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Maurice M. Rapport, a biochemist who helped isolate and name the neurotransmitter serotonin, which plays a role in regulating mood and mental states, and who first described its molecular structure, a development that led to the creation of a wide variety of psychiatric and other drugs, died on Aug. 18 in Durham, N.C. He was 91.

The death was confirmed by his daughter, Erica Rapport Gringle.

In the 1940s Dr. Rapport (pronounced RA-port) was a freshly minted biochemist from the California Institute of Technology when he began working at the Cleveland Clinic Foundation with Irvine H. Page, a leading specialist on high blood pressure and cardiovascular disease.

Scientists had known since the 1860s of a substance in the serum released during clotting that constricts blood vessels by acting on the smooth muscles of the blood-vessel walls. In the 20th century, researchers pinpointed its source in blood platelets, but its identity remained a mystery.

Dr. Rapport, working with Dr. Page and Arda A. Green, isolated the substance and, in a paper published in 1948, gave it a name: serotonin, derived from “serum” and “tonic.”

On his own, Dr. Rapport identified the structure of serotonin as 5-hydroxytryptamine, or 5-HT, as it is called by pharmacologists. His findings, published in 1949, made it possible for commercial laboratories to synthesize serotonin and study its properties as a neurotransmitter.

More than 90,000 scientific papers have been published on 5-HT, and the Serotonin Club, a professional organization, regularly holds conferences to report on research in the field.

Initially, researchers focused on agents to block serotonin, which, by constricting blood vessels, causes blood pressure to rise. After researchers discovered its presence in the brain, and its chemical similarity to LSD, which mimics serotonin in the brain, they began focusing on serotonin’s role in regulating mood and mental functioning.

Further research showed that serotonin also plays a critical role in the central nervous system — where it helps regulate mood, appetite, sex and sleep — and the gut.

This new understanding of the structure and functioning of serotonin led to a changing view of mental disorders as chemical imbalances and opened the way to the development of antidepressants and antipsychotic drugs that act on 5-HT, as well as drugs for treating cardiovascular and gastrointestinal disease.

Maurice Rapoport was born on Sept. 23, 1919, in Atlantic City. His father, a furrier who had emigrated from Russia, left the family when Maurice was a small child. His mother changed the spelling of the family name and Maurice later adopted the middle initial “M,” although it did not stand for anything.

After graduating from DeWitt Clinton High School in the Bronx, he earned a bachelor’s degree in chemistry from City College in 1940 and a doctorate in organic chemistry from Cal Tech in 1946. For his work on serotonin he was awarded a Fulbright Scholarship in 1952 to study with Dr. Daniel Bovet, later a Nobel Prize winner for his work in pharmacology, at the Istituto Superiore di Sanità in Rome.

After doing research in biochemistry at Columbia, immunology at the Sloan-Kettering Institute for Cancer Research and biochemistry at the Albert Einstein College of Medicine, Dr. Rapport joined the staff of the New York Psychiatric Institute, where he created the division of neuroscience by combining the old divisions of chemistry, pharmacology and bacteriology. He also held the post of professor of biochemistry at Columbia’s College of Physicians and Surgeons.

Dr. Rapport retired in 1986 and was a visiting professor in the neurology department of the Albert Einstein College of Medicine until his death.

Dr. Rapport did important research on cancer, cardiovascular disease, connective-tissue disease and demyelinating diseases, a type of nervous-system disorder that includes multiple sclerosis.

One productive area of his research focused on the immunological activity of lipids found in the nervous system, notably cytolipin H, which he isolated from human cancer tissue in 1958. He also identified the lipid galactocerebroside as the substance responsible for producing antigens specific to the brain, a finding that led to a better understanding of the immune system.

Dr. Rapport’s wife, Edith, died in 1988. He lived in Hastings-on-Hudson with his longtime companion, Nancy Reich, who survives him, before failing health made it necessary for him to move in with his daughter, Erica, in Durham, in July. Other survivors are his son, Ezra, of Oakland, Calif.; five grandchildren; and a great-granddaughter.

Maurice M. Rapport, Who Studied Serotonin, Dies at 91,
NYT,
2.9.2011,
https://www.nytimes.com/2011/09/03/health/03
rapport.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

Talk Doesn’t Pay,

So Psychiatry

Turns to Drug Therapy

March 5, 2011
The New York Times
By GARDINER HARRIS

DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.

“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.”

With thinning hair, a gray beard and rimless glasses, Dr. Levin looks every bit the psychiatrist pictured for decades in New Yorker cartoons. His office, just above Dog Daze Canine Hair Designs in this suburb of Philadelphia, has matching leather chairs, and African masks and a moose head on the wall. But there is no couch or daybed; Dr. Levin has neither the time nor the space for patients to lie down anymore.

On a recent day, a 50-year-old man visited Dr. Levin to get his prescriptions renewed, an encounter that took about 12 minutes.

Two years ago, the man developed rheumatoid arthritis and became severely depressed. His family doctor prescribed an antidepressant, to no effect. He went on medical leave from his job at an insurance company, withdrew to his basement and rarely ventured out.

“I became like a bear hibernating,” he said.

Missing the Intrigue

He looked for a psychiatrist who would provide talk therapy, write prescriptions if needed and accept his insurance. He found none. He settled on Dr. Levin, who persuaded him to get talk therapy from a psychologist and spent months adjusting a mix of medications that now includes different antidepressants and an antipsychotic. The man eventually returned to work and now goes out to movies and friends’ houses.

The man’s recovery has been gratifying for Dr. Levin, but the brevity of his appointments — like those of all of his patients — leaves him unfulfilled.

“I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.”

“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

When he started in psychiatry, Dr. Levin kept his own schedule in a spiral notebook and paid college students to spend four hours a month sending out bills. But in 1985, he started a series of jobs in hospitals and did not return to full-time private practice until 2000, when he and more than a dozen other psychiatrists with whom he had worked were shocked to learn that insurers would no longer pay what they had planned to charge for talk therapy.

“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group. To maintain their incomes, physicians often respond to fee cuts by increasing the volume of services they provide, but psychiatrists rarely earn enough to compensate for their additional training. Most would have been better off financially choosing other medical specialties.

Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house, 14 miles from Dr. Levin’s office. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

“Medication is important,” she said, “but it’s the relationship that gets people better.”

Dr. Levin’s initial efforts to get insurers to reimburse him and persuade his clients to make their co-payments were less than successful. His office assistants were so sympathetic to his tearful patients that they often failed to collect. So in 2004, he begged his wife, Laura Levin — a licensed talk therapist herself, as a social worker — to take over the business end of the practice.

Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment.

As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars. If patients say they cannot make the appointments she scheduled, Ms. Levin changes them.

“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”

She said that she would like to be more giving of herself, particularly to patients who are clearly troubled. But she has disciplined herself to confine her interactions to the business at hand. “The reality is that I’m not the therapist anymore,” she said, words that echoed her husband’s.

Drawing the Line

Ms. Levin, 63, maintains a lengthy waiting list, and many of the requests are heartbreaking. On a January day, a pregnant mother of a 3-year-old called to say that her husband was so depressed he could not rouse himself from bed. Could he have an immediate appointment? Dr. Levin’s first opening was a month away.

“I get a call like that every day, and I find it really distressing,” Ms. Levin said. “But do we work 12 hours every day instead of 11? At some point, you have to make a choice.”

Initial consultations are 45 minutes, while second and later visits are 15. In those first 45 minutes, Dr. Levin takes extensive medical, psychiatric and family histories. He was trained to allow patients to tell their stories in their own unhurried way with few interruptions, but now he asks a rapid-fire series of questions in something akin to a directed interview. Even so, patients sometimes fail to tell him their most important symptoms until the end of the allotted time.

“There was a guy who came in today, a 56-year-old man with a series of business failures who thinks he has A.D.D.,” or attention deficit disorder, Dr. Levin said. “So I go through the whole thing and ask a series of questions about A.D.D., and it’s not until the very end when he says, ‘On Oct. 28, I thought life was so bad, I was thinking about killing myself.’ ”

With that, Dr. Levin began to consider an entirely different diagnosis from the man’s pattern of symptoms: excessive worry, irritability, difficulty falling asleep, muscle tension in his back and shoulders, persistent financial woes, the early death of his father, the disorganization of his mother.

“The thread that runs throughout this guy’s life is anxiety, not A.D.D. — although anxiety can impair concentration,” said Dr. Levin, who prescribed an antidepressant that he hoped would moderate the man’s anxiety. And he pressed the patient to see a therapist, advice patients frequently ignore. The visit took 55 minutes, putting Dr. Levin behind schedule.

In 15-minute consultations, Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications.

“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”

Dr. Levin, wearing no-iron khakis, a button-down blue shirt with no tie, blue blazer and loafers, had a cheery greeting for his morning patients before ushering them into his office. Emerging 15 minutes later after each session, he would walk into Ms. Levin’s adjoining office to pick up the next chart, announce the name of the patient in the waiting room and usher that person into his office.

He paused at noon to spend 15 minutes eating an Asian chicken salad with Ramen noodles. He got halfway through the salad when an urgent call from a patient made him put down his fork, one of about 20 such calls he gets every day.

By afternoon, he had dispensed with the cheery greetings. At 6 p.m., his waiting room empty, Dr. Levin heaved a sigh after emerging from his office with his 39th patient. Then the bell on his entry door tinkled again, and another patient came up the stairs.

“Oh, I thought I was done,” Dr. Levin said, disappointed. Ms. Levin handed him the last patient’s chart.

Quick Decisions

The Levins said they did not know how long they could work 11-hour days. “And if the stock market hadn’t gone down two years ago, we probably wouldn’t be working this hard now,” Ms. Levin said.

Dr. Levin said that the quality of treatment he offers was poorer than when he was younger. For instance, he was trained to adopt an unhurried analytic calm during treatment sessions. “But my office is like a bus station now,” he said. “How can I have an analytic calm?”

And years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit. “You have to have a diagnosis to get paid,” he said with a shrug. “I play the game.”

In interviews, six of Dr. Levin’s patients — their identities, like those of the other patients, are being withheld to protect their privacy — said they liked him despite the brief visits. “I don’t need a half-hour or an hour to talk,” said a stone mason who has panic attacks and depression and is prescribed an antidepressant. “Just give me some medication, and that’s it. I’m O.K.”

