser” from jaw to ear.

Mr. Clergeau was charged with assault and battery with a dangerous weapon, destruction of property and disorderly conduct. After a couple of days in jail, he was sent to the Brandon School and Residential Treatment Center in Natick.

In July, police officers reported there because Mr. Clergeau had become enraged during classroom detention. Having placed a staff member in a headlock and repeatedly punched him, Mr. Clergeau was charged again with assault and battery.

By September, he had been transferred to the Lowell Treatment Center. Not long after settling in, he was disruptive in class and ordered to return to his locked residential unit. He refused.

“He said, ‘If I’m getting in trouble for nothing, I might as well do something,’ ” Mr. Casaubon, a staff member at the school, said. Then Mr. Clergeau started hurling wooden chairs at his teacher.

Seeking to restrain him, Mr. Casaubon, who is muscular but shorter than Mr. Clergeau, managed to pin him against the wall. Mr. Clergeau promised to calm down if released. Mr. Casaubon let him go, he said, and the young man “sucker punched” him.

Mr. Casaubon, who needed surgery to rebuild his broken eye socket, said he pursued charges reluctantly, because “I knew nothing would happen.” (The case is still pending.) But, he said, “everybody was yelling at me to go to the police so that it would go on record that this guy is a violent person and shouldn’t be in public. I mean, that was him on meds. Imagine when he’s off meds.”

Afterward, Mr. Casaubon said, staff members learned that Mr. Clergeau had a record of previous assaults with similar modes of attack. “I sure wish I had known he strikes when you let go,” he said. “But it could have been worse. I’m not dead.”

Mr. Clergeau’s next stop was Westborough State Hospital, a hauntingly beautiful 19th-century asylum on a hilly campus overlooking a lake. The hospital has since closed because of budget cuts.

Mr. Clergeau was placed in a treatment program that served a combination of fragile, traumatized teenagers and violent juvenile offenders. It was a difficult mix.

Mr. Allard, who had a diagnosis of bipolar disorder and had been committed there after an encounter with the police, said Mr. Clergeau ruled the roost, intimidating his fellow patients and the staff, too.

During several months at the hospital, Mr. Clergeau reportedly assaulted nine staff members, sending a few out on medical leave, a person familiar with his stay there said. “You could feel the rage radiating off him,” another person said.

Both people spoke on the condition of anonymity because they feared repercussions for exposing what had happened.

The basketball game occurred on Mr. Clergeau’s 18th birthday, the day he technically aged out of the child welfare department’s care.

Two days later, he smashed a dresser drawer, fashioned a weapon and threatened to impale anybody who came near him. The unit was cleared of patients, the state police were called and Mr. Clergeau, after barricading himself in his room, was persuaded to surrender peacefully. He was led away in handcuffs.

Only then did the program staff learn, through a fax sent anonymously, that Mr. Clergeau had a record of violence, with eight outstanding warrants at that time.

The hospital’s human rights officer filed an internal complaint on behalf of Mr. Allard, which set off a departmental investigation that dragged on without resolution. But Mr. Clergeau was not prosecuted for anything that happened at the hospital. That was partly because the state Department of Mental Health discourages the criminalization of its adolescent patients; staff members did not press assault charges.

The police, learning about the attack on Mr. Allard after the fact, were in the process of opening an investigation when the weapon incident occurred.

“As we responded the next day and locked up the subject on the eight outstanding warrants, the investigation into the past A & B did not go anywhere,” David Procopio, a state police spokesman, said, referring to assault and battery.

Now back in his hometown, Ware, and feeling stable with an apartment and a job, Mr. Allard was stunned to learn that Mr. Clergeau had never been held accountable for, as he put it, “the attempted murder of me.”

“I can’t believe they let him out into a public place,” he said.

 

Last Resort

Mr. Clergeau was discharged from Westborough with the expectation that he would be imprisoned. Hospital authorities told the state police that he was “not a psych patient,” which appears to reflect a medical opinion that he belonged in a correctional setting.

At that point, Mr. Clergeau’s Lowell assault case was reactivated. A judge set bail at $1,000, and after a few weeks at a juvenile detention center, he was released to his father.

The family reunion did not go well.

“When they let him out of jail, they didn’t give him any medication,” his father said. “A lawyer told me, ‘He turned 18 now. They give him medication only if he asks.’ I say, ‘Stupid law.’ He has mental problems.”

After a month, under pressure from the Cambridge housing authority, Joslin Clergeau filed a restraining order against his son.

It was late April 2010, and Mr. Clergeau was now homeless.

In May, Mr. Clergeau was arrested on outstanding warrants while going door to door selling magazine subscriptions in Brookline. Once again taken to a juvenile detention center, he awaited the prosecution of his Berkshires case. He was found guilty of disorderly conduct and destruction of property — with no finding on the assault charge for what the judge deemed insufficient evidence — and sentenced to 30 days in jail.

In mid-August, Mr. Clergeau showed up at the Lowell Transitional Living Center. A 90-bed shelter for single adults, with limited social services and a meals program, it is often the “last resort” for people who get “shuffled around,” Gary Baker, the board president, said.

Anne Marie Malavich, case management supervisor there, said Mr. Clergeau arrived empty-handed, without any identification documents much less his own case files. She said he came across as “a very, very angry young man” with a “smirk on his face” and “an air of defiance.”

“Being sent to me was like being sent to the principal, and he was constantly being sent to me,” Ms. Malavich said.

Mary-Anne Buhlmann, 53, the slain man’s girlfriend, said, “Pericles was trouble, a troubled soul.”

In a darkened apartment with “The Price is Right” on the television and a memorial photo album bound with black ribbon by her side, Ms. Buhlmann said she and Mr. Roldan met at the shelter over a decade ago. She was a former battered woman, and he had “some demons,” she said; after moving into their own apartment, they remained connected to the shelter through his job there.

Last fall, Mr. Roldan came home uncharacteristically rattled, with a cut on his head, she said. He said Mr. Clergeau had whacked him, then claimed to have mistaken him for somebody else.

After that, Mr. Roldan told her that he was considering quitting his job because of Mr. Clergeau’s volatility. Not long before his death, he said he had been forced to penalize Mr. Clergeau for breaking rules.

“Jose said, ‘Mary-Anne, I had to kick Pericles out for a while and now he’s telling me he’s going to kill me,’ ” she said.

On Jan. 29, Mr. Roldan had been trying to calm an agitated Mr. Clergeau, who was accusing other residents of staring at him, when Mr. Clergeau stabbed him, severing his jugular vein. When the police arrived, he was still alive, barely, lying on the floor, a blood-soaked towel pressed to his neck.

Mr. Roldan was medically evacuated by helicopter. Before it was known that he had died, one officer transporting Mr. Clergeau told another that the charge was going to be “assault by means of a dangerous weapon.” Mr. Clergeau interrupted.

“He looked at me and said, ‘Officer, it’s going to be murder,’ ” Officer Marisol Nobrega noted in her report. “Murder.”

    Teenager’s Path and a Killing Put Spotlight on Mental Care, NYT, 2.8.2011,
    http://www.nytimes.com/2011/08/03/us/03mental.html

The Value of Medicaid

July 17, 2011
The New York Times


Medicaid is under assault these days from nearly every direction. Governors complain that they cannot afford to put up their share of the money. Congressional Republicans led by Paul Ryan want to reduce the federal contribution by $771 billion over the next decade and shift more costs to the states and low-income Americans. President Obama has expressed willingness to cut Washington’s contribution by $100 billion over that period to help reduce the deficit.

Meanwhile, conservative critics of Medicaid — and of health care reform’s requirement to expand it — have made the outlandish claim that it provides such poor care that enrollees would be better off having no coverage.

They cite a few studies that seemed to show that, in some cases, patients on Medicaid had worse outcomes than those without any insurance. They claim this is because Medicaid pays so poorly that many doctors refuse to treat the patients, who are then unable to get care or go to the least-skilled doctors.

Those claims have now been refuted by a new study of Oregon’s program, conducted under the leadership of Katherine Baicker, a Harvard health economics professor who was an adviser to President George W. Bush, and Amy Finkelstein, an economics professor at M.I.T. It found that Medicaid patients reported both better health and more financial stability than uninsured poor people.

The research was made possible by unusual circumstances in Oregon, where officials had only enough money to expand Medicaid enrollments by about 10,000 people in 2008. They used a lottery to decide who got coverage among the almost 90,000 people who applied. That made it possible to conduct a “gold standard” clinical trial in which two randomly selected groups with the same demographic characteristics could be compared — those who won the lottery and those who did not. None of the studies cited by the critics had randomly selected control groups.

The Oregon study provides striking results for its first year. The group that gained Medicaid coverage was significantly more likely to have received care from a hospital or a doctor, or to use prescription drugs, belying the notion that enrollees could not find providers. The insured group was far more likely to get preventive care, like mammograms, and to have a regular doctor.

Those people were also more likely to report being in better physical and mental health. And they were better off financially: less likely to pay out of pocket, have unpaid medical bills sent to collection agencies, or need to borrow money or ignore other bills to pay for medical care.

The critics rightly point out that just because the Medicaid enrollees reported that their health was better does not mean that it actually was better. In the second year, researchers are measuring actual blood pressure, cholesterol levels, blood sugar and other physical data.

The study estimated that the additional care the new enrollees got drove up spending (from all sources) on the average individual by about $775, roughly 25 percent, above the $3,200 average for the uninsured control group.

Any politicians eager to find savings by denying poor people access to Medicaid should recognize that they will be harming the health and financial well-being of highly vulnerable Americans. Expanding Medicaid will increase spending in the short run. But the nation will benefit from a healthier, more productive population that, in the long run, may have less need for costly medical services.

    The Value of Medicaid, NYT, 17.7.2011, http://www.nytimes.com/2011/07/18/opinion/18mon1.html

Sunday Dialogue:

Seeking a Path Through Depression’s Landscape

July 16, 2011
The New York Times

Do antidepressants work? Doctors and patients respond to a letter on Wednesday that questioned their liberal use.

THE LETTER

To the Editor:

“In Defense of Antidepressants,” by Peter D. Kramer (Sunday Review, July 10), reflects a high-stakes battle involving pharmaceutical companies, health care providers and patients.

Billions in profits are at stake for the drug industry, which has sometimes suppressed negative data about antidepressants. Doctors have financial incentives to treat depression pharmacologically because quick medication evaluations are more profitable than more time-consuming psychotherapeutic treatment. And then there are some practitioners wedded to psychological treatments who are eager to debunk the supposed superiority of pharmacologic treatment in part to expand their own practices.

While this battle rages, we must not lose sight of the patient. The arguments are complex, and a clear answer to whether antidepressants will work for an individual patient is often not easy to find. The data used and analyzed in the various studies — highly sophisticated and often not comparable — are not easy for patients or even practitioners to decipher.

What is a patient to do?

I would suggest to those suffering from depression that they find a provider who is willing to listen, asks probing questions about how well they are responding, spends an appropriate amount of time, is willing to switch course if they don’t improve, and is even willing to consult with another expert colleague. Fortunately many patients will improve over time.

WARREN R. PROCCI
Pasadena, Calif., July 12, 2011

The writer is president of the American Psychoanalytic Association and a clinical professor of psychiatry at David Geffen School of Medicine, U.C.L.A.

READERS REACT

As a professional ethicist, I share Dr. Procci’s concerns about the medical-pharmaceutical complex and how the obsession with ever-greater profits can hinder, not promote, ethically intelligent patient care.

But as someone who has been using antidepressants successfully for many years, I can say from experience that some of that concern is misplaced. My life is richer and infinitely more satisfying because of this medication. I offer my profound gratitude to the dedicated researchers and conscientious clinicians who have made this possible.

BRUCE WEINSTEIN
New York, July 13, 2011

Dr. Procci is right that there is a continuing high-stakes battle over the use of psychiatric drugs, but it is more one-sided than he suggests. These drugs are greatly overused, mainly because of the pharmaceutical industry’s influence on the psychiatric profession.

Many have devastating side effects, especially in children and when used long term. Studies generally show that the benefits are small.

Contrary to the arguments of Dr. Kramer, many sound clinical trials have failed to find antidepressants effective at all in mild to moderate depression. Anecdotes of effectiveness are no substitute for clinical trials, since they can’t take into account the placebo effect or how often a drug is ineffective or harmful.

Despite the risks and uncertain benefits, the number of Americans taking psychiatric drugs is soaring, and the heavy reliance on drugs diverts resources from efforts to find better methods of treatment.

Mental illness is a serious problem, but in the absence of sound evidence, we should be skeptical about all treatment claims — particularly those promoted by the pharmaceutical industry.

MARCIA ANGELL
Cambridge, Mass., July 13, 2011

The writer is a senior lecturer in social medicine at Harvard Medical School and former editor in chief of The New England Journal of Medicine. She is the author of two recent articles on psychiatric drugs in The New York Review of Books.

Dr. Procci’s advice is for the depressed patient to identify the ethical caregiver. That is not so simple in a medical care system that denies access, limits complex consultation, and rewards technology and procedures.

Questions about the efficacy of antidepressants are but one chapter in a larger moral and social tale without clear answers. Except perhaps one: The medical system we have today plainly does not work. What to do next is far more challenging than listening to Prozac.

RONNIE S. STANGLER
Seattle, July 13, 2011

The writer is a professor of psychiatry, University of Washington in Seattle.

I agree with Dr. Procci’s suggestion for the type of doctor whom patients should seek, but good luck finding one who practices this philosophy of treatment and is willing to spend so much time with each patient. They do exist, but they’re few and far between.

Then, try to tell an insurance company that longer sessions are more cost effective in the long run and conducive to overall health than the 15-minute sessions with the script writers who ask how you feel on a 1-to-10 scale, then prescribe accordingly. After that, make up the difference between the insurance company’s paltry “reasonable and customary” fee schedule and the actual fee.

KIPPI FAGERLUND
Derwood, Md., July 14, 2011

As a practicing psychiatrist, I have found antidepressants to be extremely effective. However, there are two main obstacles to finding an optimal medication regimen for patients: Each patient’s brain circuitry is unique, so what works well for one person may not necessarily do so for another; the severity of mental illness lies on a continuum, influenced by genes, life experiences and personality.

It is extraordinarily difficult, if not impossible, to design a clinical study that can truly take into account all of these differences. Thus, we are left with studies whose results often conflict.

Perhaps in the distant future, we will have a machine that will analyze each patient’s brain and create a customized medication regimen, but until then, clinicians are left with the reality that prescribing medication for depression remains much more of an art than a science.

LORI SIMON
New York, July 13, 2011

Without antidepressant drugs, there would be no psychiatry. Psychiatrists for more than 20 years, since serotonin-enhancing drugs were introduced, have, for financial reasons, elected to become psychopharmacologists, and many have given up traditional psychotherapy. Instead, they frequently shunt people who require talking therapy to psychologists.

If as suggested by randomized, controlled studies, the placebo response approaches that of the drugs, the individual psychiatrist really has no way to tell whether patients are better because of the drug or simply because they have been prescribed a drug.

If these drugs were taken away from psychiatrists, or if psychologists could legally prescribe these drugs, psychiatry would perish.

IVAN R. DRESSNER
Hopatcong, N.J., July 13, 2011

The writer is a clinical associate professor of neurosciences, University of Medicine and Dentistry of New Jersey.

Dr. Procci’s suggestion that people seek help from clinicians who are willing to listen to and work with them is entirely reasonable — as far as it goes. But it does not capture a seismic shift that has been occurring in mental health care.

While the media focus has been on what the professional or the pill is going to do for the suffering person, the emerging recovery movement has made clear what individuals can and must do to help themselves — individually and collectively — and how central self-help and mutual aid are to recovery.

When it comes to dealing with psychiatric challenges, there are no magic doctors or magic pills. There is no effortless recovery.

With this in mind, I would add the following to Dr. Procci’s advice: Seek other people in recovery and recovery-oriented clinicians who can help support you while you learn how to do the work of recovery on your own.

KEN THOMPSON
Pittsburgh, July 13, 2011

The writer is an associate professor of psychiatry at the University of Pittsburgh.

When my patients respond to treatment for major depression, as a psychiatrist I am often not sure how much it is from the medication and how much from talking to an empathic listener. For depressions accompanied by agitation and psychosis, it is clear that medication, as part of the treatment regimen, is helpful and essential.

The type of provider that Dr. Procci suggests that patients seek should be a psychiatrist (at least for the initial evaluation) who is adept at both psychotherapy and psychopharmacology. If the depression is mild, I agree with Dr. Kramer that medication should be used sparingly and as a second line.

JEFFREY B. FREEDMAN
New York, July 13, 2011

The writer is a former president of the New York County Branch of the American Psychiatric Association.

I’m sure psychoanalysis is a good option for some depressives, those who can afford it. But taking a generic form of Celexa for $4 a month gives me a fighting chance to face my demons on my own, with some help from my friends.

DEBORAH FINK
Ames, Iowa, July 13, 2011

THE WRITER RESPONDS

I tend to agree with the skeptics who question the efficacy of antidepressants and condemn their prolific use.

Marcia Angell has long highlighted the ways in which the pharmaceutical industry, the psychiatric profession and academia have at times colluded to erode appropriate boundaries.

Another problem is the insurers’ control over access to practitioners and the kind of care they can render.

Kippi Fagerlund poignantly exemplifies how third-party payers relentlessly limit treatment options to those seen as quickly “cost effective,” such as brief medication management visits rather than psychotherapeutic approaches.

Ronnie Stangler rightly sees this as a huge obstacle to quality care. I agree.

The hot crucible of the psychiatrist’s office is far removed from the cool sterility of research labs and academic offices. Patients in real-world settings often do find antidepressants singularly helpful. This doesn’t exonerate the excessive claims of the pharmaceutical industry. It only demonstrates the need for the individual practitioner to maintain his or her focus on the patient’s needs.

The bottom line: We doctors must push our professional organizations to disseminate only the highest quality data, free from conflicts of interest, to assist us in clinical decision making, and we must seek relief from obsessive cost-control management of patient care.

And those suffering from depression should insist on being given access to all available treatments and true information about their efficacy. It is unconscionable for patients to be held hostage to one form of treatment supported by such weak data.

WARREN R. PROCCI
Pasadena, Calif., July 14, 2011

    Sunday Dialogue: Seeking a Path Through Depression’s Landscape, NYT, 16.7.2011,
    http://www.nytimes.com/2011/07/17/opinion/sunday/l17dialogue.html

In Defense of Antidepressants

July 9, 2011
The New York Times
By PETER D. KRAMER

PROVIDENCE, R.I.

IN terms of perception, these are hard times for antidepressants. A number of articles have suggested that the drugs are no more effective than placebos.

Last month brought an especially high-profile debunking. In an essay in The New York Review of Books, Marcia Angell, former editor in chief of The New England Journal of Medicine, favorably entertained the premise that “psychoactive drugs are useless.” Earlier, a USA Today piece about a study done by the psychologist Robert DeRubeis had the headline, “Antidepressant lift may be all in your head,” and shortly after, a Newsweek cover piece discussed research by the psychologist Irving Kirsch arguing that the drugs were no more effective than a placebo.

Could this be true? Could drugs that are ingested by one in 10 Americans each year, drugs that have changed the way that mental illness is treated, really be a hoax, a mistake or a concept gone wrong?

This supposition is worrisome. Antidepressants work — ordinarily well, on a par with other medications doctors prescribe. Yes, certain researchers have questioned their efficacy in particular areas — sometimes, I believe, on the basis of shaky data. And yet, the notion that they aren’t effective in general is influencing treatment.

For instance, not long ago, I received disturbing news: a friend had had a stroke that paralyzed the right side of his body. Hoping to be of use, I searched the Web for a study I vaguely remembered. There it was: a group in France had worked with more than 100 people with the kind of stroke that affected my friend. Along with physiotherapy, half received Prozac, and half a placebo. Members of the Prozac group recovered more of their mobility. Antidepressants are good at treating post-stroke depression and good at preventing it. They also help protect memory. In stroke patients, antidepressants look like a tonic for brain health.

When I learned that my friend was not on antidepressants, I suggested he raise the issue with his neurologists. I e-mailed them the relevant articles. After further consideration, the doctors added the medicines to his regimen of physical therapy.

Surprised that my friend had not been offered a highly effective treatment, I phoned Robert G. Robinson at the University of Iowa’s department of psychiatry, a leading researcher in this field. He said, “Neurologists tell me they don’t use an antidepressant unless a patient is suffering very serious depression. They’re influenced by reports that say that’s all antidepressants are good for.”

Critics raise various concerns, but in my view the serious dispute about antidepressant efficacy has a limited focus. Do they work for the core symptoms (such as despair, low energy and feelings of worthlessness) of isolated episodes of mild or moderate depression? The claim that antidepressants do nothing for this common condition — that they are merely placebos with side effects — is based on studies that have probably received more ink than they deserve.

The most widely publicized debunking research — the basis for the Newsweek and New York Review pieces — is drawn from data submitted to the Food and Drug Administration in the late 1980s and the 1990s by companies seeking approval for new drugs. This research led to its share of scandal when a study in The New England Journal of Medicine found that the trials had been published selectively. Papers showing that antidepressants work had found their way into print; unfavorable findings had not.

In his book “The Emperor’s New Drugs: Exploding the Antidepressant Myth,” Dr. Kirsch, a psychologist at the University of Hull in England, analyzed all the data. He found that while the drugs outperformed the placebos for mild and moderate depression, the benefits were small. The problem with the Kirsch analysis — and none of the major press reports considered this shortcoming — is that the F.D.A. material is ill suited to answer questions about mild depression.

As a condition for drug approval, the F.D.A. requires drug companies to demonstrate a medicine’s efficacy in at least two trials. Trials in which neither the new drug nor an older, established drug is distinguishable from a placebo are deemed “failed” and are disregarded or weighed lightly in the evaluation. Consequently, companies rushing to get medications to market have had an incentive to run quick, sloppy trials.

Often subjects who don’t really have depression are included — and (no surprise) weeks down the road they are not depressed. People may exaggerate their symptoms to get free care or incentive payments offered in trials. Other, perfectly honest subjects participate when they are at their worst and then spontaneously return to their usual, lower, level of depression.

THIS improvement may have nothing to do with faith in dummy pills; it is an artifact of the recruitment process. Still, the recoveries are called “placebo responses,” and in the F.D.A. data they have been steadily on the rise. In some studies, 40 percent of subjects not receiving medication get better.

The problem is so big that entrepreneurs have founded businesses promising to identify genuinely ill research subjects. The companies use video links to screen patients at central locations where (contrary to the practice at centers where trials are run) reviewers have no incentives for enrolling subjects. In early comparisons, off-site raters rejected about 40 percent of subjects who had been accepted locally — on the ground that those subjects did not have severe enough symptoms to qualify for treatment. If this result is typical, many subjects labeled mildly depressed in the F.D.A. data don’t have depression and might well respond to placebos as readily as to antidepressants.

Nonetheless, the F.D.A. mostly gets it right. To simplify a complex matter: there are two sorts of studies that are done on drugs: broad trials and narrow trials. Broad trials, like those done to evaluate new drugs, can be difficult these days, because many antidepressants are available as generics. Who volunteers to take an untested remedy? Research subjects are likely to be an odd bunch.

Narrow studies, done on those with specific disorders, tend to be more reliable. Recruitment of subjects is straightforward; no one’s walking off the street to enter a trial for stroke patients. Narrow studies have identified many specific indications for antidepressants, such as depression in neurological disorders, including multiple sclerosis and epilepsy; depression caused by interferon, a medication used to treat hepatitis and melanoma; and anxiety disorders in children.

New ones regularly emerge. The June issue of Surgery Today features a study in which elderly female cardiac patients who had had emergency operations and were given antidepressants experienced less depression, shorter hospital stays and fewer deaths in the hospital.

Broad studies tend to be most trustworthy when they look at patients with sustained illness. A reliable finding is that antidepressants work for chronic and recurrent mild depression, the condition called dysthymia. More than half of patients on medicine get better, compared to less than a third taking a placebo. (This level of efficacy — far from ideal — is typical across a range of conditions in which antidepressants outperform placebos.) Similarly, even the analyses that doubt the usefulness of antidepressants find that they help with severe depression.

In fact, antidepressants appear to have effects across the depressive spectrum. Scattered studies suggest that antidepressants bolster confidence or diminish emotional vulnerability — for people with depression but also for healthy people. In the depressed, the decrease in what is called neuroticism seems to protect against further episodes. Because neuroticism is not a core symptom of depression, most outcome trials don’t measure this change, but we can see why patients and doctors might consider it beneficial.

Similarly, in rodent and primate trials, antidepressants have broad effects on both healthy animals and animals with conditions that resemble mood disruptions in humans.

One reason the F.D.A. manages to identify useful medicines is that it looks at a range of evidence. It encourages companies to submit “maintenance studies.” In these trials, researchers take patients who are doing well on medication and switch some to dummy pills. If the drugs are acting as placebos, switching should do nothing. In an analysis that looked at maintenance studies for 4,410 patients with a range of severity levels, antidepressants cut the odds of relapse by 70 percent. These results, rarely referenced in the antidepressant-as-placebo literature, hardly suggest that the usefulness of the drugs is all in patients’ heads.

The other round of media articles questioning antidepressants came in response to a seemingly minor study engineered to highlight placebo responses. One effort to mute the placebo effect in drug trials involves using a “washout period” during which all subjects get a dummy pill for up to two weeks. Those who report prompt relief are dropped; the study proceeds with those who remain symptomatic, with half getting the active medication. In light of subject recruitment problems, this approach has obvious appeal.

Dr. DeRubeis, an authority on cognitive behavioral psychotherapy, has argued that the washout method plays down the placebo effect. Last year, Dr. DeRubeis and his colleagues published a highly specific statistical analysis. From a large body of research, they discarded trials that used washouts, as well as those that focused on dysthymia or subtypes of depression. The team deemed only six studies, from over 2,000, suitable for review. An odd collection they were. Only studies using Paxil and imipramine, a medicine introduced in the 1950s, made the cut — and other research had found Paxil to be among the least effective of the new antidepressants. One of the imipramine studies used a very low dose of the drug. The largest study Dr. DeRubeis identified was his own. In 2005, he conducted a trial in which Paxil did slightly better than psychotherapy and significantly better than a placebo — but apparently much of the drug response occurred in sicker patients.

Building an overview around your own research is problematic. Generally, you use your study to build a hypothesis; you then test the theory on fresh data. Critics questioned other aspects of Dr. DeRubeis’s math. In a re-analysis using fewer assumptions, Dr. DeRubeis found that his core result (less effect for healthier patients) now fell just shy of statistical significance. Overall, the medications looked best for very severe depression and had only slight benefits for mild depression — but this study, looking at weak treatments and intentionally maximized placebo effects, could not quite meet the scientific standard for a firm conclusion. And yet, the publication of the no-washout paper produced a new round of news reports that antidepressants were placebos.

In the end, the much heralded overview analyses look to be editorials with numbers attached. The intent, presumably to right the balance between psychotherapy and medication in the treatment of mild depression, may be admirable, but the data bearing on the question is messy.

As for the news media’s uncritical embrace of debunking studies, my guess, based on regular contact with reporters, is that a number of forces are at work. Misdeeds — from hiding study results to paying off doctors — have made Big Pharma an inviting and, frankly, an appropriate target. (It’s a favorite of Dr. Angell’s.) Antidepressants have something like celebrity status; exposing them makes headlines.

It is hard to locate the judicious stance with regard to antidepressants and moderate mood disorder. In my 1993 book, “Listening to Prozac,” I wrote, “To my mind, psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety.” In 2003, in “Against Depression,” I highlighted research that suggested antidepressants influence mood only indirectly. It may be that the drugs are “permissive,” removing roadblocks to self-healing.

That model might predict that in truth the drugs would be more effective in severe disorders. If antidepressants act by usefully perturbing a brain that’s “stuck,” then people who retain some natural resilience would see a lesser benefit. That said, the result that the debunking analyses propose remains implausible: antidepressants help in severe depression, depressive subtypes, chronic minor depression, social unease and a range of conditions modeled in mice and monkeys — but uniquely not in isolated episodes of mild depression in humans.

 

BETTER-DESIGNED research may tell us whether there is a point on the continuum of mood disorder where antidepressants cease to work. If I had to put down my marker now — and effectively, as a practitioner, I do — I’d bet that “stuckness” applies all along the line, that when mildly depressed patients respond to medication, more often than not we’re seeing true drug effects. Still, my approach with mild depression is to begin treatments with psychotherapy. I aim to use drugs sparingly. They have side effects, some of them serious. Antidepressants help with strokes, but surveys also show them to predispose to stroke. But if psychotherapy leads to only slow progress, I will recommend adding medicines. With a higher frequency and stronger potency than what we see in the literature, they seem to help.