Another patient, a licensed therapist who has post-partum depression worsened by several miscarriages, said she sees Dr. Levin every four weeks, which is as often as her insurer will pay for the visits. Dr. Levin has prescribed antidepressants as well as drugs to combat anxiety. She also sees a therapist, “and it’s really, really been helping me, especially with my anxiety,” she said.

She said she likes Dr. Levin and feels that he listens to her.

Dr. Levin expressed some astonishment that his patients admire him as much as they do.

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”

The Levins’s youngest son, Matthew, is now training to be a psychiatrist, and Dr. Donald Levin said he hoped that his son would not feel his ambivalence about their profession since he will not have experienced an era when psychiatrists lavished time on every patient. Before the 1920s, many psychiatrists were stuck in asylums treating confined patients covered in filth, so most of the 20th century was unusually good for the profession.

In a telephone interview from the University of California, Irvine, where he is completing the last of his training to become a child and adolescent psychiatrist, Dr. Matthew Levin said, “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”

Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy, NYT, 5.3.2011,
http://www.nytimes.com/2011/03/06/health/policy/06doctors.html

Poll Reveals Depth and Trauma

of Joblessness in U.S.

December 15, 2009
The New York Times
By MICHAEL LUO
and MEGAN THEE-BRENAN

More than half of the nation’s unemployed workers have borrowed money from friends or relatives since losing their jobs. An equal number have cut back on doctor visits or medical treatments because they are out of work.

Almost half have suffered from depression or anxiety. About 4 in 10 parents have noticed behavioral changes in their children that they attribute to their difficulties in finding work.

Joblessness has wreaked financial and emotional havoc on the lives of many of those out of work, according to a New York Times/CBS News poll of unemployed adults, causing major life changes, mental health issues and trouble maintaining even basic necessities.

The results of the poll, which surveyed 708 unemployed adults from Dec. 5 to Dec. 10 and has a margin of sampling error of plus or minus four percentage points, help to lay bare the depth of the trauma experienced by millions across the country who are out of work as the jobless rate hovers at 10 percent and, in particular, as the ranks of the long-term unemployed soar.

Roughly half of the respondents described the recession as a hardship that had caused fundamental changes in their lives. Generally, those who have been out of work longer reported experiencing more acute financial and emotional effects.

“I lost my job in March, and from there on, everything went downhill,” said Vicky Newton, 38, of Mount Pleasant, Mich., a single mother who had been a customer-service representative in an insurance agency.

“After struggling and struggling and not being able to pay my house payments or my other bills, I finally sucked up my pride,” she said in an interview after the poll was conducted. “I got food stamps just to help feed my daughter.”

Over the summer, she abandoned her home in Flint, Mich., after she started receiving foreclosure notices. She now lives 90 minutes away, in a rental house owned by her father.

With unemployment driving foreclosures nationwide, a quarter of those polled said they had either lost their home or been threatened with foreclosure or eviction for not paying their mortgage or rent. About a quarter, like Ms. Newton, have received food stamps. More than half said they had cut back on both luxuries and necessities in their spending. Seven in 10 rated their family’s financial situation as fairly bad or very bad.

But the impact on their lives was not limited to the difficulty in paying bills. Almost half said unemployment had led to more conflicts or arguments with family members and friends; 55 percent have suffered from insomnia.

“Everything gets touched,” said Colleen Klemm, 51, of North Lake, Wis., who lost her job as a manager at a landscaping company last November. “All your relationships are touched by it. You’re never your normal happy-go-lucky person. Your countenance, your self-esteem goes. You think, ‘I’m not employable.’ ”

A quarter of those who experienced anxiety or depression said they had gone to see a mental health professional. Women were significantly more likely than men to acknowledge emotional issues.

Tammy Linville, 29, of Louisville, Ky., said she lost her job as a clerical worker for the Census Bureau a year and a half ago. She began seeing a therapist for depression every week through Medicaid but recently has not been able to go because her car broke down and she cannot afford to fix it.

Her partner works at the Ford plant in the area, but his schedule has been sporadic. They have two small children and at this point, she said, they are “saving quarters for diapers.”

“Every time I think about money, I shut down because there is none,” Ms. Linville said. “I get major panic attacks. I just don’t know what we’re going to do.”

Nearly half of the adults surveyed admitted to feeling embarrassed or ashamed most of the time or sometimes as a result of being out of work. Perhaps unsurprisingly, given the traditional image of men as breadwinners, men were significantly more likely than women to report feeling ashamed most of the time.

There was a pervasive sense from the poll that the American dream had been upended for many. Nearly half of those polled said they felt in danger of falling out of their social class, with those out of work six months or more feeling especially vulnerable. Working-class respondents felt at risk in the greatest numbers.

Nearly half of respondents said they did not have health insurance, with the vast majority citing job loss as a reason, a notable finding given the tug of war in Congress over a health care overhaul. The poll offered a glimpse of the potential ripple effect of having no coverage. More than half characterized the cost of basic medical care as a hardship.

Many in the ranks of the unemployed appear to be rethinking their career and life choices. Just over 40 percent said they had moved or considered moving to another part of the state or country where there were more jobs. More than two-thirds of respondents had considered changing their career or field, and 44 percent of those surveyed had pursued job retraining or other educational opportunities.

Joe Whitlow, 31, of Nashville, worked as a mechanic until a repair shop he was running with a friend finally petered out in August. He had contemplated going back to school before, but the potential loss in income always deterred him. Now he is enrolled at a local community college, planning to study accounting.

“When everything went bad, not that I didn’t have a choice, but it made the choice easier,” Mr. Whitlow said.

The poll also shed light on the formal and informal safety nets that the jobless have relied upon. More than half said they were receiving or had received unemployment benefits. But 61 percent of those receiving benefits said the amount was not enough to cover basic necessities.

Meanwhile, a fifth said they had received food from a nonprofit organization or religious institution. Among those with a working spouse, half said their spouse had taken on additional hours or another job to help make ends meet.

Even those who have stayed employed have not escaped the recession’s bite. According to a New York Times/CBS News nationwide poll conducted at the same time as the poll of unemployed adults, about 3 in 10 people said that in the past year, as a result of bad economic conditions, their pay had been cut.

In terms of casting blame for the high unemployment rate, 26 percent of unemployed adults cited former President George W. Bush; 12 percent pointed the finger at banks; 8 percent highlighted jobs going overseas and the same number blamed politicians. Only 3 percent blamed President Obama.

Those out of work were split, however, on the president’s handling of job creation, with 47 percent expressing approval and 44 percent disapproval.

Unemployed Americans are divided over what the future holds for the job market: 39 percent anticipate improvement, 36 percent expect it will stay the same, and 22 percent say it will get worse.

Marina Stefan and Dalia Sussman contributed reporting.

Poll Reveals Depth and Trauma of Joblessness in U.S.,
NYT,
15.12.2009,
https://www.nytimes.com/2009/12/15/
us/15poll.html

Poor Children

Likelier to Get Antipsychotics

December 12, 2009
The New York Times
By DUFF WILSON

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?

The questions go beyond the psychological impact on Medicaid children, serious as that may be. Antipsychotic drugs can also have severe physical side effects, causing drastic weight gain and metabolic changes resulting in lifelong physical problems.

On Tuesday, a pediatric advisory committee to the Food and Drug Administration met to discuss the health risks for all children who take antipsychotics. The panel will consider recommending new label warnings for the drugs, which are now used by an estimated 300,000 people under age 18 in this country, counting both Medicaid patients and those with private insurance.

Meanwhile, a group of Medicaid medical directors from 16 states, under a project they call Too Many, Too Much, Too Young, has been experimenting with ways to reduce prescriptions of antipsychotic drugs among Medicaid children.

They plan to publish a report early next year.

The Rutgers-Columbia study will also be published early next year, in the peer-reviewed journal Health Affairs. But the findings have already been posted on the Web, setting off discussion among experts who treat and study troubled young people.

Some experts say they are stunned by the disparity in prescribing patterns. But others say it reinforces previous indications, and their own experience, that children with diagnoses of mental or emotional problems in low-income families are more likely to be given drugs than receive family counseling or psychotherapy.

Part of the reason is insurance reimbursements, as Medicaid often pays much less for counseling and therapy than private insurers do. Part of it may have to do with the challenges that families in poverty may have in consistently attending counseling or therapy sessions, even when such help is available.

“It’s easier for patients, and it’s easier for docs,” said Dr. Derek H. Suite, a psychiatrist in the Bronx whose pediatric cases include children and adolescents covered by Medicaid and who sometimes prescribes antipsychotics. “But the question is, ‘What are you prescribing it for?’ That’s where it gets a little fuzzy.”

Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors have given antipsychotics that the patients do not seem to need. Recently, for example, he met with a 15-year-old girl. She had stopped taking the antipsychotic medication that had been prescribed for her after a single examination, paid for by Medicaid, at a clinic where she received a diagnosis of bipolar disorder.

Why did she stop? Dr. Suite asked. “I can control my moods,” the girl said softly.

After evaluating her, Dr. Suite decided she was right. The girl had arguments with her mother and stepfather and some insomnia. But she was a good student and certainly not bipolar, in Dr. Suite’s opinion.

“Normal teenager,” Dr. Suite said, nodding. “No scrips for you.”

Because there can be long waits to see the psychiatrists accepting Medicaid, it is often a pediatrician or family doctor who prescribes an antipsychotic to a Medicaid patient — whether because the parent wants it or the doctor believes there are few other options.

Some experts even say Medicaid may provide better care for children than many covered by private insurance because the drugs — which can cost $400 a month — are provided free to patients, and families do not have to worry about the co-payments and other insurance restrictions.

“Maybe Medicaid kids are getting better treatment,” said Dr. Gabrielle Carlson, a child psychiatrist and professor at the Stony Brook School of Medicine. “If it helps keep them in school, maybe it’s not so bad.”

In any case, as Congress works on health care legislation that could expand the nation’s Medicaid rolls by 15 million people — a 43 percent increase — the scope of the antipsychotics problem, and the expense, could grow in coming years.

Even though the drugs are typically cheaper than long-term therapy, they are the single biggest drug expenditure for Medicaid, costing the program $7.9 billion in 2006, the most recent year for which the data is available.

The Rutgers-Columbia research, based on millions of Medicaid and private insurance claims, is the most extensive analysis of its type yet on children’s antipsychotic drug use. It examined records for children in seven big states — including New York, Texas and California — selected to be representative of the nation’s Medicaid population, for the years 2001 and 2004.