My own beliefs aside, it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They’re not. To give the impression that they are is to cause needless suffering.

As for my friend, he had made no progress before his neurologists prescribed antidepressants. Since, he has shown a slow return of motor function. As is true with much that we see in clinical medicine, the cause of this change is unknowable. But antidepressants are a reasonable element in the treatment — because they do seem to make the brain more flexible, and they’ve earned their place in the doctor’s satchel.

 

Peter D. Kramer is a clinical professor of psychiatry at Brown University.

    In Defense of Antidepressants, NYT, 9.7.2011,
    http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html

Preserving Health Coverage for the Poor

July 5, 2011
The New York Times


The poor and disabled people who rely on Medicaid to pay their medical bills could be in grave jeopardy in this sour I’ve-got-mine political climate.

Older Americans, a potent voting bloc, have made clear that they won’t stand for serious changes in Medicare. Medicaid, however, provides health insurance for the most vulnerable, who have far less political clout.

There is no doubt that Medicaid — a joint federal-state program — has to be cut substantially in future decades to help curb federal deficits. For cash-strapped states, program cuts may be necessary right now. But in reducing spending, government needs to ensure any changes will not cause undue harm to millions.

As Medicaid currently works, the federal government sets minimum requirements for eligibility and for services that must be covered; states can expand on services and include more people. The federal government is required to pay from half to three-quarters of the cost, depending on the wealth of a state’s population. In tough economic times, Medicaid enrollments typically soar as government revenues shrink, adding budget woes.

House Republicans led by Paul Ryan want to turn Medicaid into a federal block grant program that would grow slowly and shift more costs to states and patients. Their plan would save $771 billion over a decade. Mr. Ryan also wants to repeal a big expansion of Medicaid required by the health care reforms. All told, he would cut $1.4 trillion over 10 years — roughly a third of the more than $4 trillion in projected federal spending in that period.

President Obama, who would retain the Medicaid expansion, has proposed a cut of $100 billion, less than 2.5 percent of projected federal spending, which would be much more manageable, though a lot will depend on how it is carried out. The great danger in proposing $100 billion in cuts at the start is that Republicans will take that as an opening bid that can be negotiated upward, toward the unreasonable Ryan-level cuts the House has already approved.

The best route to savings — already embodied in the reform law — is to make the health care system more efficient over all so that costs are reduced for Medicaid, Medicare and private insurers as well. Various pilot programs to reduce costs might be speeded up, and a greater effort could be made to rein in malpractice costs.

Congressional Democrats and advocates for the poor are most worried that the administration will use a new “blended rate” for federal matching funds — which would replace a patchwork of matching formulas for poor people and children with a single rate for each state — as a way to lower the federal contribution. This could lead some states to reduce the benefits they offer, seek waivers to cut people from the rolls, or reduce their already low payments to hospitals and other providers.

The deficit-reduction push could also threaten the health care reform law’s aim to have states cover more people under Medicaid starting in 2014 with the help of greatly enhanced federal matching funds. President Obama might be tempted to reduce higher federal contribution rates as part of his $100 billion savings. He must be careful not to trade away his goal of near-universal coverage to burnish his credentials as a deficit-cutter.

    Preserving Health Coverage for the Poor, NYT, 5.7.2011
    http://www.nytimes.com/2011/07/06/opinion/06wed1.html

Study Links Smoking Drug to Cardiovascular Problems

July 4, 2011
The New York Times
By DUFF WILSON

Chantix, the best-selling prescription drug for smoking cessation, was linked to an increased risk of a heart attack, stroke or other serious cardiovascular event for smokers without a history of heart disease compared with smokers who did not use the drug, according to a Canadian medical journal report released on Monday.

The finding added to previous warnings about the pill’s connection to psychiatric problems and cardiovascular risks for people with a history of heart disease.

It posed a new challenge to a product that has been prescribed to 13 million people and had $755 million in sales last year.

Officials of Pfizer, the manufacturer of Chantix, and the Food and Drug Administration responded that they had been planning to conduct a joint analysis of clinical trials on whether Chantix posed heart risks, due next year.

“This would have raised a red flag for us if the flag hadn’t already been flying,” Dr. Celia Winchell, a team leader with the agency’s Center for Drug Evaluation and Research, said in an interview.

Pfizer, in a statement, said the analysis in the Canadian Medical Association Journal was based on too few heart or cardiovascular events to draw conclusions about the risks. The company said Chantix brought “immediate and substantial” health benefits to smokers who quit.

The senior author of the new report, Dr. Curt D. Furberg, a Wake Forest medical professor, said there were better ways to quit and called for removal of the drug from the market.

“It piles up,” he said. “I don’t see how the F.D.A. can leave Chantix on the market.”

The lead author, Dr. Sonal Singh, assistant professor of medicine at Johns Hopkins University, said the agency and Pfizer had failed to pursue signs of cardiovascular risk since Chantix was approved in 2006.

“The F.D.A. should have already put it on their warning label,” Dr. Singh said. “The risk is substantial, the risk is present in smokers without heart disease, and Pfizer knew about this for five years.”

Last month, the agency issued a safety notice about cardiovascular risk from Chantix use by people with a history of cardiovascular disease, based on a study of 700 people.

The new report is broader, analyzing 14 randomized clinical trials involving 8,200 patients, excluding those with cardiovascular disease so that it gives a better picture of which heart problems the drug could cause in otherwise healthy people trying to quit smoking.

The new study, known as a meta-analysis, compiled data from 14 random, blinded, placebo-controlled clinical trials that tracked cardiovascular outcomes. It found 52 out of 4,908 people taking Chantix had serious cardiovascular events, a rate of 1.06 percent, compared with 27 out of 3,308 people taking a placebo, a rate of 0.82 percent. While the absolute difference is only 0.24 percent, the weighted, relative difference is 72 percent.

“We have known for many years that Chantix is one of the most harmful prescription drugs on the U.S. market, based on the number of serious adverse effects reported to the F.D.A.,” Dr. Furberg said in a statement. “It causes loss of consciousness, visual disturbances, suicides, violence, depression and worsening of diabetes. To this list we now can add serious cardiovascular events.”

Dr. Furberg, who once directed clinical trials for the government and writes widely about drug safety, has been paid as an expert witness in cases against Pfizer. Dr. Singh and two other researchers said they had no conflicts of interest.

When combining studies of smokers with and without pre-existing disease, the study found that doctors could expect to get one extra cardiac event associated with Chantix for every 28 smokers they treated with the drug. The researchers also estimated one additional person would quit for every 10 treated with Chantix.

The benefit of Chantix was emphasized in a separate commentary in the journal by Dr. J. Taylor Hays of the Mayo Clinic in Rochester, Minn. He described the meta-analysis as “timely and important” but said it lacked overall size and standardization. Dr. Hays, who has been paid by Pfizer to study Chantix, said the benefits of quitting smoking outweighed the risks of the drug.

Chantix is selling well overseas. In Japan, for instance, some pharmacies ran out for a while recently, even as the drug failed to meet expectations in the United States because of health warnings and bad publicity.

    Study Links Smoking Drug to Cardiovascular Problems, NYT, 4.7.2011,
    http://www.nytimes.com/2011/07/05/business/05smoke.html

Relaxing, Touching the Memory,

Music Helps With the Final Transition

July 3, 2011
The New York Times
By SUZANNE DeCHILLO

Every week, three music therapists from MJHS Hospice and Palliative Care crisscross the city and suburbs to sing songs to the dying. With guitars strapped to their backs, a flute or tambourine and a songbook jammed in their backpacks, they play music for more than 100 patients, in housing projects, in nursing homes and even in a lavish waterfront home. The time for chemotherapy and radiation is over.

The music begins: a song to hold death at bay, a song to embrace death, or to praise God. A Vietnam veteran asks for a song in Vietnamese. One man asked only for songs with death in the lyrics, to force his family to talk to him about the future. He was ready to talk about it. They weren’t. So the therapist sang Queen’s version of “Another One Bites the Dust.” “Amazing Grace” and other spiritual songs are most often requested just before death.

James D. Williams, 85, of Brooklyn, who is dying of cancer, says, “Right now I am on borrowed time.” A therapist, Charla Burton, visits to sing hymns with Mr. Williams and his wife of 61 years, Daphne, 79. “The Lord has kept me and I am very grateful,” Mr. Williams says. “With the backup of my wife. She holds on to me.” Both were born in Belize, and their songs, part of their spiritual practice, have a joyful Caribbean lilt.

In Oceanside, N.Y., Merle Gross, 73, is dying of breast cancer. Sitting beside an ocean inlet, she and Ms. Burton make selections for a songbook she wants to leave behind. If there is time enough, it will include songs for every member of her family, all the people she loved and her dog, Shayna.

And in a Manhattan housing project, a mother cradles her 6-month-old daughter, Cecilia, and Meredith Traver plays a lullaby on her guitar, softly singing the words, “Papa is going to buy you a mockingbird.”

One of the youngest patients in the program, Cecilia Havre, has a genetic defect, Trisomy 18; half those born with this disorder do not survive beyond the first week of life. The baby smiles at her mother, Chantel Vazquez, and her father, Eddie Havre. Cecilia is deaf, but the music soothes her parents. Cecilia is thriving in hospice — or end-of-life — care and may be moved to palliative care, where treatment may be incorporated.

Rose Vuolo, 86, an Alzheimer’s patient on Long Island, has had visits from Ms. Burton for four months.

Rose rarely speaks. “She has gotten progressively worse,” says her grandson, Paul Motisi. “It’s become constant confusion.” Except sometimes when Ms. Burton visits.

Ms. Burton plays the Cole Porter song “Begin the Beguine” — the lyrics of which even Cole Porter said he could not remember without the sheet music. Yet on a good day, Rose sings along, with perfect pitch and range. It was the song she and her husband danced to at their wedding.

Millicent Wilson, 94, who is dying of colon cancer in the Bronx, stopped singing after her husband died and she got sick, says her son, Mark V. Wilson, who stopped working to take care of her. But because of her music therapist, Yelena Zatulovsky, his mother is singing again.

At the end of a song, she asks him, “Mark, why don’t you dance anymore?”

    Relaxing, Touching the Memory, Music Helps With the Final Transition, NYT, 3.7.2011,
    http://www.nytimes.com/2011/07/04/nyregion/music-therapy-helps-the-dying.html

Some With Histories of Mental Illness

Petition to Get Their Gun Rights Back

July 2, 2011
The New York Times
By MICHAEL LUO

PULASKI, Va. — In May 2009, Sam French hit bottom, once again. A relative found him face down in his carport “talking gibberish,” according to court records. He later told medical personnel that he had been conversing with a bear in his backyard and hearing voices. His family figured he had gone off his medication for bipolar disorder, and a judge ordered him involuntarily committed — the fourth time in five years he had been hospitalized by court order.

When Mr. French’s daughter discovered that her father’s commitment meant it was illegal for him to have firearms, she and her husband removed his cache of 15 long guns and three handguns, and kept them after Mr. French was released in January 2010 on a new regime of mood-stabilizing drugs.

Ten months later, he appeared in General District Court — the body that handles small claims and traffic infractions — to ask a judge to restore his gun rights. After a brief hearing, in which Mr. French’s lengthy history of relapses never came up, he walked out with an order reinstating his right to possess firearms.

The next day, Mr. French retrieved his guns.

“The judge didn’t ask me a whole lot,” said Mr. French, now 62. “He just said: ‘How was I doing? Was I taking my medicine like I was supposed to?’ I said, ‘Yes, sir.’ ”

Across the country, states are increasingly allowing people like Mr. French, who lost their firearm rights because of mental illness, to petition to have them restored.

A handful of states have had such restoration laws on their books for some time, but with little notice, more than 20 states have passed similar measures since 2008. This surge can be traced to a law passed by Congress after the 2007 massacre at Virginia Tech that was actually meant to make it harder for people with mental illness to get guns.

As a condition of its support for the measure, the National Rifle Association extracted a concession: the inclusion of a mechanism for restoring firearms rights to those who lost them for mental health reasons.

The intent of these state laws is to enable people to regain the right to buy and possess firearms if it is determined that they are not a threat to public safety. But an examination of restoration procedures across the country, along with dozens of cases, shows that the process for making that determination is governed in many places by vague standards and few specific requirements.

States have mostly entrusted these decisions to judges, who are often ill-equipped to conduct investigations from the bench. Many seemed willing to simply give petitioners the benefit of the doubt. The results often seem haphazard.

At least a few hundred people with histories of mental health issues already get their gun rights back each year. The number promises to grow, since most of the new state laws are just beginning to take effect. And in November, the Department of Veterans Affairs responded to the federal legislation by establishing a rights restoration process for more than 100,000 veterans who have lost their gun privileges after being designated mentally incompetent by the agency.

The issue goes to the heart of the nation’s complicated relationship with guns, testing the delicate balance between the need to safeguard the public and the dictates of what the Supreme Court has proclaimed to be a fundamental constitutional right.

Mike Fleenor, the commonwealth’s attorney here in Pulaski County, whose office opposed restoring Mr. French’s rights, worries that the balance is being thrown off by weak standards.

“I think that reasonable people can disagree about issues of the Second Amendment and gun control and things like that, but I don’t believe that any reasonable person believes that a mentally ill person needs a firearm,” Mr. Fleenor said. “The public has a right to be safe in their community.”

In case after case examined by The New York Times, judges made decisions without important information about an applicant’s mental health.

Larry Lamb, a Vietnam veteran from San Diego who has suffered from depression and post-traumatic stress disorder, lost his gun rights and his cache of weapons in 2006 when he was involuntarily hospitalized after his dog’s death left him suicidal. A psychiatrist who examined Mr. Lamb wrote that he “is extremely paranoid with a full-blown P.T.S.D., believing that he is still at war in the active military and he is a personal bodyguard of the president and many senators.”

In early 2008, a Superior Court judge in San Diego granted Mr. Lamb’s petition to have his firearms rights restored, after his psychologist testified that he was not dangerous. But the judge, without access to Mr. Lamb’s full medical history, was unaware of a crucial fact: the local Veterans Affairs hospital had placed a “red flag” on Mr. Lamb, barring him from the hospital grounds because he was perceived to be a threat to personnel there.

The spread of these restoration laws is especially striking against the backdrop of the shooting of Representative Gabrielle Giffords of Arizona and others in Tucson early this year by a suspect who has been declared mentally incompetent to stand trial — a case that spotlighted anew the link between mental illness and violence.

Supporters of gun rights and mental health advocates point out that a vast majority of people with mental illness are not violent. At the same time, though, a variety of studies have found that people with serious mental illness are more prone to violence than the general population.

The difficulty of assessing risk emerges in places like Los Angeles, where the Superior Court conducts a relatively thorough review of firearms rights requests. The Times found multiple instances over the last decade in which people who won back their gun rights went on to be charged with or convicted of violent or gun-related crimes, including spousal battery, negligent discharge of a firearm or assault with a firearm.

Then there are the nightmare cases — like that of Ryan Anthony, 35, a former Emmy Award-winning animator at Disney who was involuntarily hospitalized in mid-2001 after losing his job and separating from his wife. Mr. Anthony filed a petition to get back his gun rights in early 2002, telling a court-appointed psychiatrist that he wanted to go skeet shooting.

A few weeks after the court granted his petition, Mr. Anthony bought a Remington 870 12-gauge shotgun, holed up in a Holiday Inn in Burbank, Calif., and committed suicide.

 

An N.R.A. Victory

The galvanizing revelation for gun-control advocates after the Virginia Tech massacre, the worst mass shooting in American history, was that the gunman, Seung-Hui Cho, should never have been able to buy the guns he used in the rampage.

Two years earlier, a special justice declared Mr. Cho “an imminent danger to himself as a result of mental illness” and ordered him to outpatient treatment.

Under federal law, anyone involuntarily committed or adjudicated a “mental defective” is barred from buying or possessing firearms. But the prohibition is often toothless because many states do not share their mental health records with the F.B.I.’s National Instant Criminal Background Check System.

Mr. Cho’s case offered Representative Carolyn McCarthy, Democrat of New York, a chance to advance a stalled bill that she had sponsored several years earlier to improve reporting by states to the F.B.I. database.

Ms. McCarthy’s political career and commitment to gun control was born out of tragedy. In 1993, a deranged gunman opened fire on a commuter train on Long Island, killing six people, including her husband, and gravely injuring her son. After more than a decade working on the issue in Congress, however, she had little to show for it.

Ms. McCarthy said she was wiser after years of setbacks. “I don’t believe in introducing legislation that won’t go anywhere,” she said.

She joined forces with Representative John D. Dingell, a Michigan Democrat and former N.R.A. board member, who acted as a liaison with the gun lobby. The N.R.A. had long been interested in gun-rights restoration. It also wanted to help tens of thousands of veterans who lost their rights after being designated mentally incompetent and unable to handle their finances by the Department of Veterans Affairs.

“We don’t want to treat our soldiers as potential criminals because they’re struggling with the aftermath of dealing with their service,” said Chris Cox, the association’s chief lobbyist.

The gun lobby secured a broad provision in the legislation. The new law made money available to states to help improve their record sharing, but the provision pushed by the N.R.A. made it a prerequisite for states to establish a “relief from disability” program for people with histories of mental health issues to apply for the restoration of gun rights. The Veterans Affairs Department and other federal agencies were required to do the same.

Gun-control groups attacked the provisions. “You make one bad judgment, and you could have another Virginia Tech on your hands,” Kristen Rand, legislative director for the Violence Policy Center, said in an interview.

But the most prominent gun-control organization, the Brady Campaign to Prevent Gun Violence, ultimately supported the bill. “She felt if she didn’t do this, it wasn’t going to proceed,” Paul Helmke, the group’s president, said of Ms. McCarthy. “An imperfect bill is better than no bill.”

Ms. McCarthy said her background as a nurse made her amenable to restoring someone’s rights, “if they could prove they are no longer mentally ill.”

After the bill became law in 2008, the N.R.A. began lobbying state lawmakers to keep requirements for petitioners to a minimum.

In Idaho, for example, a committee of law enforcement and mental health officials proposed requiring courts to make findings by “clear and convincing” evidence and mandating that petitioners have a recent mental health evaluation. But without the N.R.A.’s imprimatur, the legislation went nowhere.

Instead, a Republican state representative, Raúl R. Labrador, who is now a congressman, worked with the N.R.A. to draft a bill, passed last year, that dropped the requirement for a mental health evaluation and lowered the standard of proof to a “preponderance of evidence.”

A few states have set stricter standards. In New York, decisions are made by mental health officials, and applicants must submit a long list of documents, including five years’ worth of medical records and records of psychiatric and substance abuse treatment going back 20 years. State officials can also require applicants to undergo clinical evaluations and risk assessments.

So far, there has been only a trickle of petitions in states with new restoration laws. The statutes are not yet well known, and federal authorities have yet to certify many of the state programs, making them fully operational under federal law.

But the demand will almost certainly grow, given the experience of states with longer-standing restoration statutes. In California, for instance, judges restored gun rights to 180 people in 2010. At the federal level, the Veterans Affairs Department has already received more than 100 applications, of which 12 were processed and one was granted.

As for the original aim of Ms. McCarthy’s legislation, the reporting of mental health records by states to the F.B.I. database remains woeful. The reasons vary, including privacy laws, technological challenges and inattention from state officials.

But one significant hurdle has been that only a handful of states have received the federal money to improve their reporting capabilities. Officials with the Bureau of Justice Statistics indicated that while 22 states applied for grants in 2009 and 2010, only nine have gotten financing. Most of those that did not receive grants were rejected because they did not have certified restoration programs in place.

 

One State’s Experience

Lawmakers in Virginia, the scene of Mr. Cho’s rampage, were among the first to respond to the federal legislation by amending the state’s existing restoration statute to reflect the new law. To restore firearms rights, judges must find that the petitioner “will not likely act in a manner dangerous to public safety” and that “the granting of the relief would not be contrary to the public interest.” There are few specific standards or guidelines beyond that.

In 2010, judges in Virginia considered roughly 40 restoration applications and granted firearms rights under state law to 25 people — 14 who had been involuntarily committed, and 11 who had been the subjects of temporary detention orders and were voluntarily admitted for mental health treatment, according to figures from the Virginia Supreme Court and the State Police. In 2009, the courts restored rights to 21 people.

There is no central repository for cases heard around Virginia, but to get a picture of how the process works in one state, The Times obtained dozens of petitions and judges’ orders, mainly from 2009 and 2010, along with supporting documentation, and interviewed petitioners, lawyers and judges. The hearings were often relatively brief, sometimes perfunctory, and judges had wide latitude in handling the petitions.

Teresa Hall, who had moved to Idaho, said she simply wrote a letter to Hampton General District Court explaining that her commitment several years earlier occurred when she was experiencing marital difficulties. To her shock, she got a judge’s order granting her petition several days later in the mail.

“I was surprised it was that easy,” Ms. Hall said.

Some judges insisted on seeing a doctor’s note, but others did not.

In a typical case, Joshua St. Clair, who served in Iraq with the National Guard, got his gun rights back last year. About six months earlier, Mr. St. Clair, now 22, had heard a rattling at his gate. He said he “kind of blacked out” and the next thing he knew, he was pointing his M-4 assault rifle at his friend’s chest. That led to a temporary detention order, treatment for post-traumatic stress disorder and loss of his firearms rights.

He took a note from his psychiatrist to his restoration hearing, which he said “lasted maybe about five minutes,” but he said the judge did not even ask to see it. The judge asked Mr. St. Clair’s father a few questions and asked Mr. St. Clair himself whether he thought he should have his rights restored. He said, “Of course.”

Often the doctors’ recommendations came from general practitioners, not mental health professionals. The notes tended to be short, often just a few sentences.

In many cases, the hospitalizations occurred just a few months, or even weeks, earlier.

Bobby Bullion, 37, got his gun rights back about four months after he left a note for his wife and son that indicated he was considering suicide — his wife had told him she was divorcing him — and the police found him in his car with two loaded weapons. Mr. Bullion presented the judge with a letter from his psychiatrist endorsing the restoration.

Oran Greenway, 68, had his rights restored in August, just two months after he was involuntarily committed. The judge’s restoration shocked Mr. Greenway’s relatives, who said they had been worried for years about his mental stability. In an interview, he said he started taking Lexapro for depression several years ago. In 2005, he slammed a large branch on a neighbor’s head during an argument, resulting in a conviction for assault and battery.

“Knowing what I know about Oran, I wouldn’t let Oran have a gun,” said Elizabeth Dequino, a cousin who lives up the road.

Even when a court-ordered commitment occurred years ago, the wisdom of restoring certain petitioners’ firearms rights was open to question. David Neal Moon, 63, was involuntarily committed in 1995 after his struggles with schizoaffective bipolar disorder got so bad that he had threatened to commit suicide and was walking in circles around his house with a MAK-90 assault rifle, as if on guard duty, according to medical and court records and an interview with Cynthia Allison, who is now his ex-wife.

A psychiatrist’s report described him threatening to “bash in the face of his wife” and ranting about getting his guns so he could “shoot everybody.” It also mentions a violent hair-pulling episode with his wife.

He had not been committed since, but he had continued to struggle with his illness and was bad about taking his medication, Ms. Allison said.

In an interview, Mr. Moon insisted he took his medication and was not mentally ill. Yet he alluded to his phone being tapped by the State Police and “by maybe the Pentagon.”

His firearms hearing in early 2009 in Amherst General District Court, where Mr. Moon showed up in military camouflage, lasted “about eight minutes,” said Mr. Moon’s lawyer, Gregory Smith, adding that he did not recall presenting any recent medical evaluation.

Just over a month later, another judge granted Ms. Allison a protective order against her husband. The pair had split up, and Mr. Moon had been making veiled threats by phone and telling his children about demons in the walls, according to her court affidavit.

“The judge just sat there and listened to him talk,” Ms. Allison said. “I didn’t even say anything. If you listened to him talk, you could tell he’s as crazy as a bedbug.”

Among those whose applications were denied, many were turned down for technical reasons, like filing in the wrong jurisdiction or failing to show up for a hearing.

In others cases — like one last year in Lynchburg in which the petitioner, Undreas Smith, submitted a letter explaining he had been struggling with recent deaths in his family — the judge ruled against the petitioner because he failed to provide documentation from a mental health provider.

In the case of James Tuckson Jr. of Harrisonburg, who was involuntarily committed in 2006 and applied in October to get back his gun rights, prosecutors said his multiple arrests probably played a significant role in the judge’s decision to deny Mr. Tuckson’s petition.

Presented with The Times’s findings, Richard Bonnie, the chairman of the Virginia Commission on Mental Health Law Reform, which was formed after the Virginia Tech shootings, expressed concerns about the restoration process, particularly the vagueness of the statute. Mr. Bonnie said the panel would begin collecting information on the petitions on a monthly basis to better evaluate how they were being handled.

“There is an ambiguity in the statute that we need to look at,” he said.

 

‘A Hole in the Process’

When Sam French, the man with bipolar disorder whose daughter removed his guns, appeared late last year in Pulaski General District Court, he presented his recent medical records. Progress notes over several months showed that his bipolar disorder and substance abuse were in “remission.”

Nevertheless, Bobby Lilly, an assistant commonwealth’s attorney, opposed the petition, partly because Mr. French’s latest update indicated he had expressed interest in lowering the dosage of his medication. Mr. French’s two most recent hospitalizations had come after he went off his medication.

Mr. Lilly was also worried because it had been less than a year since his release. “We didn’t have a demonstrated track record of being able to comply with whatever the mental health provider’s directives were,” Mr. Lilly said.

In fact, a few months later, in March, a judge at the circuit level — the higher court in Virginia — denied Mr. French’s application for a concealed weapons permit because a five-year wait after a psychiatric commitment is required for such a permit.

But there is no waiting period for the restoration of basic gun rights.

Mr. French’s case fell to Judge Royce Glenwood Lookabill, a genial presence on the bench since 2006. Judge Lookabill said he quizzed Mr. French about whether he had had any other episodes and whether he was taking his prescribed drugs.

“I was satisfied that he wasn’t a danger — again, subject to him taking his medication,” Judge Lookabill said in an interview.

The judge acknowledged, however, that he might have made a different decision had he been aware of Mr. French’s previous commitments, including one that came after he was arrested for public drunkenness and later allegedly assaulted two police officers. (The assault charges were dropped.) No one had checked a state database for his commitment history.

“It’s a hole in the process,” said Mr. Lilly, who added that his office had only limited access to such information.

Judge Lookabill suggested that the process belonged in a higher court and should be made more adversarial. “I would feel a lot more comfortable,” he said, “if there were more safeguards.”

 

An Increased Risk

Most people with mental health issues, of course, will never be violent. But there is widespread consensus among scientists that the increased risk of violence among those with a serious mental illness — schizophrenia, major depression or bipolar disorder — is statistically significant. That risk rises when substance abuse, which is more prevalent among people with mental illness, is also present.

One frequently cited study, led by Jeffrey W. Swanson, an expert on mental health and violence who is now at Duke University, showed that 33 percent of people with a serious mental illness reported past violent behavior, compared with 15 percent of people without a major mental disorder. Violent behavior was defined as including acts ranging from taking part in more than one fistfight as an adult to using a weapon in a fight. The rate for those with substance abuse issues but without a serious mental illness was 55 percent. The highest rate, 64 percent, was exhibited by people with major mental disorders and substance abuse issues.

Other studies have concluded that additional factors significantly increase the risk of violence among people with mental illness, including exposure to violence and being a victim of violence.

But taking these data and applying them to individuals is profoundly difficult.

Scientists have concluded that it is most accurate to augment clinical judgments with an “actuarial” approach, in which variables like psychiatric diagnosis, history of violence and anger control are plugged into a risk assessment model. The models categorize people into higher and lower risk groups. But many clinicians are unfamiliar with the technique. Indeed, none of the doctors who wrote letters on behalf of their patients in cases The Times reviewed appeared to utilize the approach.

Doctors’ declarations clearly influenced judges. But most wrote their letters at the request of their patients, which Randy Otto, a former president of the American Board of Forensic Psychology and an associate professor at the University of South Florida, said can be problematic.

“They’re more subject to pressure from their patients to offer opinions that will help the patients get what they want,” Dr. Otto said.

He said many doctors, particularly those not in the mental health field, are probably not steeped in the most important clues to future violence. Even psychologists and psychiatrists, relying on their clinical judgment alone, are extremely unreliable in predicting violence, studies have shown.

“Unstructured clinical judgments, just judgments of mental health professionals about how risky someone is,” Dr. Otto said, “are probably the least reliable and the least accurate.”

 

Weighing the Threats

The difficulties of predicting violence are particularly striking in Los Angeles County, where the Superior Court has a relatively rigorous process for determining whether to restore gun rights.