The data indicated that more than 4 percent of patients ages 6 to 17 in Medicaid fee-for-service programs received antipsychotic drugs, compared with less than 1 percent of privately insured children and adolescents. More recent data through 2007 indicates that the disparity has remained, said Stephen Crystal, a Rutgers professor who led the study. Experts generally agree that some characteristics of the Medicaid population may contribute to psychological problems or psychiatric disorders. They include the stresses of poverty, single-parent homes, poorer schools, lack of access to preventive care and the fact that the Medicaid rolls include many adults who are themselves mentally ill.

As a result, studies have found that children in low-income families may have a higher rate of mental health problems — perhaps two to one — compared with children in better-off families. But that still does not explain the four-to-one disparity in prescribing antipsychotics.

Professor Crystal, who is the director of the Center for Pharmacotherapy at Rutgers, says his team’s data also indicates that poorer children are more likely to receive antipsychotics for less serious conditions than would typically prompt a prescription for a middle-class child.

But Professor Crystal said he did not have clear evidence to form an opinion on whether or not children on Medicaid were being overtreated.

“Medicaid kids are subject to a lot of stresses that lead to behavior issues which can be hard to distinguish from more serious psychiatric conditions,” he said. “It’s very hard to pin down.”

And yet Dr. Mark Olfson, a psychiatry professor at Columbia and a co-author of the study, said at least one thing was clear: “A lot of these kids are not getting other mental health services.”

The F.D.A. has approved antipsychotic drugs for children specifically to treat schizophrenia, autism and bipolar disorder. But they are more frequently prescribed to children for other, less extreme conditions, including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders — especially when the children are covered by Medicaid, the new study shows.

Although doctors may legally prescribe the drugs for these “off label” uses, there have been no long-term studies of their effects when used for such conditions.

The Rutgers-Columbia study found that Medicaid children were more likely than those with private insurance to be given the drugs for off-label uses like A.D.H.D. and conduct disorders. The privately insured children, in turn, were more likely than their Medicaid counterparts to receive the drugs for F.D.A.-approved uses like bipolar disorder.

Even if parents enrolled in Medicaid may be reluctant to put their children on drugs, some come to rely on them as the only thing that helps.

“They say it’s impossible to stop now,” Evelyn Torres, 48, of the Bronx, said of her son’s use of antipsychotics since he received a diagnosis of bipolar disorder at age 3. Seven years later, the boy is now also afflicted with weight and heart problems. But Ms. Torres credits Medicaid for making the boy’s mental and physical conditions manageable. “They’re helping with everything,” she said.

Poor Children Likelier to Get Antipsychotics, NYT, 12.12.2009,
http://www.nytimes.com/2009/12/12/health/12medicaid.html

Brain Power

Surgery for Mental Ills

Offers Hope and Risk

November 27, 2009

The New York Times

By BENEDICT CAREY

One was a middle-aged man who refused to get into the shower. The other was a teenager who was afraid to get out.

The man, Leonard, a writer living outside Chicago, found himself completely unable to wash himself or brush his teeth. The teenager, Ross, growing up in a suburb of New York, had become so terrified of germs that he would regularly shower for seven hours. Each received a diagnosis of severe obsessive-compulsive disorder, or O.C.D., and for years neither felt comfortable enough to leave the house.

But leave they eventually did, traveling in desperation to a hospital in Rhode Island for an experimental brain operation in which four raisin-sized holes were burned deep in their brains.

Today, two years after surgery, Ross is 21 and in college. “It saved my life,” he said. “I really believe that.”

The same cannot be said for Leonard, 67, who had surgery in 1995. “There was no change at all,” he said. “I still don’t leave the house.”

Both men asked that their last names not be used to protect their privacy.

The great promise of neuroscience at the end of the last century was that it would revolutionize the treatment of psychiatric problems. But the first real application of advanced brain science is not novel at all. It is a precise, sophisticated version of an old and controversial approach: psychosurgery, in which doctors operate directly on the brain.

In the last decade or so, more than 500 people have undergone brain surgery for problems like depression, anxiety, Tourette’s syndrome, even obesity, most as a part of medical studies. The results have been encouraging, and this year, for the first time since frontal lobotomy fell into disrepute in the 1950s, the Food and Drug Administration approved one of the surgical techniques for some cases of O.C.D.

While no more than a few thousand people are impaired enough to meet the strict criteria for the surgery right now, millions more suffering from an array of severe conditions, from depression to obesity, could seek such operations as the techniques become less experimental.

But with that hope comes risk. For all the progress that has been made, some psychiatrists and medical ethicists say, doctors still do not know much about the circuits they are tampering with, and the results are unpredictable: some people improve, others feel little or nothing, and an unlucky few actually get worse. In this country, at least one patient was left unable to feed or care for herself after botched surgery.

Moreover, demand for the operations is so high that it could tempt less experienced surgeons to offer them, without the oversight or support of research institutions.

And if the operations are oversold as a kind of all-purpose cure for emotional problems — which they are not, doctors say — then the great promise could quickly feel like a betrayal.

“We have this idea — it’s almost a fetish — that progress is its own justification, that if something is promising, then how can we not rush to relieve suffering?” said Paul Root Wolpe, a medical ethicist at Emory University.

It was not so long ago, he noted, that doctors considered the frontal lobotomy a major advance — only to learn that the operation left thousands of patients with irreversible brain damage. Many promising medical ideas have run aground, Dr. Wolpe added, “and that’s why we have to move very cautiously.”

Dr. Darin D. Dougherty, director of the division of neurotherapeutics at Massachusetts General Hospital and an associate professor of psychiatry at Harvard, put it more bluntly. Given the history of failed techniques, like frontal lobotomy, he said, “If this effort somehow goes wrong, it’ll shut down this approach for another hundred years.”

A Last Resort

Five percent to 15 percent of people given diagnoses of obsessive-compulsive disorder are beyond the reach of any standard treatment. Ross said he was 12 when he noticed that he took longer to wash his hands than most people. Soon he was changing into clean clothes several times a day. Eventually he would barely come out of his room, and when he did, he was careful about what he touched.

“It got so bad, I didn’t want any contact with people,” he said. “I couldn’t hug my own parents.”

Before turning to writing, Leonard was a healthy, successful businessman. Then he was struck, out of nowhere, with a fear of insects and spiders. He overcame the phobias, only to find himself with a strong aversion to bathing. He stopped washing and could not brush his teeth or shave.

“I just looked horrible,” he said. “I had a big, ugly beard. My skin turned black. I was afraid to be seen out in public. I looked like a street person. If you were a policeman, you would have arrested me.”

Both tried antidepressants like Prozac, as well as a variety of other medications. They spent many hours in standard psychotherapy for obsessive-compulsive disorder, gradually becoming exposed to dreaded situations — a moldy shower stall, for instance — and practicing cognitive and relaxation techniques to defuse their anxiety.

To no avail.

“It worked for a while for me, but never lasted,” Ross said. “I mean, I just thought my life was over.”

But there was one more option, their doctors told them, a last resort. At a handful of medical centers here and abroad, including Harvard, the University of Toronto and the Cleveland Clinic, doctors for years have performed a variety of experimental procedures, most for O.C.D. or depression, each guided by high-resolution imaging technology. The companies that make some of the devices have supported the research, and paid some of the doctors to consult on operations.

In one procedure, called a cingulotomy, doctors drill into the skull and thread wires into an area called the anterior cingulate. There they pinpoint and destroy pinches of tissue that lie along a circuit in each hemisphere that connects deeper, emotional centers of the brain to areas of the frontal cortex, where conscious planning is centered.

This circuit appears to be hyperactive in people with severe O.C.D., and imaging studies suggest that the surgery quiets that activity. In another operation, called a capsulotomy, surgeons go deeper, into an area called the internal capsule, and burn out spots in a circuit also thought to be overactive.

An altogether different approach is called deep brain stimulation, or D.B.S., in which surgeons sink wires into the brain but leave them in place. A pacemaker-like device sends a current to the electrodes, apparently interfering with circuits thought to be hyperactive in people with obsessive-compulsive disorder (and also those with severe depression). The current can be turned up, down or off, so deep brain stimulation is adjustable and, to some extent, reversible.

In yet another technique, doctors place the patient in an M.R.I.-like machine that sends beams of radiation into the skull. The beams pass through the brain without causing damage, except at the point where they converge. There they burn out spots of tissue from O.C.D.-related circuits, with similar effects as the other operations. This option, called gamma knife surgery, was the one Leonard and Ross settled on.

The institutions all have strict ethical screening to select candidates. The disorder must be severe and disabling, and all standard treatments exhausted. The informed-consent documents make clear that the operation is experimental and not guaranteed to succeed.

Nor is desperation by itself sufficient to qualify, said Richard Marsland, who oversees the screening process at Butler Hospital in Providence, R.I., which works with surgeons at Rhode Island Hospital, where Leonard and Ross had the operation.

“We get hundreds of requests a year and do only one or two,” Mr. Marsland said. “And some of the people we turn down are in bad shape. Still, we stick to the criteria.”

For those who have successfully recovered from surgery, this intensive screening seems excessive. “I know why it’s done, but this is an operation that could make the difference between life and death for so many people,” said Gerry Radano, whose book “Contaminated: My Journey Out of Obsessive-Compulsive Disorder” (Bar-le-Duc Books, 2007), recounts her own suffering and long recovery from surgery. She also has a Web site, freeofocd.com, where people from around the world consult with her.

But for the doctors running the programs, this screening is crucial. “If patients are poorly selected or not followed well, there’ll be an increasing number of bad outcomes, and the promise of this field will wither away,” said Dr. Ben Greenberg, the psychiatrist in charge of the program at Butler.

Dr. Greenberg said about 60 percent of patients who underwent either gamma knife surgery or deep brain stimulation showed significant improvement, and the rest showed little or no improvement. For this article, he agreed to put a reporter in touch with one — Leonard — who did not have a good experience.

The Danger of Optimism

The true measure of an operation, medical ethicists say, is its overall effect on a person’s life, not only on specific symptoms.

In the early days of psychosurgery, after World War II, doctors published scores of papers detailing how lobotomy relieved symptoms of mental distress. In 1949, the Portuguese neurologist Egas Moniz won the Nobel Prize in medicine for inventing the procedure.

But careful follow-up painted a darker picture: of people who lost motivation, who developed the helpless indifference dramatized by the post-op rebel McMurphy in Ken Kesey’s novel “One Flew Over the Cuckoo’s Nest,” played by Jack Nicholson in the 1975 movie.

The newer operations pinpoint targets on specific, precisely mapped circuits, whereas the frontal lobotomy amounted to a crude slash into the brain behind the eyes, blindly mangling whatever connections and circuits were in the way. Still, there remain large gaps in doctors’ understanding of the circuits they are operating on.

In a paper published last year, researchers at the Karolinska Institute in Sweden reported that half the people who had the most commonly offered operations for obsessive-compulsive disorder showed symptoms of apathy and poor self-control for years afterward, despite scoring lower on a measure of O.C.D. severity.

“An inherent problem in most research is that innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid,” Dr. Christian Ruck, the lead author of the paper, wrote in an e-mail message. The institute’s doctors, who burned out significantly more tissue than other centers did, no longer perform the operations, partly, Dr. Ruck said, as a result of his findings.

In the United States, at least one patient has suffered disabling brain damage from an operation for O.C.D. The case led to a $7.5 million judgment in 2002 against the Ohio hospital that performed the procedure. (It is no longer offered there.)

Most outcomes, whether favorable or not, have had less remarkable immediate results. The brain can take months or even years to fully adjust after the operations. The revelations about the people treated at Karolinska “underscore the importance of face-to-face assessments of adverse symptoms,” Dr. Ruck and his co-authors concluded.

The Long Way Back

Ross said he felt no difference for months after surgery, until the day his brother asked him to play a video game in the basement, and down the stairs he went.

“I just felt like doing it,” he said. “I would never have gone down there before.”

He said the procedure seemed to give the psychotherapy sessions a chance to work, and last summer he felt comfortable enough to stop them. He now spends his days studying, going to class, playing the odd video game to relax. He has told friends about the operation, he said, “and they’re O.K. with it — they know the story.”

Leonard is still struggling, for reasons no one understands. He keeps odd hours, working through most nights and sleeping much of the day. He is not unhappy, he said, but he has the same aversion to washing and still lives like a hermit.

“I still don’t know why I’m like this, and I would still try anything that could help,” he said. “But at this point, obviously, I’m skeptical of the efficacy of surgery, at least for me.”

Ms. Radano, who wrote the book about her recovery, said the most important thing about the surgery was that it gave people a chance. “That’s all people in this situation want, and I know because I was there,” she said while getting into her car on a recent afternoon.

On the passenger seat was a container of decontaminating hand wipes. She pointed and laughed. “See? You’re never completely out.”

Surgery for Mental Ills Offers Hope and Risk, NYT, 27.11.2009,
http://www.nytimes.com/2009/11/27/health/research/27brain.html

William Duke

A Crisis of Confidence for Masters of the Universe

NYT 16 December 2008

http://www.nytimes.com/2008/12/16/health/views/16mind.html

Mind

A Crisis of Confidence

for Masters of the Universe

December 16, 2008
The New York Times
By RICHARD A. FRIEDMAN, M.D.

Meltdown. Collapse. Depression. Panic. The words would seem to apply equally to the global financial crisis and the effect of that crisis on the human psyche.

Of course, it is too soon to gauge the true psychiatric consequences of the economic debacle; it will be some time before epidemiologists can tell us for certain whether depression and suicide are on the rise. But there’s no question that the crisis is leaving its mark on individuals, especially men.

One patient, a hedge fund analyst, came to me recently in a state of great anxiety. “It’s bad, but it might get a lot worse,” I recall him saying. The anxiety was expected and appropriate: he had lost a great deal of his (and others’) assets, and like the rest of us he had no idea where the bottom was. I would have been worried if he hadn’t been anxious.

Over the course of several weeks, with the help of some anti-anxiety medication, his panic subsided as he realized that he would most likely survive economically.

But then something else emerged. He came in one day looking subdued and plopped down in the chair. “I’m over the anxiety, but now I feel like a loser.” This from a supremely self-confident guy who was viewed by his colleagues as an unstoppable optimist.

He was not clinically depressed: his sleep, appetite, sex drive and ability to enjoy himself outside of work were unchanged. This was different.

The problem was that his sense of success and accomplishment was intimately tied to his financial status; he did not know how to feel competent or good about himself without this external measure of his value.

He wasn’t the only one. Over the last few months, I have seen a group of patients, all men, who experienced a near collapse in their self-esteem, though none of them were clinically depressed.

Another patient summed it up: “I used to be a master-of-the-universe kind of guy, but this cut me down to size.”

I have plenty of female patients who work in finance at high levels, but none of them has had this kind of psychological reaction. I can’t pretend this is a scientific survey, but I wonder if men are more likely than women to respond this way. At the risk of trading in gender stereotypes, do men rely disproportionately more on their work for their self-esteem than women do? Or are they just more vulnerable to the inevitable narcissistic injury that comes with performing poorly or losing one’s job?

A different patient was puzzled not by his anxiety about the market, but by his total lack of self-confidence. He had always had an easy intuitive feel for finance. But in the wake of the market collapse, he seriously questioned his knowledge and skill.

Each of these patients experienced a sudden loss of the sense of mastery in the face of the financial meltdown and could not gauge their success or failure without the only benchmark they knew: a financial profit.

The challenge of maintaining one’s self-esteem without recognition or reward is daunting. Chances are that if you are impervious to self-doubt and go on feeling good about yourself in the face of failure, you have either won the temperamental sweepstakes or you have a real problem tolerating bad news.

Of course, the relationship between self-esteem and achievement can be circular. Some argue that that the best way to build self-esteem is to tell people at every turn how nice, smart and talented they are.

That is probably a bad idea if you think that self-esteem and recognition should be the result of accomplishment; you feel good about yourself, in part, because you have done something well. On the other hand, it is hard to imagine people taking the first step without first having some basic notion of self-confidence.

On Wall Street, though, a rising tide lifts many boats and vice versa, which means that there are many people who succeed — or fail — through no merit or fault of their own.

This observation might ease a sense of personal responsibility for the economic crisis, but it was of little comfort to my patients. I think this is because for many of them, the previously expanding market gave them a sense of power along with something as strong as a drug: thrill.

The human brain is acutely attuned to rewards like money, sex and drugs. It turns out that the way a reward is delivered has an enormous impact on its strength. Unpredictable rewards produce much larger signals in the brain’s reward circuit than anticipated ones. Your reaction to situations that are either better or worse than expected is generally stronger to those you can predict.

In a sense, the stock market is like a vast gambling casino where the reward can be spectacular, but always unpredictable. For many, the lure of investing is the thrill of uncertain reward. Now that thrill is gone, replaced by anxiety and fear.

My patients lost more than money in the market. Beyond the rush and excitement, they lost their sense of competence and success. At least temporarily: I have no doubt that, like the economy, they will recover. But it’s a reminder of just how fragile our self-confidence can be.

Richard A. Friedman is a professor of psychiatry

at Weill Cornell Medical College.

A Crisis of Confidence for Masters of the Universe, NYT, 16.12.2008,
http://www.nytimes.com/2008/12/16/health/views/16mind.html

Use of Antipsychotics in Children

Is Criticized

November 19, 2008
The New York Times
By GARDINER HARRIS

WASHINGTON — Powerful antipsychotic medicines are being used far too cavalierly in children, and federal drug regulators must do more to warn doctors of their substantial risks, a panel of federal drug experts said Tuesday.

More than 389,000 children and teenagers were treated last year with Risperdal, one of five popular medicines known as atypical antipsychotics. Of those patients, 240,000 were 12 or younger, according to data presented to the committee. In many cases, the drug was prescribed to treat attention deficit disorders.

But Risperdal is not approved for attention deficit problems, and its risks — which include substantial weight gain, metabolic disorders and muscular tics that can be permanent — are too profound to justify its use in treating such disorders, panel members said.

“This committee is frustrated,” said Dr. Leon Dure, a pediatric neurologist from the University of Alabama School of Medicine who was on the panel. “And we need to find a way to accommodate this concern of ours.”

The meeting on Tuesday was scheduled to be a routine review of the pediatric safety of Risperdal and Zyprexa, popular antipsychotic medicines made, respectively, by Johnson & Johnson and Eli Lilly & Company. Food and Drug Administration officials proposed that the committee endorse the agency’s routine monitoring of the safety of the medicines in children and support its previous efforts to highlight the drugs’ risks.

But committee members unanimously rejected the agency’s proposals, saying that far more needed to be done to discourage the medicines’ growing use in children, particularly to treat conditions for which the medicines have not been approved.

“The data show there is a substantial amount of prescribing for attention deficit disorder, and I wonder if we have given enough weight to the adverse-event profile of the drug in light of this,” Dr. Daniel Notterman, a senior health policy analyst at Princeton University and a panel member, said when speaking about Risperdal.

Drug agency officials responded that they had already placed strongly worded warnings on the drugs’ labels.

“I’m a little puzzled about the statement that the label is inadequate,” said Dr. Thomas Laughren, director of the agency’s division of psychiatry products. “I’m anxious to hear what more we can do in the labeling.”

Kara Russell, a spokeswoman for Johnson & Johnson, said, “Adverse drug reactions associated with Risperdal use in approved indications are accurately reflected in the label.”

But panelists said the current warnings were not enough.

While panel members spoke at length about Risperdal, they said their concerns applied to the other medicines in its class, including Zyprexa, Seroquel, Abilify and Geodon.

The committee’s concerns are part of a growing chorus of complaints about the increasing use of antipsychotic medicines in children and teenagers. Prescription rates for the drugs have increased more than fivefold for children in the past decade and a half, and doctors now use the drugs to settle outbursts and aggression in children with a wide variety of diagnoses, even though children are especially susceptible to their side effects.

A consortium of state Medicaid directors is evaluating the use of the drugs in children on state Medicaid rolls to ensure that they are being properly prescribed.

The growing use of the medicines has been driven partly by the sudden popularity of the diagnosis of pediatric bipolar disorder.

The leading advocate for the bipolar diagnosis is Dr. Joseph Biederman, a child psychiatrist at Harvard University whose work is under a cloud after a Congressional investigation revealed that he had failed to report to his university at least $1.4 million in outside income from the makers of antipsychotic medicines.

In the past year, Risperdal prescriptions to patients 17 and younger increased 10 percent, while prescriptions among adults declined 5 percent. Most of the pediatric prescriptions were written by psychiatrists.

From 1993 through the first three months of 2008, 1,207 children given Risperdal suffered serious problems, including 31 who died. Among the deaths was a 9-year-old with attention deficit problems who suffered a fatal stroke 12 days after starting therapy with Risperdal.