In California, anyone placed on a 72-hour or 14-day psychiatric hold and determined to be a danger to themselves or others loses gun rights for five years. But upon discharge, the person can apply to have these prohibitions lifted. Applicants in Los Angeles County are required to provide records from all involuntary hospitalizations, which are checked against a list provided by the State Department of Justice. They must also be examined by a court-appointed psychiatrist, who can call friends or relatives to gather more information.

Under the statute, the burden is on the district attorney to establish that the petitioner “would not be likely to use firearms in a safe and lawful manner.”

Over all, 1,579 petitions have been filed in Los Angeles Superior Court since 2000. More than 1,000 were dismissed, usually because applicants did not furnish the required documentation or failed to show up. Of those who actually got hearings, 381 won their cases.

“Dealing with somebody who suffers from severe mental illness and mixing that with firearms, you really have to cross the t’s and dot the i’s,” said Richard J. Vagnozzi, a deputy district attorney who handles these cases. Mr. Vagnozzi said the process “isn’t perfect, but we do the best we can with the available data and what we’re allowed to do.”

Even with the vigorous checks, there are people like Afshin Poordavoud, who lost his gun rights in June 2000. During a heated argument with his brother, Mr. Poordavoud threatened to shoot himself. His brother called the police, and Mr. Poordavoud was hospitalized briefly, according to court records.

Several months later, Mr. Poordavoud petitioned to have his firearms rights restored and to have the police return his shotgun and 9-millimeter semiautomatic handgun. A court-appointed psychiatrist recommended that the decision be put off for three months and that Mr. Poordavoud get a full psychiatric evaluation and treatment, pointing out that the hospital had found him to be “likely depressed and minimizing his level of depression and suicidal risk.”

Mr. Poordavoud returned to court three months later with a letter from a therapist, indicating he had been undergoing treatment. This time, a different psychiatrist examined him but wrote at the end of his report, “Inconclusive: I have no opinion.” The psychiatrist suggested that the case be referred back to the initial doctor so she could interview Mr. Poordavoud’s therapist and obtain the full file from his hospitalization.

The judge, however, granted Mr. Poordavoud’s restoration request that same day in a pro forma hearing.

In late 2004, Mr. Poordavoud drove up to a house in Chatsworth, Calif., in the middle of the night and began banging on the windows and the doors, shouting for an acquaintance to come out, according to court testimony.

When a man opened the door, Mr. Poordavoud sprayed him and two others with mace, according to court testimony. In the ensuing fight, Mr. Poordavoud slashed at one of them with a pair of brass knuckles fitted with blades.

Mr. Poordavoud retrieved a gun from his car and fired a single shot that missed. In an interview, he said he had only fired in the air in self-defense.

The police eventually charged Mr. Poordavoud with multiple felonies. He pleaded guilty to assault with a deadly weapon and using tear gas not in self-defense, and he was sentenced to about a year in county jail.

“I had an anger problem,” said Mr. Poordavoud, who is no longer allowed to have guns because of his felony record. “I still have an anger problem.”

Violence against others is not the only concern.

Ryan Anthony, the talented but troubled Disney artist who had a history of alcoholism, had talked about suicide for years with relatives. His father, Michael Anthony, said his son once threatened to jump off a highway overpass; another time, he vowed to hang himself from a chandelier in his home. A few months before he filed his petition to restore his firearms rights, he had attempted suicide by swallowing some pills, said his brother Loren.

But Mr. Anthony was able to hide his troubled past when a court-appointed psychiatrist examined him for the restoration hearing in April 2002. He told Dr. Rose Pitt, according to court records, that he had simply been going through a difficult period after he lost his job and split up with his wife. He was normally not a drinker, he said, but began drinking heavily. Since his involuntary hospitalization in mid-2001, he had been sober and attending Alcoholics Anonymous meetings, Dr. Pitt wrote in her report.

“Does not own guns but wants to skeet shoot, and so wants to purchase guns,” Dr. Pitt wrote. “There does not appear to be any contraindication to his being able to get guns.”

His relatives were incredulous. Had they been called, they said, they would have told officials to deny his request.

“I would have said, ‘No, that doesn’t sound right,’ ” Loren Anthony said. “He didn’t like guns.”

Mr. Anthony had been staying with Steven and Sofia Shafit, family friends. They said he had been doing better but was still hurting.

About two weeks after he got his firearms rights restored, he borrowed $300 from Ms. Shafit, saying he wanted to take a girl on a date. Instead, he went out and bought a shotgun — investigators found the receipt by his body — and checked into a room at a Holiday Inn.

On the desk, he left a three-page suicide note, according to a report from the Los Angeles County coroner’s office. At some point, he lay down on the bed, placed the barrel of the shotgun in his mouth and pulled the trigger.

Toby Lyles, Lisa Schwartz and Jack Styczynski contributed research.

    Some With Histories of Mental Illness Petition to Get Their Gun Rights Back, NYT, 2.7.2011,
    http://www.nytimes.com/2011/07/03/us/03guns.html

How Budget Cuts Affect the Mentally Ill

June 24, 2011
The New York Times


To the Editor:

“A Schizophrenic, a Slain Worker, Troubling Questions” (front page, June 17):

The story of Deshawn James Chappell, a man with schizophrenia accused of killing one of his caregivers, is a tragedy that could have been prevented if Mr. Chappell had been receiving the proper treatment. However, only a very small percentage of people who live with schizophrenia ever become violent, and then it is usually when the treatment system fails them and they discontinue their medications.

Our mental health care system, which is reeling from repeated state, county and federal budget cuts, is simply too overwhelmed to provide all of the compassionate and quality treatment that patients need. It is imperative that we as a society prioritize the treatment of psychiatric disorders to align with the high prevalence of these disabling conditions.

Doing so would ultimately cost less than warehousing and treating people in jails and prisons, where those with mental illnesses all too often end up.

JOHN OLDHAM
President
American Psychiatric Association
Arlington, Va., June 20, 2011

To the Editor:

The violence against social workers has become a risk of the profession, and one that needs to be addressed nationally. Social workers are frequently sent to dangerous situations, alone and unarmed, in neighborhoods that the police do not enter without a partner and a gun. We lack legislation at the federal level to protect social workers, and despite advocacy efforts, the Teri Zenner Social Worker Safety Act has yet to become law.

Detailed safety training for social workers who make home visits is desperately needed. The day before Stephanie Moulton was murdered in Massachusetts, another social worker, Frances Mortenson, was stabbed by a client during a home visit in New York.

Stephanie Moulton’s death provokes questions about the value we as a society place on social workers’ lives.

SHERRY SATURNO
Valhalla, N.Y., June 17, 2011

The writer is a social worker.

To the Editor:

When politicians try to balance serious budget problems on the most vulnerable among us, we all pay the consequences. The mentally ill may not have the influence of the wealthy or the cachet of popular programs, but they most certainly need comprehensive, decent care.

The victims in this horribly sad story include not only the dedicated social worker but also the alleged killer and his family. We have let all parties down by not acknowledging the true cost of caring for our mentally ill to ensure that they and their caregivers are safe and protected.

EDWIN ANDREWS
MARILYN ANDREWS
Malden, Mass., June 18, 2011

To the Editor:

Like most states, New York is cutting mental health services because of its budget shortfall. Yet even under these difficult circumstances, we have an opportunity to do better — for people with mental illness, their families and the people charged with their care.

As part of a restructuring of its Medicaid program, New York will move adults with serious mental illness and children with serious emotional disturbance from a fee-for-service to a managed care environment. In other states such as Pennsylvania, this model is showing positive outcomes for enrollees as well as cost savings, as behavioral health organizations partner with government to manage the care of people with complex needs and high health and mental health care costs.

At the same time, a generous federal match to establish health homes (a team of providers responsible for a patient’s care) and better coordinate care of people with serious mental illness is available through the Affordable Care Act.

If it seizes these opportunities, New York has the chance to actively engage mental health consumers and their families in treatment, and integrate mental health and health care more successfully. In such a scenario, tragedies like the one you describe might be avoided.

WENDY BRENNAN
Executive Director
The National Alliance on Mental
Illness of New York City
New York, June 17, 2011

    How Budget Cuts Affect the Mentally Ill, NYT, 24.6.2011, http://www.nytimes.com/2011/06/25/opinion/l25mental.html

Chemical Suicides, Popular in Japan,

Are Increasing in the U.S.

June 18, 2011
The New York Times
By ERICA GOODE

In Japan it is known as detergent suicide, a near-instant death achieved by mixing common household chemicals into a poisonous cloud of gas.

By some counts, more than 2,000 people there have taken their own lives, inhaling the gas — in most cases hydrogen sulfide — in cars, closets or other enclosed spaces. The police now say they are seeing an increasing number of similar suicides in the United States, inspired by Web sites that carry recipes for the chemical mix as well as detailed instructions on how to use it.

And as in Japan, where the suicides have caused whole neighborhoods to be evacuated and sent dozens of people to the hospital, the desperate and despondent are not the only victims.

Of 72 chemical suicides experts have documented in the United States since 2008, at least 80 percent have resulted in injuries to police officers, firefighters, emergency workers or civilians exposed to the gas, despite the efforts of suicide victims to protect others by putting warning signs on car windows or closet doors, said Deputy Chief Jacob Oreshan of the New York State Office of Fire Prevention and Control, who has been tracking the cases.

Last year there were 36 chemical suicides in the United States. Since Jan. 1, there have been at least 27, indicating that the incidence is rising, Chief Oreshan said. Those numbers, however, still represent a tiny fraction of the 34,000 or so suicides reported each year.

The injuries to first responders have so far been minor. But in some cases where police officers have opened car doors or broken car windows without protective equipment, the gas “is knocking them right to the ground,” Chief Oreshan said. To avoid exposure, rescuers cannot reach the victim until the hazard is cleared, a process that can take hours.

And that, said Michael Cerone, the police chief in Irvington, N.Y., is “heart wrenching.”

“You want to help,” he said. “You want to get in there.”

On March 28, Chief Cerone went to investigate a report of a person slumped inside a Jeep Liberty parked on a deserted dirt road. A sign on the window warned against breaking the glass and urged rescuers to call a hazardous materials team, he said. The bomb squad was summoned, and a robot was sent to breach the car’s rear window. Houses in the neighborhood were evacuated.

At that moment, a few miles away, Dr. Stephen Kelly, a family practice physician, was at the police station in Irvington waiting to file a missing person report on his 24-year-old son, John. As he stood there, a dispatcher on the police radio described the car and the body found inside and Dr. Kelly knew immediately what had happened.

He and his wife, Janet, a nurse, had spent hours that afternoon in an increasingly frantic search for their son, who had suffered since childhood from a severe form of obsessive-compulsive disorder and depression and had been hospitalized in December after a suicide attempt. Dr. Kelly had quit his practice to stay home and try to help John overcome his depression.

Despite John’s illness, he had graduated from college with a degree in psychology and was working at a nearby psychiatric hospital.

“He didn’t let people know,” his mother said. “He was always counseling others.”

Other suicides have followed a similar pattern. On May 23, a 23-year-old woman died in her car in the Hollywood Hills neighborhood of Los Angeles, after mixing up the recipe and placing signs on the window saying “Danger! Chemicals Inside! Call 911.”

She had made a suicide pact with a man who changed his mind at the last minute and left the car, the police said. In a suicide in Baldwin, Mich., on Jan. 8, emergency workers were taken to the hospital after a firefighter moved a canister in the car of a suicide victim, causing the gas to be re-released. And in Massachusetts, an elderly woman was sickened when the toxic fumes leaked through her ceiling from an upstairs apartment.

“Suicide is generally intended for one victim,” said Richard Perrin, under sheriff of the Lake County Sheriff’s Department, who was at the scene of the suicide in Michigan. “Whereas this form of suicide has the potential to affect many, whether it be intended or unintended, and that’s what makes it so dangerous.”

Under Sheriff Perrin is one of about 50 police and fire officials who are part of a nationwide working group organized by Chief Oreshan to educate first responders about the suicides.

In Japan, Web sites advertised the chemical suicide method as a way to “die easily and beautifully,” according to one 2008 news report. After the number of people affected by detergent suicides reached alarming proportions — in the central city of Konan, a 14-year-old girl’s suicide sickened 90 of her neighbors in 2008; in Otaru, 350 people were evacuated after a 24-year-old man’s suicide — government officials tried to persuade Internet sites to remove the recipes.

But the proliferation of the sites has proved difficult to control, and instructions remain readily available, in some cases provided by visitors to suicide forums in answer to pleas from desperate people.

“In my last post I told my story,” one forum participant with the user name “Death” wrote under the headline “researching reliable ways to go.” “I am now here to ask if anyone can put a link to the Japanese detergent suicide recipe.”

Hydrogen sulfide is a colorless gas that smells strongly of rotten eggs and is produced naturally by the decomposition of organic matter. Deaths from it most commonly occur from accidental exposures in mineshafts or sewers. The gas dissipates quickly, but if inhaled at high concentrations it can cause convulsions, coma and a rapid death.

“You definitely don’t take any chances, because literally one breath will kill you,” said Dr. Kurt Kleinschmidt, chief of medical toxicology at the University of Texas Southwestern Medical School, who has been following the suicides.

Dr. Kleinschmidt said the lethality of the method left no room for ambivalence or second thoughts.

John Kelly, the young man who died in Irvington, seemed determined not to be deterred. In the months before his suicide, he had told his parents that he felt increasingly trapped by his obsessions. His world was shrinking, he said.

In a journal entry written a few days before he died, he wrote about his struggles with his disorder: “Need to up the ante, apply the skills. Putting in the work. Gotta put in the effort. There’s no shortcut.”

He noted that he should “look into yoga” and reminded himself that if he felt suicidal he should “take a Klonipin, go to the gym, call a suicide hot line.”

The morning of March 28, Dr. Kelly said, he and his wife talked to John about plans for him to go to McLean Hospital in Boston for further treatment.

“Does that give you hope?” his father asked him. He said it did.

This article has been revised to reflect the following correction:

Correction: June 18, 2011

An earlier version of this article contained an incorrect given name for John Kelly's father. He is Dr. Stephen Kelly, not Michael.

    Chemical Suicides, Popular in Japan, Are Increasing in the U.S., R, 18.6.2011,
    http://www.nytimes.com/2011/06/19/us/19chemical.html

Cancer death rates continue drop: report

CHICAGO | Fri Jun 17, 2011
1:06am EDT
Reuters
By Julie Steenhuysen

CHICAGO (Reuters) - U.S. cancer death rates are continuing to fall, but not all segments of the population are benefiting, the American Cancer Society said Friday.