At least 11 of the deaths were children whose treatment with Risperdal was unapproved by the F.D.A. Once the agency approves a medicine for a particular condition, doctors are free to prescribe it for other problems.

Panel members said they had for years been concerned about the effects of Risperdal and similar medicines, but F.D.A. officials said no studies had been done to test the drugs’ long-term safety.

Dr. Dure said he was concerned that doctors often failed to recognize the movement disorders, including tardive dyskinesia and dystonia, that can result from using these medicines.

“I have a bias that extra-pyramidal side effects are being under-recognized with these agents,” Dr. Dure said.

Dr. Laughren of the F.D.A. said the agency could do little to fix the problem. Instead, he said, medical specialty societies must do a better job educating doctors about the drugs’ side effects.

Use of Antipsychotics in Children Is Criticized, NYT, 19.11.2008,
http://www.nytimes.com/2008/11/19/health/policy/19fda.html

Bailout Provides

More Mental Health Coverage

October 6, 2008
The New York Times
By ROBERT PEAR

WASHINGTON — More than one-third of all Americans will soon receive better insurance coverage for mental health treatments because of a new law that, for the first time, requires equal coverage of mental and physical illnesses.

The requirement, included in the economic bailout bill that President Bush signed on Friday, is the result of 12 years of passionate advocacy by friends and relatives of people with mental illness and addiction disorders. They described the new law as a milestone in the quest for civil rights, an effort to end insurance discrimination and to reduce the stigma of mental illness.

Most employers and group health plans provide less coverage for mental health care than for the treatment of physical conditions like cancer, heart disease or broken bones. They will need to adjust their benefits to comply with the new law, which requires equivalence, or parity, in the coverage.

For decades, insurers have set higher co-payments and deductibles and stricter limits on treatment for addiction and mental illnesses.

By wiping away such restrictions, doctors said, the new law will make it easier for people to obtain treatment for a wide range of conditions, including depression, autism, schizophrenia, eating disorders and alcohol and drug abuse.

Frank B. McArdle, a health policy expert at Hewitt Associates, a benefits consulting firm, said the law would force sweeping changes in the workplace.

“A large majority of health plans currently have limits on hospital inpatient days and outpatient visits for mental health treatments, but not for other treatments,” Mr. McArdle said. “They will have to change their plan design.”

Federal officials said the law would improve coverage for 113 million people, including 82 million in employer-sponsored plans that are not subject to state regulation. The effective date, for most health plans, will be Jan. 1, 2010.

The Congressional Budget Office estimates that the new requirement will increase premiums by an average of about two-tenths of 1 percent. Businesses with 50 or fewer employees are exempt.

The goal of mental health parity once seemed politically unrealistic but gained widespread support for several reasons:

¶Researchers have found biological causes and effective treatments for numerous mental illnesses.

¶A number of companies now specialize in managing mental health benefits, making the costs to insurers and employers more affordable. The law allows these companies to continue managing benefits.

¶Employers have found that productivity tends to increase after workers are treated for mental illnesses and drug or alcohol dependence. Such treatments can reduce the number of lost work days.

¶The stigma of mental illness may have faded as people see members of the armed forces returning from Iraq and Afghanistan with serious mental problems.

¶Parity has proved workable when tried at the state level and in the health insurance program for federal employees, including members of Congress.

Dr. Steven E. Hyman, a former director of the National Institute of Mental Health, said it was impossible to justify insurance discrimination when an overwhelming body of scientific evidence showed that “mental illnesses represent real diseases of the brain.”

“Genetic mutations and unlucky combinations of normal genes contribute to the risk of autism and schizophrenia,” Dr. Hyman said. “There is also strong evidence that people with schizophrenia have thinning of the gray matter in parts of the brain that permit us to control our thoughts and behavior.”

The drive for mental health parity was led by Senator Pete V. Domenici, Republican of New Mexico, who has a daughter with schizophrenia, and Senator Paul Wellstone, the Minnesota Democrat who was killed in a plane crash in 2002. Mr. Wellstone had a brother with severe mental illness.

Prominent members of both parties, including Betty Ford, Rosalynn Carter and Tipper Gore, pleaded with Congress to pass the legislation.

Representatives Patrick J. Kennedy, Democrat of Rhode Island, and Jim Ramstad, Republican of Minnesota, led the fight in the House. Mr. Kennedy has been treated for depression and, by his own account, became “the public face of alcoholism and addiction” after a car crash on Capitol Hill in 2006. Mr. Ramstad traces his zeal to the day in 1981 when he woke up in a jail cell in South Dakota after an alcoholic blackout.

The Senate passed a mental health parity bill in September 2007. The House passed a different version in March of this year.

A breakthrough occurred when sponsors of the House bill agreed to drop a provision that required insurers to cover treatment for any condition listed in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.

Employers objected to such a requirement, saying it would have severely limited their discretion over what benefits to provide. Among the conditions in the manual, critics noted, are caffeine intoxication and sleep disorders resulting from jet lag.

Doctors often complain that insurers, especially managed care companies, interfere in their treatment decisions. But doctors and mental health advocates cited the work of such companies in arguing that mental health parity would be affordable, because the benefits could be managed.

Pamela B. Greenberg, president of the Association for Behavioral Health and Wellness, a trade group, said providers of mental health care typically drafted a treatment plan for each person. In complex cases, she said, a case manager or care coordinator monitors the patient’s progress.

A managed care company can refuse to pay for care, on the grounds that it is not medically necessary or “clinically appropriate.” But under the new law, insurers must disclose their criteria for determining medical necessity, as well as the reason for denying any particular claim for mental health services.

Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, an advocacy group, said, “Under the new law, we will probably see more aggressive management of mental health benefits because insurers can no longer impose arbitrary limits.”

The law will also encourage insurers to integrate coverage for mental health care with medical and surgical benefits. Under the law, insurers cannot have separate cost-sharing requirements or treatment limits that apply only to mental illness and addiction disorders.

The law comes just three months after Congress eliminated discriminatory co-payments in Medicare, the program for people who are 65 and older or disabled.

Medicare beneficiaries pay 20 percent of the government-approved amount for most doctors’ services but 50 percent for outpatient mental health services. The co-payment for mental health care will be gradually reduced to 20 percent over six years.

The mental health parity law was forged in a highly unusual consensus-building process. For years, mental health advocates had been lobbying on the issue.

Insurers and employers, which had resisted earlier versions of the legislation, came to the table in 2004 at the request of Mr. Domenici and Senators Edward M. Kennedy, Democrat of Massachusetts, and Michael B. Enzi, Republican of Wyoming.

Each side had, in effect, a veto over the language of any bill. Insurers and employers, seeing broad bipartisan support for the goal in both houses of Congress, decided to work with mental health advocates. Each side gained the other’s trust.

“It was an incredible process,” said E. Neil Trautwein, a vice president of the National Retail Federation, a trade group. “We built the bill piece by piece from the ground up. It’s a good harbinger for future efforts on health care reform.”

Bailout Provides More Mental Health Coverage, NYT, 6.10.2008,
http://www.nytimes.com/2008/10/06/washington/06mental.html

Op-Ed Columnist

The Luxurious Growth

July 15, 2008

The New York Times

By DAVID BROOKS

We all know the story of Dr. Frankenstein, the scientist so caught up in his own research that he arrogantly tried to create new life and a new man. Today, if you look at people who study how genetics shape human behavior, you find a collection of anti-Frankensteins. As the research moves along, the scientists grow more modest about what we are close to knowing and achieving.

It wasn’t long ago that headlines were blaring about the discovery of an aggression gene, a happiness gene or a depression gene. The implication was obvious: We’re beginning to understand the wellsprings of human behavior, and it won’t be long before we can begin to intervene to enhance or transform human life.

Few talk that way now. There seems to be a general feeling, as a Hastings Center working group put it, that “behavioral genetics will never explain as much of human behavior as was once promised.”

Studies designed to link specific genes to behavior have failed to find anything larger than very small associations. It’s now clear that one gene almost never leads to one trait. Instead, a specific trait may be the result of the interplay of hundreds of different genes interacting with an infinitude of environmental factors.

First, there is the complexity of the genetic process. As Jim J. Manzi pointed out in a recent essay in National Review, if a trait like aggressiveness is influenced by just 100 genes, and each of those genes can be turned on or off, then there are a trillion trillion possible combinations of these gene states.

Second, because genes respond to environmental signals, there’s the complexity of the world around. Prof. Eric Turkheimer of the University of Virginia, conducted research showing that growing up in an impoverished environment harms I.Q. He was asked what specific interventions would help children realize their potential. But, he noted, that he had no good reply. Poverty as a whole has this important impact on people, but when you try to dissect poverty and find out which specific elements have the biggest impact, you find that no single factor really explains very much. It’s possible to detect the total outcome of a general situation. It’s harder to draw a linear relationship showing cause and effect.

Third, there is the fuzziness of the words we use to describe ourselves. We talk about depression, anxiety and happiness, but it’s not clear how the words that we use to describe what we feel correspond to biological processes. It could be that we use one word, depression, to describe many different things, or perhaps depression is merely a symptom of deeper processes that we’re not aware of. In the current issue of Nature, there is an essay about the arguments between geneticists and neuroscientists as they try to figure out exactly what it is that they are talking about.

The bottom line is this: For a time, it seemed as if we were about to use the bright beam of science to illuminate the murky world of human action. Instead, as Turkheimer writes in his chapter in the book, “Wrestling With Behavioral Genetics,” science finds itself enmeshed with social science and the humanities in what researchers call the Gloomy Prospect, the ineffable mystery of why people do what they do.

The prospect may be gloomy for those who seek to understand human behavior, but the flip side is the reminder that each of us is a Luxurious Growth. Our lives are not determined by uniform processes. Instead, human behavior is complex, nonlinear and unpredictable. The Brave New World is far away. Novels and history can still produce insights into human behavior that science can’t match.

Just as important is the implication for politics. Starting in the late 19th century, eugenicists used primitive ideas about genetics to try to re-engineer the human race. In the 20th century, communists used primitive ideas about “scientific materialism” to try to re-engineer a New Soviet Man.

Today, we have access to our own genetic recipe. But we seem not to be falling into the arrogant temptation — to try to re-engineer society on the basis of what we think we know. Saying farewell to the sort of horrible social engineering projects that dominated the 20th century is a major example of human progress.