Overall, the group predicts 1,596,670 new cancer cases in the United States and 571,950 deaths in 2011.

Death rates for all cancer types fell by 1.9 percent a year from 2001 to 2007 in men and by 1.5 percent a year in women from 2002 through 2007.

Steady overall declines in cancer death rates have meant about 898,000 who would have died prematurely from cancer in the past 17 years did not, the organization said.

Americans with the least education are more than twice as likely to die from cancer as those with the most education, according to the group's annual cancer report.

Death rates for all cancer types have fallen in all racial and ethnic groups among both men and women since 1998 with the exception of American Indian/Alaska Native women, among whom rates were stable.

Black and Hispanic men have had the largest annual decreases in cancer death rates since 1998, falling by 2.6 percent among blacks and 2.5 percent among Hispanics.

New cases of lung cancer among women fell after rising steadily since the 1930s. The decline comes more than a decade after lung cancer rates in men started dropping and reflects differences in smoking trends among U.S. men and women, who took up smoking later in the last century than men.

Lung cancer is expected to account for 26 percent of all cancer deaths among women in 2011 and remains the No. 1 cancer killer of both men and women in the United States.

Breast cancer comes in No. 2 for women. Prostate cancer is the second most common killer of men, and colon cancer is the third-leading cause of cancer deaths for both sexes.

These four cancers account for almost half the total cancer deaths among men and women.

Cancer rates vary considerably among racial and ethnic groups. For all cancer types, black men have a 14 percent higher rate of new cases and a 33 percent higher death rate than white men, while black women have a 6 percent lower rate of new cancer cases and a 17 percent higher death rate than white women.

The report found cancer rates in the least educated were 2.6 times higher than in the most educated. This was most pronounced in lung cancer, reflecting higher smoking rates among those with less education.

Thirty-one percent of men with 12 or fewer years of education are smokers, compared with 12 percent of college graduates and 5 percent of men with advanced degrees.

 

(Editing by Todd Eastham)

    Cancer death rates continue drop: report, R, 17.6.2011,
    http://www.reuters.com/article/2011/06/17/us-usa-cancer-idUSTRE75G0NU20110617

Factbox: Latest U.S. cancer statistics

Fri Jun 17, 2011
1:03am EDT
Reuters

(Reuters) - About 1,6 million Americans will be diagnosed with cancer in 2011 and 571,950 will die of cancer, more than 1,500 people a day, according to the American Cancer Society's latest report on cancer.

Cancer is the second most common cause of death in the United States after heart disease, accounting for 1 in every 4 deaths.

Here are the latest American Cancer Society statistics on cancer in the United States:

* Lung cancer -- An estimated 221,130 Americas will be diagnosed with lung cancer in 2011, accounting for about 14 percent of all cancer cases. Lung cancer rates have been falling steadily among men, and have just begun falling among women. An estimated 156,940 men and women will die from lung cancer in 2011, accounting for about 27 percent of all cancer deaths expected in 2011.

* Breast cancer - An estimated 230,480 women and 2,140 men will get breast cancer in 2011. Excluding skin cancers, breast cancer is the most frequently diagnosed cancer in women. Some 39,520 women and 450 men will die from breast cancer in 2011. Breast cancer is the second leading cause of death among women behind lung cancer.

* Prostate cancer -- An estimated 240,890 U.S. men will be diagnosed with prostate cancer in 2011. Prostate cancer is the most frequently diagnosed cancer in men, and far more black men than white men develop this cancer, although it is not clear why. An estimated 33,720 U.S. men will die from prostate cancer in 2011, making prostate cancer the second-leading cause of cancer death in men behind lung cancer.

* Childhood cancer -- Some 11,210 children aged 14 years and under will develop cancer in 2011. These cancers are rare, representing less than 1 percent of all new cases of cancer. But childhood cancer has been climbing at a rate of 0.6 percent per year since 1975. An estimated 1,320 children are expected to die from cancer in 2011.

 

Source: The American Cancer Society

(Reporting by Julie Steenhuysen in Chicago; Editing by Todd Eastham)

    Factbox: Latest U.S. cancer statistics, R, 17.3.2011,
    http://www.reuters.com/article/2011/06/17/us-factbox-cancer-idUSTRE75G0PL20110617

A Schizophrenic, a Slain Worker, Troubling Questions

June 16, 2011
The New York Times
By DEBORAH SONTAG

BOSTON — Last November, Yvette Chappell found herself increasingly anxious that her 27-year-old son, Deshawn James Chappell, was spiraling downward into deep psychosis. He was exhibiting intense paranoia and calling late at night to complain about deafening voices in his head.

For over a year, Mr. Chappell, a schizophrenic with a violent criminal record, had seemed relatively stable in a state-financed group home in Charlestown. But after a fight with another resident, Mr. Chappell was shuttled from home to home, and his mother believed that he had fallen off his medication along the way.

Ms. Chappell said she had tried to communicate this concern to his caretakers, but it was not until mid-January that she found somebody who listened.

The woman introduced herself as Stephanie and said she would be Mr. Chappell’s counselor at his new group home in Revere. She confirmed that Mr. Chappell had stopped getting his antipsychotic injections but made his mother a promise: “She said: ‘Don’t worry. I’m going to get Deshawn back on track.’

“I thought everything was going to be O.K. because he had somebody who cared,” Ms. Chappell said, her voice breaking.

Two days after that conversation, Stephanie Moulton, a petite, street-smart 25-year-old, was dead, and Mr. Chappell was accused of murdering her. They had been alone at the Revere home, where, her family said, Ms. Moulton generally worked a solo shift. Mr. Chappell beat her, stabbed her repeatedly and then dumped her partially nude body in a church parking lot, prosecutors said.

The killing on Jan. 20 stunned the mental health care community in Massachusetts. The “shattering event,” as one former state mental health official called it, occurred days before Gov. Deval Patrick, a Democrat, released his proposed budget, which would slash mental health spending for the third year in a row. And it raised the timely but uncomfortable question of whether such continuous belt-tightening had played a role in Ms. Moulton’s death.

Many people wondered aloud whether the system had failed both the suspect and the victim. How had Ms. Moulton ended up alone in a home with a psychotic man who had a history of violence and was off his medication? How had Mr. Chappell been allowed to deteriorate without setting off alarms? Should he have still been living in a group home, or did he need the tighter supervision of a hospital?

“People are reeling right now,” Dr. Kenneth Duckworth, a former medical director for the State Department of Mental Health, said after the killing. “Will this case be the canary in the coal mine? Will it signal that we’ve gone too far in reducing client-staff ratios, in closing hospitals, in pushing independence for people who may still be too sick?”

Massachusetts, which compared with other states faces a relatively modest budget shortfall of $1.5 billion, is hardly alone in cutting money for mental health care. State mental health departments, serving vulnerable populations with little political clout, almost always get disproportionately squeezed during tough times. During the current fiscal crisis, many states have sharply reduced both inpatient and community-based mental health care.

Yet Massachusetts has been in the mental health vanguard since it opened the country’s first large public asylum in the early 19th century. It handled deinstitutionalization better than most states, forging a comparatively robust community system — group homes, outpatient clinics, day treatment centers — to replace shuttered hospitals. And it has a Democratic-led legislature, historically progressive on social welfare policy, as well as a governor who has acknowledged his own wife’s battle with crippling depression.

The state mental health commissioner, Barbara A. Leadholm, said she believed her department was providing high-quality care despite the budget cuts it was obliged to accommodate.

“We have to be responsive to what the administration and the legislature feel they can financially afford,” she said, adding that a “major recontracting initiative” had transformed the system positively while cuts were being made.

But advocates for the mentally ill, along with mental health care providers and experts, paint a picture of an underfinanced department straining to meet the varying needs of its clients — 19,900 people like Mr. Chappell with severe and persistent mental illness, many of whom function quite well in subsidized housing with support services.

Over the last two years, the department has increased its reliance on private community providers who say they are underfinanced and struggling to stay afloat. It has closed one state hospital and a small inpatient psychiatric center. It has whittled its client list by almost a thousand. And it has laid off a quarter of its case managers, severing important relationships for thousands of people with serious mental illness and transferring them to younger, lower-paid workers in the private sector.

In the cuts being debated now, Mr. Patrick proposes to eliminate roughly a quarter of the 626 long-term care beds left in the state’s psychiatric hospital system. This unnerves many mental health professionals. Not only do they believe that there are already far too few beds for new cases — “It’s harder to get into a state hospital than into Harvard Medical School,” Dr. Duckworth said — but they also worry about discharging long-institutionalized patients into communities whose resources are clearly strained.

“It’s sort of a cross your fingers and pray approach,” said Scott Bezzini, a mental health outreach worker who is on leave to work for his union.

Hospital, corrections and municipal officials have long complained about people with mental illness crowding emergency rooms, homeless shelters and prisons in Massachusetts, saying mental health budget cuts transfer obligations to them. A quarter of the state’s inmates now need mental health treatment, compared with 15 percent in 1998, Department of Correction data show.

The first time Mr. Chappell secured a state hospital bed — and the treatment that comes with it — was when he ended up behind bars. After a conviction for assault and battery in 2007, he was sent briefly to a prison psychiatric hospital, Bridgewater State. That is where he is now being detained once again.

 

The Arraignment

On the day in late March when Mr. Chappell was arraigned on first-degree murder charges, Stephanie Moulton’s relatives filed grimly into a high-ceilinged courtroom in Boston.

They were unprepared, they said later, for some of the details that would be revealed: the “multiple, deep penetrating stab wounds to her neck,” the “blunt impact injuries to her head, torso and upper extremities,” the pants and underwear “dangling from one ankle.” The victim’s fiancé, Ryan Papazian, face hidden beneath a Bruins cap, bounced his legs as the facts of the case were read.

Seated beside his court-appointed lawyer, Jeffrey T. Karp, Mr. Chappell appeared dazed. He looked backward myopically, and his mother put her index finger to her lips and emphatically mouthed “Shh.”

A court forensic psychologist testified that Mr. Chappell, despite two months of treatment at Bridgewater, was “still very, very psychotic.”

The psychologist, Jeffrey Miner, cited non sequiturs that Mr. Chappell had spouted in a private session. He said that Mr. Chappell, a native of nearby Chelsea, told him variously that he hailed from Texas and rooted for the Washington Redskins and that he wanted “a lawyer from U.C.L.A. with a 3.5 grade-point average.” When Dr. Miner asked a follow-up question, Mr. Chappell responded, “Masseuse.”

“My sense is he is no way competent to stand trial,” Dr. Miner told the judge, recommending that he be returned to Bridgewater to see if his competency could be established through further treatment. The judge agreed. A trial date of April 26, 2012, was set.

Ms. Moulton’s relatives sat frozen, mouths agape, on the edge of their seats. Suddenly, her fiancé sprang to his feet, whisked off his cap and hurled it at the defendant. “Clear the court, clear the court,” the court officers ordered, tackling Mr. Papazian as other relatives rushed forward.

Kimberly Flynn, Ms. Moulton’s mother, shouted: “He kills my daughter, and you’re roughing up my family? He sits there and pretends he’s crazy, and you come down on us?”

Mr. Chappell was hustled away, and his mother fled, shaking. “My heart goes out to them because I am also in the same shoes,” Ms. Chappell said later, explaining that her brother had recently been murdered and that she alternately visited courthouses as the mother of a murder suspect and the sister of a murder victim. “But that was not cool. There’s something wrong with my child.”

 

A Desire to Help, Then Fear

A few weeks later, Ms. Flynn, 46, wearing blue scrubs after her shift as a visiting nurse, sat calmly in her kitchen in a public housing unit outside Boston. She showed off the centerpiece she had designed for a memorial fund-raiser at the Peabody Elks Lodge — a vase filled with marbles and her daughter’s favorite knickknacks: a frog, a butterfly, mini flip-flops.

Ms. Flynn said she hoped to raise enough money to bury Ms. Moulton’s ashes. “I got to put my daughter to rest,” she said. “She’s still upstairs in an urn on her bureau.”

At the kitchen table, Ms. Moulton’s father, a welder, and her teenage brothers wore new tattoos — “Stephanie” written atop a cross adorned with a rose.

Ms. Moulton, the first in her family to graduate from college, got an associate’s degree in mental health and a bachelor’s in social work. She was drawn to the field because she was close to an uncle with schizophrenia and had observed intimately the effects of the illness on his family, said her brother Anthonee Flynn, 18.

“Personally, I told her she was crazy,” he said of her career choice, “but she wanted to help.”

After graduating, Ms. Moulton managed a Victoria’s Secret store for a year before landing an entry-level position with the North Suffolk Mental Health Association, which, like other agencies under contract with the state, offers starting salaries of $12 to $14 an hour.

“With the resources we have, with the dollars in the system, we can’t pay the kind of wages people should get for this work,” said Jackie K. Moore, the chief executive of North Suffolk, one of the state’s largest behavioral health care providers, with an annual budget of $43 million.

Over the last half-century, as Massachusetts eliminated over 20,000 long-term psychiatric hospital beds and many of the public, unionized jobs that went with them, the state developed a network of private agencies, mostly nonprofit, to provide care for severe mental illness.

The community system never had enough money, many experts say, but recent budget cuts, combined with Medicaid reimbursement rates that did not keep pace with rising costs, have seriously weakened it.

“The outpatient treatment system in Massachusetts is dying on the vine,” said Vicker V. DiGravio III, the chief executive of the Association for Behavioral Healthcare, which represents providers in the state.

Providers have trouble finding psychiatrists and other clinicians who are willing to work in the community; they depend on recent social work graduates, who usually move on quickly to better-paying jobs at hospitals or in private practice. They also have difficulty recruiting and retaining quality workers for group homes, and many hired do not have even have the college degree that Ms. Moulton possessed.

“The end result,” Mr. DiGravio said, “is a system where the folks with the least professional experience are serving the clients with the most intensive needs — because the Department of Mental Health serves only those people with the most severe mental illness.”

At North Suffolk, workers in group homes get at least a week’s training, as Ms. Moulton most likely did before starting her job at a residence in Chelsea.

“People go through an orientation,” Ms. Moore said. “They learn about mental illness. They learn ways to de-escalate a situation.”

Initially, Ms. Moulton loved her new job, where she supervised residents, accompanied them to appointments, distributed medication and cooked, her mother said. “Stephanie was like me,” she said. “We have the patience of saints when it comes to patients.”

Then, one Friday last fall, something happened. The residents were receiving small cash allowances, Ms. Flynn said, and one, believing he was owed more than he got, “flipped out.” He screamed, tossed furniture, threw objects. Ms. Moulton, 5-foot-1 and about 100 pounds, locked herself in an office and called for help.

Afterward, she grew frightened.

“She had to take anxiety pills,” her brother said, “and she started carrying around a knife.”

“A knife?” her mother said, looking alarmed. “She did?”

“She didn’t have it on her the day that stuff happened,” he said, referring to her stabbing death. “I found it in her room.”

Ms. Moulton began making plans to pursue a nursing degree. She also asked North Suffolk for a transfer and started working a shift from 3 to 11 p.m. at the home in Revere. Her family said she always worked alone at the home, which usually had seven residents, whom she described as easy and placid.

“She said they were all old people, in their 50s and stuff, so there was nothing to worry about,” Ms. Flynn said. “When this guy was sent in there, she must not have known what she was dealing with.”

 

A Rapid Descent

Tucked away in a recessed corner of the basement cafeteria of Massachusetts General Hospital, Mr. Chappell’s mother kissed an old picture of her son dressed in a white tuxedo.

“He took a girl with a prosthetic leg and arm to her senior prom because nobody else would,” said Ms. Chappell, an operations associate in the hospital’s gastroenterology department. “That was the kind of stuff he’d do before he changed.”

Ms. Chappell, 44, and her husband, a carpenter, raised five children in Chelsea. The second oldest, Deshawn, a stocky 5-foot-7, was a running back on his high school football team and went to work as a deliveryman after graduation. He had been an outgoing, churchgoing boy, and his mother thought he would grow up to be a minister.

Ms. Chappell said she first grew concerned when her son, a snappy dresser, began neglecting his appearance and wearing “his pants hanging all the way down his behind.” But that was a style. It was when he stopped talking about God and started talking about the Devil that her worry deepened.

“He would say the Devil was telling him to do things,” she said. “He would talk about curses and hexes and a lot of things that didn’t make sense.”

Symptoms of schizophrenia usually manifest in men during late adolescence and early adulthood. Ms. Chappell saw in her son what she called “familiar patterns” — her mother suffered from schizophrenia, too, she said.

Ms. Chappell said she urged her son to seek help but had little control over his life. He moved out of her home and, as his condition deteriorated, started getting in trouble with the law.

The arrests began in the summer of 2003 when Mr. Chappell, then 19, was charged with armed robbery and assault. The victim was a homeless man with $96 in his pocket. Mr. Chappell accosted the man twice, slashing his forehead the first time and then punching him in the eye, causing an injury that required surgery, according to court records. The charges were dismissed.

Mr. Chappell’s record also includes drug and alcohol charges; he was apparently drinking and smoking marijuana while his schizophrenia was emerging, which can be a combustible mix.

By the time he turned 21, he was in such agony that he asked for help, his mother said. He told her that the voices in his head prevented him from sleeping and that he was showering constantly because his skin was crawling. He said he felt so angry that he feared he would hurt himself or somebody else, and he asked her to take him to her hospital, she said.

Mr. Chappell was admitted to Massachusetts General for a couple of weeks. That is when schizophrenia was diagnosed and he was prescribed antipsychotic medication, his mother said. Over the next couple of years, though, he did not take his medication consistently because the side effects bothered him, she said.

He was hospitalized in acute-care hospitals at least four more times, including once in a center known for substance abuse treatment. During that time, he was also arrested several more times on assault charges, which were ultimately dismissed.

Because Mr. Chappell’s medical records are private, it cannot be determined if acute-care hospitals tried to discharge him to a state hospital for continuing care but, as sometimes happens, could not find a bed available.

“This guy, with his history, certainly would have spent time in a state hospital 20 years ago,” said Dr. William Fisher, a psychiatry professor at the University of Massachusetts Medical School.

 

A Focus on Recovery

Deinstitutionalization was the result of a struggle to end protracted and unnecessary confinement. It was also a way for states to offload considerable expense to the federal government.

Care in “institutions for mental disease” has never been covered by Medicaid; community care is. Indeed, in the view of experts on public psychiatry like Dr. Jeffrey Geller of the University of Massachusetts Medical School, cost-shifting has been “the major driving force” behind deinstitutionalization, “with the philosophy a tag-on.”

Community care, if done right, is nonetheless widely considered the most humane and effective way to treat people with serious mental illness.

But many in the field worry that deinstitutionalization has gone too far, stripping states of the minimum number of long-term psychiatric beds needed to accommodate people during acute stages of illness, as well as those with high-risk behaviors that make discharge dangerous. Massachusetts will have 466 such beds if proposed cuts are approved.

Today only 3 percent of the Mental Health Department’s clients live in state hospitals. For those in the community, the department has shifted in recent years from a model of care that sees serious mental illness as a long-term disability to a “recovery” model, which seeks to move clients into increasingly less restrictive, less supervised and less costly living situations.

“It’s all about getting people discharged as opposed to getting them treatment,” said Jill Homer, a state-employed case manager for three decades, who nonetheless feels that the system has “fumbled through” its downsizing fairly well.

Dr. Marie H. Hobart, medical director of Community Healthlink in Worcester, said she worried that the new approach “pretends” serious mental illness is linear, that people who improve will never suffer setbacks. She said that seriously ill clients were being allowed to leave the care of the Department of Mental Health, with some ending up homeless or in jail.

“In the past, D.M.H. would recognize that this is a person with schizophrenia, a condition that is ongoing and not something that can be cured,” she said.

Jennifer Ives, 37, a client of the department, said she appreciated the new focus on recovery. “It’s saying you’re not going to be like this forever,” said Ms. Ives, who has borderline personality disorder. But the recent loss of her case manager of eight years has made her feel isolated and anxious about “slipping backwards.”

“I was highly upset when she told me she had to terminate my case,” Ms. Ives said. “She helped me put out fires when they were just a little smoke. She was my mediator with the system, and there are real flaws with the system. Nobody knows what the other hand is doing. Nobody ever has time for you.”

One mother of a grown man with schizoaffective disorder said her son’s condition, relatively stable for 15 years, declined when the department started pushing him to become more independent. “We started hearing ‘He can take his medication on his own,’ ” said the mother, who asked that her name be withheld to respect her son’s privacy.

“He lost his therapist,” she said. “He lost his case manager. The professional level of the workers he encountered was lower. And our son was not able to take care of himself. He was not eating properly, he started playing around with his medications, and he just became very, very symptomatic. In the end, we got him checked into a private psychiatric hospital. It was his first hospitalization in 15 years.”

 

Within the System

For young adults with new psychotic disorders like Mr. Chappell, becoming a client of the Department of Mental Health is difficult. “You have to have had a lot of trouble to get into the system,” Dr. Hobart said.

Mr. Chappell finally made it in after his fifth arrest on assault charges resulted in a conviction.

That arrest occurred in November 2006 after Mr. Chappell’s stepfather, who had raised him and occasionally hired him to work construction, dismissed him from a job. Mr. Chappell, using “an unknown hard object,” responded by fracturing three bones in his stepfather’s left eye socket, a police report said. When officers arrived, the stepfather was “holding his head with a cloth and had blood running from his mouth.”

In 2007, Mr. Chappell, sentenced to a year in jail but required to serve only three months, ended up at the prison psychiatric hospital. When his mother visited him there, she said, she was heartened to see the effects of an enforced medication regimen. “This was the son I raised,” she said. “He talked about going back to school and getting a college degree.”

After his release, Mr. Chappell spent nearly a year living with his grandmother before he got off a waiting list and into a group home in Charlestown. That living situation appeared to stabilize him, his mother said, although she thinks he mostly stayed in his room and did not participate in day programs. He got antipsychotic injections every other week from a nurse at a clinic until he apparently stopped going.

Ms. Moore, the chief executive of North Suffolk, would not discuss Mr. Chappell’s case. Asked what her employees did if residents became noncompliant with their medication, she said: “I don’t like to use the word ‘compliant.’ That implies you can force people to take medication, which you can’t.” Still, she said, “Our staff is trained to observe and document, to note and report any changes, any symptomology. We would not ignore it.”

When Mr. Chappell went home for Thanksgiving, his behavior was alarming. “He was talking intensely about people watching him,” his mother said. “He felt too uneasy to leave the house. When Shawn was on his medicine, you could tell. He was quiet. He was not agitated like he was then.”

After that, Ms. Chappell called the home in Charlestown one day and learned that her son had been transferred after fighting, she said. She tracked him to a temporary residence in Chelsea. She called there repeatedly, but nobody returned her calls.

Her son, she said, “felt like they weren’t helping him anymore. He felt like they were bouncing him all around.” He declined to join the family for Christmas because he did not have gifts. He began phoning relatives and “making delusional statements,” said Mr. Karp, his lawyer. “I uncovered many witnesses who describe his deterioration as obvious.”

Over all, the risk of violence from people with mental disorders is considered low. But studies have shown that it can be elevated by various factors apparent in Mr. Chappell’s profile — delusions and hallucinations, a lack of treatment or failure to take medication, abuse of alcohol or drugs. The strongest predictor of violence by a mentally ill person is believed to be past violence.

In early January, Mr. Chappell was transferred to the Revere home. Ms. Moulton was not the only one there who realized he was not taking his medication, Mr. Karp said. But it is unclear what she or anybody else knew about Mr. Chappell’s medical and criminal history. Many providers, doctors and workers say that collaboration on cases is rare in an increasingly fragmented system with fewer case managers.

After Ms. Moulton’s killing, a local newspaper headline said, “Group home blind to man’s criminal past.” But Ms. Moore said “an inference was made” that North Suffolk did not have criminal offender record information on Mr. Chappell because it does not run criminal background checks on all residents. She declined to elaborate.

That Ms. Moulton was left alone in the home with a resident was apparently not unusual. Under new contracts with providers, the state government does not specify staffing levels, and providers are free to allocate employees as they see fit while stretching dollars to cover their programs.

“If providers want to leave a house unstaffed or single-staffed, they can — and they do,” said Toby Fisher, a senior field policy specialist for the Service Employees International Union, which represents many of the state’s mental health workers.

Ms. Moore said: “There are times when there’s only one person on a shift. We have reduced the staffing at some places where we feel the clients are independent enough that they don’t need staff.”

 

That Day in January

On Jan. 20, Anthonee Flynn heard a few staccato raps on the door. “Cops were standing there, asking where my mom was,” he said. Located at work by her fiancé, Ms. Flynn was told there was an emergency. She asked if Anthonee was all right; he was. “I said, ‘Stephanie’s dead, isn’t she?’ ” She imagined a car accident. A state trooper arrived to escort her to a police station.

“He said Stephanie was murdered, that they knew who the man was and that he was one of the patients,” Ms. Flynn said. “I was screaming and screaming and screaming.”

Prosecutors say that shortly after Ms. Moulton arrived to work a day shift, the other residents left to attend programs. She had been scheduled to accompany Mr. Chappell to a counseling session. Another employee stopped by to pick them up and discovered blood in the driveway where Ms. Moulton usually parked her Chrysler PT Cruiser. The car was missing.

Mr. Chappell killed Ms. Moulton inside the residence, prosecutors say.

“The hardest part is not being able to know what transpired between those two,” Ms. Flynn said. “I keep thinking, was she yelling for me?”

After depositing her body in a parking lot, Mr. Chappell abandoned the car and stole clothes to replace his bloody ones, prosecutors say. He then called his grandmother.

His mother, at Massachusetts General, was getting calls from North Suffolk looking for him. “I didn’t know what was going on,” she said. “Then I got a phone call stating that somebody saw my son on the news. Everything else is a blur.”

Learning that her son was heading toward her mother’s house in Roxbury, Ms. Chappell started driving there herself. She also alerted the police.

“Yes, I turned my son in,” she said. “I was nervous about how it might go down if I didn’t. I begged the police not to hurt him. When I got to my mom’s, I just hugged my son and I told him I loved him. He looked scared. Then they took him away. ”

 

Looking to the Future

After Ms. Moulton’s funeral drew hundreds of mourners, the mental health commissioner convened a task force to review the system’s safety and training practices.

At the first of a series of statewide hearings, in a cavernous college auditorium in Fitchburg, several panel members expressed discomfort with their mission.

“The overwhelming majority of consumers are not more dangerous than the general population, although there is a very small group that does cause concern,” said Dr. Kenneth Appelbaum, a co-chairman of the task force. “How to go about addressing safety concerns without adding stigma is a challenge.”

Rising to address the panel, Laurie Martinelli, the executive director of the National Alliance on Mental Illness in Massachusetts, said the issue raised by Ms. Moulton’s case — and by the subsequent killing of a homeless shelter employee — was not whether people with mental illness were violent.

“The elephant in the room is the state mental health budget,” she said. “Did the murders have something to do with funding cutbacks?”

The “historical budget levels” posted on the department’s Web site show a nearly 10 percent decline in appropriations for mental health from 2009 through 2011. Additional information requested for this article — on midyear cuts, budget supplements and trust fund spending — indicates that the money available to the department probably declined somewhat less, by about 6 percent.

Joellen Stone, a client of the department trained to help others with mental illness, told the panel that the people she counsels are living in “utter poverty — in apartments with bed bugs and rats and drug dealers in the hall.”

“They’re closing hospitals, and people are ending up in nursing homes or substandard housing. It just saddens me,” she said. “If we don’t get funding, we’re either on the street, in prison, dead or rather be dead. And when people are disempowered, that’s when they’re likely to become violent.”

Throughout the spring, the legislature, especially the Senate, showed resistance to the governor’s proposed mental health cuts. Budget reconciliation talks are taking place this month.

In mid-May, Mr. Chappell returned to court, standing taller and looking less puzzled. Judge Carol S. Ball said prison hospital officials now found him competent to assist in his own defense but acknowledged that “there’s a certain amount of in-and-out-ness.” Scrutinizing him from the rear of the courtroom, his mother noticed that he was mumbling to himself.

On the courthouse steps afterward, Ms. Flynn turned toward a warming sun and said she had finally buried her daughter the previous week. Exhausted by her loss, she had taken a leave from her job but could not stop thinking about what had happened in Revere.

She filed a wrongful death suit against North Suffolk and was planning to testify at the Statehouse about worker safety. She wanted answers, she said, and justice.

“Stephanie should be here now, planning her wedding and rolling her eyes at me like she always does,” Ms. Flynn said. “It was just totally unnecessary for her to get killed and murdered on the job when all she was trying to do was help people.”