We can strive to eliminate that multivariate thing we call poverty. We can take people out of environments that (somehow) produce bad outcomes and try to immerse them into environments that (somehow) produce better ones. But we’re not close to understanding how A leads to B, and probably never will be.

This age of tremendous scientific achievement has underlined an ancient philosophic truth — that there are severe limits to what we know and can know; that the best political actions are incremental, respectful toward accumulated practice and more attuned to particular circumstances than universal laws.

Bob Herbert is off today.

The Luxurious Growth,
NYT,
15.7.2008,
http://www.nytimes.com/2008/07/15/opinion/15brooks.html?ref=opinion

This Land

Through Decades of Change,

a Core Crew Remains

June 30, 2008

The New York Times

By DAN BARRY

Danbury, Conn.

Lately, in the maintenance garage at the Danbury rest stop just off Interstate 84, the topic of conversation can shift suddenly from grass-cutting and litter pickup to death. What happens afterward? Where do we go? When I die, will you remember me?

Is there coffee in heaven?

The conversation among the four workers might return just as abruptly to what needs to be mowed next, or it might simply surrender to silence, like a lawn mower out of gas. After a while they will wriggle their hands back into their work gloves and return to prettifying the grounds for people who barely notice them, who are just passing through.

Then, when midafternoon arrives, the men will climb back into a state-owned van. Bob, 57, who wants to be known simply as Bob, sits in the way back, his Special Olympics cap worn at an almost jaunty angle. Bobby McKay, 62, sits in the middle row, staring out the window, his travel-worthy coffee mug cradled like a puppy in his hands. Tony Daversa, 59, sits in the front passenger seat, chattering about everything he sees, including a passing cemetery.

“There’s the body,” he says one afternoon.

“Will you shut up,” his friend Bob jokes from the back.

“There’s the body,” Tony says again, in sing-song.

At the wheel is Dave Lavery, 51, their driver, supervisor, counselor, friend. On the way to work he always stops the van at the South Britain Country Store so they can buy coffee, and on the way home he stops there again because refills are free. He gently reminds Bob not to curse. He encourages Bobby to talk. He listens to Tony’s questions about mortality, prompted by recent deaths in Tony’s small, removed world.

Soon a collegelike campus comes into view, signaling that Dave has safely returned them once again to the Southbury Training School, a 1,600-acre residence for people with mental retardation. Bob, Bobby and Tony have lived here since before man landed on the moon, since before J.F.K. was shot, for as long as they remember.

The van drops the men off in front of their home buildings. Bobby, who had a paper route before he was placed here as a teenager, back when his hair was dark, plops onto the couch, exhausted but still eager to go to a minor-league baseball game in a few hours. Bob, whose parents placed him here when he was 8, leans before his stereo system and pushes buttons until it emits the feel-the-fire wailing of Kenny Rogers.

“Listen to this,” Bob says, playing air drums. “Listen.”

Tony, who bounced around foster homes before coming here as a young teenager, stops briefly in his bedroom, then hustles out to a second job picking up trash in another building. His lined face conveys the then and the now of his life: the wide eyes of full engagement with his world today, offset by a telltale mangled ear.

Decades ago someone stomped on his ear while he was sleeping; stomp might be too gentle a word, given that his ear now looks like a small conch.

“I don’t know who did it,” he says, big eyes looking away.

These men were here at the Southbury Training School — opened in 1941 as a “school for mental defectives” — in the early 1960s, when it was the best that government had to offer: a place where even the well-to-do sent their mentally impaired and troubled boys and girls, a place of many swing sets.

They were here in the mid-1980s, when conditions became so substandard, even dangerous, that the school, then with a population of more than 1,100, was placed under federal oversight and stopped accepting admissions.

They were here through the 1990s, as the school struggled to improve its care, as some residents moved off campus, often to group homes, and other residents, mostly older ones, died. And they were here in 2006, when the school was released from the supervision of a court monitor, although a consent decree with the federal government remains.

The swing sets are gone, but these men are here still, a part of a declining, aging population that has dropped below 500. They live in settings similar to group homes, have one-on-one contact with social workers, work out in the gym, keep bank accounts, plan for day trips and shopping trips. And every weekday morning they climb into that van and head off for work at a rest stop welcoming people to Connecticut.

Twenty years ago, the state Department of Transportation hired a crew from the training school to maintain the rest area’s grounds. Dave was put in charge, and among those he selected for the initial crew was Bobby, who some staff members thought should not leave school grounds. Bobby has proved them wrong; he and his crew mates continue to work hard to keep the rest area clean, and they take evident pride in their yellow D.O.T. vests.

“It says to the world: I made it,” Dave explains.

Another workday dawns. Dave drives the van through the school’s verdant campus, collecting his crew. He has known these men for decades. A couple of them spend Thanksgiving with his family every year.

As always, the van stops at the country store for coffee. The men sit mostly in silence on the 25-mile ride to the rest stop, save for the occasional slurp from a travel mug. And soon after they arrive at the maintenance garage and open its doors, Tony puts on a pot of coffee.

Over the years, a lot of coffee has been drunk in the van and at the garage, because coffee has special meaning. It goes back to when an extra cup of coffee could be a privilege, or maybe a way for a staff member to say thank you, good job, I can depend on you. A hint of independence now flavors their coffee.

And over the years, the crew’s makeup has changed; people have come and gone. Two years ago, there were five: Dave, Bob, Bobby, Tony and a birdlike man named Robert, who did not speak but would communicate with gestures. Dave would look in his rearview mirror and see Robert moving fist over fist. Coffee, he was saying.

But Robert, who used to set out napkins for his workmates when they ate lunch in the maintenance garage, died last summer. Then Danny, another training school resident, died. Then others died, including Bob’s father and a beloved staff member at the school named Gina.

Tony in particular began struggling with mortality. As a result, the garage’s refrigerator is adorned with a haphazardly taped collage of death notices and memorial announcements — for Robert and Danny and Gina and Bob’s dad. There is also a circled advertisement for the Naugatuck funeral home that Tony says will take care of him when he dies and goes to heaven — where, he has been assured, there will be coffee.

“But God don’t want me yet,” he says.

The men finish their coffee. Bobby sits. Tony has a cigarette. Bob lights up a pipe. Among them, a combined 140 years at the Southbury Training School.

After a while, Dave says it’s time to get back to work. The men stand up and walk out of the dim garage.

Through Decades of Change, a Core Crew Remains, NYT, 30.6.2008,
http://www.nytimes.com/2008/06/30/us/30land.html

Insure Me, Please

The Murky Politics of Mind-Body

March 30, 2008
The New York Times
By SARAH KERSHAW

From Plato and Aristotle to Descartes, the great thinkers have for millennia argued over what is known in philosophy as the “mind-body problem,” the relationship between spirit and flesh. Dualism tends to win the day: The mind and the body, while linked, are separate. They exist independently, perhaps mingling but not merging.

The debate lives on these days in less abstract form in the United States: How much of a difference should it make to health care — and health insurance — if a condition is physical or mental?

Decades of culture change and recent scientific studies have blurred the line between these types of disorders. Now a critical moment has been reached in a 15-year debate in statehouses and in Congress over whether treatment for problems like depression, addiction and schizophrenia should get the same coverage by insurance companies as, say, diabetes, heart disease and cancer.

This month, the House passed a bill that would require insurance companies to provide mental health insurance parity. It was the first time it has approved a proposal so substantial.

The bill would ban insurance companies from setting lower limits on treatment for mental health problems than on treatment for physical problems, including doctor visits and hospital stays. It would also disallow higher co-payments. The insurance industry is up in arms, as are others who envision sharply higher premiums and a free-for-all over claims for coverage of things like jet lag and caffeine addiction.

Parity raises all sorts of tricky questions. Is an ailment a legitimate disease if you can’t test for it? A culture tells the doctor the patient has strep throat. But if a patient says, ‘‘Doctor, I feel hopeless,’’ is that enough to justify a diagnosis of depression and health benefits to pay for treatment? How many therapy sessions are enough? If mental illness never ends, which is typically the case, how do you set a standard for coverage equal to that for physical ailments, many of which do end?

The United States has a long history of separating the treatment of mental and physical illnesses, dating back to the days when the severely mentally ill were put in poorhouses, jails and, later, public asylums. That ended after the deinstitutionalization movement of the 1960s, but mental health experts and advocates say that the delivery of services is still far from equal, because emotional illness is still not considered to be on a par with medical illness.

Countries like Canada and the United Kingdom, with national health care systems that don’t limit access to any services, have long ago moved toward merging these two branches of health care, and the Scandinavian countries are known for treating mental illnesses as medical diseases, according to researchers who have studied the various systems.

In the United States over the last five years, research studies examining the link between physical brain abnormalities and disorders like severe depression and schizophrenia have begun to make a strong case that the disorders are not scary tales of minds gone mad but manifestations of actual, and often fatal, problems in brain circuitry. These disorders affect behavior and mood, and they look different from Parkinson’s disease or multiple sclerosis in brain imaging. Still, a growing number of studies — and many more are under way — are making the biological connection, redefining the concept of mental illness as brain illness.

“Insurance companies balk at this, but there are striking similarities between mental and physical diseases,” said George Graham, the A.C. Reid professor of philosophy at Wake Forest University. “There is suffering, there is a lacking of skills, a quality of life tragically reduced, the need for help. You have to develop a conception of mental health that focuses on the similarities, respects the differences but does not allow the differences to produce radically disparate and inequitable forms of treatment.”

While squarely in the minority, some still question the legitimacy of calling any mental ailment a disease. A louder chorus argues that addiction is a behavioral and social problem, even a choice, but not a disease, as many mental health professionals and the founders and millions of followers of Alcoholics Anonymous maintain.

Critics of parity say that anything that would not turn up in an autopsy, as in depression or agoraphobia, cannot be equated with physical illness, either in the pages of a medical text or on an insurance claim. These critics also say that because the mental abnormality research is so new, it should still be considered theory rather than an established basis for equal payment and treatment. “Schizophrenia and depression refer to behavior, not to cellular abnormalities,” said Jeffrey A. Schaler, a psychologist and an assistant professor of justice, law and society at American University in Washington. “So what constitutes medicine? Is it what anybody says is medicine? Is it acupuncture? Is it homeopathy?”