    A Schizophrenic, a Slain Worker, Troubling Questions, R, 16.6.2011,
    http://www.nytimes.com/2011/06/17/us/17MENTAL.html

Obama administration to appeal healthcare ruling

ATLANTA | Wed Jun 8, 2011
1:24am EDT
Reuters
By Matthew Bigg

ATLANTA (Reuters) - Lawyers for President Barack Obama will on Wednesday seek to stave off the biggest legal challenge yet to healthcare reform, his signature domestic policy achievement.

The administration will present oral arguments as it appeals a ruling by a Florida judge who declared the Affordable Care Act unconstitutional, backing claims by 26 U.S. states that are seeking repeal.

A three-judge panel at the 11th Circuit Court of Appeals in Atlanta will hear oral arguments by both sides. While a Virginia appeals court heard a similar case in May, this case is significant because of the number of states backing it.

No ruling is expected for months and legal experts expect an appeal to the Supreme Court, regardless of which side wins.

The law aims to increase access to healthcare and slow the growth in costs. The White House views it as a cornerstone of Obama's presidency. Republicans say it will send costs soaring and represents intrusive government power especially because it mandates all individuals to buy health insurance.

They plan to make their campaign for repeal a pillar of efforts to defeat Obama at presidential elections in 2012.

"Opponents of reform claim that the law's individual responsibility provision exceeds Congress' power to regulate interstate commerce because it penalizes 'inactivity.' They are wrong," the White House said on its blog on Tuesday.

"Individuals who choose to go without health insurance are actively making an economic decision that affects all of us," it said of the provision to fine Americans who do not buy insurance, which comes into effect in 2014.

The 2010 law also allows young people to remain on their parents' health insurance into their twenties and prevents insurers from denying coverage for preexisting medical conditions.

Florida District Judge Roger Vinson ruled in January the entire law "must be declared void" because its requirement to buy insurance is unconstitutional, but put the ruling on hold pending appeal.

"The nation needs healthcare reform that's pursued constitutionally and in a way that does not harm our economy and our taxpayers," Florida Attorney General Pam Bondi said in a statement.

Chief Judge Joel Dubina, Judge Frank Hull and Judge Stanley Marcus will hear the appeal. Analysts will watch their questions closely for clues as to how they might rule.

Dubina was appointed by President George H. W. Bush, a Republican, while the other two were appointed by President Bill Clinton, a Democrat.

Senior administration lawyer Neal Katyal will argue for the government, while former Solicitor General Paul Clement will present Florida's case.

The case is State of Florida et al v. U.S. Department of Health and Human Services et al. Its number is 11-11021.

 

(Editing by Eric Walsh)

    Obama administration to appeal healthcare ruling, R, 8.6.2011,
    http://www.reuters.com/article/2011/06/08/us-usa-healthcare-idUSTRE7570UI20110608

Special Report: An end to AIDS?

LONDON | Wed Jun 1, 2011
11:52am EDT
Reuters
By Kate Kelland

LONDON (Reuters) - For his doctors, Timothy Ray Brown was a shot in the dark. An HIV-positive American who was cured by a unique type of bone marrow transplant, the man known as "the Berlin patient" has become an icon of what scientists hope could be the next phase of the AIDS pandemic: its end.

Dramatic scientific advances since HIV was first discovered 30 years ago this week mean the virus is no longer a death sentence. Thanks to tests that detect HIV early, new antiretroviral AIDS drugs that can control the virus for decades, and a range of ways to stop it being spread, 33.3 million people around the world are learning to live with HIV.

People like Vuyiseka Dubula, an HIV-positive AIDS activist and mother in Cape Town, South Africa, can expect relatively normal, full lives. "I'm not thinking about death at all," she says. "I'm taking my treatment and I'm living my life."

Nonetheless, on the 30th birthday of HIV, the global scientific community is setting out with renewed vigor to try to kill it. The drive is partly about science, and partly about money. Treating HIV patients with lifelong courses of sophisticated drugs is becoming unaffordable.

Caring for HIV patients in developing countries alone already costs around $13 billion a year and that could treble over the next 20 years.

In tough economic times, the need to find a cure has become even more urgent, says Francoise Barre Sinoussi, who won a Nobel prize for her work in identifying Human Immunodeficiency Virus (HIV). "We have to think about the long term, including a strategy to find a cure," she says. "We have to keep on searching until we find one."

The Berlin patient is proof they could. His case has injected new energy into a field where people for years believed talk of a cure was irresponsible.

 

THE CURE THAT WORKED

Timothy Ray Brown was living in Berlin when besides being HIV-positive, he had a relapse of leukemia. He was dying. In 2007, his doctor, Gero Huetter, made a radical suggestion: a bone marrow transplant using cells from a donor with a rare genetic mutation, known as CCR5 delta 32. Scientists had known for a few years that people with this gene mutation had proved resistant to HIV.

"We really didn't know when we started this project what would happen," Huetter, an oncologist and haematologist who now works at the University of Heidelberg in southern Germany, told Reuters. The treatment could well have finished Brown off. Instead he remains the only human ever to be cured of AIDS. "He has no replicating virus and he isn't taking any medication. And he will now probably never have any problems with HIV," says Huetter. Brown has since moved to San Francisco.

Most experts say it is inconceivable Brown's treatment could be a way of curing all patients. The procedure was expensive, complex and risky. To do this in others, exact match donors would have to be found in the tiny proportion of people -- most of them of northern European descent -- who have the mutation that makes them resistant to the virus.

Dr Robert Gallo, of the Institute of Virology at the University of Maryland, puts it bluntly. "It's not practical and it can kill people," he said last year.

Sinoussi is more expansive. "It's clearly unrealistic to think that this medically heavy, extremely costly, barely reproducible approach could be replicated and scaled-up ... but from a scientist's point of view, it has shown at least that a cure is possible," she says.

The International AIDS Society will this month formally add the aim of finding a cure to its HIV strategy of prevention, treatment and care.

A group of scientist-activists is also launching a global working group to draw up a scientific plan of attack and persuade governments and research institutions to commit more funds. Money is starting to flow. The U.S. National Institutes of Health is asking for proposals for an $8.5 million collaborative research grant to search for a cure, and the Foundation for AIDS Research, or amfAR, has just announced its first round of four grants to research groups "to develop strategies for eradicating HIV infection."

 

THE COST OF TREATMENT

Until recently, people in HIV and AIDS circles feared that to direct funds toward the search for a cure risked detracting from the fight to get HIV-positive people treated. Even today, only just over five million of the 12 million or so people who need the drugs actually get them.

HIV first surfaced in 1981, when scientists at the U.S. Centers for Disease Control and Prevention discovered it was the cause of acquired immunodeficiency syndrome (AIDS). An article in the CDC's Morbidity and Mortality Weekly Report of that June referred to "five young men, all active homosexuals" from Los Angeles as the first documented cases. "That was the summer of '81. For the world it was the beginning of the era of HIV/AIDS, even though we didn't know it was HIV then," says Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, who has made AIDS research his life's work.

In the subsequent three decades, the disease ignorantly branded "the gay plague" has become one of the most vicious pandemics in human history. Transmitted in semen, blood and breast milk, HIV has devastated poorer regions, particularly sub-Saharan Africa, where the vast majority of HIV-positive people live. As more tests and treatment have become available, the number of new infections has been falling. But for every two with HIV who get a chance to start on AIDS drugs, five more join the "newly infected" list. United Nations data show that despite an array of potential prevention measures -- from male circumcision to sophisticated vaginal or anal microbicide gels -- more than 7,100 new people catch the virus every day.

Treatment costs per patient can range from around $150 a year in poor countries, where drugs are available as cheap generics, to more than $20,000 a year in the United States.

The overall sums are huge. A recent study as part of a non-governmental campaign called AIDS2031 suggests that low and middle-income countries will need $35 billion a year to properly address the pandemic by 2031. That's almost three times the current level of around $13 billion a year. Add in the costs of treatment in rich countries and experts estimate the costs of HIV 20 years from now will reach $50 to $60 billion a year.

"It's clear that we have to look at another possible way of managing of the epidemic beyond just treating everyone forever," says Sharon Lewin, a leading HIV doctor and researcher from Monash University in Melbourne, Australia.

In some ways, we have been here before. Early AIDS drugs such as AZT came to market in the late 1980s, but within a decade they were overtaken by powerful cocktail treatments known as HAART, or highly active antiretroviral treatment. HAART had a dramatic effect -- rapidly driving the virus out of patients' blood and prompting some to say a cure was just around the corner.

But then scientists discovered HIV could lie low in pools or reservoirs of latent infection that even powerful drugs could not reach. Talk of a cure all but died out.

"Scientifically we had no means to say we were on the way to finding a cure," says Bertrand Audoin, executive director of the Geneva-based International AIDS Society. "Scientists ... don't want to make any more false promises. They didn't want to talk about a cure again because it really wasn't anywhere on the horizon."

 

GENE THERAPY

The ultimate goal would allow patients to stop taking AIDS drugs, knocking a hole in a $12 billion-a-year market dominated by Californian drugmaker Gilead and the likes of Pfizer, GlaxoSmithKline and Merck.

It's unlikely to happen anytime soon, but Brown's case has opened the door to new ideas. "What it proved was that if you make someone's cells resistant to HIV...then all the last bits of HIV, that hang around for a long time in patients on treatment, did in fact decay and disappear," says Lewin.

Now scientists working on mimicking the effect of the Berlin patient's transplant have had some success. One experimental technique uses gene therapy to take out certain cells, make them resistant to HIV and then put them back into patients in the hope they will survive and spread.

At an HIV conference in Boston earlier this year, American researchers presented data on six patients who had large numbers of white blood cells known as CD4 cells removed, manipulated to knock out the existing CCR5 gene, and then replaced.

"It works like scissors and cuts a piece of genetic information out of the DNA, and then closes the gap," says Huetter. "Then every cell arising from this mother cell has this same mutation."

Early results showed the mutated cells managed to survive inside the bodies of the patients at low levels, remaining present for more than three months in five. "This was a proof of concept," says Lewin. Another potential avenue is a small group of patients known as "elite controllers", who despite being infected with HIV are able to keep it under control simply with their own immune systems. Researchers hope these patients could one day be the clue to developing a successful HIV/AIDS vaccine or functional cure.

Scientists are also exploring ways to "wake up" HIV cells and kill them. As discovered in the late 1990s, HIV has a way of getting deep into the immune system itself -- into what are known as resting memory T-cells -- and going to sleep there. Hidden away, it effectively avoids drugs and the body's own immune response.

"Once it goes to sleep in a cell it can stay there forever, which is really the main reason why we can't cure HIV with current drugs," says Lewin. Her team in Melbourne and another group in the United States are about to start the first human trials using a drug called SAHA or vorinostat, made by Merck and currently used in cancer treatment, which has shown promise in being able to wake up dormant HIV.

 

WHAT ABOUT PREVENTION?

As scientists begin to talk up a cure, the old question of whether that's the right goal has re-emerged. Seth Berkley, a medical epidemiologist and head of the U.S.-based International AIDS Vaccine Initiative (IAVI) is concerned.

"From a science point of view, it's a fabulous thing to do. It's a great target and a lot of science will be learned. But from a public health point of view, the primary thing you need to do is stop the flow of new infections," says Berkley. "We need a prevention revolution. That is absolutely critical."

Vuyiseka Dubula agrees. The South African activist finds talk of a cure for HIV distracting, almost disconcerting. "This research might not yield results soon, and even when it does, access to that cure is still going to be a big issue," she says. "So in the meantime, while we don't have the answer on whether HIV can be cured or not, we need to save lives."

(Additional reporting by Julie Steenhuysen in Chicago,
editing by Sara Ledwith and Simon Robinson)

    Special Report: An end to AIDS?, R, 1.6.2011,
    http://www.reuters.com/article/2011/06/01/us-aids-idUSTRE75030I20110601

Judging a Cancer Drug: Avastin’s Story

June 1, 2011
The New York Times

To the Editor:

In “Drugs and Profits” (Op-Ed, May 25), Dr. Frederick C. Tucker Jr. suggests that Genentech is ignoring scientific facts in our efforts to preserve Avastin as an option for women with breast cancer.

Three large studies show with high statistical confidence that adding Avastin to the first chemotherapy extends the time a woman lives before her breast cancer worsens. The Food and Drug Administration agrees that these studies raise no new safety concerns.

The patients Dr. Tucker dismisses as anecdotes are real women. They are battling an incurable cancer, and whether to use Avastin is one of many difficult personal choices they will make. Withdrawing Avastin’s breast cancer approval in the United States indisputably reduces options here, while European women still have it available.

We continue to study Avastin and are researching more than 30 medicines that may one day yield better treatments. In the meantime, we believe that women who are trying to control their disease should retain the autonomy to decide, based on the facts, whether Avastin is right for them.

HAL BARRON
South San Francisco, May 31, 2011

The writer is chief medical officer and head of global product development for Genentech.

To the Editor:

The issue can be reduced to a simple question: How does one define efficacy in cancer treatment?

One criterion for approval of anti-cancer drugs is lack of progression, and progression is based on an increase in tumor size over time. However, it is not tumor size per se that kills, but invasion and subsequent metastases, which are unrelated to tumor size.

The tumor-reduction paradigm has not delivered, and potentially beneficial drugs continue to be rejected if they do not block tumor growth. Unless “progression” is redefined as local invasion and metastases, the problem will remain.

In Greek mythology, Procrustes either stretched or cut his guests to make them fit the bed. Are we doing the same in cancer drug research?

MICHAEL FERNANDES
Chapel Hill, N.C., May 25, 2011

The writer, a doctor, works on the development of drugs and medical devices.

To the Editor:

Frederick C. Tucker Jr. says anecdotal reports are not science. This is true, but it does not mean that they are incorrect. It is certainly probable that a small percentage of patients on a bell-shaped curve are hyper-responders, as reported by numerous oncologists throughout the country. This may be due to genetic variants as well as other unknown factors.

My own daughter has been on Avastin since November 2008, with a normal and excellent quality of life after a recurrence of metastatic triple-negative breast cancer with extensive lymph node involvement. There have been multiple such reports, and these patients should not be denied therapy as outlined by their oncologists and other doctors.

GERALD E. SCHATTNER
Roslyn Heights, N.Y., May 25, 2011

The writer is an internist.

    Judging a Cancer Drug: Avastin’s Story, 1.6.2011,
    http://www.nytimes.com/2011/06/02/opinion/l02avastin.html