Nevertheless, as federal parity legislation has wobbled along over the years, 42 states have adopted their own versions of parity, offering a patchwork of standards for insurance companies on coverage for addiction and mental illnesses. A federal law would extend insurance parity to tens of millions more Americans who are not covered under the laws and set one broad standard for the nation. As the states have experimented with parity, however, many providers have complained that insurance companies have often found it easy to deny benefits by ruling that claims are not “medically necessary,” a potentially tough standard when it comes to ailments of the mind.

Meanwhile, attitudes about mental illnesses and addiction have changed significantly in the decades since advocates for the mentally ill — and for parity — first tried to include broad coverage of mental illnesses in the nation’s insurance plans. Pop culture has normalized and even glamorized rehab and even suicide attempts, chipping away slowly at social stigmas and lending strength to the idea that the sufferer of a mental illness or addiction may be a victim, rather than a perpetrator. Still, a cancer patient generally remains a far more sympathetic figure than a cocaine addict or a schizophrenic.

But scientific advances may go a long way to help the parity cause. The biological and neurological connection lends strength to the notion that mental illnesses are as real and as urgent as physical illnesses and that there may, at long last, even be a cure in this lifetime, or the next.

And if you can cure something, you can treat it and there is a finite quality to that treatment — and its cost. So you may, if you are an insurance company, be a lot more willing to pay for it.

“The more research that is done, the more the science convinces us that there is simply no reason to separate mental disorders from any other medical disorder,” said Thomas R. Insel, director of the National Institute of Mental Health, which has conducted a series of studies on the connection between depression and brain circuitry and on Thursday released an important study showing a connection between genetics and the ability to predict the risk for schizophrenia.

Last fall, the Senate passed its own parity bill with substantial differences from the House bill, which had been co-sponsored by Representative Patrick J. Kennedy, Democrat of Rhode Island. Mr. Kennedy has admitted to struggling with addiction and depression.

Supporters and opponents both expect the negotiations over how to reconcile the two bills to be protracted; President Bush, who has voiced support for the more limited coverage called for in the Senate bill, has said he would not support the House version, which estimates a cost to the government of $3.8 billion over the next decade through coverage from federally funded insurance. The bill also includes ways to offset the cost.

The precise impact of the House bill on private health insurance premiums was difficult to calculate, insurance industry experts said, but they said that increases to group plans would be likely, with some of the costs passed on to employees. Neither bill applies to employers with 50 or fewer employees or to the individual insurance market.

Despite such warnings that premiums might increase, however, it is unclear by how much. Such extensive parity requirements have never been tested on a federal level, and one question is how many people might take advantage of new benefits even if they were available.

The uncertainty is plain when experts try to estimate the effect. The Congressional Budget Office estimated that the Senate bill, with its minimalist approach, would increase health-plan costs by four-tenths of one percent. However, a report released last month by the Council for Affordable Health Insurance, an insurance industry group, estimated that state-based parity formulas were likely to increase rates by about 5 to 10 percent, on average. And a 2006 study in The New England Journal of Medicine, examining the costs associated with a parity program put into place by President Bill Clinton for all federal employees, found that it actually didn’t increase the use or the cost of mental health services. And that plan, it said, was similar to the one proposed in the more generous House bill.

The House bill would require insurance companies that offer mental health benefits to cover treatment for the hundreds of diagnoses included in the Diagnostic and Statistical Manual of Mental Disorders, from paranoid schizophrenia to stuttering to insomnia to chronic melancholy, or dysthymia.

The Bush administration and other opponents say the list of disorders is far too broad. That leads from parity to another, parallel morass in the fields of psychiatry and pharmacology. Both fields are accused of over-diagnosis and of seizing on fashionable diagnoses — bipolar disorder or post-traumatic stress disorder, for example — for financial gain or through highly subjective assessments.

“It’s the phone-book approach of possible conditions,” said Karen Ignagni, president of America’s Health Insurance Plans, an industry group representing insurance companies that cover 200 million Americans. “And this comes at a time when advocates have made a very persuasive case about the importance of covering behavioral health.”

But in the halls of Congress, at least, the mind-body problem is far from resolved, particularly when it is uncertain who the next president will be.

The Murky Politics of Mind-Body, NYT, 30.3.2008,
http://www.nytimes.com/2008/03/30/weekinreview/30kers.html

Midlife Suicide Rises,

Puzzling Researchers

February 19, 2008

The New York Times

By PATRICIA COHEN

Shannon Neal can instantly tell you the best night of her life: Tuesday, Dec. 23, 2003, the Hinsdale Academy debutante ball. Her father, Steven Neal, a 54-year-old political columnist for The Chicago Sun-Times, was in his tux, white gloves and tie. “My dad walked me down and took a little bow,” she said, and then the two of them goofed it up on the dance floor as they laughed and laughed.

A few weeks later, Mr. Neal parked his car in his garage, turned on the motor and waited until carbon monoxide filled the enclosed space and took his breath, and his life, away.

Later, his wife, Susan, would recall that he had just finished a new book, his seventh, and that “it took a lot out of him.” His medication was also taking a toll, putting him in the hospital overnight with worries about his heart.

Still, those who knew him were blindsided. “If I had just 30 seconds with him now,” Ms. Neal said of her father, “I would want all these answers.”

Mr. Neal is part of an unusually large increase in suicides among middle-aged Americans in recent years. Just why thousands of men and women have crossed the line between enduring life’s burdens and surrendering to them is a painful question for their loved ones. But for officials, it is a surprising and baffling public health mystery.

A new five-year analysis of the nation’s death rates recently released by the federal Centers for Disease Control and Prevention found that the suicide rate among 45-to-54-year-olds increased nearly 20 percent from 1999 to 2004, the latest year studied, far outpacing changes in nearly every other age group. (All figures are adjusted for population.)

For women 45 to 54, the rate leapt 31 percent. “That is certainly a break from trends of the past,” said Ann Haas, the research director of the American Foundation for Suicide Prevention.

By contrast, the suicide rate for 15-to-19-year-olds increased less than 2 percent during that five-year period — and decreased among people 65 and older.

The question is why. What happened in 1999 that caused the suicide rate to suddenly rise primarily for those in midlife? For health experts, it is like discovering the wreckage of a plane crash without finding the black box that recorded flight data just before the aircraft went down.

Experts say that the poignancy of a young death and higher suicide rates among the very old in the past have drawn the vast majority of news attention and prevention resources. For example, $82 million was devoted to youth suicide prevention programs in 2004, after the 21-year-old son of Senator Gordon H. Smith, Republican of Oregon, killed himself. Suicide in middle age, by comparison, is often seen as coming at the end of a long downhill slide, a problem of alcoholics and addicts, society’s losers.

“There’s a social-bias issue here,” said Dr. Eric C. Caine, co-director at the Center for the Study of Prevention of Suicide at the University of Rochester Medical Center, explaining why suicide in the middle years of life had not been extensively studied before.

There is a “national support system for those under 19, and those 65 and older,” Dr. Caine added, but not for people in between, even though “the bulk of the burden from suicide is in the middle years of life.”

Of the more than 32,000 people who committed suicide in 2004, 14,607 were 40 to 64 years old (6,906 of those were 45 to 54); 5,198 were over 65; 2,434 were under 21 years old.

Complicating any analysis is the nature of suicide itself. It cannot be diagnosed through a simple X-ray or blood test. Official statistics include the method of suicide — a gun, for instance, or a drug overdose — but they do not say whether the victim was an addict or a first-time drug user. And although an unusual event might cause the suicide rate to spike, like in Thailand after Asia’s economic collapse in 1997, suicide much more frequently punctuates a long series of troubles — mental illness, substance abuse, unemployment, failed romances.

Without a “psychological autopsy” into someone’s mental health, Dr. Caine said, “we’re kind of in the dark.”

The lack of concrete research has given rise to all kinds of theories, including a sudden drop in the use of hormone-replacement therapy by menopausal women after health warnings in 2002, higher rates of depression among baby boomers or a simple statistical fluke.

At the moment, the prime suspect is the skyrocketing use — and abuse — of prescription drugs. During the same five-year period included in the study, there was a staggering increase in the total number of drug overdoses, both intentional and accidental, like the one that recently killed the 28-year-old actor Heath Ledger. Illicit drugs also increase risky behaviors, C.D.C. officials point out, noting that users’ rates of suicide can be 15 to 25 times as great as the general population.

Jeffrey Smith, a vigorous fisherman and hunter, began ordering prescription drugs like Ambien and Viagra over the Internet when he was in his late 40s and the prospect of growing older began to gnaw at him, said his daughter, Michelle Ray Smith, who appears on the television soap “Guiding Light.” Five days before his 50th birthday, he sat in his S.U.V. in Bloomfield Hills, Mich., letting carbon monoxide fill his car.

Linda Cronin was 43 and working in a gym when she gulped down a lethal dose of prescription drugs in her Denver apartment in 2006, after battling eating disorders and depression for years.

Looking at the puzzling 28.8 percent rise in the suicide rate among women ages 50 to 54, Andrew C. Leon, a professor of biostatistics in psychiatry at Cornell, suggested that a drop in the use of hormone replacement therapy after 2002 might be implicated. It may be that without the therapy, more women fell into depression, Dr. Leon said, but he cautioned this was just speculation.

Despite the sharp rise in suicide among middle-aged women, the total number who died is still relatively small: 834 in the 50-to-54-year-old category in 2004. Over all, four of five people who commit suicide are men. (For men 45 to 54, the five-year rate increase was 15.6 percent.)

Veterans are another vulnerable group. Some surveys show they account for one in five suicides, said Dr. Ira Katz, who oversees mental health programs at the Department of Veterans Affairs. That is why the agency joined the national toll-free suicide hot line last August.

In the last five years, Dr. Katz said, the agency has noticed that the highest suicide rates have been among middle-aged men and women. Those most affected are not returning from Iraq or Afghanistan, he said, but those who served in Vietnam or right after, when the draft ended and the all-volunteer force began. “The current generation of older people seems to be at lesser risk for depression throughout their lifetimes” than the middle-aged, he said.

That observation seems to match what Myrna M. Weissman, the chief of the department in Clinical-Genetic Epidemiology at New York State Psychiatric Institute, concluded was a susceptibility to depression among the affluent and healthy baby boom generation two decades ago, in a 1989 study published in The Journal of the American Medical Association. One possible reason she offered was the growing pressures of modern life, like the changing shape of families and more frequent moves away from friends and relatives that have frayed social support networks.

More recently, reports of a study that spanned 80 countries found that around the world, middle-aged people were unhappier than those in any other age group, but that conclusion has been challenged by other research, which found that among Americans, middle age is the happiest time of life.

Indeed, statistics can sometimes be as confusing as they are enlightening. Shifts in how deaths are tallied make it difficult to compare rates before and after 1999, C.D.C. officials said. Epidemiologists also emphasize that at least another five years of data on suicide are needed before any firm conclusions can be reached about a trend.

The confusion over the evidence reflects the confusion and mystery at the heart of suicide itself.

Ms. Cronin explained in a note that she had struggled with an inexplicable gloom that would leave her cowering tearfully in a closet as early as age 9. After attempting suicide before, she had checked into a residential treatment program not long before she died, but after a month, her insurance ran out. Her parents had offered to continue the payments, but her sister, Kelly Gifford, said Ms. Cronin did not want to burden them.

Ms. Gifford added, “I think she just got sick of trying to get better.”

Midlife Suicide Rises, Puzzling Researchers,
NYT,
19.2.2008,
http://www.nytimes.com/2008/02/19/us/19suicide.html

Orphanages Stunt Mental Growth,

a Study Finds

December 21, 2007

The New York Times

By BENEDICT CAREY

Psychologists have long believed that growing up in an institution like an orphanage stunts children’s mental development but have never had direct evidence to back it up.

Now they do, from an extraordinary years-long experiment in Romania that compared the effects of foster care with those of institutional child-rearing.

The study, being published on Friday in the journal Science, found that toddlers placed in foster families developed significantly higher I.Q.’s by age 4, on average, than peers who spent those years in an orphanage.

The difference was large — eight points — and the study found that the earlier children joined a foster family, the better they did. Children who moved from institutional care to families after age 2 made few gains on average, though the experience varied from child to child. Both groups, however, had significantly lower I.Q.’s than a comparison group of children raised by their biological families.

Some developmental psychologists had sharply criticized the study and its sponsor, the MacArthur Foundation, for researching a question whose answer seemed obvious. But previous attempts to compare institutional and foster care suffered from serious flaws, mainly because no one knew whether children who landed in orphanages were different in unknown ways from those in foster care. Experts said the new study should put to rest any doubts about the harmful effects of institutionalization — and might help speed up adoptions from countries that still allow them.

“Most of us take it as almost intuitive that being in a family is better for humans than being in an orphanage,” said Seth Pollak, a psychologist at the University of Wisconsin, who was not involved in the research. “But other governments don’t like to be told how to handle policy issues based on intuition.

“What makes this study important,” he went on, “is that it gives objective data to say that if you’re going to allow international adoptions, then it’s a good idea to speed things up and get kids into families quickly.”

In recent years many countries, including Romania, have banned or sharply restricted American families from adopting local children. In other countries, adoption procedures can drag on for many months. In 2006, the latest year for which numbers are available, Americans adopted 20,679 children from abroad, more than half of them from China, Guatemala and Russia.

The authors of the new paper, led by Dr. Charles H. Zeanah Jr. of Tulane and Charles A. Nelson III of Harvard and Children’s Hospital in Boston, approached Romanian officials in the late 1990s about conducting the study. The country had been working to improve conditions at its orphanages, which became infamous in the early 1990s as Dickensian warehouses for abandoned children.

After gaining clearance from the government, the researchers began to track 136 children who had been abandoned at birth. They administered developmental tests to the children, and then randomly assigned them to continue at one of Bucharest’s six large orphanages, or join an adoptive family. The foster families were carefully screened and provided “very high-quality care,” Dr. Nelson said.

On I.Q. tests taken at 54 months, the foster children scored an average of 81, compared to 73 among the children who continued in an institution. The children who moved into foster care at the youngest ages tended to show the most improvement, the researchers found.

The comparison group of youngsters who grew up in their biological families had an average I.Q. of 109 at the same age, found the researchers, who announced their preliminary findings as soon in Romania as they were known.

“Institutions and environments vary enormously across the world and within countries,” Dr. Nelson said, “but I think these findings generalize to many situations, from kids in institutions to those in abusive households and even bad foster care arrangements.”

In setting up the study, the researchers directly addressed the ethical issue of assigning children to institutional care, which was suspected to be harmful. “If a government is to consider alternatives to institutional care for abandoned children, it must know how the alternative compares to the standard care it provides. In Romania, this meant comparing the standard of care to anew and alternative form of care,” they wrote.

Any number of factors common to institutions could work to delay or blunt intellectual development, experts say: the regimentation, the indifference to individual differences in children’s habits and needs; and most of all, the limited access to caregivers, who in some institutions can be responsible for more than 20 children at a time.

“The evidence seems to say,” said Dr. Pollak, of Wisconsin, “that for humans, we need a lot of responsive care giving, an adult who recognizes our distinct cry, knows when we’re hungry or in pain, and gives us the opportunity to crawl around and handle different things, safely, when we’re ready.”

Orphanages Stunt Mental Growth, a Study Finds,
NYT,
21.12.2007,
https://www.nytimes.com/2007/12/21/
health/21cnd-foster.html

For Children,

a Scary World Out There

(in There, Too)

November 12, 2007

The New York Times

By TINA KELLEY

Fears of crawling insects, the dark and all types of vegetables are common among young children, as any child-rearing expert will attest.

And increasingly over the past few years, parents have seen their children contend with another fear: automatic flush toilets.

Kristen Kligerman discovered this on a visit to Newark Liberty International Airport. In the ladies’ room, her daughter Magda, then 4, leapt off the toilet and refused to get back on after it suddenly flushed.

“She was just terrified,” recalled Ms. Kligerman, an architect in Manhattan. “I had to explain that it was a machine, and it flushed the toilet.”

Automatic toilets, their infrared eyes flashing, have proliferated in restaurants, airports, museums, department stores and office buildings. The American Museum of Natural History has them. So does Bloomingdale’s.

Unlike their antiquated, manually operated predecessors, the toilets can flush at the slightest movement, and emit a high-pitched whine that, to some ears, sounds like a cat being strangled.

Even some adults confess that the machines make them nervous. But to many toddlers, they are the stuff of nightmares.

“One feature of things in the world that make kids anxious is unpredictability, and things that are new or novel,” said Philip Kendall, director of the Child and Adolescent Anxiety Disorders Clinic at Temple University. “A novel experience for kids can be when that machine flushes automatically. They didn’t touch anything. It can be a bit shocking. Most people get over it, but kids are a little less prepared to do that.”

So many children are afraid of the toilets that parents have begun trading strategies for outsmarting the electric eyes. One company has developed a portable device to block the sensors, and a Web site (www.mouseplanet.com/potties) lists all of the manual toilets at Disneyland.

Robyn Whitlock of Naperville, Ill., said that her twin boys, now 5 ½, could rattle off every McDonald’s in a 20-mile radius that had automatic toilets. She said she would drive three miles out of her way to find an old-fashioned device.

“If it was an emergency, I’d cover his ears,” she said of her son Andrew.

For Jenny Tate, her 4-year-old daughter Eve’s terror meant stopping at three different highway rest stops on a trip to Virginia during the summer. At the first stop, the automatic toilet set off hysteria.

“Her eyes got really big, and she leapt off and hung on to me,” said Ms. Tate, of Maplewood, N.J. “I went back to put her on the seat and she was clinging to me, and wouldn’t let me put her on it.”

Two rest stops later, it became clear that all the toilets were the same, and the situation became urgent. “I ended up having to hold her down, crying and struggling with me the whole time,” said Ms. Tate, who added that Eve’s fears have since abated.

Jerilyn Ross, president of the Anxiety Disorders Association of America, said that a fear of automatic toilets did not, in itself, meet the criteria for a psychiatric diagnosis.

“Anxiety in and of itself is normal and healthy,” she said, “but when anxiety is excessive, irrational, and if it interferes with one’s daily life, then it may be an anxiety disorder, which is something that may need to be treated.”

She added, “If it persists beyond normal developmental stages and interferes with a child’s life, so they won’t go into the bathroom or go to school because they’re afraid of needing the bathroom and hearing the toilet flush, then it’s more than normal anxiety.”

She said that children usually outgrow their fears in six months to a year.

Meanwhile, the ease with which the toilets inspire terror has not escaped the eyes of entrepreneurs.

Jeffrey Kay, a marketing consultant in Mount Kisco, N.Y., said he decided to find a way to deal with automatic flushes in 2002, after his daughter, Courtney, then 3 or 4, was surprised by one and started losing ground in potty training.

He developed the Flush-Stopper, a reusable piece of plastic with putty on the back that can be placed on the toilet’s electric eye, blocking the sensor. The device comes with a resealable bag, for sanitary storage. Mr. Kay estimated that he had sold more than 110,000 of the devices, which cost $2.99.

Automatic toilets, he said, are built to work for adults, not for children, who wiggle around a lot.

“Sometimes they spit back at you, so I could understand why kids get scared,” he said. “I think toilets are intimidating enough without them attacking you.”

Susan Kennedy, director of marketing for Sloan Valve, a manufacturer of automatic bathroom fixtures in Franklin Park, Ill., said that automatic toilets were invented to increase hygiene in public bathrooms. They save water, she noted, and cut down on the need for cleaning.

Parents, Ms. Kennedy said, should be grateful for the existence of the automatic flush. “It’s going to keep their kids from getting sick, not touching handles of the flush valve,” she said.

Asked about the noise that the devices sometimes emitted, Ms. Kennedy conceded, “Yes, it’s a different sound, and you don’t have control over it, but you don’t really need to.”

Elizabeth Pantley, author of “The No-Cry Potty Training Solution,” advised parents not to overreact to the toilets or to their children’s concerns. She suggested that parents take children who are starting potty training to a plumbing fixture store to show them what is underneath, behind and around a toilet, and what happens when a toilet flushes.

For children who panic about automatic flushing, she said, “You can say, ‘Ooh, look what happened, it flushed without you.’ That really helps a lot.”

Other parents carry Post-it notes to cover the sensors; some get online help before taking long trips.

Having survived Magda’s airport bathroom incident, Ms. Kligerman tried to educate her about the toilets, to assuage her fear. She pointed out the way the light on the toilets flashed before the flush, like a countdown. It did not help much, she said.

Little children, she noted, like to take their time.

“They sit there and sing their little song,” she said.
“To be hurried by the countdown clock is not something
that is pleasant.”

For Children, a Scary World Out There (in There, Too),
NYT,
12.11.2007,
https://www.nytimes.com/2007/11/12/
nyregion/12flush.html

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